Every finding on record at Hillside Heights Rehabilitation Suites

Based on interview and record review the facility failed to provide training to their staff that at a minimum educates staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property and procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property for 1 (CNA A) of 5 employees reviewed for staff training.The facility failed to ensure required Abuse and Neglect training was verified or provided prior to CNA A providing resident care on [DATE].This failure could place residents at risk of injury or harm due to being cared for by untrained staff.Findings included:Record review of CNA A's employee file on [DATE], revealed CNA A was employed through a staffing agency and his first day providing care at the facility was [DATE]. Further review revealed the file contained an Abuse Assessment expired on [DATE] and no documentation of current training related to abuse, neglect, and exploitation. Record review of Staffing Agency's blank Abuse Neglect and Misappropriation Assessment form on [DATE], the form was blank and contained no evidence of education material attached to the form. During a telephone interview on [DATE] at 10:25 AM, CNA A stated he was employed through a staffing agency and worked his first shift at the facility on [DATE] and had not worked at the facility since that date. CNA A stated all his trainings were current, including abuse and neglect. During an interview on [DATE] at 1:24 PM, the ADM stated she was speaking with the staffing agency account manager regarding CNA A's training records. The staffing agency account manager stated via speaker phone that she was unable to locate documentation demonstrating CNA A had completed current Abuse, Neglect, and Exploitation training. The account manager would not answer questions regarding any training related to CNA A. The ADM stated a potential negative outcome of failing to verify required training prior to resident care was that staff may not have received education regarding abuse, neglect, and exploitation. The ADM stated she was responsible for ensuring all staff, including agency staff, completed required training and that documentation was verified prior to providing resident care. During an interview on [DATE] at 3:08 PM, the HR stated she and the ADM were responsible for verifying staff training requirements prior to staff caring for residents. The HR stated CNA A accepted the shift through the staffing agency at the last minute and the required training verification had been missed. The HR pulled up the staffing agency website where CNA A's credentials were located. The abuse training was highlighted with an expiration date of [DATE], all other trainings, history checks were marked current. The HR stated a potential negative outcome for failing to verify required training prior to resident care was that staff may not have received education regarding abuse, neglect, and exploitation. During an interview on [DATE] at 3:20 PM, the DON stated she and the ADM were responsible for ensuring staff had completed their training prior to being on the floor. The DON stated a potential negative outcome for not ensuring staff were trained prior to direct care services would be the staff would not be aware of or educated on abuse or neglect.Record Review of the facility provided policy titled Abuse, Neglect and Exploitation or Mistreatment not dated, revealed the following: Training: All new and current employees, including volunteers receive continuous education training and reinforcement that identify all aspects of abuse prohibition. Education/training material include abuse and neglect education is provided and required by regulatory agencies.

Based on observations, interviews, and record reviews the facility failed to ensure the resident has the right to be free from abuse, neglect, misappropriation of resident property, for 6 residents (Resident #1, Resident #5, Resident #15, Resident #17, Resident #22, and Resident #41) of 83 residents reviewed for abuse and neglect.The facility failed to ensure Resident #1, Resident #5, Resident #15, Resident #17, Resident #22, and Resident #41 were not neglected during the 06:00 PM to 06:00 AM shift beginning on 04/19/26.The facility failed to ensure Resident #1 was not lying in a bed covered in feces.The facility failed to ensure Resident #5 was not lying in a bed soaked in urine.The facility failed to ensure Resident #15 was not lying asleep on a couch in just a soaked brief and t-shirt and later on a soaked couch in just a brief.The facility failed to ensure Resident #17 was not lying in a bed soaked in urine.The facility failed to ensure Resident #22 was assessed upon reporting a fall and was not lying in her bed upside down.The facility failed to ensure Resident #41 was not lying in a bed soaked in urine.These failures could place residents at risk of injury, infection, and/or negatively impacted self-esteem.Findings Included:Record review of Resident #1's admission record dated 04/27/26 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, muscle wasting and atrophy, muscle weakness, difficulty in walking, altered mental status, and cognitive communication deficit (difficulty with one or more of the following: attention, memory, perception, language, problem-solving, and reasoning).Record review of Resident #1's admission MDS completed 04/20/26 revealed a BIMS of 12 which indicated moderately impaired cognition. Section GG Functional Abilities revealed Resident #1 required substantial maximal assistance defined as Helper dose MORE THAN HALF the effort. Helper lifts or holds truck or limbs and provides more than half the effort with toileting and all transfers.Record review of Resident #1's care plan last reviewed/revised on 04/20/26 revealed he had cognitive loss especially with short term recall. He experienced occasional bladder incontinence related to age. One of the interventions was, Provide incontinent care after each incontinent episode. Resident #1 was at risk for skin breakdown. Interventions included keeping him as clean and dry as possible, minimizing skin exposure to moisture, and keeping his linens clean, dry, and wrinkle free.Record review of Resident #1's active orders dated 04/27/26 revealed the following orders with corresponding start dates:04/09/26 BED MOBILITY with assist of 1-204/09/26 TOILETING with assist of 1-204/09/26 TRANSFER with assist of 1-2During an observation and interview on 04/27/26 at 05:37 AM Resident #1 was lying in bed on his back. When asked if staff took good care of him, he stated, That depends. When asked if there was a time staff did not take good care of him, he did not answer the question.During an observation and interview on 04/27/26 at 10:02 AM Resident #1 was lying in bed on his back. He stated he did not remember a night when the nurse did not check on him, and he ended up in a bed covered in feces. When asked if staff took good care of him on the night shift he looked down and away and stated, I don't want to answer the question.During an interview and observation on 04/27/26 at 10:06 AM Resident #1's skin showed no issues, redness, or irritation. Resident #1 denied any issues and stated he was pleased with his care.Record review of Resident #5's admission record dated 04/27/26 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, diarrhea, difficulty in walking, cognitive communication deficit (difficulty with one or more of the following: attention, memory, perception, language, problem-solving, and reasoning), infectious gastroenteritis and colitis (inflammation of stomach and large intestine often resulting in bloody diarrhea, abdominal pain, and cramping.), benign prostatic hyperplasia with lower urinary tract symptoms (the flow of urine is blocked due to the enlargement of prostate the gland; symptoms include increased frequency of urination at night and difficulty in urinating), and muscle wasting and atrophy.Record review of Resident #5's admission MDS completed on 04/15/26 revealed a BIMS of 14 which indicated intact cognition. Section GG Functional Abilities revealed Resident #5 used a wheelchair and had impairment of both lower extremities. He required substantial/maximal assistance defined as Helper dose MORE THAN HALF the effort. Helper lifts or holds truck or limbs and provides more than half the effort for toileting and all transfers.Record review of Resident #5's care plan last reviewed/revised on 04/21/26 revealed he had behavioral symptoms and as an intervention staff were to ensure his physical needs including toileting were met. Resident #5 was noted to have gastroenteritis with frequent diarrhea. He was noted to be incontinent of bowel and bladder, and staff were to provide incontinent care after each incontinent episode. Resident #5 was at risk of falling and staff were to keep his call light in reach at all times. Record review of Resident #5's active orders dated 04/27/26 revealed the following orders and corresponding start dates:04/07/26 AMBULATION with assist of 1-204/07/26 BED MOBILITY with assist of 1-204/07/26 TOILETING with assist of 1-204/07/26 TRANSFER with assist of 1-2During an observation on 04/27/26 at 05:51 AM Resident #5 was lying in his bed with his eyes closed under a blanket.During an observation and interview on 04/27/26 at 08:15 AM Resident #5 was lying in bed on his back with the head of the bed raised slightly. He stated staff took good care of him.During an observation and interview on 04/27/26 at 10:09 AM Resident #5's skin showed no redness or irritation, and he stated he was pleased with his care.During an observation and interview on 04/27/26 at 10:12 AM Resident #5 was lying in his bed on his back. He did not seem to understand when asked about a night when staff did not check on him and he woke up in a soaked brief and bed.Record review of Resident #15's admission record dated 04/27/26 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified dementia with other behavioral disturbance (breakdown of thought process causing disruptive behavior), cognitive communication deficit (difficulty with one or more of the following: attention, memory, perception, language, problem-solving, and reasoning), muscle wasting and atrophy, muscle weakness, difficulty in walking, insomnia (problems falling and staying asleep), unsteadiness on feet, and frequency of micturition (needing to urinate more often than once every 3-4 hours).Record review of Resident #15's quarterly MDS completed on 03/17/26 revealed a BIMS of 5 which indicated severely impaired cognition. Section GG Functional Abilities revealed Resident #15 used a wheelchair and was dependent for toileting. She required substantial/maximal assistance defined as Helper dose MORE THAN HALF the effort. Helper lifts or holds truck or limbs and provides more than half the effort for transferring from chair/bed-to-chair.Record review of Resident #15's care plan last reviewed/revised on 04/01/26 revealed Resident #15 was a wanderer and at increased risk of falling. One of the interventions was [Resident #15]'s physical needs will be met; . toileting. She was to use a fall mat next to her bed as well as a scoop mattress and be monitored at least every 2 hours while in bed. Resident #15 was noted to be receiving hospice care and one of the interventions was [Resident #15] will be kept clean and comfortable. She was noted to require extensive assistance with toileting and transfers by one staff member. The goal was [Resident #15 will maintain a sense of dignity by being clean, dry, . One of the interventions included, Monitor appearance. Resident #15 was at risk for incontinence. Staff were to, Provide incontinent care after each episode of incontinence. She was at risk for skin breakdown due to incontinence. Staff were to, Keep clean and dray as possible. Minimize skin exposure to moisture. Staff were also to Provide toileting assistance every 2 hours and prn.Record review of Resident #15's active orders dated 04/27/26 revealed the following orders with corresponding start dates:11/19/25 Brief Check and document wet or dry every 3 hours02/26/26 BED MOBILITY with assist of 1-202/26/26 TRANSFER with assist of 1-2During an observation on 04/27/26 at 05:52 AM Resident #15 was lying in her bed on her right side with her eyes closed. Her bed was in the lowest position, and a fall mat was on the floor next to her bed.During an observation on 04/27/26 at 08:16 AM Resident #15 was lying in bed on her left side with her eyes closed. Her bed was in lowest position and fall mat was on the floor next to the bed. The couch in the entryway of her suite was visible from the hallway.During an observation and interview on 04/27/26 at 10:09 AM Resident #15 was in her bed with HOB raised to seated position. She did not remember a night when she slept on the sofa. She stated staff were kind and took good care of her.During an observation on 04/28/26 at 01:35 PM Resident #15's skin showed no breakdown or redness.Record review of Resident #17's admission record dated 04/27/26 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified dementia, muscle wasting and atrophy, muscle weakness, overactive bladder, difficulty walking, repeated falls, and cognitive communication deficit (difficulty with one or more of the following: attention, memory, perception, language, problem-solving, and reasoning).Record review of Resident #17's admission MDS completed 03/31/26 revealed a BIMS of 12 which indicated moderately impaired cognition. Section GG Functional Abilities revealed Resident #17 used a walker and required substantial/maximal assistance defined as Helper dose MORE THAN HALF the effort. Helper lifts or holds truck or limbs and provides more than half the effort for toileting. She required partial/moderate assistance defined as Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports truck or limbs but provides less than half the effort for all transfers.Record review of Resident #17's care plan revealed she experienced occasional bladder incontinence due to age. Staff were to provide incontinence care after each incontinent episode. She was noted to have cognitive loss especially in relation to short term recall.Record review of Resident #17's active orders dated 04/27/26 revealed the following orders and corresponding start dates:03/24/26 AMBULATION with assist of 1-203/24/26 BED MOBILITY with assist of 1-203/24/26 TOILETING with assist of 1-203/24/26 TRANSFER with assist of 1-2During an observation on 04/27/26 at 05:41 AM Resident #17 was lying in bed on her left side in the fetal position. She stated staff took good care of her and no one had been unkind to her during her stay in the facility.During an observation on 04/27/26 at 10:13 AM Resident #17's skin showed no redness or irritation. She stated she had no issues and was pleased with her care.Record review of Resident #22's admission record dated 04/27/26 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified lack of coordination, altered mental status, muscle weakness, difficulty in walking, and muscle wasting and atrophy.Record review of Resident #22's quarterly MDS completed on 01/29/26 revealed a BIMS of 9 which indicated moderately impaired cognition. Section GG Functional Abilities revealed she used a manual wheelchair and was dependent for chair/bed-to-chair transfers. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity.Record review of Resident #22's care plan last reviewed/revised on 04/21/2026 revealed she had a history of falling. An intervention to address this issue was to place her in her bed or recliner while she was in her room and not to leave her in her wheelchair. Another intervention was to observe her frequently and place her in a supervised area when out of bed.Record review of Resident #22's orders dated 04/27/26 revealed the following orders and order start dates: 05/24/24 1-2 person assist for ambulation 05/24/24 1-2 person assist for transfer05/24/24 1-2 person assist for toileting dated 05/24/24.05/24/24 at risk for falls02/26/26 1-2 person assist for bed mobilityRecord review of Resident #22's progress notes revealed the following notes:A note by LVN H on 04/20/26 at 09:39 AM This nurse and another nurse entered resident's room at approx 0615 (06:15 AM) and discovered resident laying on right side on the floor beside bed. Blanket was underneath resident and pillow was under left leg. This nurse asked resident what happened? Resident stated 'I guess I fell out of bed' Resident c/o pain to left hip and knee. Assessed for other injuries. Vital signs taken. None noted. Notified on call and administrator. Resident sent to [hospital initials] hospital for eval and treat due to guarding of left hip.A note by LVN H on 04/20/26 at 12:31 PM Returned from hospital via facility transport at approx 1200 (12:00 PM). In wheelchair with no new orders. Hip contusion. Smiling and conversating with no new c/o pain or discomfort at this time.During an observation and interview on 04/27/26 at 10:07 AM Resident #22 was seated in her wheelchair in her room. She stated she remembered the night LVN D worked and would not help her into bed. She stated, She (LVN D) was just hateful. I don't think she was really interested in doing anything. I was very stressed out that night because she had such an attitude. Resident #22 stated she fell out of her bed that night onto the fall mat next to her bed. She did not remember a fall prior to that one.During an observation on 04/28/26 at 01:23 PM Resident #22's skin showed no breakdown or redness.Record review of Resident 41's admission record dated 04/27/26 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, reduced mobility, need for assistance with personal care, difficulty in walking, cognitive communication deficit (difficulty with one or more of the following: attention, memory, perception, language, problem-solving, and reasoning), benign hyperplasia without lower urinary tract symptoms (the flow of urine is blocked due to the enlargement of prostate the gland; symptoms include increased frequency of urination at night and difficulty in urinating), muscle wasting and atrophy, and muscle weakness.Record review of Resident #41's quarterly MDS completed 02/25/26 revealed a BIMS of 9 which indicated moderately impaired cognition. Section GG Functional Abilities revealed Resident #41 used a wheelchair was required partial/moderate assistance defined as Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports truck or limbs, but provides less than half the effort for toileting and all transfers.Record review of Resident #41's care plan last reviewed/revised 04/13/26 revealed he could use the sit to stand lift for transfers. One of the interventions was, 2 staff members will use the sit to stand lift to ensure safety. Resident #41 was care planned for having a diagnosis of benign prostatic hyperplasia. One of the interventions was, Keep perineal area clean and dry. Resident #41 was noted to be frequently incontinent of bowel and bladder and to be at risk for skin breakdown, recurrent UTIs, and dignity problem (being embarrassed). The interventions included offering toileting every two hours while awake, assisting with toilet transfers, provide perineal care and provide incontinent care as indicated. Resident #41 was noted to have cognitive loss especially in the area of short-term recall. He was noted to be at risk of skin breakdown related to decreased mobility. Interventions included keeping him as clean and dry as possible and keeping his linens clean, dry, and wrinkle free.Record review of Resident #41's active orders dated 04/27/26 revealed the following orders and corresponding start dates:12/19/24 AMBULATION with assist of 1-2 persons12/19/24 TOILETING with assist of 1-2 persons12/19/24 TRANSFER with assist of 1-2 personsDuring an observation on 04/27/26 at 05:54 AM Resident # 41 was lying on his back in bed with his eyes closed. The head of his bed was slightly raised, and he had 3 pillows under his head.During an observation and interview on 04/27/26 at 10:05 AM Resident #41 was seated in his wheelchair in the doorway of his room. He stated he did not remember a night when staff did not change his brief, and he ended up soaking wet the next morning.During an interview on 04/27/26 at 04:37 AM LVN C stated she was working on 100 hall on the night of 04/19/26 when LVN D, who was working on 400 hall (Resident #22's hall), asked her for assistance. LVN C stated she walked with LVN D to Resident #22's suite and noted Resident #15 asleep on the couch in view of the hall wearing only a t-shirt and a soaked brief. LVN C stated she told LVN D, This is not cool. She stated LVN D told her, Wherever she (Resident #15) wants sleep; she's gonna sleep. LVN C stated LVN D told her she did not have time to baby talk the residents. LVN C stated she assisted LVN D with Resident #22 who stated she had fallen and her knee hurt as a result and she was in her bed upside down to take the pressure off of her knee. LVN C asked if she could assess her knee, and Resident #22 stated she just wanted to sleep. LVN C stated she put a pillow between Resident #22's legs and Resident #22 said the pillow relieved the knee pain. LVN C stated this happened at approximately 04:30 AM. She stated she returned to her hall and called the on-call phone to let ADON A know she was worried about the residents on hall 400. She stated she told ADON A about Resident #15 lying on the couch wearing only a soaked brief and T-shirt and about Resident #22 seeming to be afraid of LVN D and saying she had a fall and her knee hurt as a result. She stated ADON A told her she would let ADM know in the morning.During an interview and observation on 04/27/26 at 05:07 AM LVN C sent a text screen shot showing the time of her call to ADON A on the on-call phone was 04:35 AM on 04/20/26.During an interview on 04/27/26 at 05:47 AM LVN E stated leaving residents in wet and soiled briefs was an example of neglect.During an interview on 04/27/26 at 05:57 AM RN F stated she came to work on the morning of 04/20/26 and LVN C asked her to check on the residents on hall 400. RN F stated she joined LVN H on hall 400 and the two of them found Resident #15 asleep on the couch in the entryway to her suite in view of the hall wearing only a t-shirt with a soaked brief on the floor next to the couch RN F stated the couch was soaked with urine around Resident #15. RN F stated Resident #41 was lying bed soaked from the back of his neck down to his knees. She stated Resident #22 was on the floor of her room next to the bed with the head at the foot of the bed and her feet toward the head of the bed. She stated Resident #22 was complaining of pain, so she was sent to the hospital for evaluation. She stated Resident #1 was lying in a bed covered in feces. RN F stated all of the residents on hall 400 required a full bed change due to soaked linens. She stated, I called ADM and let her know my serious concerns. I don't like to throw the word neglect around, but I could say I have serious concerns about the care on that hall overnight or the lack of care on that hall overnight. She stated of hall 400 on the morning of 04/20/26, There was major concerns.During an interview on 04/27/26 at 06:05 AM ADM stated LVN C called in a complaint to the company hotline regarding LVN D's care of residents on the night shift of 04/19/26. She interviewed LVN D and was told Resident #15 said the couch was her bed and refused to get off of the couch. She stated LVN D told her she (LVN D) was overwhelmed and struggled through the night but did the best she could. ADM stated, My day shift nurses were upset because people were wet.During an interview on 04/27/26 at 07:11 AM LVN D stated 04/19/26 was her first time working in the facility. She stated she was shocked when she picked up the night shift to find she was responsible for total care for 6 residents and did not have a CNA to help her. She stated she had a back injury that made it impossible for her transfer residents alone. LVN D said of the residents on hall 400, Everybody was confused, dead weight, couldn't stand by themselves. She stated one resident was on a sofa and had taken her brief off. She refused to get up and go to bed and told me she was in her bed. Apparently, she had taken her brief off and dropped it on the floor. LVN D stated she was capable of assisting with brief changes but I can't solo due to her back injury. She stated of Resident #15, She had taken her brief off and denied care. I had been warned she might refuse care and not take her medications. LVN D stated Resident #41 was too big for her to provide a brief change to him. She stated some residents needed brief changes, but she was unable to change them due to being unable to stay bent over.During an interview on 04/27/26 at 06:50 AM ADM stated LVN D told her she had had 2 back surgeries and was [AGE] years old. ADM stated staff did skin sweeps on all residents on hall 400 on 04/20/26 because the day shift coming on that morning reported all the beds on hall 400 were soaked. She stated the skin sweeps revealed no redness or injury. She stated none of the residents on hall 400 were interviewable.During an interview on 04/27/26 at 07:41 AM LVN D stated, I do want to emphasize that I feel facility management was completely neglectful for not providing adequate staff and support for staff. Been told they are notorious for understaffing and leaving a nurse to do total care without the assistance of a CNA. In the past I would have immediately called the state line and reported them. They figure out who said what and then you get blackballed. She stated she did not tell the facility she could not do the job of nurse and CNA because she did not want to be blacklisted with her agency. When asked if she thought the residents on her hall on the night shift of 04/19/26 were neglected due to no CNA being assigned to assist her, she replied, I'm hoping this isn't a catch 22 scenario. I feel there was a lot more that could have been done and I did all I could do under the circumstances and the conditions. If your life is in jeopardy, I am the one you want there. If you need to be lifted up out of a w/c and transferred to the bed and I am the only one there I can't do it. And I looked down the halls and couldn't find anyone to help. She stated, If your life is in jeopardy, I am the one you want there. If you need to be lifted up out of a wheelchair and transferred to the bed and I am the only one there I can't do it. LVN D stated Resident #22 told her she wanted to go to bed and LVN D told her she (LVN D) was not able to put her to bed alone and would try to find someone to help. LVN D stated she went down halls and could not find CNAs to help her. She stated she found one CNA who told her she would be there shortly to help but did not show up. She stated Resident #22 must have put herself on her bed upside down. She stated of Resident #41, I'm quite certain he needed to be changed (brief), but I told him I could not push and lift and roll. Multiple times I went looking for CNAs to help make rounds and check on him and they would say, 'When I get time I'll come over. LVN D stated no CNA ever came to her hall to assist her.During an interview on 04/27/26 at 08:17 AM CMA G stated if she saw a resident in a soaked brief and t-shirt asleep on a couch in view of the hall, she would take care of the resident and then let the charge nurse know how she found the resident. She stated leaving residents in wet or soiled briefs was a form of neglect.During an interview on 04/27/26 at 09:08 AM ADON A stated LVN C called her on the morning of 04/20/26 to say she had concerns about the residents on hall 400. ADON A stated LVN C told her she saw a resident in a soaked brief but did not say anything else. She stated LVN C did not tell her anything about a resident who was in pain and said she fell. ADON A stated she sent a text to the two other nurses in the facility (LVN I and LVN J) asking them to send one of their CNAs to help LVN D. She stated she did not follow up to see if that was done or further check on the residents on hall 400.During an interview on 04/27/26 at 09:47 AM LVN H stated when she came to work on the morning of 04/20/26 LVN D did not give report, just said, Good luck and left the facility. She stated she and RN F found Resident #22 on the floor of her room and sent her to the hospital because she was complaining of pain in her left hip and knee. She stated she found Resident #15 sleeping in just a t-shirt on the couch visible from the hallway. LVN H stated Resident #15's soaked brief was on the floor next to the couch and the couch was also soaked where Resident #15 was seated. She stated Resident #41 was soaking wet from his ankles to his neck. She stated he was begging to get up and saying, I'm wet, I'm wet, I'm wet. She stated he was complaining about being cold. LVN H stated she and RN F let ADM know about the condition of the residents of hall 400 right away. She stated Resident #17 had a brown ring on her bottom and her bed was soaked. She stated Resident #1 had feces all over his bed. LVN H stated Resident #5 was wearing a soaked brief and his bedding was soaked as well. She stated she was in complete shock that morning as she had never come to work to find her residents in the condition they were in. She stated as she was getting all of her residents cleaned up, she did a skin sweep on them and found no redness or irritation. She stated of the residents' skin, There wasn't any extra or new redness or anything like that. Nothing out of the ordinary on them. LVN H stated none of her residents complained about the care they received overnight. She stated for the most part her residents were not interviewable with the occasional exception of Resident #22.During an interview and observation on 04/27/26 at 11:57 AM ADM was asked for the times of the text messages between the on call phone and LVN I and LVN J. ADM showed this surveyor a text exchange on the on-call phone dated 04/20/26 between ADON A, LVN I, and LVN J. At 04:45 AM ADON A asked the two LVNs to send their CNAs to hall 400 if they got the chance.During an observation and interview on 04/27/26 at 12:00 PM ADM, MS, and this surveyor entered a closet in the facility to watch recorded camera footage of LVN D on hall 400 the night of 04/19/26. According to camera footage, LVN D did not enter a resident room until after 10 PM on the night of 04/19/26. ADM stated it was nice to know you pay so much money for agency staff to sit around on their phones. LVN D did enter resident rooms after 10:00 PM but did not remain in any of the rooms for more than 2 minutes except for the instance she and LVN C entered the suite of Resident #15 and Resident #22. The two LVNs remained in the suite for 3 minutes at approximately 4:30 AM on 04/20/26.During an interview on 04/28/26 at 08:26 AM LVN K stated an example of neglect was leaving residents alone when they needed to have their briefs changed. He stated this could lead to skin breakdown and psychologically the residents would be hesitant to trust. He stated it could negatively impact their self esteem as well as cause UTIs.During an interview on 04/28/26 at 08:30 AM CMA L stated not changing a resident's wet brief was an example of neglect. She stated residents might feel embarrassed or isolate themselves if their wet briefs were not changed.During an interview on 04/28/26 at 08:32 AM CNA M stated not changing a resident's brief was an example of neglect and could result in infection.During an interview on 04/28/26 at 08:35 AM CMA G stated leaving residents in wet briefs was an example of neglect and could lead to UTIs, rashes, odor, and decreased self-esteem.During an interview on 04/28/26 at 08:36 AM SC stated leaving residents in wet briefs was an example of neglect and could cause skin breakdown.During an interview on 04/28/26 at 08:39 AM DT stated not checking on resident every 2 hours was an example of neglect and could lead to pressure sores, UTIs, and indecency.During an interview on 04/29/26 at 07:33 AM LVN J stated not changing a resident's brief was an example of neglect. She stated leaving a resident on a couch in a soaked brief and t-shirt overnight was not acceptable because the resident might fall and was not supposed to be out in public undressed. She stated, Another resident can go by and see somebody naked. LVN J stated a possible negative outcome of leaving a resident in an unchanged brief was skin breakdown or sores. She stated she remembered working on the night of 04/19/26 and ADON A asking her to send her CNAs to hall 400 to help LVN D. She stated her CNAs did not go as they had just enough time to finish their last round on her hall. LVN J stated she answered a call light for LVN D because it had been going off for a long time. She stated she was not sure how long but that she had administered a medication and charted and it was still going off. She described the location of Resident #1's room. She stated he was confused and asking about his car. LVN D stated she noticed several of the call lights for hall 400 went off for long periods of time that evening. She stated not answering a call light within 15 minutes, not changing resident briefs, and not dressing residents were examples of neglect. LVN J stated, That is inhumane. You don't do that to anybody.During an interview on 04/29/26 at 09:02 AM SC stated staff were responsible to ensure residents were not left sleeping overnight on a couch in view of the hallway wearing only a t-shirt and brief or just a t-shirt. She stated this could negatively impact the dignity of the resident. SC stated, She has a bed she needs to be in. She stated not assessing a resident for injury after a professed fall could be a form of neglect. SC stated sitting in wet or soiled briefs all night was a form of neglect and resident skin could breakdown.During an interview on 04/29/26 at 09:06 AM LVN K stated it was not okay for a resident to be left overnight sleeping on a couch in just a t-shirt and brief or just a t-shirt. He stated, For one, other patients can see them; invades their privacy and their dignity, self-esteem. We have to advocate for the patient. He stated all facility staff were responsible for ensuring this did not happen to a resident. He stated even if housekeeping walked by and noticed a resident in that position, they were responsible to let the nurse know. He stated not assessing a resident who said they fell could lead to pain, compartment syndrome, and death. LVN K stated the nurse on duty was responsible for assessing the resident.During an interview on 04/29/26 at 09:18 AM RN S stated it was not okay for a resident to be left sleeping on the couch in view of the hallway with just a t-shirt and brief or just a t-shirt for dignity and privacy reasons. She stated the nurse was ultimately responsible to ensure this did not happen to a resident. RN S stated the nurse on duty was responsible for assessing a resident who said they fell. She stated not assessing the resident could lead to the resident having an injury staff did not know about. She stated leaving residents in wet or soiled briefs was a form of neglect.During an interview on 04/29/26 at 09:24 AM LVN T stated it was not okay for a resident to be left sleeping on the couch in view of the hallway with just a t-shirt and brief or just a t-shirt. She stated, It is a dignity issue for one and plus they need to be able to sleep in their bed and g

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure freezer items were properly stored, labeled, and dated.2. The facility failed to ensure pantry foods were properly stored, labeled, and dated.3. The facility failed to ensure opened foods were discarded according to their policy. These failures could place residents who ate food served by the kitchen at risk of food-borne illness. Findings include:In an Observation of the walk- in freezer on 4/27/26 at 6:40 am revealed the following:1. (1) bag of rolls, no label or date not in original box. 2. (1) box of frozen beef patties, not sealed and open to air.3. (1) box of frozen burritos, not sealed and open to air.4. (1) box of frozen yeast rolls, not sealed and open to air. In an Observation of the walk-in pantry on 4/27/26 at 6:45 am revealed (1) plastic storage container of prepared frosting, labeled Frosting and dated 02-12. In an Observation on 4/28/26 at 9:20 am of the walk-in freezer revealed the following:1. (1) bag of rolls, no label or date not in original box. 2. (1) box of frozen beef patties, not sealed and open to air.3. (1) box of frozen burritos, not sealed and open to air.4. (1) box of frozen yeast rolls, not sealed and open to air. In an Observation of the walk-in pantry on 4/28/26 at 9:25 am revealed (1) plastic storage container of prepared frosting, labeled Frosting and dated 02-12. In an observation and interview on 4/28/26 at 1:50 pm of the walk-in freezer with the DM, revealed the plastic container of frosting dated 02-12 was still on the pantry shelf. The DM stated the facility policy stated to throw all opened or expired foods away after 3 days. She stated that the container lid had broken, and the frosting had been transferred to the plastic container. She stated she did not remember what date it was transferred but it had been a while. She stated the date of 02-12 was the date the food was received. The DM stated she was not sure if the frosting should have been thrown out or not. She stated she had discussed the frosting container with the food representative, and he had no insight for her as to how long the frosting would be good. In an interview on 4/28/26 at 1:55 pm, the DM stated of the opened food products in the freezer, she expected all staff to close food items up after use and she expected all food to be labeled and dated. She stated if foods were not properly wrapped up or labeled and dated this could cause food contamination and sickness to residents. She stated anything could fall into the opened food items. The DM stated she had been trained by the dietician in the duties of the kitchen. was responsible for training staff, and she would retrain them in all issues in the kitchen. Record Review of the facility policy and procedure, dated 2009, titled Safe Food Handling documented: Follow all local state and federal regulations when handling food. Refrigerated foods are properly covered, labeled and dated. All foods removed from the original packaging are stored in a closed container and labeled with the common name of the product and the date it was opened. Leftover foods are properly covered lobed and dated with a use by date. Foods are immediately put in the refrigerator or freezer, and leftovers are discarded after 3 days unless otherwise indicated. The day of preparation is considered Day 1. Follow USDA guidelines for food storage. Follow all state and federal regulations when handling food.

Based on observation, interview and record review, the facility failed to ensure that an assessment accurately reflected a resident's status for 1 (Resident #9) of 21 residents reviewed for accuracy of assessments. The facility failed to accurately assess Resident #9 for the use of a restraint on the MDS assessment. This failure could place residents at risk for inaccurate and incomplete MDS assessments, which could result in residents not receiving appropriate care and services. Findings included: Record review of Resident #9's face sheet, printed 04/28/26 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including, but not limited to, heart failure (a chronic condition in which the heart does not pump blood as well as it should), rheumatoid arthritis (an autoimmune condition causing inflammation of the joints), pain, muscle weakness, and muscle wasting and atrophy (breakdown of muscle tissue). Record review of Resident #9's most recent MDS, a quarterly assessment completed 02/23/26 revealed a BIMS score of 11, indicating moderate cognitive impairment. The assessment indicated the resident required substantial to maximal assistance with bed mobility. Section P0100 - Physical Restraints indicated that Resident #9 used bed rails daily. Record review of Resident #9's care plan, with a problem start date of 10/16/25 revealed the following:Resident was in need of side/rail assist bar r/t increased weakness. Approach: utilize side rail/assist bar. Record review of the clinical record for Resident #9 revealed an Order Summary Report with the following active order:Resident requires the use of a side/rail assist bar as an enabler for the benefit of transfers and/or repositioning. Start Date: 10/16/25. During an observation on 04/28/2026 at 8:36 AM, Resident #9 did not have any bedrails on her bed. During an interview on 04/28/2026 at 11:36 AM, the MDS RN stated she was the MDS Coordinator for the facility and used the RAI manual policy as guidance. She stated bed rails were not to be used for restricting movement and were not considered restraints. The MDS RN stated bed rails should not have been coded as a restraint on Resident #9's MDS assessment and the assessment would be corrected. She further stated inaccurate MDS coding could result in incorrect care planning and could impact reimbursement. During an interview on 4/29/26 at 9:30 AM, RN F stated bed rails were not to be used as restraints. She stated the facility did not use bed rails and if a resident required positioning assistance, physical therapy would evaluate as needed. RN F stated if the MDS coordinator coded bed rails as a restraint, it could be problematic. She stated the MDS coordinator was responsible for coding MDS assessments, and inaccuracies could impact resident care through incorrect care plans and affect reimbursement. During an interview on 04/29/26 at 9:27 AM, the DON stated the MDS coordinator was responsible for completing MDS assessments and that bed rails should not be coded as restraints. She stated the facility did not utilize bed rails, only assist bars. The DON stated inaccurate MDS assessments could be detrimental to the residents and could also impact reimbursement. During an observation and interview on 04/29/26 at 9:33 AM, Resident #9's bed revealed no bed rails. Resident #9 stated she had never had bed rails on her bed. During an interview on 04/29/26 at 9:35 AM, the ADM stated the MDS coordinator was responsible for completing MDS assessments. She stated bed rails were not used as restraints and should not be coded as such. The ADM stated inaccurate MDS assessments could impact reimbursement and resident care. Record review of the facility policy titled Nursing Policies and Procedures: Minimum Data Set (MDS), dated 09/28/23,revealed in part:Policy: An MDS, which is a comprehensive, accurate, standardized reproducible assessment will be completed for each resident, using the RAI process. Record review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.20.1, dated October 2025 revealed the following: SECTION P: RESTRAINTS AND ALARMSP0100. Physical RestraintsPhysical Restraints are many manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Enter Codes in BoxesUsed in Bed-A. Bed rail-B. Trunk restraint-C. Limb restraint-D. Other

Based on interview and record review the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and Adult Protective Services where state law provides jurisdiction) in accordance with State law through established procedures for 1 (Resident #9) of 21 residents reviewed for reporting of alleged violations. The facility failed to report to the State within 2 hours when Resident #9 was allegedly abused by a staff member. This failure could place residents at risk of ongoing abuse.Findings included: Record review of the intake investigation report for Intake ID#1084554 revealed the following:Incident date and time: 04/18/2026 at 12:35 PM Date facility first learned of Incident: 04/20/26 at 11:00 AM Record review of TULIP Intake Information for Case # 1084554, revealed the following:Case Type: IncidentDate received: 04/20/26 at 12:42 PM Narrative of Incident: Resident #9 alleged that CNA N slapped her while another CNA was assisting her with turning her in bed. Resident #9 reported that CNA N entered the room to and slapped her hip during care. Actions and Notifications:CNA N was suspended pending investigationSkin assessment completed with no injuries notedAbuse/neglect in-service provided Record review of Resident #9's face sheet, printed 04/28/26 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including, but not limited to, bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), history of opioid abuse, altered mental status, unspecified psychosis, depression (a mood disorder that causes a persistence feeling of sadness and loss of interest), heart failure (a chronic condition in which the heart dose not pump blood as well as it should), rheumatoid arthritis (autoimmune inflammation of the joints), pain, muscle weakness, and muscle wasting and atrophy (breakdown of muscles). Record review of Resident #9's most recent MDS, a quarterly assessment completed 02/23/26, revealed a BIMS score of 11, indicating moderate cognitive impairment. Resident #9 required substantial to maximal assistance with bed mobility, toileting, and transfers. Record review of Resident #9's care plan revealed:-Problem start date 4/20/26: Resident made false accusations regarding staff treatment.Approach: redirect resident when false accusations were made.- Problem start date 1/14/26: Behavioral symptoms related to history of opioid abuse.Approach: monitor for behavioral or physical indicators of substance abuse. Record review of Resident #9's active orders revealed: Use mechanical Lift for all transfers every shift, start date of 04/06/26. Record review of Resident #9's progress notes revealed:04/19/26 at 02:58 AM: Resident refused brief change in bed and requested sit-to-stand transfer despite Hoyer lift orders.04/19/26 at 02:59 AM: On call notified of disagreement at this time. During an interview on 04/27/26 at 5:49 AM, CNA O stated that she was present with CNA N the night of the incident and Resident #9 was irritated. CNA O stated that CNA N asked Resident #9 to roll during brief change and that Resident #9 became aggressive with CNA N. CNA O stated she went back into Resident #9's room later with another CNA to transfer her, Resident #9 stated, you saw CNA N hit me, right?. CNA O replied, no I did not. CNA O stated she did not witness a slap by CNA N to Resident #9. CNA O stated she reported the incident immediately to the charge nurse and she further stated Resident #9 tends to make a lot of false claims resulting in 2 CNA's always being present to do resident care with her. During an interview on 04/27/26 at 5:58 AM, Resident #9 stated that CNA N no longer worked with her due to the incident that was reported. During an interview on 04/29/26 at 8:09 AM, CNA N stated she was suspended pending investigation and returned to work on 04/22/26. She denied striking Resident #9 and stated she was unaware of the allegation until the investigation began. During an interview on 04/29/26 at 9:20 AM, ADON A stated she was on call the night of the incident but does not remember hearing about it. She stated the incident occurred on 04/19/26, while she was on call, and was reported to the State on 04/20/26, which was not timely. She stated delayed reporting could result in continued abuse and could give the appearance of failure to report.During an interview on 04/29/26 at 9:21 AM, the DON stated the ADM was responsible for reporting abuse allegations to the State. She confirmed the incident occurred on 04/19/26, ADON A was on call during that time, and it was not reported until 04/20/26. She stated the delay was not timely and could result in harm to the residents. The DON stated she felt the breakdown happened with on-call weekend staff. During an interview on 04/29/26 at 9:37 AM, the ADM stated she was responsible for ensuring reports to the state were made. She stated the incident was reported to the on-call nurse on 04/19/26 but was not reported to her until 04/20/26. She identified a breakdown in communication and stated delayed reporting could allow abuse to continue. Record review of facility provided policy titled Abuse, Neglect, Exploitation or Mistreatment revised March 2026, revealed the following in part.The facility's leadership prohibits neglect, mental, physical and/or verbal abuse and are reported immediately. 2. The facility shall report immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not result in serious bodily injury to the administrator of the facility and to other officials (including to the State Survey Agency in accordance with state law though established procedures. Record review of facility provided policy titled Resident Rights, from admissions handbook revision date of September 2020 revealed the following in part .#47. Protection from Abuse. The facility must develop and implement written policies and procedures and training that prohibit and prevent the mistreatment, neglect, and exploitation and abuse of residents. The facility must ensure that all alleged violations involving exploitation, mistreatment, neglect or abuse, are reported immediately. All alleged violations-immediately but not later than 1) 2 hours if the alleged violation involves abuse or results in serious bodily injury and 2) 24 hours if the alleged violation does not involve abuse and does not result in serious bodily injury, to the administrator of the facility and to other officials including state survey agency and adult protective services here state law provides for jurisdiction in long term care facilities) in accordance with state law through established procedures.

Based on interview and record review, the facility failed to ensure all residents had the right to formulate an advanced directive for 2 of 21 residents (Resident #15, Resident #103) reviewed for advanced directives. The facility failed to ensure the OOH-DNR for Resident #15 included a date by the physician signature. The facility failed to ensure the physician signed Resident #103's OOH-DNR in the required spaces. This failure could place residents at risk of not having an accurate advanced directive such as a DNR (Do Not Resuscitate), recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care and not receiving healthcare as per their or their legal representatives wishes.Findings Included: Resident #15 Record review of Resident #15's face sheet revealed an [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included but are not limited to unspecified dementia with other behavioral disturbance (cognitive decline with behaviors), intermittent explosive disorder (sudden episodes of unwarranted anger), psychotic disorder with delusions due to known physiological condition (hallucinations or delusions occur with a temporary or chronic condition), and major depressive disorder, recurrent severe without psychotic features (multiple episodes of depression that severely impair daily functioning without the presence of delusions or hallucinations). Record review of Resident #15's OOH-DNR ORDER, revealed physician signature under heading PHYSICIAN'S STATEMENT, with no date documented. Record review of Resident #15's quarterly MDS, dated [DATE], revealed a BIMS of 05. Record review of Resident #15's care plan, dated [DATE], with a problem start date of [DATE], revealed Resident #15 is care planned for Advanced Care Planning: Code Status DNR, with an approach of advance directives of Resident #15's choice completed and placed on medical record under advance directive tab or in documents in Matrix. Resident #103 Record review of Resident #103's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses include but are not limited to metabolic encephalopathy (diffuse brain function), emphysema (chronic lung condition causing shortness of breath), chronic obstructive pulmonary disease (progressive lung disease that makes it difficult to breathe), acute respiratory failure with hypoxia (lungs cannot adequately oxygenate the blood), chronic viral hepatitis C (inflammation of the liver), and unspecified dementia (decline in cognitive function). Record review of Resident #103's OOH-DNR Order, dated [DATE], under heading All persons who have signed above must sign below, acknowledging that this document has been properly completed, revealed no signature by space titled Attending physician's signature. Record review of Resident #103's care plan indicated an edited goal of Advance Care planning: Code Status DNR on [DATE]. In an interview on [DATE] at 8:44 AM, LVN H was provided with copies of Resident #15 and Resident #103's OOH-DNR. LVN H indicated that physician signature was missing from Resident 103's OOH-DNR and date was missing by physician's signature on Resident #15's OOH-DNR. LVN H stated that she would treat them as a full code. LVN H stated that a negative outcome of advance directives not being completed correctly would be it is not the resident's wishes. In an interview on [DATE] at 8:54 AM, LVN K was provided copies of Resident #15 and Resident #103's OOH-DNR. LVN K stated that Resident #15's OOH-DNR was incorrect because it was missing the date and Resident #103's OOH-DNR was missing the physician signature. LVN K stated that the documents were not complete or intact DNR's. LVN K stated a negative outcome was the resident would be a full code and could die. In an interview on [DATE] at 8:58 AM, SW V and SW P were provided with copies of Resident #15 and Resident #103's OOH-DNR. SW V stated that Resident #103's OOH-DNR was missing the doctor's signature and Resident #15's doctor did not date the form. SW V stated a negative outcome was the residents' wishes wouldn't be honored. SW P stated a negative outcome would be that the facility cannot honor the residents' wishes In an interview on [DATE] at 9:11 AM, the ADON B was provided copies of Resident #15 and Resident #103's OOH-DNR. ADON B stated that Resident #15' OOH-DNR form did not have a date for the doctor's signature and Resident #103's OOH-DNR form did not have a doctor's signature at the bottom of the form. ADON B stated the forms would be invalid DNR's. ADON B stated a negative outcome would be the resident would be a legal full code and the facility would have to take drastic measures to keep them alive and that is against their wishes. In an interview on [DATE] at 9:17 AM, the DON was provided copies of Resident #15 and Resident #103's OOH-DNR. The DON stated that the forms were not correct. The DON stated that Resident #103's OOH-DNR form only had one doctor signature and Resident #15's OOH-DNR form was missing a date. The DON stated that a negative outcome would be CPR would have to be done and it would go against their wishes. In an interview on [DATE] at 9:21 AM, the ADM was provided copies of Resident #15 and Resident #103's OOH-DNR. The ADM stated that the forms were not correct. The ADM stated the OOH-DNR forms are missing a date and the doctor is missing signature. The ADM stated that a negative outcome would be patient could either be coded or not coded and their wishes would not be followed up. Record review of policy titled Social Services Policies and Procedures Subject: Advance Directives, revised on [DATE], did not address completion of a valid OOH-DNR form. Additional policies were requested but never provided. Record review of Instructions for Issuing an OOH-DNR Order, revised [DATE], states under section D- If the person is incompetent and his/her attending physician has seen evidence of the person's previously issued proper directive to physicians or observed the person competently issue an OOH-DNR Order in a nonwritten manner, the physician may execute the Order on behalf of the person by signing and dating it in Section D. Under heading In addition, it stated the original or a copy of a fully and properly completed OOH-DNR order of the presence of an OOH-DNR device on a person is sufficient evidence of the existence of the original OOH-DNR Order and either one shall be honored by responding health care professionals.

Based on observation, interview, and record review the facility failed to based on the comprehensive assessment of a resident, ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #22) of 21 residents reviewed for quality of care.The facility failed to follow their fall management policy and assess Resident #22 after she reported falling on the night of 04/19/26.The facility failed to follow their on-call policy and provide support and staffing for the provision of quality resident care on the night of 04/19/26.These failures could place residents at risk of harm due to untreated/unrecognized injuries.Findings Included:Record review of Resident #22's admission record dated 04/27/26 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified lack of coordination, altered mental status, muscle weakness, difficulty in walking, and muscle wasting and atrophy.Record review of Resident #22's quarterly MDS completed on 01/29/26 revealed a BIMS of 9 which indicated moderately impaired cognition. Section GG Functional Abilities revealed she used a manual wheelchair and was dependent for chair/bed-to-chair transfers. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity.Record review of Resident #22's care plan last reviewed/revised on 04/21/2026 revealed she had a history of falling. An intervention to address this issue was to place her in her bed or recliner while she was in her room and not to leave her in her wheelchair. Another intervention was to observe her frequently and place her in a supervised area when out of bed.Record review of Resident #22's orders dated 04/27/26 revealed the following orders and order start dates: 05/24/24 1-2 person assist for ambulation 05/24/24 1-2 person assist for transfer05/24/24 1-2 person assist for toileting dated 05/24/24.05/24/24 at risk for falls02/26/26 1-2 person assist for bed mobilityRecord review of Resident #22's progress notes revealed the following notes:A note by LVN H on 04/20/26 at 09:39 AM This nurse and another nurse entered resident's room at approx 0615 (06:15 AM) and discovered resident laying on right side on the floor beside bed. Blanket was underneath resident and pillow was under left leg. This nurse asked resident what happened? Resident stated 'I guess I fell out of bed' Resident c/o pain to left hip and knee. Assessed for other injuries. Vital signs taken. None noted. Notified on call and administrator. Resident sent to [hospital initials] hospital for eval and treat due to guarding of left hip.A note by LVN H on 04/20/26 at 12:31 PM Returned from hospital via facility transport at approx 1200 (12:00 PM). In wheelchair with no new orders. Hip contusion. Smiling and conversating with no new c/o pain or discomfort at this time.During an interview on 04/27/26 at 04:37 AM LVN C stated she was working on 100 hall on the night of 04/19/26 when LVN D, who was working on 400 hall (Resident #22's hall), asked her for assistance. LVN C stated she walked with LVN D to Resident #22's suite and was in the entry way to the suite when she heard Resident #22 saying, Help. LVN C stated she entered Resident #22's room and Resident #22 was on her bed with her head at the foot board and her feet at the headboard with no blanket on. She stated Resident #22 told her she did not want to talk to LVN D. LVN C stated resident #22 said her leg and knee hurt and they did not start hurting until she fell. LVN C stated at this point LVN D interjected and said Resident #22 did not fall and she did not know why Resident #22 kept saying that. LVN C stated Resident #22 shut down and would not talk for a bit after she heard LVN D's voice. LVN C stated she asked Resident #22 if she could assess her knee and Resident #22 said no. LVN C stated she put a pillow between Resident #22's legs, covered her with a blanket, and returned to hall 100. She stated this happened at approximately 04:30 AM. She stated she then called ADON A on the facility on-call phone and told her she had concerns for the residents on hall 400 to include Resident #15 lying in a soaked brief on the couch and Resident #22 reporting a fall and seeming to be intimidated by LVN D. She stated ADON A said she would let ADM know in the morning and she could not move any of the CNAs off of the other halls to help on 400 hall because ADM wanted them on their own halls.During an interview on 04/27/26 at 05:57 AM RN F stated she came to work the morning of 04/20/26 and LVN C asked her to check on the residents on hall 400. RN F stated she joined LVN H on hall 400 and the two of them found Resident #22 on the floor of her room next to her bed with her head toward the footboard and her feet toward the headboard. She stated Resident #22 was complaining of pain in her left leg and was displaying guarding behavior with her left leg, so she was sent to the hospital for further evaluation.During an interview on 04/27/26 at 06:05 AM ADM stated LVN C called on-call phone and spoke to ADON A. She stated LVN C called the company's complaint hotline and reported her concerns on the hotline as well. ADM stated ADON A did not perceive what LVN C told her as abuse or neglect or she (ADON A) would have called me (ADM).During an interview on 04/27/26 at 06:33 AM LVN C stated she told ADON A about Resident #22 saying her knee was not hurting until she fell and LVN D saying to Resident #22, You didn't fall.During an interview on 04/27/26 at 07:11 AM LVN D stated 04/19/26 was her first time to work in the facility. She stated she was shocked when she picked up the night shift to find she was responsible for total care for 6 residents and did not have a CNA to help her. She stated she received report and learned, in part, that Resident #15 would sometimes refuse care and/or medication. She stated she had a back injury that made it impossible for her transfer residents alone. LVN D said of the residents on hall 400, Everybody was confused, dead weight, couldn't stand by themselves. She stated Resident #22 had stayed in her wheelchair a good portion of the evening because she said she could not stand or support herself. She stated she had LVN C help her reposition Resident #22 because she had her head at the foot of the bed and her feet at the head of the bed. She stated Resident #22 did not want to be repositioned. LVN D stated she never found Resident #22 on the floor. She stated, Nobody said anything to me about a fall.During an interview on 04/27/26 at 07:41 AM LVN D stated Resident #22 told her she wanted to go to bed and LVN D told her she (LVN D) was not able to put her to bed alone and would try to find someone to help. LVN D stated she went down halls and could not find CNAs to help her. She stated she found one CNA who told her she would be there shortly to help but did not show up. LVN D stated, If your life is in jeopardy, I am the one you want there. If you need to be lifted up out of a wheelchair and transferred to the bed and I am the only one there I can't do it. She stated Resident #22 must have put herself on her bed upside down.During an interview on 04/27/26 at 09:08 AM ADON A stated LVN C called her on the morning of 04/20/26 to say she had concerns about the residents on hall 400. ADON A stated LVN C told her she saw a resident in a soaked brief but did not say anything else. She stated LVN C did not tell her anything about a resident who was in pain and said she fell. ADON A stated she sent a text to the two other nurses in the facility (LVN I and LVN J) asking them to send one of their CNAs to help LVN D. She stated she did not follow up to see if that was done or further check on the residents on hall 400.During an interview on 04/27/26 at 09:47 AM LVN H stated when she came to work on the morning of 04/20/26 LVN D did not give report, just said, Good luck and left the facility. She stated she and RN F found Resident #22 on the floor of her room and sent her to the hospital because she was complaining of pain in her left hip and knee.During an observation and interview on 04/27/26 at 10:07 AM Resident #22 was seated in her wheelchair in her room. She stated she remembered the night LVN D worked and would not help her into bed. She stated, She (LVN D) was just hateful. I don't think she was really interested in doing anything. I was very stressed out that night because she had such an attitude. Resident #22 stated she fell out of her bed that night onto the fall mat next to her bed. She did not remember a fall prior to that one.During an interview on 04/27/26 at 10:33 AM LVN I stated she did not have any texts from the on-call phone on the night shift of 04/19/26. She stated she looked through her text messages and did not find any texts from ADON A on the night shift of 04/19/26. She stated ADON A did not text and ask her to have her CNAs assist on 400 hall.During an interview on 04/27/26 at 11:51 AM ADM stated if a resident reported a fall it was treated as an unwitnessed fall and the protocol was to file an incident report. She showed this surveyor a copy of a blank incident report that was to be filed.During an interview and observation on 04/27/26 at 11:57 AM ADM showed this surveyor the on-call phone with text messages between ADON A and LVN I and LVN J. ADON A asked the two LVNs in a text to have their CNAs check on the residents on hall 400 if they had a chance.During an observation and interview on 04/27/26 at 12:00 PM ADM, MS, and this surveyor entered a closet in the facility to watch recorded camera footage of LVN D on hall 400 the night of 04/19/26. According to camera footage, LVN D did not enter a resident room until after 10 PM on the night of 04/19/26. ADM stated it was nice to know you pay so much money for agency staff to sit around on their phones. LVN D did enter resident rooms after 10:00 PM but did not remain in any of the rooms for more than 2 minutes except for the instance she and LVN C entered the suite of Resident #15 and Resident #22. The two LVNs remained in the suite for 3 minutes at approximately 4:30 AM on 04/20/26.During an interview on 04/29/26 at 09:02 AM SC stated if a resident fell or told her they fell she would tell the nurse. She stated if the resident was not assessed by the nurse, They could have been hurt when they fell, and we didn't to an assessment to check to see. Would be a form of neglect.During an interview on 04/29/26 at 09:06 AM LVN K stated the nurse was responsible for doing an assessment on a resident who said they fell. He stated not assessing the resident and following fall protocol could mean a missed fracture which could lead to compartment syndrome (pressure build up inside a group of muscles cutting off blood flow and causing severe pain and potential tissue damage) and even death.During an interview on 04/29/26 at 09:18 AM RN S stated the nurse was responsible for assessing a resident if the resident reported a fall. She stated if a resident was not assessed and hit their head it could negatively impact the resident.During an interview on 04/29/26 at 09:24 AM LVN T stated if a resident said they fell it was to be treated as an unwitnessed fall and assessment and neurological checks were to be done by the nurse to ensure the resident did not have any injuries or a brain bleed.During an interview on 04/29/26 at 09:30 AM ADON A stated she expected staff to assess residents who reported falling. She stated if a resident obtained an injury in the fall and was not assessed it could lead to death. ADON A stated when an allegation of neglect was made the staff member accused was suspended pending an investigation which was started immediately. She stated not starting an investigation immediately and notifying ADM could result in continued neglect and injury to residents. ADON A stated when LVN C called the on-call phone on the night shift of 04/19/26 she did not ask LVN C any follow up questions about her concerns for the residents on hall 400.During an interview on 04/29/26 at 09:38 AM ADON B stated staff were to assess a resident who reported a fall, complete required paperwork, and report the fall to the nurse on call. He stated a possible negative outcome of not assessing a resident who reported a fall was the resident might be injured and staff would not know about the injury.During an interview on 04/29/26 at 09:44 AM DON stated she expected her staff to immediately assess a resident who reported a fall. She stated, We have to take them (residents) at their word. DON stated a possible negative outcome of staff not following facility fall protocol and assessing residents who reported a fall was injuries would go unnoticed.During an interview on 04/29/26 at 10:23 AM ADM stated she expected staff to follow the facility's fall protocol when a resident reported a fall. She stated a resident could have an undetected injury if fall protocol was not followed.Record review of a screen shot from LVN C of the call she made to the on-call phone on 04/20/26 to express her concern for the residents on hall 400 revealed the call was made at 04:35 AM and lasted 1 minute.Record review of text messages between on call phone, LVN I, and LVN J revealed a text sent to LVN I and LVN J at 04:45 AM on 04/20/26 from the on-call phone asking them to send their CNAs to hall 400 if they had time. LVN J texted on call phone at 04:54 AM on 04/20/26 and stated LVN D's call lights had been going off over an hour at a time the whole night.Record review of facility admission packet page titled Texas Department of Aging and Disability Services revealed the following: You, the resident do not give up any rights when you enter a nursing facility. You have a right to: 1. all care necessary for you to have the highest possible level of health .Record review of the facility admission packet pages 14-21 titled Resident Rights revealed the following: .46. Freedom from Abuse, Neglect and Exploitation. The resident has the right to be free from . neglect . 48. Quality of Life. Each resident must receive, and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. You have a right to: 1. all care necessary for you to have the highest possible level of health; .Record review of facility policy titled Patient/Resident Rights and dated 10/01/20 revealed the following: .The Facility provides care for each resident in a manner that promotes, maintains, or enhances quality of life .Record review of facility policy titled Abuse, Neglect, Exploitation, or Mistreatment and dated 11/01/17 revealed the following: . 1. The facility's Leadership prohibits neglect . 6. The facilities Leadership will implement appropriate and necessary guidelines, which prohibit the mistreatment or neglect of the patient/resident. 6. Neglect is the failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. 4 Adequate supervision of staff is maintained to identify and prevent inappropriate behaviors, such as: . C. Ignoring the patient's/residents needs requests, etc. 2. Neglect is the failure to provide goods and services or treatment and care necessary to avoid physical harm, mental anguish . We are committed to ensuring our patients/residents are free from neglect .Record review of facility policy titled Fall Management and dated 05/05/23 revealed the following: . 5. Qualified staff evaluates patient/resident for injury from a fall, identify and treat for pain related to fall, and determine contributing causes, including ascertaining what the resident was trying to do before he or she fell, addresses the risk factors for the fall such as the resident's medical condition(s), facility environment issues, or staffing issue; and determines interventions to prevent future falls and completes a Fall Investigation Worksheet. 7. Neurological evaluations will be preformed for a resident who sustains an unwitnessed fall, regardless of the resident's cognitive status at the time of the incident. 8. The physician and family are promptly notified, and an incident report is completed.Record review of facility policy titled On-Call Policy and dated March 2026 revealed the following: Purpose: To ensure proper support and staffing for the provision of quality resident/patient care.Record review of blank facility form titled Accident/Incidents/Falls Checklist revealed the following items: . INCIDENT DATE WITNESSED OR UNWITNESSED.PROGRESS NOTE.NEUROLOGICAL EVALUATION.FOCUSED PAIN ASSESSMENT.

Based on interview and record review, the facility failed to ensure that the resident environment remained as free from accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #83) of 21 residents reviewed for accident hazards.The facility failed to ensure Resident #83 did not fall from the Hoyer lift on 01/10/2026.This failure could place residents at risk for serious physical injury, including fractures, head trauma, or internal bleeding resulting from falls. Findings Included:Record review of Resident #83's admission record dated 04/27/2026 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, multiple sclerosis (is an autoimmune disease that affects the central nervous system, leading to damage of the myelin sheath that protects nerve fibers, resulting in a range of physical and cognitive symptoms), type 2 diabetes mellitus without complications, essential (primary) hypertension (high blood pressure), neuromuscular dysfunction of bladder (occurs when nerve or brain problems disrupt the normal control of bladder muscles, leading to difficulty storing or emptying urine), personal history of urinary (tract) infections, dysphagia (difficulty swallowing), hypokalemia (low potassium), insomnia, pain, hyperlipidemia (high cholesterol), nausea with vomiting, cognitive communication deficit, other reduced mobility, constipation, difficulty in walking, muscle wasting and atrophy, muscle weakness, unspecified lack of coordination, hypothyroidism (low thyroid levels which slows down metabolism), immobility syndrome (paraplegic) (a person who experiences paralysis in the lower half of their body, usually due to spinal cord injury or neurological conditions)Record review of Resident #83's quarterly MDS completed on 04/10/2026 revealed a BIMS score of 14 which indicated no cognitive impairment. Section GG Functional Abilities revealed she had impairment on both sides to both upper and lower extremities and utilized a wheelchair. She was noted to require substantial/maximal assistance with eating and oral hygiene. She was noted to be dependent for toileting hygiene, shower/bathe self, upper and lower body dressing, putting on and taking off footwear, and personal hygiene.Record review of Resident #83's progress notes revealed the following:on 01/10/26 she had a witnessed fall without injuries while being transferred with the Hoyer (a mechanical device designed to safely transfer individuals with limited mobility from one surface to another, reducing physical strain on caregivers and minimizing the risk of injury) lift by staff.Record review of her care plan showed an update for fall on 01/14/2026 and she was care planned for usage of a Hoyer lift dated 10/17/2025. Record review of Resident #83's orders revealed an order dated 10/17/2025 May use Hoyer lift for transfers.During an interview with Resident #83 on 04/27/2026 at 8:37 AM Resident stated that she fell from a Hoyer lift while being transferred by staff back to bed. She stated when staff went to lift her in the sling a strap on the sling came off of the lift causing her to slide out of the sling and onto the ground. Resident stated she did not sustain any injuries but now double checks the straps on the sling before staff lifted her up.During an interview 04/28/2026 at 1:42 PM DON stated she recalled the incident involving Resident #83 falling from the mechanical lift on 01/10/26. She said CNA Q and CNA R were putting the resident back to bed when the strap of the sling slipped off of the lift and the resident fell to the ground. She also stated the resident was assessed but not injured. DON stated in-services were completed on transfer techniques and fall precautions. During an interview 04/28/2026 at 1:45 PM CNA Q stated that him and another CNA (he didn't remember her name) were transferring the resident from her chair to her bed and the sling on the other CNAs side came off on the back, but he was unsure as to how it happened. CNA Q stated Resident #83 slid out of the sling onto the floor but was not injured. He stated he reported it to the nurse on duty (does not remember who it was at the time) and that the nurse assessed the resident and called the resident's family member. CNA Q stated he thinks they do training with the Hoyer lift every other month but is unsure. He stated a resident could be seriously injured if staff were not trained on proper use of the Hoyer lift and did not ensure the hooks were properly secured.During an interview on 04/28/2026 at 1:56 PM DON stated Physical Therapy (PT) oversees Hoyer lift trainings.During an interview on 04/28/2026 at 2:17 PM DON stated she misunderstood and thought PT did the training on Hoyer lifts but stated that they do not and that it was her job and no education was completed. During an interview on 04/29/2026 at 8:30AM CNA R stated she had worked for the facility for 2 years. CNA R stated that her and CNA Q were attempting to put the resident back to bed using the Hoyer lift when they lifted her up in the sling the strap came off of the front side and the resident slid out of the sling and fell onto the floor. She was unsure how the strap came off. She stated she notified the nurse, and the nurse assessed Resident #83 and called Resident #83's family member. No injuries were noted. CNA R stated she did not receive training on how to use the Hoyer lift before or after the incident and a negative outcome was the resident could get seriously hurt. During an interview on 04/29/2026 at 8:40 AM DON stated a negative outcome of staff not being properly trained on how to use a Hoyer lift was it could affect patient safety and both staff and residents could get injured. When asked if any Hoyer lift training was done on hire, DON stateed CNAs were instructed during orientation to always use 2 people and never do it alone. During an interview on 04/29/2026 at 8:43 AM Mechanical Lift and Accident and Hazards Policies and Procedures were requested.During an interview on 04/29/2026 at 8:45 AM ADON B stated he recalled an incident with Resident #83 on 01/10/2026 where she fell out of the Hoyer lift sling. He stated he notified of the incident. When asked if in-services were completed, he stated he thinks a verbal one was done but is unsure. He stated quarterly staff competency trainings included how to use a Hoyer lift. He stated the DON would have proof of staff competencies. He stated a negative outcome of not training staff on using Hoyer lifts was injury to patient or staff. During an interview on 04/29/2026 at 8:46 AM with DON Surveyor requested employee competencies for use of Hoyer lift, and DON stated she does not have them because she just started it last night. During an interview on 04/29/2026 at 8:52 AM ADON A stated she had been working for the facility for almost 2 years. ADON A stated a negative outcome of not training staff on how to use a Hoyer lift was it was a safety issue and could result in injury to residents. During an interview 04/29/2026 at 8:55 AM ADON B stated that he was incorrect about Hoyer lift training, and it is supposed to be completed by the DON, and she was unaware she was supposed to be doing it. A record review of in-services for January shows an in-service on transfer techniques dated 01/02/2026 and fall precautions dated 01/22/2026. Upon further review nothing was noted to have mechanical lifts or use of Hoyer lifts in training. Record review of document entitled Staff Education/Orientation Policies and Procedures for Assisting Resident from Bed to Chair dated 01/12/2024 does not mention transferring with a Hoyer lift.No other policies given during investigation.

Based on observations, interviews, and record reviews the facility failed to ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 1 (Resident #83) of 21 residents reviewed for staff competency.The facility failed to train nurse aides on use of Hoyer lifts.This failure could place residents at risk of injury or harm.Findings Included:Record review of Resident #83's admission record dated 04/27/2026 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, multiple sclerosis (is an autoimmune disease that affects the central nervous system, leading to damage of the myelin sheath that protects nerve fibers, resulting in a range of physical and cognitive symptoms), type 2 diabetes mellitus without complications, essential (primary) hypertension (high blood pressure), neuromuscular dysfunction of bladder (occurs when nerve or brain problems disrupt the normal control of bladder muscles, leading to difficulty storing or emptying urine), personal history of urinary (tract) infections, dysphagia (difficulty swallowing), hypokalemia (low potassium), insomnia, pain, hyperlipidemia (high cholesterol), nausea with vomiting, cognitive communication deficit, other reduced mobility, constipation, difficulty in walking, muscle wasting and atrophy, muscle weakness, unspecified lack of coordination, hypothyroidism (low thyroid levels which slows down metabolism), immobility syndrome (paraplegic) (a person who experiences paralysis in the lower half of their body, usually due to spinal cord injury or neurological conditions)Record review of Resident #83's quarterly MDS completed on 04/10/2026 revealed a BIMS score of 14 which indicated no cognitive impairment. Section GG Functional Abilities revealed she had impairment on both sides to both upper and lower extremities and utilized a wheelchair. She was noted to require substantial/maximal assistance with eating and oral hygiene. She was noted to be dependent for toileting hygiene, shower/bathe self, upper and lower body dressing, putting on and taking off footwear, and personal hygiene.Record review of Resident #83's progress notes revealed the following:on 01/10/26 she had a witnessed fall without injuries while being transferred with the Hoyer (a mechanical device designed to safely transfer individuals with limited mobility from one surface to another, reducing physical strain on caregivers and minimizing the risk of injury) lift by staff.Record review of her care plan showed an update for fall on 01/14/2026 and she was care planned for usage of a Hoyer lift dated 10/17/2025. Record review of Resident #83's orders revealed an order dated 10/17/2025 May use Hoyer lift for transfers.During an interview with Resident #83 on 04/27/2026 at 8:37 AM Resident stated that she fell from a Hoyer lift while being transferred by staff back to bed. She stated when staff went to lift her in the sling a strap on the sling came off of the lift causing her to slide out of the sling and onto the ground. Resident stated she did not sustain any injuries but now double checks the straps on the sling before staff lifted her up.During an interview 04/28/2026 at 1:42 PM DON stated she recalled the incident involving Resident #83 falling from the mechanical lift on 01/10/26. She said CNA Q and CNA R were putting the resident back to bed when the strap of the sling slipped off of the lift and the resident fell to the ground. She also stated the resident was assessed but not injured. DON stated in-services were completed on transfer techniques and fall precautions. During an interview 04/28/2026 at 1:45 PM CNA Q stated that him and another CNA (he didn't remember her name) were transferring the resident from her chair to her bed and the sling on the other CNAs side came off on the back, but he was unsure as to how it happened. CNA Q stated Resident #83 slid out of the sling onto the floor but was not injured. He stated he reported it to the nurse on duty (does not remember who it was at the time) and that the nurse assessed the resident and called the resident's family member. CNA Q stated he thinks they do training with the Hoyer lift every other month but is unsure. He stated a resident could be seriously injured if staff were not trained on proper use of the Hoyer lift and did not ensure the hooks were properly secured.During an interview on 04/28/2026 at 1:56 PM DON stated Physical Therapy (PT) oversees Hoyer lift trainings.During an interview on 04/28/2026 at 2:17 PM DON stated she misunderstood and thought PT did the training on Hoyer lifts but stated that they do not and that it was her job and no education was completed. During an interview on 04/29/2026 at 8:30AM CNA R stated she had worked for the facility for 2 years. CNA R stated that her and CNA Q were attempting to put the resident back to bed using the Hoyer lift when they lifted her up in the sling the strap came off of the front side and the resident slid out of the sling and fell onto the floor. She was unsure how the strap came off. She stated she notified the nurse, and the nurse assessed Resident #83 and called Resident #83's family member. No injuries were noted. CNA R stated she did not receive training on how to use the Hoyer lift before or after the incident and a negative outcome was the resident could get seriously hurt. During an interview on 04/29/2026 at 8:40 AM DON stated a negative outcome of staff not being properly trained on how to use a Hoyer lift was it could affect patient safety and both staff and residents could get injured. When asked if any Hoyer lift training was done on hire, DON stateed CNAs were instructed during orientation to always use 2 people and never do it alone. During an interview on 04/29/2026 at 8:43 AM Mechanical Lift and Accident and Hazards Policies and Procedures were requested.During an interview on 04/29/2026 at 8:45 AM ADON B stated he recalled an incident with Resident #83 on 01/10/2026 where she fell out of the Hoyer lift sling. He stated he notified of the incident. When asked if in-services were completed, he stated he thinks a verbal one was done but is unsure. He stated quarterly staff competency trainings included how to use a Hoyer lift. He stated the DON would have proof of staff competencies. He stated a negative outcome of not training staff on using Hoyer lifts was injury to patient or staff. During an interview on 04/29/2026 at 8:46 AM with DON Surveyor requested employee competencies for use of Hoyer lift, and DON stated she does not have them because she just started it last night. During an interview on 04/29/2026 at 8:52 AM ADON A stated she had been working for the facility for almost 2 years. ADON A stated a negative outcome of not training staff on how to use a Hoyer lift was it was a safety issue and could result in injury to residents. During an interview 04/29/2026 at 8:55 AM ADON B stated that he was incorrect about Hoyer lift training, and it is supposed to be completed by the DON, and she was unaware she was supposed to be doing it. A record review of in-services for January shows an in-service on transfer techniques dated 01/02/2026 and fall precautions dated 01/22/2026. Upon further review nothing was noted to have mechanical lifts or use of Hoyer lifts in training. Record review of document entitled Staff Education/Orientation Policies and Procedures for Assisting Resident from Bed to Chair dated 01/12/2024 does not mention transferring with a Hoyer lift.No other policies given during investigation.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #68) of 5 residents reviewed for infection control. -RN F did not follow EBP precautions when administering medications via Resident #68's PEG tube. This failure could place residents at risk for the spread of infections, tissue breakdown, and feelings of isolation related to poor hygiene.Findings include: Record review of Resident #68's admission record dated 04/28/2026 revealed a [AGE] year-old female admitted to the facility originally on 07/01/2025 and readmitted on [DATE] with diagnoses to included cerebral palsy (a group of permanent neurological disorders affecting movement, muscle tone, and posture caused by abnormal brain development or damaged before, during, or shortly after birth), malnutrition (lack of proper nutrition), muscle wasting (the loss of muscle mass and strength due to disease, injury, or lack of use), and gastrostomy (an opening into the stomach from the abdominal wall).Record review of Resident #68's clinical record revealed her last MDS was a quarterly completed 03/09/2026 listing her with a BIMS score of 00 indicating she was severely cognitively impaired, she had a functionality of being dependent on staff for her activities of daily, and she was listed as having a feeding tube. Record review of Resident #68's physician's orders printed 04/28/2026 revealed the following order: EBP Precautions for PEG Tube and Ostomy (a surgically created opening) (x2) once a day. Start dated: 03/03/2026. Record review of Resident #68's care plan with admission date of 07/01/2025 revealed the following: Problem:Problem Start Date: 11/07/2025. Resident is on Enhanced Barrier Precautions(EBP) related to PEG Tube/ ostomy x2. During an observation on 04/28/2026 at 8:09 AM RN F was observed administering 7 medications through Resident #68's PEG tube to include checking placement of the PEG tube by aspirating (the process of drawing in or out using a suction motion) a small amount of stomach contents and pre and post flushing of the PEG tube with water. RN F took a gown into the room, placed the gown on the back of Resident #68's wheelchair but did not put the gown on when providing care for the PEG tube. During an interview on 04/28/2026 at 8:33 AM RN F reported she was placed on light duty due to a recent surgery and was responsible for checking the facility for infection control to include the correct precautions were in place such as the EBP. RN F reported Resident #68 was on EBP for her feeding tube and she brought a gown in the room for the EBP precautions but forgot to put it on. RN F reported that since she did not follow the EBP she could have brought something into the resident or she could have carried something out to another resident. During an interview on 04/29/2026 at 8:19 AM the DON reported that when a resident was on EBP, staff should wear gloves and a gown when in the room providing direct care. The DON reported that any resident with a device such as a catheter, IV, feeding tube, dialysis, or a wound would require EBP. The DON reported if a staff member does not implement EBP correctly then they could contaminate themselves, the resident, or they could take whatever is in the room to other people. During an interview on 04/29/2026 8:47 AM ADON A reported she was the current ICP for the facility. ADON A reported for EBP all staff should wear a gown and gloves when providing care to a resident with a hole in their body that does not belong such as an IV, PEG tube, Tracheostomy (a surgically created opening), Foley, or wound. ADON A reported that a staff member that does not follow the EBP correctly can introduce infection to the residents or they can carry an infection to another resident. Record review of the facility training provided 04/23/2026 by the DON revealed the following: Inservice Title: Enhanced Barrier Precautions (EBP).Enhanced Barrier Precautions (EBP) are to be used for any high contact Resident Care. Gloves and gowns are to be donned prior to care being provided.The following patients/Residents are considered high contact-Peg Tubes-signed by RN F Record review of the facility provided policy titled Infection Prevention and Control Policy and Procedures revised 05/15/2023, revealed the following:- Subject: Transmission Based Precaution, and Enhanced Barrier Precautions.5. Health care workers will implement enhance barrier precautions according to policy.Precautions:B. EBP will be implemented during the following high-contact resident care activities.7) Device care or use: .feeding tube.C. EBP required the following:2) Gown.

Based on observation, interview, and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 (Resident #15) of 21 residents reviewed for resident rights.The facility failed to ensure Resident #15 was not sleeping on a couch in view of the hallway in a t-shirt and brief and later in just the t-shirt the night of 04/19/2026.This failure could place residents at risk of lack of personal privacy and dignity.Findings Included:Record review of Resident #15's admission record dated 04/27/26 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified dementia with other behavioral disturbance (breakdown of thought process causing disruptive behavior), cognitive communication deficit (difficulty with one or more of the following: attention, memory, perception, language, problem-solving, and reasoning), muscle wasting and atrophy, muscle weakness, difficulty in walking, insomnia (problems falling and staying asleep), unsteadiness on feet, and frequency of micturition (needing to urinate more often than once every 3-4 hours).Record review of Resident #15's quarterly MDS completed on 03/17/26 revealed a BIMS of 5 which indicated severely impaired cognition. Section GG Functional Abilities revealed Resident #15 used a wheelchair and was dependent for toileting. She required substantial/maximal assistance defined as Helper dose MORE THAN HALF the effort. Helper lifts or holds truck or limbs and provides more than half the effort for transferring from chair/bed-to-chair.Record review of Resident #15's care plan last reviewed/revised on 04/01/26 revealed Resident #15 was a wanderer and at increased risk of falling. One of the interventions was [Resident #15]'s physical needs will be met; . toileting. She was to use a fall mat next to her bed as well as a scoop mattress and be monitored at least every 2 hours while in bed. Resident #15 was noted to be receiving hospice care and one of the interventions was [Resident #15] will be kept clean and comfortable. She was noted to require extensive assistance with toileting and transfers by one staff member. The goal was [Resident #15 will maintain a sense of dignity by being clean, dry, . One of the interventions included, Monitor appearance. Resident #15 was at risk for incontinence. Staff were to, Provide incontinent care after each episode of incontinence. She was at risk for skin breakdown due to incontinence. Staff were to, Keep clean and dray as possible. Minimize skin exposure to moisture. Staff were also to Provide toileting assistance every 2 hours and prn.Record review of Resident #15's active orders dated 04/27/26 revealed the following orders with corresponding start dates:11/19/25 Brief Check and document wet or dry every 3 hours02/26/26 BED MOBILITY with assist of 1-202/26/26 TRANSFER with assist of 1-2During an interview on 04/27/26 at 04:37 AM LVN C stated she was working on 100 hall on the night of 04/19/26 when LVN D, who was working on 400 hall (Resident #22's hall), asked her for assistance. LVN C stated she walked with LVN D to Resident #22's suite and noted Resident #15 asleep on the couch in view of the hall wearing only a t-shirt and a soaked brief. LVN C stated she told LVN D, This is not cool. She stated LVN D told her, Wherever she (Resident #15) wants sleep; she's gonna sleep. LVN C stated LVN D told her she did not have time to baby talk the residents. LVN C stated she assisted LVN D with another resident in the suite, returned to her hall, and called the on-call phone to let ADON A know she was worried about the residents on hall 400. She stated she told ADON A about Resident #15 lying on the couch wearing only a soaked brief and T-shirt.During an interview and observation on 04/27/26 at 05:07 AM LVN C was asked what time she called ADON A. LVN C sent a text screen shot showing the time of her call to ADON A on the on-call phone was 04:35 AM on 04/20/26.During an interview on 04/27/26 at 05:47 AM LVN E stated leaving residents in wet and soiled briefs was an example of neglect.During an observation on 04/27/26 at 05:52 AM Resident #15 was lying in her bed on her right side with her eyes closed. Her bed was in the lowest position, and a fall mat was on the floor next to her bed.During an interview on 04/27/26 at 05:57 AM RN F stated she came to work on the morning of 04/20/26 and LVN C asked her to check on the residents on hall 400. RN F stated she joined LVN H on hall 400 and the two of them found Resident #15 asleep on the couch in the entryway to her suite in view of the hall wearing only a t-shirt with a soaked brief on the floor next to the couch RN F stated the couch was soaked with urine around Resident #15. She stated, I called ADM and let her know my serious concerns. I don't like to throw the word neglect around, but I could say I have serious concerns about the care on that hall overnight or the lack of care on that hall overnight.During an interview on 04/27/26 at 06:05 AM ADM stated she interviewed LVN D and was told Resident #15 said the couch was her bed and refused to get off of the couch. She stated LVN D told her she (LVN D) was overwhelmed and struggled through the night but did the best she could.During an interview on 04/27/26 at 07:11 AM LVN D stated 04/19/26 was her first time working in the facility. She stated she was shocked when she picked up the night shift to find she was responsible for total care for 6 residents and did not have a CNA to help her. She stated she had a back injury that made it impossible for her transfer residents alone. LVN D said of the residents on hall 400, Everybody was confused, dead weight, couldn't stand by themselves. She stated one resident was on a sofa and had taken her brief off. She refused to get up and go to bed and told me she was in her bed. Apparently, she had taken her brief off and dropped it on the floor. LVN D stated she was capable of assisting with brief changes but I can't solo due to her back injury. She stated of Resident #15, She had taken her brief off and denied care. I had been warned she might refuse care and not take her medications.During an interview on 04/27/26 at 07:41 AM LVN D stated, If you need to be lifted up out of a wheelchair and transferred to the bed and I am the only one there I can't do it.During an observation on 04/27/26 at 08:16 AM Resident #15 was lying in bed on her left side with her eyes closed. Her bed was in lowest position and fall mat was on the floor next to the bed. The couch in the entryway of her suite was visible from the hallway.During an interview on 04/27/26 at 09:08 AM ADON A stated LVN C called her on the morning of 04/20/26 and told her she was concerned about the residents on hall 400. ADON A stated LVN C told her about a resident with a soaked brief.During an interview on 04/27/26 at 09:47 AM LVN H stated she came to work on the morning of 04/20/26 and she and RN F found Resident #15 asleep on the couch with her soaked brief on the floor next to the couch. LVN H stated Resident #15's wheelchair was next to her, and she (LVN H) assumed Resident #15 put herself on the couch. She stated Resident #15's bed was not made, and she thought that was probably why Resident #15 put herself on the couch.During an observation and interview on 04/27/26 at 10:09 AM Resident #15 was in her bed with HOB raised to seated position. She did not remember a night when she slept on the sofa.During an observation and interview on 04/27/26 at 12:00 PM ADM, MS, and this surveyor entered a closet in the facility to watch recorded camera footage of LVN D on hall 400 the night of 04/19/26. According to camera footage, LVN D did not enter a resident room until after 10 PM on the night of 04/19/26. ADM stated it was nice to know you pay so much money for agency staff to sit around on their phones. LVN D did enter resident rooms after 10:00 PM but did not remain in any of the rooms for more than 2 minutes except for the instance she and LVN C entered the suite of Resident #15 and Resident #22. The two LVNs remained in the suite for 3 minutes at approximately 4:30 AM on 04/20/26.During an interview on 04/28/26 at 08:26 AM LVN K stated leaving residents in unchanged, wet briefs was an example of neglect of residents. He stated this could result in skin breakdown, decreased self-esteem, possible UTI, and psychologically cause residents not to trust care givers.During an interview on 04/28/26 at 08:30 AM CMA L stated not changing a resident's wet brief was an example of neglect. She stated residents might feel embarrassed or isolate themselves if their wet briefs were not changed.During an interview on 04/28/26 at 08:32 AM CNA M stated not changing a resident's brief was an example of neglect and could result in infection.During an interview on 04/28/26 at 08:35 AM CMA G stated leaving residents in wet briefs was an example of neglect and could lead to UTIs, rashes, odor, and decreased self-esteem.During an interview on 04/28/26 at 08:36 AM SC stated leaving residents in wet briefs was an example of neglect and could cause skin breakdown.During an interview on 04/28/26 at 08:39 AM DT stated not checking on resident every 2 hours was an example of neglect and could lead to pressure sores, UTIs, and indecency.During an observation on 04/28/26 at 01:38 PM Resident #15's skin showed no redness or breakdown.During an interview on 04/29/26 at 07:33 AM LVN J stated not changing a resident's brief was an example of neglect. She stated leaving a resident on a couch in a soaked brief and t-shirt overnight was not acceptable because the resident might fall and was not supposed to be out in public undressed. She stated, Another resident can go by and see somebody naked. LVN J stated a possible negative outcome of leaving a resident in an unchanged brief was skin breakdown or sores.During an interview on 04/29/26 at 09:02 AM SC stated all staff were responsible to ensure residents were not left sleeping overnight on a couch in view of the hallway wearing only a t-shirt and brief or just a t-shirt. She stated this could negatively impact the dignity of the resident. SC stated, She has a bed she needs to be in.During an interview on 04/29/26 at 09:06 AM LVN K stated it was not okay for a resident to be left overnight sleeping on a couch in just a t-shirt and brief or just a t-shirt. He stated, For one, other patients can see them; invades their privacy and their dignity, self-esteem. We have to advocate for the patient. He stated all facility staff were responsible for ensuring this did not happen to a resident. He stated even if housekeeping walked by and noticed a resident in that position, they were responsible to let the nurse know.During an interview on 04/29/26 at 09:18 AM RN S stated it was not okay for a resident to be left sleeping on the couch in view of the hallway with just a t-shirt and brief or just a t-shirt for dignity and privacy reasons. She stated the nurse was ultimately responsible to ensure this did not happen to a resident.During an interview on 04/29/26 at 09:24 AM LVN T stated it was not okay for a resident to be left sleeping on the couch in view of the hallway with just a t-shirt and brief or just a t-shirt. She stated, It is a dignity issue for one and plus they need to be able to sleep in their bed and get a good night's sleep. She stated the charge nurse was responsible for ensuring this did not happen to a resident. She stated if the resident insisted on sleeping on the couch the charge nurse should make sure they are clothed and have a blanket and pillow.During an interview on 04/29/26 at 09:30 AM ADON A stated if staff found a resident asleep on the couch in view of the hallway wearing just a t-shirt and brief or just a t-shirt she expected them to get the resident in the room, dressed, and covered. She stated if the resident wanted to sleep on the couch staff should redirect the resident and educate them on safety and comfort. She stated all staff were responsible for ensuring residents did not sleep as described above. ADON A stated it could negatively impact a resident's privacy and/or dignity. She stated a resident staying all night in a wet brief could lead to skin breakdown and lead the resident to think no one cares about them. ADON A stated leaving residents in their beds soaked in urine or feces was an example of neglect.During an interview on 04/29/26 at 09:38 AM ADON B stated he would expect staff to get a resident dressed and into their bed if they were found sleeping on a couch in view of the hallway wearing only a t-shirt and brief or just a t-shirt. He stated all staff were responsible for making sure this did not happen. He stated if the resident insisted on sleeping on the couch staff should cover them and shut the door, so they were not visible from the hallway. He stated otherwise a resident could get really cold and their dignity might be negatively impacted. ADON B stated leaving a resident on the couch as described above was an example of neglect. He stated residents could get UTIs and skin breakdown if left in wet briefs. He stated their dignity could be insulted.During an interview on 04/29/26 at 09:44 AM DON stated if her staff saw a resident sleeping in view of the hallway on a couch in just a t-shirt and brief or just a t-shirt she expected her staff to, Wake patient, take to room, and if they refuse to go to their room at least get them a blanket and pillow. She stated the resident could get too cold or end up getting sick if left as described above. DON stated the resident could fall off of the couch. She stated leaving a resident as described above was an example of neglect. She stated leaving residents in wet or soiled briefs could lead to skin breakdown or infection.During an interview on 04/29/26 at 10:23 AM ADM stated she would hope her staff would assist a resident who was sleeping on the couch in view of the hallway in just a t-shirt and brief or just a t-shirt to make sure that resident was appropriately dressed and clean. She stated any staff member with knowledge of the condition of the resident mentioned above was responsible to intervene. ADM stated leaving the resident as described above would be a dignity issue. She stated leaving residents in wet or soiled briefs could lead to skin breakdown.Record review of facility admission packet page titled Texas Department of Aging and Disability Services revealed the following: You, the resident do not give up any rights when you enter a nursing facility. If anyone . violates your dignity, you have the right file a complaint. You have a right to: . 2. safe, decent and clean conditions; . 4. be treated with courtesy, consideration, and respect; . 6. privacy, .Record review of the facility admission packet page 14-21 titled Resident Rights revealed the following: . The facility protects and promotes the rights of each resident in our care. 1. Basic Rights. Each resident has the right to a dignified existence . 15. Privacy. Each resident has the right to privacy with regard to accommodations, treatment, communications, personal care . 49. Resident Dignity. The facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment, that maintains or enhances his/her quality of life .Record review of facility policy titled Patient/Resident Rights and dated 10/01/20 revealed the following: . The Facility employs measures to ensure patient and resident personal dignity, well-being, and self-determination are maintained . The Facility treats each resident with respect and dignity. The Facility provides care for each resident in a manner that promotes, maintains, or enhances quality of life .

Based on observation, interview, and record review, the facility failed to ensure the resident received adequate supervision to prevent accidents for 1 of 1 Residents (Resident #1) reviewed for Accidents and Hazards. On 04/05/2025, the facility failed to secure the van lift strap to Resident #1's wheelchair while in use which resulted in Resident #1 rolling off backwards when the lift was suspended in the air and caused Resident #1 to be hospitalized in the Intensive Care Unit with multiple fractures on his spine. The noncompliance was identified as PNC. The IJ began on 04/05/2025 and ended on 04/07/2025. The facility had corrected the noncompliance before the survey began. This deficient practice could place residents at-risk of harm, serious injury, or death. Findings included: Review of the facility's self-reported incident indicated on 04/05/2025 at approximately 1:00PM Resident #1 was leaving the dialysis center after treatment. He was in his wheelchair and ready to be transported back to the facility in the facility's van by CNA A. The incident report simply stated, Resident #1 was on the van lift and was being transferred back to the facility. He fell backwards off the lift, hitting the ground. Resident #1 was transferred by EMS to [local hospital] ER for further evaluation and treatment. There was also a complaint which was made against the facility in this matter. A by-stander who witnessed the incident felt the actions that took place were grave enough to warrant a complaint on behalf of Resident #1, due to the way CNA A attempted to load Resident #1 into the van. A phone interview with the complainant on 04/22/2025 at 5:38PM reflected the following: The complainant stated she was taking her husband to dialysis on Saturday 04/05/2025 when Resident #1 was being loaded into the facility's van after his dialysis treatment. The complainant stated she saw the van driver use the lift on the side of the van to raise Resident #1's wheelchair but thought CNA A had not secured the wheelchair properly before starting the lift. The complainant stated CNA A started the lift and rode to the top, with Resident #1. The complainant stated CNA A stepped inside the open door of the van, leaving Resident #1 unattended on the lift while in the raised position. Resident #1 immediately rolled off the back of the lift and landed on his back, while still in his wheelchair. The complainant stated the day was cold, wet, and snowy. Resident #1 was not dressed for the weather and had landed in a puddle of water when he fell . The complainant immediately called 911 and her granddaughter got a jacket from their truck to warm Resident #1 until EMS arrived. Record review of Resident #1's clinical records revealed a [AGE] year-old male who was admitted to the facility on [DATE] with a diagnoses of Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral ( a combination of diabetic complications affecting both eyes, leading to vision loss) Cognitive communication deficit, Unspecified lack of coordination, Muscle wasting and atrophy, not elsewhere classified, unspecified site, Muscle weakness (generalized), Other reduced mobility, Encounter for observation for suspected exposure to other biological agents ruled out, Type 2 diabetes mellitus with diabetic nephropathy, Type 2 diabetes mellitus with diabetic chronic kidney disease, Type 2 diabetes mellitus with hypoglycemia without coma, Venous insufficiency (chronic) (peripheral) (a condition where the veins in the legs have difficulty returning blood to the heart. This results in blood pooling in the lower extremities, leading to symptoms like swelling, pain, and skin changes), Benign prostatic hyperplasia with lower urinary tract symptoms (frequent or urgent urination, waking up multiple times at night to urinate (nocturia), difficulty starting urination, a weak urine stream, dribbling at the end of urination, and the feeling of not fully emptying the bladder), Dependence on renal dialysis (refers to a condition when an individual's kidneys are no longer functioning properly and require regular dialysis treatments to filter blood and maintain bodily function). Review of Resident #1's Quarterly MDS dated [DATE] indicated he had a BIMS score of 15, indicating he was cognitively intact. Resident #1 required a 1- to 2-person assist for all ADLs. His means of mobility were a wheelchair and Hoyer lift. His care plan dated 03/18/2025 revealed he was a fall risk related to impaired sight, Diabetes Mellitus, muscle weakness and occasional low blood pressure. Resident #1 was dependent on a wheelchair for ambulation. An interview with the Administrator on 04/24/2025 at 8:12AM revealed she received a call from the DON at approximately 1:30PM on 04/05/2024 which informed her Resident #1 had fallen in his wheelchair from the van and was at the hospital. The DON told the Administrator they did not know what happened, but he had fallen. The Administrator stated it took approximately 1-hour for her to arrive at the facility from her home. The Administrator stated she interviewed CNA A as soon as she arrived at the facility. In that interview, CNA A told the Administrator she locked Resident #1's wheelchair wheels when she pushed him onto the lift. CNA A stated the lift plate at the back of the lift was up, so she did not know how he could have rolled off. CNA A stated Resident #1 was unable to tell her how he rolled off, as well. The Administrator suspended CNA A from her duties at the facility, in lieu of an investigation and she was no longer allowed to drive the facility's van. A phone interview with Resident #1's RR on 04/24/2025 at 9:46AM reflected stated Resident #1 was not doing well since the fall. The RR stated Resident #1 was still in ICU and was very fragile. He had been in the ICU for almost 2-weeks. Resident #1 broke T4 and T5 in his back and surgery could not be completed due to his fragility. The orthopedic surgeon stated he would not survive the surgery. The RR lived approximately 45 miles out of town, so she called a local friend, who went to the hospital and checked on Resident #1 until she could arrive. The RR stated when the Administrator called her she stated that Resident #1 was not secured when he was lifted with the van lift. The RR was told by the Administrator that EMS had taken Resident #1 to [local hospital] and he had been admitted . The RR was told the van driver had to go back to the facility to meet with HR about the incident, so the facility had sent the maintenance man's son, who was also an employee, to sit with Resident #1 until the RR could arrive. When the RR arrived, no one was with Resident #1. When the RR was able to speak with Resident #1, he told her he was up in the air when he felt himself falling backward. The RR stated Resident #1 was blind, and should have been secured very well, since he had to rely on the help of others for his safety. The RR stated she felt it was incredibly negligent on the part of the facility to let the incident happen. The RR stated she was not sure if Resident #1 lost consciousness and Resident #1 was unable to tell her if he had lost consciousness after the fall. The RR stated the ER took x-rays of Resident #1's head and back and found no injury to his head, but his spine had swelling, and it appeared there were fractures at T4 and T5 in his back. The RR stated Resident #1's quality of life was taken from him, and he would never be the same again. The surgeons had stated he would have chronic back pain and problems with his back, for the rest of his life. The RR stated the Administrator told her the dialysis center had video of the incident. The RR called the dialysis center and made an appointment to view the video, but when she arrived the RR was told the corporate office had told the dialysis center, not to release the video. The RR stated she received a call from the DON a few days after the incident, but the RR was too mad to speak with her because Resident #1 could still die. The RR stated that was the last communication she received from anyone at the facility. She stated up to the time of the incident, Resident #1's care at the facility had been good. He got his medications on time, had no issues with his insulin and seemed to be contented living there. Record review of [local hospital] ER visit notes dated 04/05/2025 reflected Resident #1 presented to the ER at 1:19PM with complaints of back pain after a fall prior to arrival. Resident #1 reported he was leaving his dialysis treatment when the accident occurred. He was being loaded into a van while in his wheelchair on the van lift when he fell back off the lift while still in the wheelchair and hit his head and back. He notes that he was elevated off the ground. Resident #1 denied loss of consciousness. Resident #1 denied the use of supplemental 02 at home. ER triage notes read as followed: Patient arrived from dialysis center due to a fall. Patient had just finished dialysis and was being loaded into van by a wheelchair lift when he was not secured properly and fell backwards. Pt hit head and is on Eliquis (blood thinner). Pt did not have loss of consciousness. Resident #1 was discharged from the ER and admitted to the Surgical Critical Care Unit of the same hospital at 4:48PM with the following diagnostic considerations and differential diagnoses: lntra-cranial hemorrhage, skull fracture, subdural hematoma, subarachnoid hemorrhage, epidural hemorrhage, rib fractures, a thoracic/lumbar/ cervical spine fractures, hip fracture, pelvic injury. The plan was as followed: Check general labs electrolytes since the patient did just recently have dialysis. We will also check imaging of the patient's head neck thoracic spine and lumbar spine. The patient does not really appear to have any true cervical spine discomfort with given the mechanism wheel look. The patient was found to have a T4-T5 vertebral fracture with some facet widening along with hemorrhage in that area concerning for significant spinal cord injury. That is said the patient does not have any deficits he is able to move all his extremities without any significant difficulty he has good sensation throughout. The patient's case was discussed with the nurse practitioner for [ Neurosurgeon]. She will have him look at the imaging and once they have reviewed the imaging we will adjust any necessary treatment and then proceed. IMAGING CT Head Without Contrast (Results Pending) CT Thoracic Spine Without Contrast (Results Pending) CT Lumbar Spine Without Contrast (Results Pending) The patient's case was discussed with [Neurosurgeon] through Nurse Practitioner; they recommend that we admit the patient from the trauma service to the SICU; the patient has an unstable fracture at T4 and T5 and will require close monitoring. On 04/05/2025 at 6:02PM The CICU Physician charted the following in Resident #1's [local hospital] medical record: CT Thoracic Spine Without Contrast PROCEDURE: CT THORACIC SPINE WITHOUT CONTRAST COMPARISON: None. INDICATIONS: Fall with thoracic spine pain concern for injury, TECHNIQUE: Multi-planar CT images were obtained and created without intravenous contrast. FINDINGS: VERTEBRAE: There was bridging anterior vertebral body osteophytes throughout the thoracic spine compatible with DISH. There is a fracture through the anterior inferior corner of the T4 vertebral body with extension to the disc space and into the superior T5 end plate. There is associated mild widening of the T4-T5 facet joints with mild retrolisthesis of T4 and TS measuring 4 mm, traumatic in etiology. This results in severe bilateral neural foraminal stenosis and mild spinal canal stenosis. There is mild haziness in the spinal canal ventral to the spinal cord which may represent a small amount of epidural hemorrhage without definite mass effect on the thecal sac. PARASPINAL AREA: Large prevertebral edema or hemorrhage at the level of T4-T5. DISC LEVELS: Fracture through the T4-T5 disc space. ALIGNMENT: Traumatic retrolisthesis of T4 and TS measuring 4 mm. OTHER: Multilevel degenerative changes throughout the thoracic spine with mild multilevel spinal canal and foraminal stenosis. There is a consolidation in the right lower lung which could represent pneumonia or atelectasis. Mild left lower lobe atelectasis. Cardiac pacer leads are present. Moderate atherosclerosis of the coronary arteries and aorta. CONCLUSION: 1. Acute fractures through the anterior inferior corner of the T4 vertebral body with the fracture extending into the disc space in the superior endplate of T5 in the setting of DISH. There is widening of the bilateral T4-TS facet joints which likely indicates facet capsular injuries and associated traumatic retrolisthesis of T4 and TS measuring 4 mm. This results in severe bilateral neural foraminal stenosis and at least mild spinal canal stenosis. Minimal hyperdense stranding in the anterior epidural space at this level may represent blood products, however there is no definite hematoma or substantial mass effect on the thecal sac identified on this exam. An MRI could be performed to assess for mass effect on the spinal cord if clinically indicated. 2. Moderate hemorrhage or edema anterior to the T4-TS fractures. CT Lumbar Spine Without Contrast PROCEDURE: CT LUMBAR SPINE WO CONTRAST COMPARISON: None. INDICATIONS: Fall with a lower back pain concern for injury, TECHNIQUE: Multi-planar CT images of the lumbar spine were obtained without IV contrast. FINDINGS: BONES: No fractures. Bilateral pars defects at L5. Osteophytes all lumbar levels. Schmorl's nodes superior endplates L1 and L2. A mild bi concave deformities L3, L4 and L5. Hypertrophy of the spinous processes with faceted appearance consistent with Braestrup's disease series 8, image 36. ALIGNMENT: Grade 1 anterolisthesis L5 on S1. PARASPINAL AREA: Arterial calcifications. Atrophy left kidney. Right kidney not well seen. LUMBAR DISC LEVELS: T12-L1: No significant disc/facet abnormality, spinal stenosis, or foraminal stenosis. L1-L2: Calcification within the disc. Mild bilateral facet arthrosis. L2-L3: Facet arthrosis and ligamentum flavum thickening contribute to central canal and foraminal stenosis. L3-L4: Bilateral facet arthrosis and ligamentum flavum thickening contribute to central canal and foraminal stenosis. L4-L5: Bilateral facet arthrosis and ligamentum flavum thickening contribute to central canal and foraminal narrowing. L5-S1: Disc space narrowing anterolisthesis leads to narrowing of the foramina bilaterally. CONCLUSION: 1. No acute fractures. 2. Bilateral pars defects of at L5 with grade 1 anterolisthesis of L5 on S1. 3. Degenerative changes all lumbar levels. 4. Baastrup's disease. 5. Atherosclerosis. CT Head Without Contrast PROCEDURE: CT HEAD WO CONTRAST COMPARISON: None. INDICATIONS: Fall with head trauma on Eliquis concern for injury. TECHNIQUE: CT images were created without intravenous contrast. FINDINGS: VENTRICLES: The ventricles, sulci and cisterns are mildly enlarged. CEREBRUM: No intracranial hemorrhage. Symmetrically diminished attenuation in the deep white matter consistent with mild leukoaraiosis. , CEREBELLUM: Small high attenuation extra-axial lesion abutting the [NAME] surface measuring 1.3 x 0.7 cm series 7, image 37 and also demonstrated on axial series 5 images 9-10 consistent with a meningioma. BRAINSTEM: Negative. SKULL: No fractures. Small right frontal scalp laceration. SINUSES: Normal. OTHER: Arterial calcifications. CONCLUSION: 1. No intracranial hemorrhage. 2. Small meningioma in the right posterior fossa. 3. Mild atrophy and leukoaraiosis. 4. Small right frontal scalp laceration. ASSESSMENT AND PLAN: Patient Active Problem List Diagnosis o Acute kidney injury superimposed on chronic kidney disease o Type 2 diabetes mellitus with hypoglycemia, with long-term current use of insulin (HCC) o Mixed hyperlipidemia o Morbid obesity with BMI of 50.0-59.9, adult (HCC) o Benign prostatic hyperplasia with lower urinary tract symptoms o Paroxysmal atrial fibrillation (HCC) o Microcytic anemia o Coronary artery disease involving native coronary artery of native heart without angina pectoris o Hypervolemia, unspecified hypervolemia type o Chronic kidney disease requiring chronic dialysis (HCC) o ESRD (end stage renal disease) on dialysis (HCC) o Coagulopathy o Fall o Closed unstable burst fracture of fourth thoracic vertebra, initial encounter (HCC) Fall Assessment & Plan Patient is status post fall complaining of back pain and suffered an unstable thoracic spine fracture. Patient will be admitted to surgical ICU with strict spine precautions. Tertiary evaluation to be performed in the morning. Coagulopathy Assessment & Plan Patient has history of coronary artery disease along with paroxysmal AFib currently on Eliquis. Last dose was this morning. Patient requires full reversal for Eliquis. Paroxysmal atrial fibrillation (HCC) Assessment & Plan Patient has history of coronary artery disease along with paroxysmal AFib currently on Eliquis. Last dose was this morning. Patient requires full reversal for Eliquis. * Closed unstable burst fracture of fourth thoracic vertebra, initial encounter (HCC) Assessment & Plan Patient is status post fall complaining of back pain and suffered an unstable thoracic spine fracture. Patient will be admitted to surgical ICU with strict spine precautions. [Neurosurgeon] has been consulted who will evaluate the patient. He initially recommended MRI, however, could not be done secondary to presence of pacemaker. Also recommended keeping mean arterial pressure greater than 70, IV Decadron. Appreciate his recommendations. Chronic kidney disease requiring chronic dialysis (HCC) Assessment & Plan Patient has history of chronic kidney disease on hemodialysis through a left upper extremity fistula. Will consult [Nephrologist]. Coronary artery disease involving native coronary artery of native heart without angina pectoris. Assessment & Plan Patient has history of coronary artery disease along with paroxysmal AFib currently on Eliquis. Last dose was this morning. Patient requires full reversal for Eliquis. Morbid obesity with BMI of 50.0-59.9, adult (HCC) Assessment & Plan BMI of 48.6 likely related to excess calories. Supportive care at this point. Mixed hyperlipidemia Assessment & Plan Chronic diagnosis. Patient takes atorvastatin. Will resume when able. Type 2 diabetes mellitus with hypoglycemia, with long-term current use of insulin (HCC) Assessment & Plan Chronic diagnosis. We will obtain HbA1c in the morning. Start more moderate category sliding scale. Antibiotics: Ancef on-call Nutrition: Keep NPO Analgesia: Tylenol, Robaxin with as-needed fentanyl Sedation: Not indicated Thromboprophylaxis: SCDs only, no chemoprophylaxis Ulcer prophylaxis: Start Protonix Glucose: Will obtain HbA1c in the morning, start sliding scale insulin Plan for today: o Admit to surgical ICU o Start Levophed to keep mean arterial pressure greater than 70 o Reverse Eliquis o Pain control o Strict spine precautions o Add duo nebs o Will obtain CT chest abdomen pelvis without contrast o I have consulted [Hospitalist] to help assist with medical management The patient is extremely critical. I had an extensive discussion with the patient and his RR over the phone. I updated them about his condition, including the potential risks and complications associated with his fall, given his advanced age, multiple comorbidities (OM, pacemaker, OA, HTN), and current anticoagulation therapy with Eliquis. I also discussed the need for continuous monitoring and potential consultations with orthopedic and neurology specialists. All their questions were answered thoroughly, ensuring they understood the gravity of the situation and the steps being taken. The patient is a full code. ICU RN notes from 04/05/2025 at 6:22PM read as follows: Admitting DX: Burst fracture of 4th thoracic vertebra Current level of care: ICU Current CLS (care level score): 150 Current treatment plan: admitted following a fall for an unstable burst fracture of T4. Nephrology consult for chronic dialysis. Intubated and placed on pressers within 24 hours. Neurosurgery consulted - pt not a good surgical candidate due to multiple factors, recommended palliative care consult. Barriers to discharge: Remains in critical care, not stable to transfer to lower level of care. Resident #1 remained in ICU at [local hospital] until 04/17/2025 at or around 5:00 PM when he was transferred to [local LTAC] for continued care. Resident #1's hospital discharge plan dated 04/17/2025 at 2:36PM read as follows: Spoke with NP regarding discharge plan and patient is able to transfer from ICU to LTAC due to higher level of medical need. Spoke with patient's RR and she has toured [local LTAC] and is agreeable. Patient Care Levels complete. Called and sent referral. Case manager will remain available. Pt has been approved for [local LTAC] and can transfer today at 5:00PM via ambulance. Pt and family informed. Pt scheduled for dialysis today at 2:00PM but will complete dialysis tonight at the LTAC. Nurse given number to call report. No other needs at this time. Primary RN notified this RN patient will be transferring to LTAC at 5:00PM via ambulance. Per Case Manager note, dialysis is to be done tonight at LTAC. Nephrologist notified, no treatment at [local hospital] today. Fax order sheet to dialysis center for LTAC dialysis. Occupational Therapy orders sent to [local LTAC] at 3:43PM read as follows: ROM: patient consulted and evaluated in SICU on 4/9/2025. During evaluation patient demonstrated primary impairments in bed mobility, functional transfers, activity tolerance, sustained grasp, dynamic sitting/standing balance, insufficient spinal precautions, cognition including anxiety and problem solving, visual scanning, and gross weakness/deconditioning impacting safety, participation, and independence with all ADLs. Pt scored 6 out of 24 on the AM-PAC Daily Activity assessment indicating over 100% impairment completing all basic ADLs successfully/independently, meaning patient will require assistance at time of discharge. Therefore, without skilled OT service, patient is at a higher risk for loss of independence with basic necessary ADLs, loss of dignity, and inability to return to the community reducing their quality of life. OTR initiated a Plan of Care to approximate prior level of independence and improve impairments to baseline. Pertinent Surgical History: No plans for surgical intervention per neuro at this time. Assessment: Pt initially evaluated by occupational therapy on 4/9/2025 by OTR. During patient's plan of care, this patient seen by therapy 3 times and received: -Dynamic therapeutic activities utilized to improve functional performance, activity tolerance, and balance with therapist supervision and grading to ensure maximum patient benefit. -AOL training and functional transfer training with OT practitioners providing graded assistance and cueing to ensure maximum safety and independence. Patient made fair progress towards goals however due to pain and short length of stay, all goals remain active at time of discharge from hospital to SNF. Continued occupational therapy services are recommended. Plan of care, discharge recommendations, AE equipment, and safety education with spinal precaution with TLSO education reviewed with patient and/or family prior to discharge from hospital. Will discontinue acute care OT orders at this time. An interview with the Administrator on 04/24/2025 10:33AM revealed CNA A had returned to work after her internal investigation, because they could not prove she had done anything wrong during the transport of Resident #1. She stated she had called the dialysis center to inquire about video footage but was told the cameras would not have picked up the area where Resident #1 fell . She stated the doctors at the hospital told the RR, Resident #1 was not secured on the lift, not herself or anyone else at the facility. The Administrator stated Resident #1 was very particular about the brakes on his wheelchair due to his blindness and any time there were issues with his wheelchair he called the MD immediately. An interview with the CM of the dialysis center on 04/24/2025 at 1:00PM revealed there was video of the incident involving Resident #1 falling off the lift of the facility's van. Review of the video with the CM clearly showed CNA A push Resident #1 onto the lift and up to the front of the lift platform. It was difficult to see if CNA A or Resident #1 locked the wheelchair wheels, but CNA A activated the lift and rode with Resident #1 to the top, where they were both even with the open entrance to the van. CNA A then stepped inside the van, out of the video frame and Resident #1 was seen rolling backward off the lift and onto the parking lot pavement below. It was approximated from the video footage that the fall height was about 3-3 1/2 feet. Resident #1 was still in his wheelchair at the time of the fall and bystanders came to his aid. At that point, the video stopped. An interview with CNA A on 04/24/2025 at 2:12PM revealed she pushed Resident #1 out of the dialysis center to the place in the parking lot where the van was waiting. CNA A operated the lift into the down position and then pushed Resident #1 onto the lift platform. CNA A stated she made sure Resident #1's wheels were locked and then took two steps inside the van to try to pull him forward into the back of the van. CNA A stated when she looked back, Resident #1 was not there, and she heard him scream. CNA A stated she ran to him, and he was on his back, on the parking lot pavement, in the wheelchair. CNA A stated she pushed Resident #1 out of the dialysis center, but tried to pull him into the van, because he was too heavy to push over the lip of the van entrance. This investigator told CNA A the security footage from the day of the event was viewed at the dialysis center and she was seen pushing Resident #1 out of the dialysis center in the snow. CNA A had trouble getting Resident #1 off the sidewalk but kept pushing until she got him over a small patch of snow and onto the parking lot and the van's lift. CNA A changed her story and could not remember if she pushed or pulled him onto the ramp of the van. This investigator told her the video footage revealed she pushed him onto the ramp, rode the ramp to the top with Resident #1 and then stepped inside the van, where Resident #1 was left unattended. Resident #1 was then seen rolling off the back of the elevated lift and onto the pavement below. CNA A had no comment. An interview on 04/24/2025 at 2:34PM with Resident #2 revealed she also was a dialysis patient but had never been driven to dialysis by CNA A. Resident #2's RR was in the room at the time of the interview and stated Resident #2 had not had any issues with transportation provided by the facility. Resident #2 stated she felt safe during her travels. An interview on 04/24/2025 at 2:43PM with Resident #3 revealed she also was a dialysis patient but had never been driven to dialysis by CNA A. Resident #3 stated she had not had any issues with the transportation provided by the facility and felt safe during her travels. An interview on 04/24/2025 at 3:07PM with the MD the van had not been used by the facility and had been in the repair shop since the incident. The MD stated the lift on the van held 800 lbs. which was more than ample to lift Resident #1 and his wheelchair. The MD stated the plate at the back of the platform was designed to keep wheelchairs from rolling off the lift should have been in an upright position if the lift was engaged and moving up. He stated there should not have been a way for Resident #1 to roll off the platform. The MD stated he had checked all circuits after the incident, and all were working properly. The MD provided the maintenance work order dated 04/05/2025 which reflected the following: Drove van to facility. Upon arrival I inspected the lift operation. Pushed the unfold button. Lift unfolded 1/4 of way down and stopped. Manually operated lift into van and discontinued van operation. The requested priority was High meaning the lift needed to be evaluated by an outside source within 24-hours. Record review on 4/24/25 of the MD provided policy for Transporting Wheelchair-bound Residents which was used as part of his re-training for van drivers on 04/06/2025 revealed: Safety for Using a Wheelchair Lift: 1. Move the wheelchair, outward facing, all the way onto the lift. If you need a handhold, use one indicated by the lift manufacturer. Set both wheelchair breaks and fasten the lift safety restraint, if applicable. 2. Do no ride on the lift with the passenger but go int the van and meet the lift. 3. Move the patient/resident so they are facing forward in the van. 4. Lock the wheelchair and secure the wheelchair to the van and buckle the patient/resident in. 5. Keep the patient/resident away for any heat source or other hazard that would lead to an injury or irritate the skin. If the passenger has a cane make sure it is secured. If the patient/resident is visually impaired, secure the cane within the passenger's reach. The MD stated CNA A was not trained to load residents onto the platform of the lift, facing the inside of the van; they were to be loaded outward facing. The MD stated CNA A was trained to double-check the breaks on all resident's wheelchairs to ensure safety. The MD stated the van did not have safety restraints on the lift platform. The restraints were used once the resident was loaded inside the van. The MD stated CNA A was not trained to ride on the lift with Resident #1 but had been trained to go up the stairs and meet the resident inside the van. The MD stated CNA A had passed the competency test as a van driver on 02/05/2024 and had attended all in-services given by him, since that time. The MD stated there was not a check list to validate safe van lift use. The MD stated the manufacturer's recommendations were used instead. The MD did not provide a copy of the recommendations. The MD provided the invoice from [Fleet management] after the incident which indicated the van had been inspected by the owner and a technician on 04/08/2025 and reported the following: Inspected the van on-site. Took videos and pictures. Upon inspection it was determined by both parties that the outer barrier (roll stop) had no faults and worked as designed. [Fleet Management] will hold off on the repairs until the State agency looks over the lift. Record review on 4/24/25 of re-training on Transport Accidents on 04/07/2025 to all van drivers regarding any falls or accidents which occurred while on transportation revealed the following: A. Do not move the resident. B. Immediately call 911 to have the resident assessed. C. Notify the DON, Administrator and Maintenance immediately. Record review on 4/24/25 of the QAPI committee met on 04/07/2025 at 12:00PM and was attended by the following committee members: Medical Director, DON, (2) ADONs, Activity Director, MD, Social Services, (2) Nurse Assessment Coordinators and Human Resources. The Administrator was on vacation in Hawaii and did not attend the meeting by phone. The Mitigation Plan was put into effect under F689 Free from Accidents/Hazards/Supervision/Devices and read as follows: What corrective action(s) will be accomplished for those residents found to have been affected by the alleged deficient practice? Practice issue: Free of accident/hazards/supervision/devices Resident fell while being lifted on the facility van lift on 04/05/2025. Resident was sent to the ER. The physician and family were notified. The staff member was suspended, and the incident was reported to HHSC. Staff was re-educated beginning on 04/06/2025 and will

Based on interviews and record reviews the facility failed protect a resident's right to be free from misappropriation of resident property and/or exploitation for 2 of 3 residents (Resident #4 and Resident #5) reviewed for Misappropriation of Resident Property. LVN C was found to have left the facility with pain pills belonging to Residents #4 and #5 on the morning of 04/11/2025 as he left his shift at 7:00AM. This failure could cause residents to experience a decreased quality of life, unrelieved pain, and mental anguish. Findings included: The incident report submitted by the facility on 04/11/2025 indicated at or around 7:00AM, RN B witnessed LVN C behaving erratically. LVN C was unable to focus, could not sit or stand still and exhibited repetitive speech. RN B offered to walk LVN C to his car with the thought he was having a medical incident. When they both arrived at LVN C's car, he fumbled for his keys in his pockets and various pills and a syringe of an unknown substance fell to the ground. RN B immediately asked LVN C what the contents of his pocket were, and he admitted to taking narcotics and other pills off of the medication cart on the 200 hallway. RN B checked to ensure LVN C was able to drive himself home and returned to the facility with the drugs. The confiscated drugs were placed in separate containers and locked in the DON's office pending further investigation. An interview with the Administrator on 04/24/2025 at 8:12AM reflected no drug testing was performed on LVN C or on any staff members working with LVN C during his shift from 7:00PM on 04/10/2025 through 7:00AM on 04/11/2025. She stated as the Abuse Coordinator for the facility, LVN C had admitted to taking the pills, so she felt there was no need to test other staff members. She was unable to say if any pills had been passed to other staff members during the shift. The Administrator stated the medication counts were correct after the event, so she assumed all the pills had been retrieved by RN B at the time of the incident. She was unable to answer how the counts were correct if LVN C had left the building with the pills and syringe. She stated she had been told they were correct by the DON. The Administrator stated she left for vacation the morning of the incident and it was not the first thing at the front of her mind at the time. The Administrator stated LVN C had been suspended on 04/11/2025 pending an internal investigation and was terminated on 04/16/2025. A police report was filed with local police outlining the theft of the medications. The police report # was 25-0505104 and was filed on 04/11/2025. An interview with the DON on 04/24/2025 at 8:29AM revealed the narcotic counts in the medication cart had been correct when LVN C took over the shift at 7:00PM on 04/10/2025. The counts were not correct when LVN C handed off the medication cart to RN B at 7:00AM on 04/11/2025. She stated the total amount of controlled substance pills that were missing from the cart was 25, along with 2 syringes of Morphine totaling 5.1ml. The DON and RN B immediately began pain assessment rounds on the residents of the 200 hallway and found that Resident #4 had not received her morning dose of Lorazepam and Resident #5 had not received her morning dose of Tramadol. Resident #4's pain level was 9 out of 10 with all-over radiating pain and Resident #5's pain level was 6 out of 10 with lower back pain. The DON stated during these pain assessment rounds she had also found an empty syringe on the bathroom counter of one resident and had asked her if she had received her morning dose of Morphine. The resident told the DON she had not received the dose and asked for it due to all-over pain and pain in her left breast that was 9 out of 10. An interview on 04/24/2025 at 2:55PM with Resident #4 reflected she had missed the administration of her morning pain medication only one time that she could remember but having pain was something she was used to, so she thought she had probably waited for the next dose. An interview on 04/24/2025 at 4:12PM with Resident #5 reflected she had missed the administration of her pain medication one night before she went to bed. She stated she thought she had fallen asleep, so her pain must not have been too bad, or she would have asked a nurse for a pill. Record review of Resident #4's clinical records revealed Resident #4 was a [AGE] year-old female who was admitted to the facility on [DATE] with the following diagnoses: Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Unspecified glaucoma (condition where there's a build-up of fluid in the eye that puts pressure on the optic nerve and retina, potentially leading to vision loss or blindness), Anxiety disorder, unspecified, Insomnia, unspecified (inability to sleep),Pain, unspecified, Gastro-esophageal reflux disease without esophagitis (heart burn without reflux), Unspecified osteoarthritis, unspecified site, Trigger finger, right ring finger, Secondary hyperparathyroidism of renal origin (a condition where the parathyroid glands produce excessive parathyroid hormone (PTH) due to chronic kidney disease (CKD), Unspecified abdominal pain, Syncope and collapse (loss of consciousness with falling),Nondisplaced spiral fracture of shaft of left tibia, initial encounter for closed fracture (a fracture where the broken bones remain aligned), Long term(current) use of insulin, Dependence on supplemental oxygen, Chronic kidney disease, stage 3 unspecified, Other chronic pain, Bipolar disorder, unspecified, Major depressive disorder, recurrent, unspecified, Hypothyroidism, unspecified (a condition where the thyroid gland does not produce enough thyroid hormones), Type 2 diabetes mellitus with diabetic chronic kidney disease, Type 2 diabetes mellitus with hyperglycemia (refers to a situation where someone diagnosed with type 2 diabetes has persistently high blood sugar levels (hyperglycemia)), Chronic respiratory failure with hypoxia (a long-term condition where the lungs are unable to adequately provide oxygen to the body, leading to chronically low blood oxygen levels). Review of Resident #4's MDS dated [DATE] indicated she had a BIMS score of 15 indicating she was cognitively intact. Her care plan dated 03/04/2025 indicated she was at risk for pain related to glaucoma, osteoarthritis, and previous fracture of the left tibia. Her pain would be managed through prescribed medications and exercise, as able. Resident #4's orders were as follows: Orders: acetaminophen [OTC] tablet; 500 mg; amt: 1 tab; oral Three Times A Day Ativan (lorazepam) - Schedule IV tablet; 0.5 mg; amt: 1 tab; oral Three Times A Day Behavior Monitoring Every Shift: ANTIANXIETY Drug- Symptoms include restlessness, shortness of breath, agitation. Special Instructions: Behavior: 1. restlessness 2. shortness of breath 3. agitation INTERVENTIONS: A: Physical Needs Met B: Distraction C: Redirection D: Validation E: Activity Program F: Quiet Time/Rest G: Increased Observation H: Removal of Stressors J: Other K: No interventions needed OUTCOMES: 1. Improved, 2. Unchanged, Every Shift Behavior Monitoring Every Shift: ANTIDEPRESSANT Drug- Symptoms include voicing sad thoughts, social withdrawal, decreased appetite Special Instructions: Behavior:1. voicing sad thoughts 2. social withdrawal 3. decreased appetite INTERVENTIONS: A: Physical Needs Met B: Distraction C: Redirection D: Validation E: Activity Program F: Quiet Time/Rest G: Increased Observation H: Other I: No interventions needed OUTCOMES:1. Improved, 2. Unchanged, W. Worsened Every Shift Behavior Monitoring Every Shift: ANTIPSYCHOTIC Drug Use- Symptoms include refusing care, yelling out, delusions. Special Instructions: Behavior: 1. refusal of care 2. yelling out 3. delusions INTERVENTIONS: A: Physical Needs Met B: Distraction C: Redirection D: Validation E: Activity Program F: Quiet Time/Rest G: Increased Observation H: Removal of Stressors J: Other K: No interventions needed OUTCOMES: 1. Improved, 2. Unchanged, Every Shift EQUIPMENT Oxygen: Change O2 tubing/nasal cannula/mask/humidification system weekly Once a Day on Sun bariatric Bed, Wheelchair, Hoyer lift, air mattress EQUIPMENT: Keep O2 cannula/mask/tubing and/or Nebulizer mask/tubing bagged when not in use Every SHIFT Check resident for level of pain utilizing numeric rating scale 0-10 or verbal descriptor scale(M)Mild, (Mo)Moderate, (S)Severe, (VS)Very Severe Monitor for side effects every shift: ANTIANXIETY. Special Instructions: SIDE EFFECTS: 0. NONE 1. Hypotension 2. Sedation 3. Dizziness 4. Dry Mouth 5. Blurred Vision 6. Urinary Retention 7. Drowsiness, Fatigue 8. Slurred Speech 9. Confusion 10. Nightmares 11. Appetite Changes Every Shift Monitor for side effects every shift: ANTIDEPRESSANTS Special Instructions: SIDE EFFECTS: 0. NONE 1. Dry Mouth 2. Blurred Vision 3. Constipation 4. Urinary Retention 5. Hypotension 6. Appetite Changes 7. Headache 8. Insomnia 9. Dyspepsia 10. Weight Changes 11. Suicidal ideations; Wishes of death; Attempts to harm self Every Shift Monitor for side effects every shift: ANTIPSYCHOTIC DRUG USE Special Instructions: SIDE EFFECT CODES: 0. NONE 1. Neck Stiffness 2. Confusion 3. Muscle Rigidity 4. Involuntary Movements 5. Drooling 6. Tremors 7. Restlessness 8. Sleep Disturbances 9. Dry Mouth 10. Blurred Vision 11. Constipation 12. Sedation Every Shift Quarterly Observations due every three months (Focused Observation, Braden, Elopement, Pain, Fall, B/B, Side Rail) Once A Day on 3rd Fri of Jan, Apr, Jul, Oct Record review of Resident #5's clinical records revealed Resident #5 was an [AGE] year-old female who was admitted to the facility on [DATE] with the following diagnoses: Unspecified dementia, severe, with other behavioral disturbance, Major depressive disorder, recurrent severe without psychotic features, Generalized anxiety disorder, Other chronic pain, Essential (primary) hypertension, Other idiopathic scoliosis (the most common type of scoliosis, characterized by an abnormal spinal curvature with an unknown cause), site unspecified, Unspecified inflammatory spondylopathy, lumbar region (degenerative condition affecting the lower back (lumbar spine) ), Cognitive communication deficit, Pain, unspecified, Traumatic subdural hemorrhage with loss of consciousness of unspecified duration, sequela (a serious medical condition where bleeding occurs in the space between the brain and the dura mater (the outermost layer of tissue surrounding the brain), resulting in pressure buildup and potentially causing loss of consciousness), Presence of neurostimulator (a medical device that delivers electrical stimulation to nerves to modulate their activity, often for pain relief or other therapeutic purposes), Muscle wasting and atrophy, not elsewhere classified, unspecified site, Muscle weakness (generalized), Other osteoporosis without current pathological fracture, Unspecified fracture of first lumbar vertebra, subsequent encounter for fracture with routine healing. Review of Resident #5' MDS dated [DATE] indicated she had a BIMS score of 7 indicating she was moderately, cognitively impaired. Resident #5's care plan dated 04/11/2025 indicated she was at risk for pain related to scoliosis, spondylitis, previous lumbar fracture, and osteoporosis. Her pain would be managed through prescribed medications, neurostimulator and exercise, as able. Resident #5's orders were as follows: Orders: Tramadol - Schedule IV tablet; 50 mg; amt: 1 tab; oral Every 8 Hours - PRN Trazodone tablet; 100 mg; amt: 2 tablets; oral At Bedtime Behavior Monitoring twice daily: ANTIDEPRESSANT Drug ** Note Drug/Condition to be monitored** Special Instructions: INTERVENTIONS: A: Physical Needs Met B: Distract C: Redirect D: Validate E: Activity Program F: Quiet Time/Rest G: Inc Observation H: Other I: No interventions needed OUTCOMES:1. Improved, 2. Unchanged, 3. Worsened, twice a Day. Behavior Monitoring twice daily: HYPNOTIC Drug Use **Note Drug and Behavior/Condition to be monitored**Special Instructions: INTERVENTIONS: A: Physical Needs Met B: Distract C: Redirect D: Validate F: Quiet Time/Rest G: Increased Observation H: Removal of Stressors J: Other K: No interventions needed OUTCOME: 1. Improved, 2. Unchanged, 3. Worsened Twice a Day EQUIPMENT: Low Bed, Wheelchair Every SHIFT (2) Check resident for level of pain utilizing numeric rating scale 0-10 or verbal descriptor scale(M)Mild, (Mo)Moderate, (S)Severe, (VS)Very Severe, Every Shift Monitor for side effects twice daily: ANTIDEPRESSANTS Special Instructions: SIDE EFFECTS: 0. NONE 1. Dry Mouth 2. Blurred Vision 3. Constipation 4. Urinary Retention 5. Hypotension 6. Appetite Changes 7. Headache 8. Insomnia 9. Dyspepsia 10. Weight Changes 11. Suicidal ideations; Wishes of death; Attempts to harm self Twice a Day Monitor for side effects twice daily: HYPNOTICS Special Instructions: SIDE EFFECT CODES: 0. NONE 1. Sedation 2. Dizziness 3. Confusion 4. Nightmares 5. Daytime Anxiety 6. Hallucinations 7. Fatigue 8. Headache 9. Sedation Twice a Day Quarterly Observations due every three months (Braden, Elopement, Pain, Fall, B/B) Once a Day on 1st Mon of Every 3rd Month Record review of medication count records from LVN C's shift which started at 7:00PM on 04/10/2025 reflected Resident #4 had 90 Lorazepam 0.5 mg pills and 3 hydrocodone-acetaminophen-5-325 mg pills at the beginning of the shift when the cart was handed off to him. Medication count records from the next morning on 04/11/2025 at 7:00AM reflected Resident #4 had 89 Lorazepam 0.5 mg. pills and 2 hydrocodone-acetaminopen-5-325 pills remaining. The medication administration record revealed that neither medication was charted as administered to Resident #4 by LVN C. Pain assessment rounds performed by RN B the morning on 04/11/2025 when the missing pills were discovered reflected Resident #4 had not received medication the night before and currently had a pain level of 9 out of 10 with all-over body pain. Record review of medication count records from LVN C's shift which started at 7:00PM on 04/10/2025 reflected Resident #5 had 12 Tramadol 50mg pills at the beginning of the shift when the cart was handed off to him. Medication count records from the next morning on 04/11/2025 at 7:00AM reflected Resident #5 had 10 Tramadol pills remaining. The medication administration record from the same time frame revealed no Tramadol had been charted as administered to Resident #5 by LVN C. Pain assessment rounds performed by RN B the morning on 04/11/2025 when the missing pills were discovered reflected Resident #5 had not received medication the night before and currently had a pain level of 6 out of 10 with lower pain. An interview with RN B on 04/25/2025 at 8:40AM reflected she was on duty the night and early morning of the incident with LVN C. She stated LVN C's behavior was erratic, and he was sweating profusely. She asked if he was he having a medical problem. RN B stated LVN C became angry and could not help her complete med counts. RN B stated all the narcotic counts were off the morning 04/11/2025 and when she asked LVN C about them, he stated he didn't know anything about them, yet there were medication cards lying on top of the med cart and there were 2 vials of Morphine that he could not remember to whom they belonged. LVN C then told RN B that he suddenly remembered and took one vial of Morphine into an unnamed resident's room. She stated she went into the unnamed resident's room a few minutes later and asked the resident if she had gotten her Morphine and she stated she had not. RN B stated she found an empty syringe in the resident's bathroom on the counter. RN B stated she went to find LVN C and stated to him, I'm taking off my RN badge and putting on my friend badge. What's going on with you? RN B stated LVN C became very angry, and she began to try to get him out of the building, but it took some time as he was resistant. When RN B got LVN C to his truck, he reached in the pocket of his pants to try to find his keys and when he could not, he reached into his jacket pocket and pulled the keys out, along with 2 cups of pills and a syringe of what she thought was probably Morphine. RN B stated she took the drugs from LVN C and told him he needed to get some help. RN B offered to drive LVN C home, but he would not let her, so she had the maintenance man go and sit with him in his truck to see if he was even able to drive himself home. RN B stated LVN C had several disciplinary write ups concerning medication administration/medication charting and she knew the Administrator and the DON were aware of those problems. She stated she had no idea why they continued to keep him working when he'd had so many problems with medications. RN B stated everyone who worked with him knew he had a problem. LVN C would sometimes stay until 10:30AM or 11:00AM charting, when his shift ended at 7AM. RN B stated she thought he was falsifying records, but neither she nor the DON had been able to find definitive proof. She stated there was no way to tell exactly how many pills or vials of Morphine he had taken over the time he has been employed. An interview with the DON on 04/25/2025 at 9:16AM reflected LVN C had several disciplinary concerns in his file regarding medication administration and medication charting. She stated he was written up the first time on 04/17/2024 for failure to follow policy when he left his med cart unlocked. He was written up the second time on 12/09/2024 for medication error when he entered all the medications for a new resident under a different resident's name and chart. LVN C's third write up was on 02/07/2025 for administering medication without an order. She stated the pill in question was an Ambien and it was unknown if he had given it to a resident or had taken it himself. LVN C was also written up at the same time for incomplete charting since, You can't chart a med you don't have an order for. The DON stated LVN C was originally suspended on 04/11/2025 pending the investigation for the missing pills and Morphine that were found in his pockets as he left the building around 7:30AM, at the end of his shift. The DON stated on 04/16/2025 LVN C was terminated. She stated he was kept on staff for so long with so many infractions, due to their corporate policy of progressive discipline. She stated the policy was as follows: 1st offense-verbal warning. 2nd offense-documented verbal warning. 3rd offense-written warning. 4th offense-final warning and then termination if another offense occurs. Review of in-service documentation from 04/11/2025 reflected licensed staff were educated on medication administration, documentation, medication discrepancies and reporting of suspected drug diversion. An attempt to speak with LVN C by phone was made on 04/25/2025 at 9:17AM. LVN C was not available for comment and there was no VM to leave a message for a return call. Review of facility policy for Pharmacy Services; Section 2; Subject 2.6 Storage and Reconciliation of Controlled Substances dated April 2024 revealed the following: Policy: 1. The Facility will have systems in place to ensure the safe and secure storage of Controlled Substance Medications. 2. The facility will conduct routine reconciliations of all Controlled Substances to prevent any potential loss or diversion. Procedures: 1. Only authorized staff, licensed nurses and pharmacy personnel will have access to controlled medications. 2. Medications listed in Schedules II, III, IV, and V are dispensed by the pharmacy in readily accountable quantities and containers designed for counting of contents. 3. All controlled medications must be maintained in separately locked, permanently affixed compartments. The access key to controlled medications is not the same key which gives access to other medications. Duplicate keys to all medication storage areas, including those for controlled medications, are kept by the Director of Nursing. A. The authorized staff member will always have the Controlled Substances key(s) in his/her possession while on duty. 4. A scheduled reconciliation (shift change count) of controlled substance inventory should be completed every nursing shift change and documented as required by state regulations. A. At the end of every shift the nurse/authorized staff member reporting on duty and the nurse/authorized staff member reporting off duty meet at the designated medication cart or storage area to count all Controlled Substance drugs. B. The off-going nurse/authorized staff member reads off each controlled substance inventory record sheet on drug at a time. C. The on-coming nurse/authorized staff member counts the number of remaining Controlled Substance drugs and announces that number out loud. D. The on-coming nurse/authorize staff member visually checks this number against the Inventory Record Sheet. E. The nurse/authorized staff member should always use the meniscus level of the liquid to estimate the volume of a liquid-controlled substance. F. Liquid controlled medications are often dispensed in multi-dose containers which indicate approximate volume. Any observed discrepancy between the recorded amount and what appears to be remaining in the container should be reported to the DON. G. The Shift Change Sheet requires that a count of Controlled Substance medication card and packages in the medication cart be completed at each shift change. It also requires that a card and/or package count of resident-specific Controlled Substances stored outside of the med cart i.e., refrigerated items and the integrity of all Controlled Substance Emergency Drug Kits. H. Both staff members (off-going and on-coming) sign the Controlled Substance Shift Change Sheet with the date and time of the shift change. By doing so, both are verifying that the medication counts for all Controlled Substances and that the counts of the number of Controlled Substance cards and/or packages are accurate at the time of shift change. I. The on-duty nurse/authorized staff member is responsible for noting any change in Controlled Substance medication card count or Controlled Substance package count on the Shift Change Sheet during their shift. J. Upon being relieved from duty, the off-going nurse/authorized staff member transfers the key to the on-coming staff member taking his/her place. K. In counting Controlled Substance drugs, the nurse/authorized staff member, notices any defect in a drug container or products, they shall immediately report any suspicion of substitution or tampering with controlled drugs to the Director of Nursing. 5. If any discrepancy is found, nursing should check the patient's/resident's order sheets and medical record to see of a controlled substance has been administered and not recorded. Check previous recording on the Controlled Substance Inventory Sheets for mistakes in arithmetic or error in transferring numbers from one sheet to the next. A. If the cause of the discrepancy cannot be located and/or the count does not balance, the nurse must report the matter to the Director of Nursing/designee and generate the appropriate report. B. The DON/designee will then investigate to determine if a diversion has occurred. C. If the DON/designee determines that a diversion has occurred, the DON/designee will notify the LTC Provider Pharmacy and consult with Human Resources and the Clinical Services Director to determine actions to be taken. D. The DON may suspend the nurse(s) pending further investigation. E. If diversion is substantiated, the Director of Nursing and Human Resources report the diversion and the identity of the individual to the local authorities/police, the State Board of Nursing, and the DEA at the guidance of the Pharmacy.

Based on observations, interviews, and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 10 residents (Resident #1) reviewed for care planning. The facility failed to ensure that Resident #1's care plan addressed the use of an arm immobilizing device. This failure could cause residents to experience a decreased quality of life and reduced mental and psychosocial well-being due to resident's needs not being met. Findings included: Record review of Resident #1's medical chart revealed Resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE] with a BIMS score of 13 (which indicated she was cognitively intact) and a primary diagnosis of Spastic Quadriplegic Cerebral Palsy. (Spastic Quadriplegia is the most severe form of Cerebral Palsy, affecting both arms and legs. People with this type of quadriplegia often cannot walk and have very limited use of their arms.). Resident #1's MDS dated [DATE] reflected the need for full asstance with dressing, a 1-2 person assist with both transfer and toileting and the need for set-up and weighted silverware while eating. Record Review of Resident #1's Physician's orders revealed there was no order for the arm immobilizer, nor was the immobilizer part of Resident #1's Care Plan. On 03/04/2025 at 11:30AM an observation of and interview with Resident #1 was conducted. Resident #1 was observed to be wearing an immobilizer on her right arm, which kept her arm close to her body and across the front of her chest. Resident #1 stated she had not hurt her arm in any way but had Cerebral Palsy. She stated she would require help from staff to remove the immobilizer from her arm. In an interview on 03/04/2025 at 11:39AM the DON stated the order for the immobilizer had possibly been archived and she would print a copy of both the order and the Care Plan for my review. On 03/04/2025 at 12:33PM the DON stated there was no order for the immobilizer and it had not been addressed in Resident #1's Care Plan. She stated she believed the immobilizer was placed by an unknown Physical Therapist, sometime last summer and staff removed it every night before Resident #1 went to bed. She stated the negative outcome of not having an order and Care Plan for the immobilizer would have been new staff would not know to remove the immobilizer at night and it might cause Resident #1 to develop a pressure injury. The DON stated the negative outcome of not wearing the immobilizer during the day would have been Resident #1's spastic arm might have hit a doorway as she was ambulating. The DON ensured the order had been obtained from the doctor and the Care Plan had been updated. She was unsure why there had not been an order for the immobilizer previously, nor why the immobilizer had not been addressed in Resident #1's MDS or Care Plan. Record Review of Resident #1's orders and progress notes reflected she had not received PT since admission, so it was unclear how the immobilizer was placed by a Physical Therapist. Facility policy and procedure for Care Plan Process, Person-Centered Care stated the following: A. The facility will develop and implement a baseline and comprehensive Care Plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet the professional standards of quality care. Person-centered care means the facility focuses on the resident as the center of control and supports each resident in making his or her own choices. Person-centered care includes trying to understand what each resident is communicating, verbally and non-verbally, identifying what is important to each resident with regard to daily routines and preferred activities, and understanding the resident's life before coming to the nursing home. The services provided or arranged by the facility, as outlined by the comprehensive person-centered Care Plan, will meet professional standards of quality. The person-centered Care Plan includes: A. Date B. Problem C. Resident goals for admission and desired outcomes D. Time frames for achievement E. Interventions, discipline specific services, and frequency F. Refusal of services and/or treatments 1) Evaluation of resident's decision-making capacity 2) Educational attempts 3) Attempts to find alternative means to address the identified risk/need. G. Discharge Plans 1) Resident's preference and potential for future discharge 2) Resident's desire to return to the community and any referrals to local contact agencies and/or other appropriate entities, for this purpose H. Resolution/Goal Analysis

Based on observation, interview, and record review, the facility failed to ensure the residents received treatment and care in accordance with professional standards of practice for 1 of 24 residents (Resident #25) reviewed for physician orders for treatments. In eight observations over three days, the facility failed to follow physician orders and apply TED hose as ordered for Resident # 25. (Thrombo-Embolic Deterrent hose which are medical stockings designed to prevent blood clots to the legs). The failure could affect residents currently residing in the facility resulting in not receiving needed care to maintain optimum health and placing them at risk for injury and/or deterioration in their condition. Findings include: Record review of Resident # 25's face sheet printed 01/21/2025 revealed a [AGE] year-old male. Resident #25 was admitted on [DATE] with the following diagnoses: dementia, unspecified,( a group of thinking and social symptoms characterized by impairment of at least two brain function such as memory loss and judgement) type 2 diabetes mellitus ( chronic condition where the body does not use insulin properly)with diabetic neuropathy (condition where nerves in the body are affected)legs or , acquired absence of right leg below knee, weakness, depression, and heart failure ( a condition where the heart cannot pump as much blood as is needed). Record review of Resident # 25's MDS, dated [DATE] revealed a BIMS of 10 indicating no cognitive impairment. His functionality per his last MDS revealed he required substantial/maximal assistance to complete bathing, toileting, and lower body dressing. Resident # 25 needed partial/moderate assistance with upper body dressing, and supervision or touch assistance with eating and oral hygiene. Record review of Resident #25's Care Plan dated 12/10/24 documented Resident #25 needed the assistance of 1 to 2 staff for ADLs. He was at risk for pain, had peripheral vascular disease and had right below knee amputation. Record review of Resident #25's physician's orders dated 12/22/24, documented TED hose to left leg while awake, off at bedtime. Once a day 8:00 am Order start date was 06/25/2024 with no discontinue date. In an observation on 01/21/2025 at 10:40 am, Resident # 25 was sitting in a wheelchair in his room. There were no TED hose observed on his leg. In an observation on 01/21/2025 at 12:25 pm , Resident # 25 was sitting in a wheelchair in his room,. There were no TED hose observed on his leg. In an observation on 01/21/2025 at 2:15 pm, Resident # 25 was sitting in a wheelchair in his room. There were no TED hose observed on his leg. In an observation and interview on 01/22/2025 at 10:00 am, Resident # 25 was sitting in a wheelchair in his room. There were no TED hose observed on his leg. Resident #25 stated he was supposed to wear TED hose, but he did not know where they were. Resident # 25 stated staff did not put the TED hose on his leg all the time. He stated it had been a long time since he had the hose on. He stated he thought the staff forgot he was supposed to wear the hose. Resident #25 stated he had not had them on at all this week. He stated he usually had some TED hose in his drawer and if he had some, he would put them on himself, but they were hard to get on and he could not get them on by himself. He stated the hose were supposed to help his leg not swell. He stated his leg had been swelling . Observations of his leg by this writer did not reveal his leg was swollen at this time. In an observation on 01/22/2025 at 3:40 pm, Resident # 25 was sitting in a wheelchair in his room, and there were no TED hose observed on his leg. In an observation and interview on 01/23/2025 at 9:15 am, Resident # 25 was sitting in a wheelchair in his room, and there were no TED hose observed on his leg. Resident #25 stated he was supposed to wear TED hose, but he did not know where they were. He stated no one came to put them on this week and if he had some, he would put them on himself. He stated the hose were usually in his drawer. He stated the hose were to help his leg not swell. In an interview on 01/23/2025 at 9:31 am LVN E stated she usually works with Resident #25 and is well acquainted with his needs. She stated Resident #25 has an order for TED hose to be on all day every day. When asked why Resident #25 did not have TED hose on this week during the day she stated she thought he had the hose on. She stated a negative outcome for not having the hose on could be he could get a blood clot. She stated she was trained by the other nurses in the facility. She stated the CNAs should have put the TED hose on Resident #25 every day that he was out of bed. In an observation and interview on 01/23/2025 at 9:31 am, CNA F stated she was aware Resident #25 had an order for TED hose when out of bed. She stated she was not aware he did not have the TED hose on at this time. She stated she would put the hose on Resident #25 at this time. CNA F got the TED hose out of Resident #25's drawer and put the hose on. Resident #25 stated his foot was really swollen. CNA F commented to Resident #25 his foot was swollen. Resident #25 stated to CNA F he had not had the hose on all week, and he would have put the hose on himself, but he did not know where they were, and he had a hard time putting the hose on by himself. In an observation and interview on 01/23/2025 at 10:10 am, the DON stated she expected all staff follow the physicians' orders. She stated an order would be put into the charting system after it is written by a physician. The order then would be listed on the Treatment Administration Record. The DON stated an order for TED hose would be listed on the Treatment Administration Record and the system would trigger the staff to put the hose on the resident. She stated she expected the LVNs to put TED hose on a resident, but they could allow the CNAs to put TED hose on. The DON stated she and the ADON's would review the documentation every morning to monitor whether physician orders were being followed. If physician orders were not followed, she would follow up with staff for explanations for why the orders were not followed. The DON stated the morning review had not pulled up Resident #25. The DON stated she was not aware Resident #25 had not had his TED hose on this week. The DON printed the 14 Day Administrative History and stated Resident #25 had not had TED hose on every day as ordered. She stated she trained the nurses to do their jobs and expects physicians' orders were followed 100 percent for all orders and all residents. The DON stated she had not done any trainings on TED hose in the facility. She stated the consequences of not wearing the TED hose for a resident would be blood clots and circulation issues. In an interview on 1/23/25 at 10: 55 am the ADM stated she could not locate any policies on TED hose, Quality of Care, following physician orders or documentation of treatment administration.

Based on observation, interview, and record review, the facility failed to ensure that residents who need respiratory care were provided such care consistent with professional standards of practice for 3 (Resident #68, Resident #78, and Resident #246) of 24 residents reviewed for respiratory care. -The facility failed to have orders for oxygen administration for Resident #68 who was receiving oxygen therapy via NC. -The facility failed to change nebulizer tubing for Resident #79 for 4 months. -The facility failed to have orders for oxygen administration for Resident #246 who was receiving oxygen therapy via NC. This failure could affect residents on respiratory therapy by placing them at risk for respiratory compromise and associated complications such as shortness of breath, confusion, respiratory failure, and exacerbation of their condition. Findings include: Resident #68 Record review of Resident #68's admission record dated 01/21/25 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, wheezing (shrill whistle or coarse rattle heard when the airway is partially blocked), cognitive communication deficit (difficulty with one or more of the following: attention, memory, perception, language, problem-solving, and reasoning), and chronic combined congestive heart failure (a type of progressive heart disease where both aspects of the heart's pumping mechanism are significantly impaired over a prolonged period resulting in shortness of breath, swelling, fatigue, wheezing, and confusion or forgetfulness). Record review of Resident #68's admission MDS completed on 12/26/24 revealed the following: Section C: Resident #68 had a BIMS of 9 which indicated moderately impaired cognition. Section O: Resident #68 received oxygen therapy While a Resident. Record review of Resident #68's care plan last reviewed and revised by MDS RN on 01/21/25revealed no mention of Resident #68 receiving oxygen therapy. He was to be monitored for signs of respiratory distress, shortness of breath, difficulty breathing, fast/shallow breaths, crackling breath sounds, and oxygen saturation below 95%. No mention made in the care plan regarding how to address any of these concerns, should they arise. Record review of Resident #68's order report dated 12/21/24 to 01/21/25 revealed no order for oxygen administration. Record review of Resident #68's EMAR dated 01/21/25 and covering his entire stay in the facility revealed no mention of oxygen therapy. Record review of Resident #68's vitals report regarding his oxygen saturation dated 01/21/25 revealed during his stay in the facility his oxygen saturation was checked 66 times and he was receiving oxygen 47 of those times. During an observation on 01/21/25 at 09:55 AM Resident #68 was seated in his w/c in his room receiving O2 via NC at 3.5 lpm. During an observation and interview on 01/21/25 at 02:04 PM Resident #68 was seated in his w/c in his room receiving O2 via NC at 3.5 lpm. He stated he had used O2 24/7 for three years. During an observation on 01/21/25 at 08:24 AM Resident #68 was lying on his bed with his eyes closed receiving O2 via NC at 3.5 lpm. Resident #78 Record review of Resident #78's clinical record revealed an [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), muscle wasting (the loss of muscle mass and strength due to disease, injury, or lack of use), and shortness of breath. Record review of Resident #78's clinical record revealed her last MDS was a quarterly completed 12/10/24 listing her with a BIMS of 9 indicating she was moderately cognitively impaired, and she had a functionality of requiring supervision or touching assistance with most of her activities of daily living. Record review of Resident #78's Medications Administration History: 1/1/25 - 1/23/25 revealed the following administration: Resident #78 received Ipratropium-albuterol solution for nebulization; 0.5mg-3mg (2.5mg base)/3ml inhalation every 6 hours-received daily 1/1/25 through 1/23/25 via nebulizer. Record review of Resident #78's clinical record revealed a care plan with last conference date of 12/18/24 revealed the following: Problem: Resident requires oxygen therapy R/T COPD. Start Date: 6/18/24. Approach: -No approaches were listed related to nebulizer care. During an observation and interview on 01/21/25 at 10:28 AM Resident #78 was observed in her room sitting at the side of her bed. Resident #78 had a nebulizer on her bedside dresser with the mask stored in a small bag. The nebulized tubing was dated 9/2/24 and the mask was noted to be slightly white/discolored with particulates on the inside of the mask. Resident #78 reported that the staff provide for her respiratory care but was unable to remember when the tubing or mask had been changed. During an observation and interview on 01/23/25 at 08:01 AM Resident #78's nebulizer tubing was still marked 9/2/24. Resident #78 stated that she used the nebulizer quite a bit and that it helped her a lot with her breathing. During an interview on 01/23/25 at 08:02 AM LVN E (the nurse responsible for Resident #78 this shift) reported that Resident #78 received her nebulizer on a scheduled dose daily every 6 hours. LVN E entered Resident #78's room, observed the nebulizer tubing, and stated, Oh my gosh. That should have been changed by night shift. I believe it is supposed to be changed every Sunday. LVN E observed the tubing and stated, It is either dated 9/2/24 or 9/7/24, that second number is a little difficult to read. LVN E immediately removed the mask and tubing and threw them in the trash. LVN E reported that not changing the tubing per policy could result in the tubing becoming clogged or the resident getting and infection. During an interview on 01/23/25 at 09:52 AM the DON reported that respiratory equipment should be checked q shift for issues such as kinking, becoming dirty, or found on the floor, or something like that. If any issues were found, then mask or tubing should be replaced. The DON reported the facility policy was that all respiratory equipment to include the nebulizer masks and tubing were to be changed weekly by the night shift. The DON reported that if the tubing or mask was not changed as it should then the resident was at risk for infection. Resident #246 Record review of Resident #246's admission record dated 01/21/25 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, combined congestive heart failure (a progressive heart disease that affects the pumping action of the heart muscles resulting in shortness of breath and fatigue) and anxiety disorder (serious mental illness characterized by extreme mood swings such as extreme excitement or extreme depressive feelings). Record review of Resident #246's EHR revealed no MDS assessment completed. Record review of Resident #246's care plan last reviewed and revised by ADON A on 01/17/25 revealed no mention of oxygen therapy. Record review of Resident #246's order report dated 12/21/24 to 01/21/25 and thereby covering her entire stay in the facility revealed no order for oxygen administration. Record review of Resident #246's EMAR dated 01/21/24 and covering her entire stay in the facility revealed no mention of oxygen administration. Record review of Resident #246's vitals report regarding her oxygen saturation dated 01/21/25 revealed during her stay in the facility her oxygen saturation was checked 13 times and she was receiving oxygen 8 of those times. During an observation on 01/21/25 at 09:43 AM Resident #246 was lying her bed receiving O2 via NC at 5 lpm. During an observation and interview on 01/21/24 at 02:07 PM Resident #246's family member was seated in Resident #246's room. Resident #246 was in the bathroom being assisted by staff. Her oxygen tubing extended from the oxygen concentrator into the bathroom. The concentrator was set on 5 lpm. Resident #246's family member stated Resident #246 had been receiving O2 therapy for 10-[AGE] years. During an interview on 01/23/25 at 09:47 AM CNA C stated nurses were responsible for setting oxygen levels. During an observation and interview on 01/23/25 at 09:52 AM LVN D, a nurse on Resident #68 and Resident #246's hall, stated nurses were responsible for setting oxygen levels based on physician's orders. When asked to find the orders for Resident #68 and Resident #246 he sat down at his computer and began to search. After 2-3 minutes had passed, LVN D stated he could not find the orders for either Resident. He stated, Neither one is in the system. LVN D stated a possible negative outcome of administering oxygen therapy without a physician's order was hyperoxygenation (condition where the body has too much oxygen in its tissues and organs, can lead to oxygen toxicity), could create confusion. During an interview on 01/23/25 at 09:57 AM MDS LVN and MDS RN stated care plans should include details regarding oxygen therapy. They stated they looked in physician's orders, progress notes, and vital signs in the EHR to determine if oxygen therapy should be included in care plan. MDS RN stated administering oxygen therapy without a physician's order could negatively affect a resident. MDS LVN stated, Acting without physician's orders . is not a good thing. During an interview on 01/23/25 at 10:10 AM ADON B stated nurses were responsible to set oxygen levels according to physician orders. She stated she did not know why Resident #68 and Resident #246 were receiving oxygen without physician's orders. She stated the facility had standing orders for oxygen from 2-4 lpm for oxygen saturations below 90%. ADON B stated receiving oxygen without orders could negatively affect a resident. She stated, Not everybody needs oxygen, there is such a thing as too much oxygen. If they are breathing fine on their own, it is not good for them to have oxygen. During an interview on 01/23/25 at 10:23 AM DON stated nurses were responsible for setting oxygen levels. She stated they knew what level to set the oxygen to by referring to physician's orders. She stated a resident receiving oxygen without physician's orders could experience hypoxia (not enough oxygen in the body) or a change in mental status. She stated the facility did not have standing orders for oxygen because she did away with them. She stated, We really don't do standing orders because everybody is an individual and I do not like them (standing orders). They (facility) had them in the past, but I said, 'No.' Record review of facility policy titled Respiratory Policies and Procedures and dated 2024 revealed the following: Subject: Oxygen Therapy . A. Maintain the patient's/resident's target oxygen saturation level within the provider's recommended range. Oxygen therapy will be used to raise the patient's/resident's PaO2 to an acceptable baseline using the lowest FlO2. The licensed nurse is to check the oxygen outlet port to verify flow in accordance with provider's order. Verify the provider's order for the oxygen therapy; all orders for oxygen therapy will include administration modality, liter flow, continues our as needed (PRN). PRN orders will include the specific guidelines as to when the patient/resident is to use oxygen. Select the most appropriate oxygen delivery device based on the provider's order . Record review of facility policy titled Physician's Orders and dated 2023 revealed the following: . Upon admission the Facility has physician orders for the resident's immediate care to include but not limited to . B. Medications, if necessary C. Routine care orders to maintain or improve the resident's functional abilities until staff can conduct a comprehensive assessment and develop an appropriate care plan. The facility should not administer medications or biologicals except upon the order of a physician/prescriber lawfully authorized to prescribe them. Record review of the facility provided policy titled Respiratory Policy and Procedures revised 2-12-2024, revealed the following: Subject: Oxygen Therapy -no information related to nebulizer equipment therapy/maintenance. 46534

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure freezer items were properly stored, labeled, and dated. 2. The facility failed to ensure proper hand hygiene and glove use was practiced. These failures could place residents who ate food served by the kitchen at risk of food-borne illness. Findings include: Observation of the walk-in freezer on 1/21/25 at 9:50 am, revealed a large plastic bucket with the following foods thrown into the bucket: 1. (1) Ziplock bag of [NAME], no label or date, not in original box. 2. (1) bag of frozen okra, no label or date, not in original box. 3. (1) bag of frozen hash brown patty triangles, no label or date, not in original box. 4. (2) bags of biscuits, no label or date, not in original box. 5. (2) bags of frozen unidentifiable brown food, no label or date, not in original box. In an observation on 1/22/25 at 11:00 am, of the walk-in freezer revealed the following was observed: 1. (1) Ziplock bag of [NAME], no label or date, not in original box. 2. (1) bag of frozen okra, no label or date, not in original box. 3. (1) bag of frozen hash brown patty triangles, no label or date, not in original box. 4. (2) bags of biscuits, no label or date, not in original box. 5. (2) bags of frozen unidentifiable brown food, no label or date, not in original box. In an observation and interview on 1/22/25 at 12: 15 pm, the DM was observed with gloved hands to touch food trays, picked up the serving utensils, put the serving utensils down on the counter, removed the lids off the food on the tray line, picked up the serving utensils and placed them into the food items, picked up tray tickets and put them down, picked up a plate, put the plate down, picked up tray tickets again and then picked up a plate. The DM began plating the food. The DM then picked up a roll with her gloved hands and placed it on the plate. The DM then picked up another plate, plated the food and picked up another roll with her gloved hand and placed the roll on the plate. The DM was asked if she realized she had touched various surfaces in the kitchen and then used her hand to pick up the roll. The DM smiled and said oops. Then went to get the tongs. The DM did not change her gloves. In an observation on 1/22/25 at 3:20 pm, of the walk-in freezer revealed the following was observed: 1. (1) Ziplock bag of [NAME], no label or date, not in original box. 2. (1) bag of frozen okra, no label or date, not in original box. 3. (1) bag of frozen hash brown patty triangles, no label or date, not in original box. 4. (2) bags of biscuits, no label or date, not in original box. 5. (2) bags of frozen unidentifiable brown food, no label or date, not in original box. 6. (1) baggie of frozen cookie dough, no label or date, not in original box. In an interview and a walk through of the kitchen on 1/23/25 at 9:50 am, the DM stated she knew she should have changed her gloves and used tongs to serve the bread at lunch, but she just forgot. She stated the consequences of not washing hands and changing gloves and not using tongs to serve the bread would be cross contamination for the resident. The DM stated of the bucket of frozen food items the staff just throw everything that is leftover in the bucket. She stated everything should be labeled and dated and that she expected all staff to label and date all food items when used and stored. She stated if foods were not properly wrapped up or labeled and dated this could cause food contamination and sickness to residents. The DM stated she trained the kitchen staff and she had been trained by the dietician in labeling and dating as well as hand hygiene and using tongs to serve bread. Record Review of the facility policy and procedure, dated 9/19/24, titled Safe Food Handling documented employees wash hands prior to handling food. Follow all local state and federal regulations when handling food. Refrigerated foods are properly covered, labeled, and dated. Food is served with clean sanitized utensils. There is no bare hand contact. All foods removed from the original packaging are stored in a closed container and labeled with the common name of the product and the date it was opened. Record Review of the facility policy and procedure, dated 9/9/24, titled Indications for Glove Use documented employees must wash hands before putting on gloves, when changing into fresh gloves and immediately after removing gloves. Change gloves when an unsanitary item is touched. Examples include making sandwiches, handling flatware, putting rolls on plates, .Change gloves when beginning a different task. Record Review of the facility policy and procedure, dated 9/19/24, titled Safe Food Preparation documented Avoid touching ready to eat foods with bare hands. Use tongs or other utensils instead. When gloves are worn , they are clean and changed between tasks. Record Review of the facility policy and procedure, dated 9/19/24, titled Food Safety in Receiving and Storage documented Tightly seal opened packages. Refrigerated food items are properly covered, labeled, and dated clearly marked to indicate a use by date. Containers holding food or food ingredients that are removed from the original packaging are identified with the common name of the food and labeled and dated.

Based on interview, and record review, the facility failed to ensure all residents had the right to formulate an advanced directive for 1 (Resident #21) of 15 residents reviewed for advanced directives in that: Resident #21 had a DNR in her record that both witnesses signed the document 5 days before the Medical Power of Attorney signed the document. This failure could place residents a risk for not receiving healthcare as per their or their legal representatives wishes. Findings included: Record review of Resident #21's face sheet printed [DATE] revealed she was a [AGE] year-old female resident admitted to the facility originally on [DATE] and readmitted on [DATE] with diagnoses to include multiple sclerosis (a chronic disease that damages the central nervous system, specifically the brain and spinal cord), pain, muscle wasting (the loss of muscle mass and strength due to disease, injury, or lack of use), diabetes (a chronic condition that affects the way the body processes blood sugar (glucose), and paraplegia (paralysis of the legs and lower body). Section Advance Directives listed Resident #21 as a DNR (Do Not Resuscitate). Record review of Resident #21's last MDS was a quarterly assessment completed [DATE] listing her with a BIMS score of 15 indicating she was cognitively intact, and she had a functionality of being dependent on staff for most of her activities of daily living. Record review of Resident #21's care plan with last care conference of [DATE] revealed the following: Problem: Start Date-[DATE] Advanced Care Planning: Code Status DNR Goal: Resident will be informed of her rights to complete advanced directives to direct her medical care and make her values and treatment goals known. Resident's stated desires will be honored. Approach: Advanced directives of resident's choice completed and placed on medical record under advanced directive tab or in documents in Matrix. Resident will be informed of her right to complete advanced directives to direct her medical care and make her values and treatment goals known. Residents stated desires will be honored. Record review of the clinical record for Resident #21 revealed an Order Summary with active orders as of [DATE] with the following order: Code Status: DNR - Start date: [DATE]. Record review of the clinical record for Resident 21 revealed a DNR dated [DATE] (signed by Declaration by legally guardian, agent, or proxy) with the following: Section B: Declaration by legal guardian, agent, or proxy on behalf of the adult person who is incompetent or otherwise incapable of communication. 1. The document is signed by the agent in a Medical Power of Attorney dated [DATE]. Section Two Witnesses: We have witnessed the above noted competent adult person or authorized declarant making his/her signature above and , if applicable, the above-noted adult person making an OOH-DNR by nonwritten communication to the attending physician. -Witness one signed the document [DATE] (5 days before the Medical Power of Attorney) -Witness two signed the document [DATE] (5 days before the Medical Power of Attorney) Section Physician's Statement-signed by the physician [DATE] During an interview on [DATE] at 02:51 PM, LVN G and ADON B were present. Both staff reported that Resident #21 was a DNR and that if Resident 21 was found without a heart rate or respirations they would not initiate CPR. ADON B reviewed Resident #21's DNR and stated, This is not a valid DNR because the witnesses signed the form before anyone else. LVN G reviewed the form and stated, The people who witnessed, witnessed before anybody else signed the form. LVN G reported that she would immediately take the DNR to the social worker for correction. ADON B reported that if a resident had a DNR that was not valid then the staff would have to code the resident and go against that resident or the resident's family's wishes. LVN G reported that the facility possibly would not code a resident that should have been coded. During an interview on [DATE] at 09:48 AM the DON reported that witnesses should never sign a DNR until all other signatures are completed. The DON reported that if a witness signs a DNR before the resident, family, MPOA, or POA then the form was invalid and the resident would not be a DNR, the resident would be a full code and the resident or the family's wishes would not be honored which could affect that residents care. During an interview on [DATE] at 12:26 PM the SW reported that she did not know why Resident #21's DNR was incorrectly completed, that they checked the DNR's each time they had care plan conferences but that they did not review the dates on the DNRs, just that the DNR's were dated, and all the required signatures were present. The SW reported that they were going to implement a new procedure that included checking the dates when the signatures were provided. The SW reported that the facility did not complete Resident #21's DNR form, that the resident's FM O completed the form, and she did not know why FM O had the witnesses sign the form first. The SW reported that neither of the witnesses for Resident #12's DNR form were affiliated with the facility. The SW reported that if the DNR was not completed correctly then it was not valid, and the resident would not receive the care they wished to have. Record review of the facility provided policy titled Advanced Directives revision [DATE], revealed the following: Policy-The facility recognized the resident right to formulate and advanced directive. Intent-This policy and procedure provide instructions to facility staff or obtaining, honoring, and implementing advanced directives to the fullest extent of the law. The Facility's Policy on Advance Directives. 2. Compliance with State Law. The facility will comply with each States law regarding advance directives and similar declarations. Record review of the OUT-OF-HOSPITAL DO-NOT-RESUSCITATE (OOH-DNR) ORDER-TEXAS DEPARTMENT OF STATE HEALTH SERVICES, undated revealed the following: -The original or a copy of a fully and properly completed OOH-DNR Order or the presence of an OOH-DNR device on a person is sufficient evidence of the existence of the original OOH-DNR Order and either one shall be honored by responding health care professional In addition, the OOH-DNR Order must be signed and dated by two competent adult witnesses, who have witnessed either the competent adult person making his/her signature in section A, or authorized declarant making his/her signature in either sections B, C, or E, and if applicable, have witnessed a competent adult person making an OOH-DNR Order by nonwritten communication to the attending physician, who must sign in Section D and also the physician's statement section.

Based on observation, interview, and record review the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 (Resident #246) of 24 residents reviewed for baseline care plans. The facility failed to include Resident #246's oxygen therapy in her baseline care plan. This failure could result in residents not receiving needed care and treatment. Findings Included: Record review of Resident #246's admission record dated 01/21/25 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, combined congestive heart failure (a progressive heart disease that affects the pumping action of the heart muscles resulting in shortness of breath and fatigue) and anxiety disorder (a group of mental health conditions characterized by excessive and persistent worry, fear, and nervousness that can significantly interfere with daily life). Record review of Resident #246's EHR revealed no MDS assessment completed. Record review of Resident #246's care plan last reviewed and revised by ADON A on 01/17/25 revealed no mention of oxygen therapy. Record review of Resident #246's vitals report regarding her oxygen saturation dated 01/21/25 revealed, during her stay in the facility, her oxygen saturation was checked 13 times and she was receiving oxygen 8 of those times. During an observation on 01/21/25 at 09:43 AM Resident #246 was lying her bed receiving O2 via NC at 5 lpm. During an observation and interview on 01/21/24 at 02:07 PM Resident #246's family member was seated in Resident #246's room. Resident #246 was in the bathroom being assisted by staff. Her oxygen tubing extended from the oxygen concentrator into the bathroom. The concentrator was set on 5 lpm. Resident #246's family member stated Resident #246 had been receiving O2 therapy for 10-[AGE] years. During an interview on 01/23/25 at 09:57 AM MDS LVN and MDS RN stated they were responsible for completing comprehensive care plans and DON and the ADONs were responsible for completing baseline care plans. MDS LVN and MDS RN stated care plans should include details regarding oxygen therapy. MDS LVN stated a possible negative outcome of a care plan not including O2 therapy was there would be no communication between different nurses as far as consistency in care if (oxygen was) not in (the) care plan. During an interview on 01/23/25 at 10:10 AM ADON B stated she, ADON A, and DON were responsible for completing baseline care plans. She stated she was over Resident #246's hall. She stated she did not know why Resident #246 did not have O2 therapy in her care plan. She stated a possible negative outcome of the baseline care plan not mentioning O2 therapy was staff would not have documentation to refer to regarding resident care. During an interview on 01/23/25 at 10:23 AM DON stated she and the ADONs were in charge of baseline care plans. She stated baseline care plans should include information regarding O2 therapy if the resident was receiving O2 therapy. She stated a possible negative outcome of the care plan not mentioning O2 therapy hypoxia and/or a change in the resident's mental status. Record review of facility policy titled Care Plan Process, Person-Centered Care and dated 5/5/2023 revealed the following: . The facility will develop and implement a baseline and comprehensive care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The facility will provide the resident and their legal representative with a summary of the baseline person-centered care plan that includes but is not limited to . a summary of the resident's medications, . any services and treatments to be administered by the facility . The baseline person-centered care plan will include the minimum healthcare information necessary to properly care for the resident .

Based on interviews and record reviews the facility failed to ensure the residents had the right to participate in his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 1 of 24 residents (Resident #38) reviewed for resident rights. The facility failed to obtain a signed informed consent based on information of the benefits, risks, and options available for Resident #38's prior to administering Seroquel, a psychotropic medication, (a psychoactive drug taken to exert an effect on the chemical make-up of the brain and nervous system). This failure could place residents at risk of receiving medications without their prior knowledge or consent, or that of their responsible party or being aware of the benefits and risks of the medications prescribed. Findings included: Record review of Resident #38's face sheet, dated 01/22/2025, revealed a [AGE] year-old-female who was admitted to the facility on [DATE] with diagnoses to include anxiety disorder (fears that are strong enough to interfere with daily life), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), muscle weakness, unspecified dementia (cognitive loss), cognitive communication deficit (impaired thought processes), and difficulty walking. Record review of admission MDS assessment dated [DATE] revealed Resident #38 was sometimes understood. The MDS revealed Resident #38 had a BIMS score of 7 out of 15 which indicated the resident's cognition was severely impaired. Record Review of Section N0415 indicated Resident #38 was taking antidepressants, antipsychotics, and antianxiety medications. Record review of a care plan for Resident #38 dated 12/28/2024 revealed a focus area of Psychotropic Drug Use: Resident is at risk for adverse consequences related to receiving treatment of anxiety. Goal section of care plan revealed that Resident #38 will not exhibit signs of drug related side effects or adverse drug reaction. Approach section of care plan stated that they will assess if the resident's behavioral/mood symptoms present a danger to the resident and/or others. Intervene as needed. Record review of Resident #38's order summary report dated 12/23/2024-01/23/2025 revealed the following orders: Seroquel 100 mg give 1 tablet by mouth twice a day related to depression. Record review of Resident #38's electronic medical record of revealed no consent for Seroquel. Record review of Resident #38's MRR recommendation dated 12/1/2024-12/16/2024 revealed, Per new regulations, resident is receiving an antipsychotic that requires the new informed consent form (Form 3713) to be filled out and signed by provider + resident/responsible party. Antipsychotic medication needing new informed consent: Seroquel. During an interview on 01/23/2025 at 1:00 PM, the DON stated that the facility did not have a signed consent form for Resident #38's Seroquel. She stated that Hospice had ordered it and the facility requires a signed consent form for all psychotropic medications. The DON stated that a possible negative outcome for not having a consent for psychotropic medications could be that a wrong medication could be given . During an interview on 01/23/2025 at 1:13 PM, the ADON stated the consent should have been obtained prior to the residents being given psychotropic medications. The ADON stated a potential negative outcome to the residents was the resident would have side effects, there could be behaviors and the family would not know. Record review of facility policy titled Pharmacy Services: Section 6 - Medication Management. Subject: Psychotropic Drugs - Use of dated 04/01/2022 revealed in part . 1. A psychotropic drug is any drug that affects brain activities associate with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: a. Anti-psychotic b. Anti-depressant c. Anti-anxiety and d. Hypnotic 6. A consent form will be completed for each psychotropic medication prescribed .

Based on interview, observation and record review, the facility failed to provide the necessary care, treatment, and services, consistent with professional standards of practice, to prevent development of pressure injuries for three (Resident #1, Resident#2, Resident# 3) of twelve residents reviewed for pressure ulcer. 1. The facility failed to identify pressure ulcer for Resident #1 on residents left heel when completing weekly skin assessments from 01/13/2023 admitted until 02/19/2023, when a family member asked staff to look at the black area on Resident #1's left heel. 2. The facility failed to complete an initial skin assessment to identify any skin concerns for Resident #1 upon admission to the facility on [DATE]. 3. The facility failed to complete an accurate comprehensive care plan for Resident #1 to indicate Resident #1 was at risk for pressure ulcers. 4. The facility failed to identify a new pressure ulcer for Resident #2, failed to identify an open area on Resident #3's coccyx. On 02/24/2023 at 5:45 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 02/27/23 at 2:15 PM, the facility remained out of compliance at a severity level of actual harm at a scope of pattern, due to facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures could place residents who are at risk for developing worsening pressure ulcers, Osteomyelitis (infection of the bone), Sepsis (infection of the blood) pain, loss of limb and or death. Finding included: Record review of Resident #1's undated face sheet reflected, Resident #1 was admitted to the facility on [DATE] with the following diagnoses: pyogenic arthritis (pain in join), muscle weakness, cognitive communication deficit (difficulty with thinking), difficulty in walking, muscle wasting and atrophy, (decrease in muscle tissue), sepsis unspecified organism, edema. Record review of the MDS for Resident #1 dated 01/17/2023 reflected a BIMS score of 11. (Moderately impaired). Section M0150 revealed the resident was at risk for pressure ulcers 1, indicating yes. Section M0210 revealed Resident #1 did not have any unhealed pressure ulcers 0 indicating none, Section M1040 revealed other skin problems- surgical wound. Record review of Resident #1's care plan revised 2/23/23 reflected that Resident #1 was at risk for pressure ulcers R/T impaired mobility. Goal -Resident #1's skin will remain intact. Approach - Conduct a systematic skin inspection _ (left blank on care plan no indication of how many times) (weekly, daily, etc). Pay particular attention to the bony prominences. Report any signs of skin breakdown, (sore, tender, red, or broken areas). Resident #1 has a surgical incision and is at increased risk for infection. Approach - Weekly skin assessments by licensed nurse notify physician of any changes to skin. Record review of Braden Scale for Resident #1 dated 01/13/2023 had a score of 16 indicating at risk for pressure ulcers and one dated 02/27/2023 had a score of 16 indicating at risk for pressure ulcers. (Interpretation of score: 19 or higher = not at risk, 15-18 = at risk, 13-14 = moderate risk, and 10-12 = high risk, and 9 or less = very high risk). During an interview on 02/23/2023 at 2:10PM, the family member for Resident #1, stated that the care has gotten worse the longer Resident #1 has been at the facility. The family member stated that after Resident #1 had gotten out of the hospital she noticed a blister on the back of his foot on 01/18/2023. Family Member stated that she has been telling the staff at the facility about the red spot and blister on his heel for several weeks. The family member stated they could not recall which staff members were notified because they are floaters and never the same person working. The family member stated she notified the facility staff about the blister on 01/18/2023 and stated then on 02/19/2023 while visiting she noticed that Resident #1's heel was black. The family member stated the area on Resident #1's heel was huge and looks like his foot is dying. The family member stated she spoke with the nurse working on 02/19/2023 about Residents #1 heel and the nurse told her she would look to see if there was anything about Resident #1's heel documented and then told her no it was not in his books. The family member stated she could not recall the name of the nurse working on 02/19/2023. The family member stated the nurse did look at his heel and put ointment on his heel and told her they would float it, family member stated not sure what they have done since 02/19/2023 for Resident #1's heel. During an interview on 02/23/2023 at 4:20PM, Resident #1 stated everything has been pretty good but he has a bad heel and he pointed to his left foot and stated, 'well I have a bad foot. Resident #1 stated he was not having any pain with his left foot. Resident #1 agreed to an observation of his lower legs and feet to be completed. RN B, assisted with the observation of Resident #1's skin assessment of his lower legs and feet. Observation on 02/23/2023 at 4:25PM of Resident #1's left heel revealed a black circular area on the left heel. During an interview on 02/23/2023 at 4:30PM RN B, stated she provided care for Resident #1 on 02/23/2023. RN B, stated she provided care for Resident #1 before shortly after he was admitted to the facility and then not again until 02/23/2023. She stated that Resident #1 does have some edema in his lower extremities however she was not aware of any open areas or wounds, that nothing was reported to her in report about wounds. RN B, stated she was not aware of the wound on his left heel and did not have anything documented on her notes for the wound and did not receive any information from the previous shift in report about the wound. RN B, stated that she would look at the electronic records and see if there is any documentation about the wound. Record reviewed of progress note for Resident #1 dated 02/19/2023 revealed on assessment res. Had a black sore on his L heel, wound care provided, and float heels while in bed. Record review of physician orders for Resident #1 dated 02/20/2023 revealed an order for daily wound treatment: Cleanse heel with cleanser and apply betadine to heel and allow to dry. Special Instructions: Drainage: S=Saturated, M=Moist, D=Dry General Appearance: R=Red, Y=Yellow, B=Black, W=White, P=Pink, T=Tan, PU=Purple, BR=Brown, GR=Gray Surrounding Skin: M=Macerated, R=Reddened, F=Firm, N=Normal, Once a Day 0600-1400. Cephalexin capsule; 500mg oral three times a day. During an interview on 02/23/2023 at 5:08PM, NP C with Wound Care Specialist stated she had received a call the day before, from WCN D asking if she could look at Resident #1' left heel. NP C evaluated Resident #1's left heel on 02/23/2023. NP C stated that the wound on his heel has had to have been there for some time, the wound doesn't look infected, it is stable eschar, that he has had it for a while. NP C stated she cleaned it really good and then she removed a little of the skin, stated stable black eschar, he had old skin prep and betadine areas. Peeled off a little bit of callus around it. NP C stated the facility staff didn't mention any time frame to her of how long Resident #1 had the wound, just that WCN had cleaned it and was unsure what to do for the resident. NP C stated Resident #1's wound doesn't look infected and it is attached and that he had good pulses. NP C, stated, the question is when did it occur and that takes several weeks to occur and turn that color. She stated that she was not sure how the facility does their skin assessments here at the facility, but she will ask the ADON about the initial skin assessments how they do them upon admission. NP C then called ADON on speaker phone during the interview and asked ADON about the admission skin assessments. The ADON stated the facility does not have a nurse that does admitting skin assessments it would be the nurse on the floor doing the admitting skin assessments. NP C stated that type of wound is from pressure and the wound will heal that the wound is 3.6X4.5 centimeters. That if Resident #1 eats properly and keeps pressure off it then should heal out in about 6-8 weeks. Record Review of wound report dated 02/24/2023 from NP C, for Resident #1 reflected Wound was currently classified as unstageable/unclassified wound with etiology of Pressure Ulcer and is located on the Left Calcaneus. The wound measures 3.5cm length X 4.6cm width; 12.645cm^2 area. There is no tunneling, or undermining noted. There is a none present amount of drainage noted. The wound margin is distinct with the outline attached to the wound base. There is no granulation within the wound bed. There is a large (67-100%) amount of necrotic tissue within the wound bed including Eschar. The peri-wound skin appearance had no abnormalities noted for color. Peri-wound temperature was noted as No Abnormality. Record review of wound care order dated 02/24/2023 form NP C, revealed Primary Wound Dressing: Wound #1 Left Calcaneus: Other- Cleanse with wound cleanser. Pat dry. Paint entire heel liberally with betadine q shift. Heel cup or heel pillow while in wheelchair. During an interview on 02/24/2023 at 9:48 AM with DON E regarding Resident #1, stated about 3 weeks ago she removed Resident #1's PICC line. DON E denied anyone coming to her regarding his left heel wound. DON E stated that when NP C from wound care was at the facility on 02/23/2023, that the only thing she talked to her about was where to find different reports in electronic records regarding resident's skin. During an interview on 02/24/2023 at 10:05 AM with ADON regarding admission assessments, she stated that a complete head to toe assessment should be completed by the admitting charge nurse. ADON stated after WCN F quit working at the facility on 01/13/2023, she verbally informed the nursing staff that they would be responsible for doing the skin checks and treatments. Regarding CNA shower sheets, she stated that they had them, but it was not being enforced. ADON stated that WCN D completed an in-service on 02/20/2023 indicated that the CNA's were responsible for filling them out on every resident and turning them in to their charge nurse for review and signature, then the form should go to, WCN D, who will then assess any resident that was identified to have skin issues. The ADON stated without thorough skin assessments being completed, a lot could happen to a resident. The ADON stated NP C voiced she would be back to see him next week. The ADON stated that she only became aware of the wound on Monday 2/20/23 when WCN D notified her on what needed to be done. The ADON stated, WCN D notified NP I, and she ordered po antibiotic Keflex for prophylactic since resident was scheduled to be discharged , and to get a referral for a podiatry consult. The SWK worked on the referral and Resident #1 wasn't going to be able to be seen until June. Resident #1 also developed C-diff, which delayed discharged , and Resident #1 remained at the facility. The ADON stated WCN D reached out to NP I, to come assess. The ADON stated that when WCN D notified her of the wound she did not go look at Resident #1's heel. The ADON stated that WCN D was new, so she was just telling her what steps needed to be followed, what should occur upon identification of a wound, wound observation, physician notification, ADON's/MDS update care plan. During an interview on 02/24/2023 at 11:24 AM, with RN B, she stated she does skin assessments, will get with the CNA's, and try to get the assessment done with their shower, she stated that was the best time. RN B, stated she had taken care of Resident #1 on 02/23/2023, and did not see the wound prior to that. RN B, stated she was not sure how she missed it. RN B, stated she did not receive in report anything regarding Resident #1's wound. During an interview on 02/24/2023 at 11:15 AM, the ADON stated she did not find any documentation of the wound on Resident #1's heel. The ADON stated the facility had a 24 - hour report that they can print and pass on to staff for each shift so staff will know what care was needed for each resident. During an interview on 02/24/2023 at 11:17 AM, the Administrator stated the only documentation they have for Resident #1's heel was the physician order for the antibiotic and wound care dated 02/20/2023. The Administrator stated, If you don't document it didn't happen, we dropped some balls here its been the craziest thing in the world trying to get people and we have had a lot of agency staff. The Administrator stated he received an email from Resident #1's family member earlier in the week maybe, Wednesday (02/22/2023) . The Administrator stated the family member mentioned the wound in the email and he had passed that information on to the ADON. The Administrator was asked to provide a copy of the email he received from the family for Resident #1 and he did not provide a copy. During an interview on 02/24/2023 at 11:45 AM, LVN A stated she provided care for Resident #1 on 02/19/2023. LVN A stated a family member for Resident #1 was in the facility visiting Resident #1 and mentioned the area on the heel to her (LVN A). LVN A stated the family member for Resident #1 was cutting or filing Resident #1's toenails and that was how the family member noticed the area. LVN A stated she went to the room of Resident #1 and looked at his left heel. LVN A stated she observed a circle not open but really, really blackish hard, not opened, like the size of if you put your thumb and pointer finger together and make a circle. LVN A stated she contacted WCN D or the ADON on (02/19/2023) to let them know about it and then made the progress note. LVN A stated the family member for Resident #1 mentioned she saw it a few weeks ago but was like a pinpoint size small dot. LVN A stated she has not had to do a full skin assessment on him because they had a wound nurse, and she does that. LVN A stated she did work in the facility on 2/19/23 and prior to that she worked on 2/17/23 and 2/18/23. She stated no one had mentioned anything to her about his foot and when she has seen him, he had on socks. LVN A stated the 24 - hour report sheets were usually two days old if not older and she doesn't always get one. LVN A stated there had not been a wound nurse that does a complete skin assessment for a while at the facility. LVN A stated the new wound nurse was the one that would do a full skin assessment. LVN A stated the admitting floor nurse was the one that would do the initial skin assessment on admission. During an interview on 02/24/2023 at 12:00 PM, WCN D reported that LVN A was not the one that reported the wound for Resident #1 to her. WCN D stated it was CNA H that came to her on Monday (02/20/2023) to ask her if she could look at Resident #1's heel. WCN D stated she went to assess Resident #1 and there was a dressing on his left heel. WCN D stated she took that off and cleaned it, then notified ADON and contacted NP I for orders. During an interview on 02/24/2023 at 1:00 PM, WCN F denied knowing about Resident #1 being admitted on [DATE] the same day she quit her job at the facility. WCN F stated that his name was not familiar to her, and she verified she did not see that resident. During an interview on 02/24/2023 at 3:30 PM with Resident #1, resident agreed for skin assessment. Resident's left heel was observed with an area of black eschar. WCN D stated that upon assessment the area of eschar was hard, Peri-wound is firm without redness or any drainage. Resident #1 denied any pain when WCN D was cleaning and treating area. The residents' right heel was firm with no redness noted. Observations of legs, chest, elbows, shoulders, back, and bottom revealed no issues. During an interview on 02/24/2023 at 1:50PM, CNA H stated she worked with Resident #1 off and on over the three months she has worked at the facility. CNA H and worked with him this week and showered him on Tuesday (02/20/2023). She stated she washed his feet and she saw a black dot maybe the size of a dime. She stated Resident #1 didn't say anything about it. She stated she told the nurse about it, but it was an agency nurse, and she doesn't recall her name. She stated the agency nurse said she would look at it in a little bit. She stated that was the first time it was noticeable to her. She stated she believed the new wound care nurse WNC D, had looked at it by then. She stated the facility has trained her that if she sees something she reports to the nurse and that since the new wound care nurse WCN D started the CNA's had to fill out a shower sheet for each resident when assisting them with showers. CNA H stated prior to that they were not doing the showers sheets. During an interview on 02/24/2023 at 3:55 PM, Surveyor introduced herself and asked NP I if she could come to the conference room for an interview. NP I stated, I'm busy and if I have time I will see. NP I did not comply with interview request. During an interview on 02/24/2023 at 3:57 PM, with LVN G regarding the Admission Assessment on Resident #1 and the blank area on the skin section. LVN G verbalized she had been told by WCN F, that she will come back and fill that information in. She was not aware of Resident #1 having any skin issues, not to my knowledge. LVN G stated she has worked with him since admission, and she has not done a skin assessment on him because she was told all skin assessments are done by WCN F. Record review of Resident #2's undated face sheet, reflected that Resident #2 was admitted to the facility on [DATE], with a readmission on 02/04/2023 with the following diagnoses: unspecified intracranial injury with loss of consciousness of unspecified duration (traumatic brain injury), osteomyelitis of vertebrae (infection of the bone), sacral, sacrococcygeal region, pressure ulcer of right buttock, attention and concentration deficit following cerebral infarction (memory difficulty, trouble focusing, stroke), seizures, obesity, moderate protein-calorie malnutrition, history of stage 3 pressure ulcer of left heel, Polyosteoarthritis (pain in swelling in multiple joints), fusion of spine in lumbar region, depression, and history of traumatic brain injury at 14-years old. Record review of the Annual MDS dated [DATE] reflected Resident #2 had a BIMS score of 9 (moderately impaired), and extensive assistance of two staff members for bed mobility and transferring. Section M0150 indicated that Resident #2 was at risk of developing pressure ulcers/injuries. Section M0210 indicated that Resident #2 has one or more unhealed pressure ulcers/injuries. Section M0300 indicated there was one unstageable pressure ulcer due to coverage of wound bed by slough and/or eschar that was present upon admission/entry or reentry. M1040 indicated no other ulcers, wounds, or skin problems. During interview on 02/24/2023 at 2:15 PM with Resident #2, he indicated he was doing ok and the only problem he had was a sore on his hip. Resident #2 voiced that he had been in healthcare facilities since he was 17-years-old. During an observation on 2/24/2023 at 2:18 PM of Resident #2's skin assessment, performed by WCN D, revealed that left heel was soft and red with a dark-brownish discoloration. Wound measurement noted to be 3 cm x 2 cm. During interview on 02/24/2023 at 2:28 PM with WCN D and charge nurse LVN L revealed they were not aware of Resident #2's left heel DTI. Record review of Resident #2's care plan with a date of 02/24/2023 as being last date reviewed/revised does not reflect Resident #2's DTI (deep tissue injury) to left heel or that Resident #2 was at risk for altered skin integrity. Record review on 02/25/2023 of Resident #2's medical record reflected that Resident #2's Braden Scale for Predicting Pressure Score Risk dated 02/04/2023 had a score of 12, which indicates high risk. (Interpretation of score: 19 or higher = not at risk, 15-18 = at risk, 13-14 = moderate risk, and 10-12 = high risk, and 9 or less = very high risk). Record review of progress notes from 02/04/2023-02/24/2023 did not reflect Resident #2's left heel. Record review of Wound Management tab did not address the left heel. Record review of Physician Orders reflected an order for weekly skin assessments every Wednesday with a start date of 05/27/2022. There was no order for treatment to left heel wound until 02/24/2024, indicating daily wound treatment of left heel to clean with wound cleanser, skin prep, and float heels. Record review of Weekly Skin Observation dated 02/15/2023 does not reflect Resident # 2's left heel. Review of Weekly Skin Observation dated 02/22/2023 reflected no alterations in skin. During an interview on 02/26/2023 at 10:40 AM with MDS J reflected that a care plan was a guideline for the staff to provide appropriate care to the resident. If a care plan does not address all areas of concern, then it could prevent the resident from getting the appropriate care. During an interview on 02/26/2023 at 11:52 AM with MDS K revealed if a wound was not identified and addressed, then the wound could get worse. MDS K stated she had recently been in-serviced on wounds, and that the Braden Scale for Predicting Pressure Ulcer will be done on admission and then weekly. Record review of Resident #3's undated face sheet reflected that Resident #3 was admitted to the facility on [DATE], with the following diagnoses: Alzheimer's disease with late onset (affects memory), dementia in other diseases with other behavioral disturbance. Record review of Resident #3's Annual MDS assessment dated [DATE], reflected that Resident #3 had a BIMS score of 01 (sever cognitive impact) extensive assistance of two staff for bed mobility and transferring. Section M0150 reflected Resident #3 was at risk for developing pressure ulcers/injuries. M0210 reflected that Resident #3 has one or more unhealed pressure ulcers/injuries. M0300 reflected one unstageable pressure ulcer due to coverage of wound bed by slough and/or eschar, not present upon admission/entry or reentry. M1040 indicated no other ulcers, wounds, or skin problems. During an observation on 2/24/2023 at 2:35 PM of Resident #'3's skin assessment by WCN D revealed buttocks with blanchable redness and 0.5 cm x 0.8 cm open area on Resident #3's coccyx. During an interview on 02/24/2023 at 2:45 PM with the ADON and WCN D reflected they were unaware of open area to Resident #3's coccyx. The ADON verbalized that there was a standing order for barrier cream. Record review of Resident #3's care plan dated 02/08/2023 as being last date reviewed/revised did not reflect resident was at risk for alterations in skin integrity, or the 0.5 cm x 0.8 open area to Resident #3's coccyx. Record of Resident #3's medical record on 02/25/2023 revealed there was no Braden Scale For Predicting Pressure Ulcer during the dates of 09/01/2022 to 02/25/2023. Record review of Nursing Progress Notes for Resident #3 revealed no documentation regarding coccyx until 02/24/2023 when WCN D put in a note for the charge nurse to contact the physician for ulcer on coccyx. Record review of the Wound Management reflected that Resident #3's right heel ulcer was identified on 05/27/2022. There was no documentation related to the open area on coccyx identified on 02/24/2023. Record review of February 2023 physician orders reflected an order for weekly skin assessment every Friday with a start date of 04/11/2022. There was no treatment order noted for the wound on coccyx. Record review of Weekly Skin Observation for Resident #3 dated 02/03/2023 revealed treatment to right heel, Weekly Skin Observation dated 02/17/2023 revealed no alterations in skin. During an interview on 02/26/2023 at 9:55 AM with LVN N, reflected that she had been recently in-serviced on wounds, skin assessments and reporting any changes. LVN N stated that the ADON and DON E had in-serviced her, but she had not signed any papers. During an interview on 02/26/2023 at 10:15 AM with RN M reflected that she had been recently in-serviced regarding skin assessments and reporting any changes by the ADON and DON E. RN M stated that it was not anything new, verbalizing that she already does that. RN M was not aware of Resident #3's wound to coccyx. During an interview on 02/26/2023 at 11:52 AM with MDS K reflected that she does the skilled assessments and stated that she developed her care plan based on the admission assessment, diagnoses, medications, behaviors, and she also pulls the wound report. MDS K stated that she was not aware of Resident #1's unstageable heel wound until Wednesday 02/22/2023, and then stated she updated the care plan on Friday 02/24/2023. MDS K stated if a wound is not identified and addressed, then the wound could get worse. MDS K stated she had recently been in-serviced by the ADON and DON E on wounds, and that the Braden Scale for Predicting Pressure Ulcer will be done on admission and then weekly. Record review completed of the following policies: Wound Care: Pressure Ulcer (All rights reserved -2017 CMS FR: 9/7/2017 F684 F686 Email revision 3/23/2017, MR revision 1/18/2017. Complete revision 6/1/2015 Subject: Pressure Ulcers Policy: Pressure ulcers will be evaluated and treated in accordance with professional standards of practice to heal and prevent pressure ulcers unless clinically avoidable. Definitions: Pressure Ulcer/Injury (PU/PI) refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. A pressure injury will present as intact skin and may be painful. A pressure ulcer will present as an open ulcer, the appearance of which will vary depending on the stage and maybe painful. The injury occurs as a result on intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by skin temperature and moisture, nutrition, perfusion, co-morbidities and conditions of the soft tissue. Procedures 1. Evaluate the pressure ulcer initially for location; stage (see specific policy), size (in cm's), sinus tracts, undermining, tunneling, exudate (type, odors), necrotic tissue, and the presence and or absence of granulation tissue and epithelialization. 2. Determine and record the date of onset for each pressure ulcer identified as Stage II or greater. The date of onset is included in the information for the wound on the weekly wound tracking sheet and carried over week to week until healed. If a wound deteriorates to a higher stage, the original onset date is retained. 5. Identify the most sever tissue type for any pressure ulcer on the appropriate forms as follows: D. Necrotic tissues (Eschar): dead or devitalized tissue that is hard or soft in texture: black, brown, or tan color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/edges of the wound. 6. Re-Evaluate pressure ulcers at least weekly. If the patient's/resident's condition or the condition of the wound deteriorates, or if there is no significant progress within a reasonable time frame (2 weeks), the treatment plan should be re-evaluated. Record review completed for facility policy: Wound Care Policies and Procedures (All Rights Reserved 2015. Complete Revision: 6/1/2015 Subject: Wound Evaluations Policy: Evaluation of wounds will be preformed on admission, weekly and on discovery. Procedures: Evaluation is the formal process in which wound characteristics, underlying conditions and contributory medical history are identified/quantified. Evaluation should result in treatment approaches including elimination or compensation for causative factors and a prognosis for healing. 3. Evaluation results are communicated to the members of the care team through documentation, care plan meetings, and care planning. This was determined to be an Immediate Jeopardy (IJ) on 02/24/2023 at 5:45PM. The Administrator, ADON, WCN D, DON E, were notified. The Administrator was provided with the IJ Template on 02/24/2023 at 5:45PM. The following Plan of Removal submitted by the facility was accepted on 02/25/2023 at 2:15PM Record review of the facility Plan of Removal reflected the following: (Facility Name) Plan of Removal 2/24/2023 F686 Revision 2 Resident #1 had complete full body assessment on 2/24/3023, Physician was notified, and treatment order was received. Responsible party was notified of current skin condition & treatment Resident #1 care plan reflects: current skin condition, ordered treatment, offloading of left heel while in bed, Wound Care, Nurse practitioner weekly visits and dietary referral to prevent further skin breakdown. Residents who reside in the facility have the potential to be affected by this alleged deficient practice. A facility wide skin sweep, using current census, starting 2/24/2023 will be completed by 2/25/2023 to validate wounds/skin integrity status. Any concern identified will be addressed upon discovery. Braden Scales will be updated on each resident to determine residents at risk for skin breakdown. Pressure Ulcer Risk Evaluation form will be completed on residents with Braden score of 18 or below to further identify conditions which may contribute to skin breakdown Physician and responsible party will be notified if any resident is identified with new skin concerns during facility wide skin sweep. The Nursing team will implement any new physician orders. Any resident identified during facility wide skin sweep will have their care plan appropriately updated to reflect their current skin condition, including additional approaches to prevent further skin breakdown based on the root cause of their current skin issue. The Registered Nurse (Acting Director of Nursing) was re-educated by the Clinical Consultant on 2/24/2023 on the expectations and oversite on the skin program. This included: Full body skin assessments will be completed by Admission Nurse on New Admissions/Readmissions Braden Scales will be completed by admission nurse on admission, readmission, weekly for 3 weeks then quarterly and or residents with changes of condition to determine residents at risk for skin breakdown. Pressure Ulcer Risk Evaluation form will be completed by admission nurse on residents with Braden score of 18 or below to further identify conditions which may contribute to skin breakdown Resident Care plans will be updated identifying Resident at risk for skin breakdown or resident with actual skin integrity concerns Certified Nurse's Aides will complete skin inspections using shower sheets following resident scheduled shower days. 24-hour report will be monitored Monday through Friday during Morning Clinical meeting to identify any new Changes of condition or new skin concerns and validate information being shared to nurses shift to shift. Nurse management will review on weekends. Validation of Admission/Weekly skin assessments and Braden scales will be completed daily Monday through Friday by Director of Nursing/Nurse managers during Morning Clinical meeting to validate completion, accuracy and timeliness. Director of Nursing/Designee will Round Weekly to validate skin prevention measures are in place/occurring and on weekends by charge nurse The Registered Nurse (Acting Director of Nursing) was able to verbalize understanding of education given in order to educate the licensed nurses and Certified Nursing Aides on the following, beginning 2/24/2023: Full body assessment will be completed on Newly admitted and readmitted residents to identify any skin concerns within first 24 hours. Braden Scales will be completed on admission, readmission, weekly for 3 weeks then quarterly and or on residents with changes of condition to determine residents at risk for skin breakdown. Pressure Ulcer Risk Evaluation form will be completed on residents with [NAME] [TRUNCATED]

Based on observation, interview and record review the facility failed to ensure the resident environment remains as free of accident hazards as is possible for 1 of 10 Residents (Resident #1) reviewed for accident hazards. The facility failed to ensure Resident #1's assistive devices, the assist bars, were secured safely to her bed. When wiggled side to side, both assist bars had movement. There was a 3-inch gap between the mattress and one of the assist bars. Resident #1 was found hanging from the assist bar, her neck and jaw were wedged between the bar and the mattress. She was blue, unresponsive and had no pulse. Resident #1 was pronounced dead minutes later. An Immediate Jeopardy was identified that occurred on [DATE]. The Immediate Jeopardy was removed [DATE]; however, the facility remained out of compliance at an isolated incident of actual harm, due to the facility's need to complete in-service training and evaluate the effectiveness of corrective systems. This failure could affect other residents by putting them at an increased and unnecessary risk of harm and/or fatal injury. Findings include: Record review of Resident #1's closed clinical record revealed a [AGE] year-old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident #1's quarterly MDS dated [DATE] revealed her BIMS score was 2 out of 15, indicating severe cognitive impairment. She required extensive assistance by 2 or more people for bed mobility and transfers. She was always incontinent of bowel and bladder. She received scheduled pain medication, antipsychotic and opioid medications. She was 63 inches tall and weighed 115 pounds. Record review of Resident #1's care plan revealed Resident #1 was at risk for falls related to limited mobility and pain in joints due to arthritis. The Problem Start Date was [DATE]. The care plan also documented Resident #1 required staff assistance of one staff member with most ADLs. The Problem Start Date for this was also [DATE]. One of the approaches was to assist with repositioning as appropriate and maintain body in functional alignment. Another approach was quarter side rails for repositioning only, teach energy conservation techniques, and proper use of side rails for repositioning if able. Record review of Resident #1's Restraint/Adaptive Equipment - Siderail Review and Consent form with an observation and completed date of [DATE] documented the following: · The medical condition for which the use of siderails were being considered was listed as [MEDICAL CONDITION]. · The risk factors listed to choose from for risk of entrapment were: Agitation, Pain, Confusion, [MEDICAL CONDITION], Uncontrolled body movement, and Other. None of these risk factors were checked. According to Resident #1's Care Plan, her [DIAGNOSES REDACTED]. According to Resident #1's Care Plan, she was also diagnosed with [REDACTED]. According to Resident #1's Care Plan, Resident #1 became aggressive when staff redirected her, however, Agitation was not checked as a risk factor for entrapment. Resident #1's quarterly MDS dated [DATE], documented Resident #1 had disorganized thinking which is a sign and symptom of [MEDICAL CONDITION], however, [MEDICAL CONDITION] was not checked as a risk factor for entrapment. There were no risk factors checked for entrapment even though Resident #1 had 4 of the 5 risk factors listed on the form. · According to this form, there was no physician order for [REDACTED].>· The date listed for explaining the risks/benefits of the use of siderails was [DATE]. There were no signatures of the family giving consent for the use of the side rails, nor was there a signature of the staff completing the form. Record review of Nurse's note for Resident #1 dated [DATE] at 12:02 a.m., documented the following: CNA (name) alerted this nurse that pt was crying & that she (CNA) needed assistance. Arrived @ pt's room & noted pt had slid out of bed on to fall mat on the floor, right side leaning up against bed frame, & res was tightly gripping right side rail with her arm. Both CNA (name) & this nurse assisted res to reposition to a position of comfort, then res was assisted up onto the bed. Res then repositioned for comfort in the bed. Assessment done by this nurse. No delayed injuries, bruises, cuts or other open areas noted. All needs met @ this time. Bed down, call light within resident's reach. WCTM. (Written by LVN A) Record review of Nurse's note written by RN D on [DATE] at 12:57 am documented the following: Upon notification from (LVN E), resident had been found lying with her legs and lower body were off the right side of the bed in a crouching like position while her head and upper body remained on the bed. Upon getting assistance to place resident back in the bed, it was noted that the resident was blue and no pulse or respirations were noted. After verifying that the resident was a DNR, no resusitation (sic) measures were taken. Upon assessing, death was pronounced at 2043 (8:43 pm) by this nurse. DON notified. NP (F) notified of residents death. Record review of the incident report written by LVN E, with an incident date of [DATE] at 8:30 pm, documented the following: Found Res (Resident #1) hanging from her neck from the rails. She was blue. Her neck and jaw was (sic) hinged on the rail. Her right arm was under her. She was slumped and hanging. During an observation and interview at 1:40 pm on [DATE] with Resident #3, she was in her room, on the far bed by the window. She was lying on her bed watching TV. She said her roommate, Resident #1, passed away recently. Resident #3 said she was in the room when it happened, but the curtain was closed, and she didn't see anything. When describing what she heard when Resident #1 passed away, Resident #3 said Resident #1 used to snore loudly but this time she was making a really loud snoring noise. Resident #3 was about to press her call light to get Resident #1 some help but a nurse came in to give her some medicine. Resident #3 told the nurse Resident #1 was making strange noises and to check on her. A short time later, Resident #3 was told Resident #1 had passed away. Resident #3's ¼ bedrails were down on the sides of her bed. She said the staff put them up at bed time and put them down during the day. She said it has been that way since she was admitted a couple of months ago. During an observation on 1:45 pm on [DATE] of Resident #1's bed, none of the mattress retainers (metal clips attached to the bed frame on each corner of the bed to hold the mattress in place) were up to hold the mattress securely in place and the mattress could slide lengthwise and sideways on the frame of the bed. The ¼ bedrails were loose when wiggled side to side (towards the bed and away from the bed) giving movement of 1 inch on the right bedrail and ½ inch movement on the left bedrail (from the position of standing, looking at the bed). When the mattress was up against the right bedrail and the right bedrail was not moved there was a ¾ inch gap between the mattress and right bedrail. When the mattress was slid over against the left bedrail and the right bedrail was pushed away from the bed, there was a 3-inch gap between the right bedrail and the mattress. During an interview with CNA B at 2:06 pm on [DATE], she said she worked the day shift starting at 7:00 am on [DATE], the morning after Resident #1 expired. She was told by CNA C, who worked the night shift and witnessed Resident #1 entrapped between the bedrail and mattress, that Resident #1's head was caught between the bedrail and bed, and she choked to death. Resident #1 had been checked on 1 ,[DATE] hours prior to being found like that. CNA B said to ask the Maintenance Director about the monitoring of bed rails to make sure they are tight, she thought he oversaw bedrail maintenance. When asked if anyone else was responsible for checking the tightness of the bedrails, CNA B said it would be a good idea if the CNAs checked the bedrails but the don't. During an interview and observation, in an unoccupied room with Maintenance Director at 4:36 pm on [DATE], Maintenance Director confirmed he was responsible for the installation and maintenance of the beds, including the bedrails. When asked how often he inspects the bedrails, he said every month. When asked to describe what is done when he inspects the beds and the tightness of the bedrails, he demonstrated in the unoccupied room, his routine. He said he visually looks at the bedrails. When asked how he can visually determine how tight the bedrail is to the bed frame, he said he looks at the bolt to see if it is coming out. He said he does not physically grab the bedrail and shake it side to side from the bed. He will see if it is loose going towards the up and down position, but not side to side. When discussing the mattress retainers that were in the down position on the bed, therefore not securing the mattress in place, MA said he was not sure if they should be in the up position or not. He said he doesn't check the mattress retainers as part of his inspection. At 4:47 pm on [DATE], the DON and ADM were asked to come into the unoccupied room with the Maintenance Director. When ADM, DON and the Maintenance Director were shown how much movement there was when the mattress was not secure, and the bedrails were not tightly secured to the bed frame, they did not think the amount of movement was significant. The DON said she was more concerned with the risk of skin tears the mattress retainers could cause than a resident's head becoming entrapped between the mattress and the bedrail. The Maintenance Director said the manufacturer wouldn't make the retainers go down if they wanted them to be up, he thought they were optional. The ADM said he thought the facility was following the Manufacturer's recommendations and specifications. He said they have an outside agency come out to inspect the bed annually in addition to the Maintenance Director's monthly inspections. ADM said they couldn't have done anything different to prevent what happened to Resident #1. During an interview with CNA C at 5:45 pm on [DATE], she said she was doing hydration rounds, handing out snacks, and answering call lights on the evening of [DATE]. When she stepped out of a Resident's room, LVN [NAME] called out for help from Resident #1's room. When CNA C entered Resident #1's room, she saw her sitting on floor on the fall matt with her face wedged between the mattress and rail. Resident #1 had no signs of life. CNA C assisted LVN [NAME] getting Resident #1 back onto the bed. CNA C said the last time she checked on Resident #1 was between 7:15 pm - 7:20 pm and she was sleeping. About 8:20 pm is when she went back in the room with LVN E. No one else went in Resident #1's within that time. Resident #3, her roommate, was in there but she keeps the curtain was closed between them. During an interview with LVN [NAME] at 5:56 pm on [DATE], she said came to work at 7:00 pm and went around and checked on each resident, as is her normal routine. When she checked on Resident #1, she was in bed, asleep on her back. LVN [NAME] saw the CNAs delivering ice water to all residents. LVN [NAME] then got her computer work done, got the med cart and treatment cart ready to make rounds and administer medications. LVN [NAME] said Resident #3, Resident #1's roommate, needed some medication. When she entered their room, she noticed Resident #1 was laying funny on her side. LVN [NAME] quickly gave Resident #3 her medications and went to check on Resident #1. LVN [NAME] said she could see Resident #1 was hanging from her neck and her body was crumpled to the floor. LVN [NAME] said she tried to get her up but couldn't. She went out into the hall and got a CNA to come help. They both lifted her up onto the bed. She was purple and blue. Had sputum bubbles coming out of her mouth. She tried to arouse her but couldn't. There was no pulse. LVN [NAME] said she then went to get RN D to pronounce Resident #1's death. RN D was working on Hall 4. RN D checked for a pulse and said she was gone. During an interview with Maintenance Director on [DATE] at 8:04 am, Maintenance Director provided documentation showing the last time he inspected Resident #1's bed was (MONTH) 10, 2019. The name of the form was Maintenance/Housekeeping Policies and Procedures - Patient/Resident Room Checklist. The section titled, Bed frames, mattresses, bed rails (if applicable) documented the following tasks but the tasks did not include ensuring the mattress was snug against the mattress retainers or that the bed rails/assist bars were tightly secure to the bracket as their policy stated. This Checklist only documented the following: With bed in the highest position, inspect all pivot point rivets. If rivets are broken, remove and replace with bolt and double nuts. Verify Inspection locking mechanism on all bed brakes. Verify that bed rails operate and lock in the desired position. Leave the bed in the lowest position with the bed brakes locked. Verify that bed rails or mattresses obtained separately from the bed frame are compatible. Inspect bed control panel covering for signs of damage where liquids cold (sic) leak in and inspect beds power cord, cord plug and wall plug for damage. Maintenance Director confirmed this was part of his visual inspection he does of the beds he demonstrated the day before. At 8:30 am on [DATE], an interview was held with the outside agency that the ADM and DON said comes out annually to inspect the beds. The contractor confirmed his agency comes to the facility annually. He reported that they service medical devices at the facility including the facility's oxygen concentrators, lifts, AED, suction machine, grounding checks on beds, and calibration of wheelchair scales. He reported that they only check the grounding and electrical wires of the beds, they do not check the maintenance any of the mechanical parts of the beds. The contractor reported that the beds are not considered medical devices for the purposes of his company, which is why they only check electrical grounding and wiring on them. They only do this as a general safety measure since residents sleep on them. During an interview at 9:56 am on [DATE] with Maintenance Director, he was shown the manufacturer's handbook for the facility beds (provided by facility) and was asked what his interpretation was regarding the retainer bars at the head and the foot of the beds; if they should be engaged in the up position. He reported he feels like usage of the retainers was optional. He was unable to indicate anything in the manual that led him to believe the writers were implying that they were optional and repeatedly stated that he just feels that the retainers were optional. After reviewing the maintenance inspection information in the manual, he said he feels as though he is fulfilling the inspection requirements, although reported he has no documentation to prove it other than his monthly sign check-off log. When asked why he did not tell surveyors about doing many of the things on the inspection lists when he walked surveyors through his bed maintenance procedure yesterday, he reported he does a visual inspection to check welds, fasters, and bolts for looseness claiming he does not have to handle them manually to determine if they are loose or worn. During an interview with the ADM on [DATE] at 10:25 am, he was shown the manufacturer's manual for the facility beds. He was shown the assembly instruction and asked how he interprets the manufacturer's intentions for the mattress retainers in the assembly instruction, and whether the retainers should be in the up position and engaged. He stated, I don't think it's a must. He stated he feels that way because the document uses the word should which to him implies the retainers are optional. He reported the mattresses stay in place and there is very little maneuvering room for the mattresses. ADM was then shown the maintenance recommendations in the manufacturer's manual and asked if he feels the facility is fulfilling the inspection and maintenance requirements in the manual. He stated it looks pretty good to me. We pretty much cover it. During an interview on [DATE] at 2:15 pm with RN D, she reported she was the RN on duty the night Resident #1 passed away. She reported the LVN [NAME] was working that night and came running and hollering down the hall requesting assistance. RN D reported that when she entered the room, the Resident #1 was already in the bed on her left side, and CNA C stated she had no pulse. RN D said they rolled the resident onto her back. She felt no pulse or breathing, verified no heart beat or respirations, verified DNR, pronounced the resident dead, and notified DON and NP F. RN D reported that LVN [NAME] had told her the resident was found on the floor and that she and CNA C moved the resident to a bed. During an interview with the DON at 3:03 pm on [DATE], she said Resident #1 was found with her lower body off the side of her bed and her head and neck were between the assist bar and mattress. Resident #1 had no signs of life and the RN that was working that night pronounced her death at 8:43 pm. DON said they call them assist bars not siderails. She said their policy calls them siderails though. After the Resident #1's incident, she went thru the facility and measured all the beds for the distance between the assist bars and mattresses. DON assessed everyone to see if they used them for bed mobility or transfers, specific for each person's ability. Maintenance Director took off the assist bars not being used. DON got consents for the Residents using the assist bars. She is starting to add the use of the assist bars to the Residents' care plans as well. She got physicians' orders for assist bars for everyone for in the event they use them, like a standing order. During an interview with the DON at 3:13 pm on [DATE] she produced a copy of the facility's policy titled, Bed rails and side rails, Installation and Use. When asked if this policy was being followed since they call them assist bars, she wouldn't answer. In an attempt to clarify that we were talking about the same piece of equipment attached to the bed frames, she confirmed that we were. During another interview with the DON at 5:09 pm on [DATE], when asked if Resident #1 had a more recent assessment for bedrails since [DATE], she said no. When asked if she followed their policy on how often residents should be assessed for bedrails, she said she never considered them bedrails because they don't call them bedrails at this facility, they call them assist bars. She said she is now following the Federal Regulations for bedrails and will be reassessing each resident quarterly, annually, and after a significant change in condition. She said prior to this incident, she was only assessing residents upon admission. Since this incident, DON said all the Residents have been reassessed for the use of bedrails/assist bars. Record review of the facility's Bed Rails and Side Rails, Installation and Use policy and procedure, with a revision date of [DATE] documented the following: Policy: The facility will ensure the correct installation, use and maintenance of bed rails/side rails when their use is determined to be appropriate for the patient/resident. Procedures: 2. The resident will be evaluated for the risk of entrapment prior to installation. 4. The risks and benefits of bed rails/side rails will be reviewed with the resident and/or responsible party and consent will be obtained prior to the installation of bed rails/side rails. 6. Facility will install and maintain bed rails/side rails per the manufacturer's recommendations and specifications for the duration of use. 7. Qualified staff will assess the patient/resident for continued use of bed rails/side rails at a minimum of quarterly, annually and with significant change. Record review of the facility's Medical Bedframe Owner's Manual, REV 003, documented the following: ENTRAPMENT WARNING Accurate assessment of the patient and monitoring of correct maintenance and use of equipment are required to prevent entrapment . Make sure the mattress is the correct size for the bed frame and the assist bars are secure to the frame to decrease the risk of entrapment. ASSEMBLY Mattress Retainer Adjustment Mattress Retainer is designed to keep the mattress in place on the sleep surface. Determine what the length of bed you will need to use. Please read important information on Mattress Retainer and follow instructions on installation. If you are using a 80 bed frame you will need to move the head and foot section mattresses retainers to the 80 slots which is the middle position. The remaining mattress retainers on the perimeter of the sleep deck should be moved in the upward position. Place the mattress on mattress support deck. The mattress should now be snug against all of the mattress retainers. (However, observations showed the mattresses were found to be easily moved because these retainers were not in use.) ASSIST BAR ASSEMBLY Tighten knobs until Assist Bar is secure against the bracket. If Assist Bar is loose continue to tighten until it is secure. WARNING Patient entrapment with assist bars may cause injury or death. To prevent patient entrapment the mattress must fit bed frame and side rails snugly. (However, observations showed the bed rails were loose and could be wiggled from side to side.) Please follow the manufacturer's instructions and monitor patient frequently. QUARTERLY MAINTENANCE CHECK Inspect bed and Assist Bars/Rails bolts, if loose tighten and if missing replace. PATIENT SAFETY Patients who have problems with memory, sleeping, incontinence, pain, uncontrolled body movement, or who get out of bed and walk unsafely without assistance, must be carefully assessed for the best ways to keep them from harm, such as falling. Assessments by the patient's health care team will help to determine how best to keep the patient safe. Potential risks of bed rails may include: Strangling, suffocating, bodily injury or death when patients or part of their body are caught between rails or between the bed rails and mattress. When bed rails are used, perform an on-going assessment of the patient's physical and mental status; closely monitor high-risk patients. Consider the following: reduce the gaps between the mattress and side rails. The ADM, DON, and CSD were notified on [DATE] at 5:22 pm that an Immediate Jeopardy situation had been identified due to the above failures. The facility submitted their Plan of Removal on [DATE] at 10:00 pm. The facility's Plan of Removal was accepted on [DATE] at 11:58 a.m. and included: Residents identified that utilize the bed rails/assist bars will have the following protocol initiated: Physician order will be obtained for the resident to utilized bed/rails/assist bars for bed mobility and/or transfers; An evaluation for the bed rail/assist bars will be completed by a licensed nurse. Care Plan will be updated to reflect the use of bed rails/assist bars for bed mobility and /or transfers; Consent will be completed for use and signed by the Resident or Responsible Party/Power of Attorney; The bed rails/assist bars, bed frames and mattresses were evaluated by the maintenance director and the administrator for compatibility and proper functionality. This was completed on (MONTH) 17, 2019 and repeated on (MONTH) 20, 2019. The Maintenance Director's evaluations completed on (MONTH) 20, 2019 included lifting the mattress for the evaluation and engaging as necessary the mattress retainers. The Maintenance Director evaluation of the bed rail/assist bars for excessive movement with tightening of the bolts as well as other areas of the bed rails/assist bars per manufacturers recommendation. Licensed nurses and Certified nursing assistants were re-educated by the clinical consultant and the Director of Nursing regarding: The process of conduction an evaluation for the use of bed rails/assist bars upon admission, quarterly and with significant change including identifying risks for entrapment; gaps between the mattress and bed rail/assist bars, mattress sliding or not fitting properly Reporting to maintenance or the administrator for addressing promptly if a risk for entrapment is identified. This re-education will be completed by (MONTH) 21, 2019. Any Licensed nurse or Certified Nursing Assistant not receiving this re-education by this date will receive prior to next scheduled shift. This information will be presented in New Hire Orientation. The Maintenance Director and the Administrator were re-educated by the Vice President of Plant Operations regarding conducting a regular inspection of bed frames, mattresses, and bed rails/assist bars as part of a regular maintenance program to identify areas of possible entrapment. This was completed on (MONTH) 20, 2019. On [DATE] at 4:01 pm, the surveyor confirmed the plan of removal had been implemented sufficiently to remove the Immediate Jeopardy by: Reviewed updated resident assessments/evaluations for bed rails/assist bars, physician orders, care plans, consents. Observed 18 beds with bed rails/assist bars. They were no longer loose but fit tightly on the bed frames. The mattresses were secured within the mattress retainers. Interviewed 5 nurses, 1 MA, and 5 CNAs. They all said they had been an in-serviced on the process of conducting an evaluation for the use of bed rails/assist bars upon admission, quarterly and with significant change in condition including identifying risks for entrapment; gaps between the mattress and bed rails/assist bars, mattress sliding or not fitting properly. If there was any concern with the bed, bed rails/assist bars, or mattress, they would notify the Maintenance Director. On [DATE] at 4:01 pm, the ADM, DON, and CSD were informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at an isolate incident of actual harm, due the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review the facility failed to conduct regular inspection of all bed frames, mattresses, and bed rails, as part of a regular maintenance program to identify areas of possible entrapment for 1 of 10 Residents (Resident #1) reviewed for bed rails. The facility failed to follow the manufacturers' recommendations and specifications for installing and maintaining bed rails to identify areas of possible entrapment. Resident #1 was found hanging from the quarter bedrail, her neck and jaw were wedged in the rail. She was blue, unresponsive and had no pulse. Resident #1 was pronounced dead minutes later. An Immediate Jeopardy was identified that occurred on [DATE]. The Immediate Jeopardy was removed [DATE]; however, the facility remained out of compliance at an isolated incident of actual harm, due to the facility's need to complete in-service training and evaluate the effectiveness of corrective systems. This failure could affect other residents by putting them at an increased and unnecessary risk of harm and/or fatal injury. Findings include: Record review of Resident #1's closed clinical record revealed a [AGE] year-old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident #1's quarterly MDS dated [DATE] revealed her BIMS score was 2 out of 15, indicating severe cognitive impairment. She required extensive assistance by 2 or more people for bed mobility and transfers. She was always incontinent of bowel and bladder. She received scheduled pain medication, antipsychotic and opioid medications. She was 63 inches tall and weighed 115 pounds. Record review of Resident #1's care plan revealed Resident #1 was at risk for falls related to limited mobility and pain in joints due to arthritis. The Problem Start Date was [DATE]. The care plan also documented Resident #1 required staff assistance of one staff member with most ADLs. The Problem Start Date for this was also [DATE]. One of the approaches was to assist with repositioning as appropriate and maintain body in functional alignment. Another approach was quarter side rails for repositioning only, teach energy conservation techniques, and proper use of side rails for repositioning if able. Record review of Resident #1's Restraint/Adaptive Equipment - Siderail Review and Consent form with an observation and completed date of [DATE] documented the following: · The medical condition for which the use of siderails were being considered was listed as [MEDICAL CONDITION]. · The risk factors listed to choose from for risk of entrapment were: Agitation, Pain, Confusion, [MEDICAL CONDITION], Uncontrolled body movement, and Other. None of these risk factors were checked. According to Resident #1's Care Plan, her [DIAGNOSES REDACTED]. According to Resident #1's Care Plan, she was also diagnosed with [REDACTED]. According to Resident #1's Care Plan, Resident #1 became aggressive when staff redirected her, however, Agitation was not checked as a risk factor for entrapment. Resident #1's quarterly MDS dated [DATE], documented Resident #1 had disorganized thinking which is a sign and symptom of [MEDICAL CONDITION], however, [MEDICAL CONDITION] was not checked as a risk factor for entrapment. There were no risk factors checked for entrapment even though Resident #1 had 4 of the 5 risk factors listed on the form. · According to this form, there was no physician order for [REDACTED].>· The date listed for explaining the risks/benefits of the use of siderails was [DATE]. There were no signatures of the family giving consent for the use of the side rails, nor was there a signature of the staff completing the form. Record review of Nurse's note for Resident #1 dated [DATE] at 12:02 a.m., documented the following: CNA (name) alerted this nurse that pt was crying & that she (CNA) needed assistance. Arrived @ pt's room & noted pt had slid out of bed on to fall mat on the floor, right side leaning up against bed frame, & res was tightly gripping right side rail with her arm. Both CNA (name) & this nurse assisted res to reposition to a position of comfort, then res was assisted up onto the bed. Res then repositioned for comfort in the bed. Assessment done by this nurse. No delayed injuries, bruises, cuts or other open areas noted. All needs met @ this time. Bed down, call light within resident's reach. WCTM. (Written by LVN A) Record review of Nurse's note written by RN D on [DATE] at 12:57 am documented the following: Upon notification from (LVN E), resident had been found lying with her legs and lower body were off the right side of the bed in a crouching like position while her head and upper body remained on the bed. Upon getting assistance to place resident back in the bed, it was noted that the resident was blue and no pulse or respirations were noted. After verifying that the resident was a DNR, no resusitation (sic) measures were taken. Upon assessing, death was pronounced at 2043 (8:43 pm) by this nurse. DON notified. NP (F) notified of residents death. Record review of the incident report written by LVN E, with an incident date of [DATE] at 8:30 pm, documented the following: Found Res (Resident #1) hanging from her neck from the rails. She was blue. Her neck and jaw was (sic) hinged on the rail. Her right arm was under her. She was slumped and hanging. During an observation and interview at 1:40 pm on [DATE] with Resident #3, she was in her room, on the far bed by the window. She was lying on her bed watching TV. She said her roommate, Resident #1, passed away recently. Resident #3 said she was in the room when it happened, but the curtain was closed, and she didn't see anything. When describing what she heard when Resident #1 passed away, Resident #3 said Resident #1 used to snore loudly but this time she was making a really loud snoring noise. Resident #3 was about to press her call light to get Resident #1 some help but a nurse came in to give her some medicine. Resident #3 told the nurse Resident #1 was making strange noises and to check on her. A short time later, Resident #3 was told Resident #1 had passed away. Resident #3's ¼ bedrails were down on the sides of her bed. She said the staff put them up at bed time and put them down during the day. She said it has been that way since she was admitted a couple of months ago. During an observation on 1:45 pm on [DATE] of Resident #1's bed, none of the mattress retainers (metal clips attached to the bed frame on each corner of the bed to hold the mattress in place) were up to hold the mattress securely in place and the mattress could slide lengthwise and sideways on the frame of the bed. The ¼ bedrails were loose when wiggled side to side (towards the bed and away from the bed) giving movement of 1 inch on the right bedrail and ½ inch movement on the left bedrail (from the position of standing, looking at the bed). When the mattress was up against the right bedrail and the right bedrail was not moved there was a ¾ inch gap between the mattress and right bedrail. When the mattress was slid over against the left bedrail and the right bedrail was pushed away from the bed, there was a 3-inch gap between the right bedrail and the mattress. During an interview with CNA B at 2:06 pm on [DATE], she said she worked the day shift starting at 7:00 am on [DATE], the morning after Resident #1 expired. She was told by CNA C, who worked the night shift and witnessed Resident #1 entrapped between the bedrail and mattress, that Resident #1's head was caught between the bedrail and bed, and she choked to death. Resident #1 had been checked on 1 ,[DATE] hours prior to being found like that. CNA B said to ask the Maintenance Director about the monitoring of bed rails to make sure they are tight, she thought he oversaw bedrail maintenance. When asked if anyone else was responsible for checking the tightness of the bedrails, CNA B said it would be a good idea if the CNAs checked the bedrails but the don't. During an interview and observation, in an unoccupied room with Maintenance Director at 4:36 pm on [DATE], Maintenance Director confirmed he was responsible for the installation and maintenance of the beds, including the bedrails. When asked how often he inspects the bedrails, he said every month. When asked to describe what is done when he inspects the beds and the tightness of the bedrails, he demonstrated in the unoccupied room, his routine. He said he visually looks at the bedrails. When asked how he can visually determine how tight the bedrail is to the bed frame, he said he looks at the bolt to see if it is coming out. He said he does not physically grab the bedrail and shake it side to side from the bed. He will see if it is loose going towards the up and down position, but not side to side. When discussing the mattress retainers that were in the down position on the bed, therefore not securing the mattress in place, MA said he was not sure if they should be in the up position or not. He said he doesn't check the mattress retainers as part of his inspection. At 4:47 pm on [DATE], the DON and ADM were asked to come into the unoccupied room with the Maintenance Director. When ADM, DON and the Maintenance Director were shown how much movement there was when the mattress was not secure, and the bedrails were not tightly secured to the bed frame, they did not think the amount of movement was significant. The DON said she was more concerned with the risk of skin tears the mattress retainers could cause than a resident's head becoming entrapped between the mattress and the bedrail. The Maintenance Director said the manufacturer wouldn't make the retainers go down if they wanted them to be up, he thought they were optional. The ADM said he thought the facility was following the Manufacturer's recommendations and specifications. He said they have an outside agency come out to inspect the bed annually in addition to the Maintenance Director's monthly inspections. ADM said they couldn't have done anything different to prevent what happened to Resident #1. During an interview with CNA C at 5:45 pm on [DATE], she said she was doing hydration rounds, handing out snacks, and answering call lights on the evening of [DATE]. When she stepped out of a Resident's room, LVN [NAME] called out for help from Resident #1's room. When CNA C entered Resident #1's room, she saw her sitting on floor on the fall matt with her face wedged between the mattress and rail. Resident #1 had no signs of life. CNA C assisted LVN [NAME] getting Resident #1 back onto the bed. CNA C said the last time she checked on Resident #1 was between 7:15 pm - 7:20 pm and she was sleeping. About 8:20 pm is when she went back in the room with LVN E. No one else went in Resident #1's within that time. Resident #3, her roommate, was in there but she keeps the curtain was closed between them. During an interview with LVN [NAME] at 5:56 pm on [DATE], she said came to work at 7:00 pm and went around and checked on each resident, as is her normal routine. When she checked on Resident #1, she was in bed, asleep on her back. LVN [NAME] saw the CNAs delivering ice water to all residents. LVN [NAME] then got her computer work done, got the med cart and treatment cart ready to make rounds and administer medications. LVN [NAME] said Resident #3, Resident #1's roommate, needed some medication. When she entered their room, she noticed Resident #1 was laying funny on her side. LVN [NAME] quickly gave Resident #3 her medications and went to check on Resident #1. LVN [NAME] said she could see Resident #1 was hanging from her neck and her body was crumpled to the floor. LVN [NAME] said she tried to get her up but couldn't. She went out into the hall and got a CNA to come help. They both lifted her up onto the bed. She was purple and blue. Had sputum bubbles coming out of her mouth. She tried to arouse her but couldn't. There was no pulse. LVN [NAME] said she then went to get RN D to pronounce Resident #1's death. RN D was working on Hall 4. RN D checked for a pulse and said she was gone. During an interview with Maintenance Director on [DATE] at 8:04 am, Maintenance Director provided documentation showing the last time he inspected Resident #1's bed was (MONTH) 10, 2019. The name of the form was Maintenance/Housekeeping Policies and Procedures - Patient/Resident Room Checklist. The section titled, Bed frames, mattresses, bed rails (if applicable) documented the following tasks but the tasks did not include ensuring the mattress was snug against the mattress retainers or that the bed rails/assist bars were tightly secure to the bracket as their policy stated. This Checklist only documented the following: With bed in the highest position, inspect all pivot point rivets. If rivets are broken, remove and replace with bolt and double nuts. Verify Inspection locking mechanism on all bed brakes. Verify that bed rails operate and lock in the desired position. Leave the bed in the lowest position with the bed brakes locked. Verify that bed rails or mattresses obtained separately from the bed frame are compatible. Inspect bed control panel covering for signs of damage where liquids cold (sic) leak in and inspect beds power cord, cord plug and wall plug for damage. Maintenance Director confirmed this was part of his visual inspection he does of the beds he demonstrated the day before. At 8:30 am on [DATE], an interview was held with the outside agency that the ADM and DON said comes out annually to inspect the beds. The contractor confirmed his agency comes to the facility annually. He reported that they service medical devices at the facility including the facility's oxygen concentrators, lifts, AED, suction machine, grounding checks on beds, and calibration of wheelchair scales. He reported that they only check the grounding and electrical wires of the beds, they do not check the maintenance any of the mechanical parts of the beds. The contractor reported that the beds are not considered medical devices for the purposes of his company, which is why they only check electrical grounding and wiring on them. They only do this as a general safety measure since residents sleep on them. During an interview at 9:56 am on [DATE] with Maintenance Director, he was shown the manufacturer's handbook for the facility beds (provided by facility) and was asked what his interpretation was regarding the retainer bars at the head and the foot of the beds; if they should be engaged in the up position. He reported he feels like usage of the retainers was optional. He was unable to indicate anything in the manual that led him to believe the writers were implying that they were optional and repeatedly stated that he just feels that the retainers were optional. After reviewing the maintenance inspection information in the manual, he said he feels as though he is fulfilling the inspection requirements, although reported he has no documentation to prove it other than his monthly sign check-off log. When asked why he did not tell surveyors about doing many of the things on the inspection lists when he walked surveyors through his bed maintenance procedure yesterday, he reported he does a visual inspection to check welds, fasters, and bolts for looseness claiming he does not have to handle them manually to determine if they are loose or worn. During an interview with the ADM on [DATE] at 10:25 am, he was shown the manufacturer's manual for the facility beds. He was shown the assembly instruction and asked how he interprets the manufacturer's intentions for the mattress retainers in the assembly instruction, and whether the retainers should be in the up position and engaged. He stated, I don't think it's a must. He stated he feels that way because the document uses the word should which to him implies the retainers are optional. He reported the mattresses stay in place and there is very little maneuvering room for the mattresses. ADM was then shown the maintenance recommendations in the manufacturer's manual and asked if he feels the facility is fulfilling the inspection and maintenance requirements in the manual. He stated it looks pretty good to me. We pretty much cover it. During an interview on [DATE] at 2:15 pm with RN D, she reported she was the RN on duty the night Resident #1 passed away. She reported the LVN [NAME] was working that night and came running and hollering down the hall requesting assistance. RN D reported that when she entered the room, the Resident #1 was already in the bed on her left side, and CNA C stated she had no pulse. RN D said they rolled the resident onto her back. She felt no pulse or breathing, verified no heart beat or respirations, verified DNR, pronounced the resident dead, and notified DON and NP F. RN D reported that LVN [NAME] had told her the resident was found on the floor and that she and CNA C moved the resident to a bed. During an interview with the DON at 3:03 pm on [DATE], she said Resident #1 was found with her lower body off the side of her bed and her head and neck were between the assist bar and mattress. Resident #1 had no signs of life and the RN that was working that night pronounced her death at 8:43 pm. DON said they call them assist bars not siderails. She said their policy calls them siderails though. After the Resident #1's incident, she went thru the facility and measured all the beds for the distance between the assist bars and mattresses. DON assessed everyone to see if they used them for bed mobility or transfers, specific for each person's ability. Maintenance Director took off the assist bars not being used. DON got consents for the Residents using the assist bars. She is starting to add the use of the assist bars to the Residents' care plans as well. She got physicians' orders for assist bars for everyone for in the event they use them, like a standing order. During an interview with the DON at 3:13 pm on [DATE] she produced a copy of the facility's policy titled, Bed rails and side rails, Installation and Use. When asked if this policy was being followed since they call them assist bars, she wouldn't answer. In an attempt to clarify that we were talking about the same piece of equipment attached to the bed frames, she confirmed that we were. During another interview with the DON at 5:09 pm on [DATE], when asked if Resident #1 had a more recent assessment for bedrails since [DATE], she said no. When asked if she followed their policy on how often residents should be assessed for bedrails, she said she never considered them bedrails because they don't call them bedrails at this facility, they call them assist bars. She said she is now following the Federal Regulations for bedrails and will be reassessing each resident quarterly, annually, and after a significant change in condition. She said prior to this incident, she was only assessing residents upon admission. Since this incident, DON said all the Residents have been reassessed for the use of bedrails/assist bars. Record review of the facility's Bed Rails and Side Rails, Installation and Use policy and procedure, with a revision date of [DATE] documented the following: Policy: The facility will ensure the correct installation, use and maintenance of bed rails/side rails when their use is determined to be appropriate for the patient/resident. Procedures: 2. The resident will be evaluated for the risk of entrapment prior to installation. 4. The risks and benefits of bed rails/side rails will be reviewed with the resident and/or responsible party and consent will be obtained prior to the installation of bed rails/side rails. 6. Facility will install and maintain bed rails/side rails per the manufacturer's recommendations and specifications for the duration of use. 7. Qualified staff will assess the patient/resident for continued use of bed rails/side rails at a minimum of quarterly, annually and with significant change. Record review of the facility's Medical Bedframe Owner's Manual, REV 003, documented the following: ENTRAPMENT WARNING Accurate assessment of the patient and monitoring of correct maintenance and use of equipment are required to prevent entrapment . Make sure the mattress is the correct size for the bed frame and the assist bars are secure to the frame to decrease the risk of entrapment. ASSEMBLY Mattress Retainer Adjustment Mattress Retainer is designed to keep the mattress in place on the sleep surface. Determine what the length of bed you will need to use. Please read important information on Mattress Retainer and follow instructions on installation. If you are using a 80 bed frame you will need to move the head and foot section mattresses retainers to the 80 slots which is the middle position. The remaining mattress retainers on the perimeter of the sleep deck should be moved in the upward position. Place the mattress on mattress support deck. The mattress should now be snug against all of the mattress retainers. (However, observations showed the mattresses were found to be easily moved because these retainers were not in use.) ASSIST BAR ASSEMBLY Tighten knobs until Assist Bar is secure against the bracket. If Assist Bar is loose continue to tighten until it is secure. WARNING Patient entrapment with assist bars may cause injury or death. To prevent patient entrapment the mattress must fit bed frame and side rails snugly. (However, observations showed the bed rails were loose and could be wiggled from side to side.) Please follow the manufacturer's instructions and monitor patient frequently. QUARTERLY MAINTENANCE CHECK Inspect bed and Assist Bars/Rails bolts, if loose tighten and if missing replace. PATIENT SAFETY Patients who have problems with memory, sleeping, incontinence, pain, uncontrolled body movement, or who get out of bed and walk unsafely without assistance, must be carefully assessed for the best ways to keep them from harm, such as falling. Assessments by the patient's health care team will help to determine how best to keep the patient safe. Potential risks of bed rails may include: Strangling, suffocating, bodily injury or death when patients or part of their body are caught between rails or between the bed rails and mattress. When bed rails are used, perform an on-going assessment of the patient's physical and mental status; closely monitor high-risk patients. Consider the following: reduce the gaps between the mattress and side rails. The ADM, DON, and CSD were notified on [DATE] at 5:22 pm that an Immediate Jeopardy situation had been identified due to the above failures. The facility submitted their Plan of Removal on [DATE] at 10:00 pm. The facility's Plan of Removal was accepted on [DATE] at 11:58 a.m. and included: Residents identified that utilize the bed rails/assist bars will have the following protocol initiated: Physician order will be obtained for the resident to utilized bed/rails/assist bars for bed mobility and/or transfers; An evaluation for the bed rail/assist bars will be completed by a licensed nurse. Care Plan will be updated to reflect the use of bed rails/assist bars for bed mobility and /or transfers; Consent will be completed for use and signed by the Resident or Responsible Party/Power of Attorney; The bed rails/assist bars, bed frames and mattresses were evaluated by the maintenance director and the administrator for compatibility and proper functionality. This was completed on (MONTH) 17, 2019 and repeated on (MONTH) 20, 2019. The Maintenance Director's evaluations completed on (MONTH) 20, 2019 included lifting the mattress for the evaluation and engaging as necessary the mattress retainers. The Maintenance Director evaluation of the bed rail/assist bars for excessive movement with tightening of the bolts as well as other areas of the bed rails/assist bars per manufacturers recommendation. Licensed nurses and Certified nursing assistants were re-educated by the clinical consultant and the Director of Nursing regarding: The process of conduction an evaluation for the use of bed rails/assist bars upon admission, quarterly and with significant change including identifying risks for entrapment; gaps between the mattress and bed rail/assist bars, mattress sliding or not fitting properly Reporting to maintenance or the administrator for addressing promptly if a risk for entrapment is identified. This re-education will be completed by (MONTH) 21, 2019. Any Licensed nurse or Certified Nursing Assistant not receiving this re-education by this date will receive prior to next scheduled shift. This information will be presented in New Hire Orientation. The Maintenance Director and the Administrator were re-educated by the Vice President of Plant Operations regarding conducting a regular inspection of bed frames, mattresses, and bed rails/assist bars as part of a regular maintenance program to identify areas of possible entrapment. This was completed on (MONTH) 20, 2019. On [DATE] at 4:01 pm, the surveyor confirmed the plan of removal had been implemented sufficiently to remove the Immediate Jeopardy by: Reviewed updated resident assessments/evaluations for bed rails/assist bars, physician orders, care plans, consents. Observed 18 beds with bed rails/assist bars. They were no longer loose but fit tightly on the bed frames. The mattresses were secured within the mattress retainers. Interviewed 5 nurses, 1 MA, and 5 CNAs. They all said they had been an in-serviced on the process of conducting an evaluation for the use of bed rails/assist bars upon admission, quarterly and with significant change in condition including identifying risks for entrapment; gaps between the mattress and bed rails/assist bars, mattress sliding or not fitting properly. If there was any concern with the bed, bed rails/assist bars, or mattress, they would notify the Maintenance Director. On [DATE] at 4:01 pm, the ADM, DON, and CSD were informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at an isolate incident of actual harm, due the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review the facility failed to ensure the correct installation, use, and maintenance of bed rails for 1 of 10 Residents (Resident #1) reviewed for bedrails. The facility failed to assess Resident #1 for risk of entrapment from bed rails prior to installation and follow the manufacturers' recommendations and specifications for installing and maintaining bed rails. Resident #1 was found hanging from the quarter bedrail, her neck and jaw were wedged in the rail. She was blue, unresponsive and had no pulse. Resident #1 was pronounced dead minutes later. An Immediate Jeopardy was identified that occurred on [DATE]. The Immediate Jeopardy was removed [DATE]; however, the facility remained out of compliance at an isolated incident of actual harm, due to the facility's need to complete in-service training and evaluate the effectiveness of corrective systems. This failure could affect other residents by putting them at an increased and unnecessary risk of harm and/or fatal injury. Findings include: Record review of Resident #1's closed clinical record revealed a [AGE] year-old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident #1's quarterly MDS dated [DATE] revealed her BIMS score was 2 out of 15, indicating severe cognitive impairment. She required extensive assistance by 2 or more people for bed mobility and transfers. She was always incontinent of bowel and bladder. She received scheduled pain medication, antipsychotic and opioid medications. She was 63 inches tall and weighed 115 pounds. Record review of Resident #1's care plan revealed Resident #1 was at risk for falls related to limited mobility and pain in joints due to arthritis. The Problem Start Date was [DATE]. The care plan also documented Resident #1 required staff assistance of one staff member with most ADLs. The Problem Start Date for this was also [DATE]. One of the approaches was to assist with repositioning as appropriate and maintain body in functional alignment. Another approach was quarter side rails for repositioning only, teach energy conservation techniques, and proper use of side rails for repositioning if able. Record review of Resident #1's Restraint/Adaptive Equipment - Siderail Review and Consent form with an observation and completed date of [DATE] documented the following: · The medical condition for which the use of siderails were being considered was listed as [MEDICAL CONDITION]. · The risk factors listed to choose from for risk of entrapment were: Agitation, Pain, Confusion, [MEDICAL CONDITION], Uncontrolled body movement, and Other. None of these risk factors were checked. According to Resident #1's Care Plan, her [DIAGNOSES REDACTED]. According to Resident #1's Care Plan, she was also diagnosed with [REDACTED]. According to Resident #1's Care Plan, Resident #1 became aggressive when staff redirected her, however, Agitation was not checked as a risk factor for entrapment. Resident #1's quarterly MDS dated [DATE], documented Resident #1 had disorganized thinking which is a sign and symptom of [MEDICAL CONDITION], however, [MEDICAL CONDITION] was not checked as a risk factor for entrapment. There were no risk factors checked for entrapment even though Resident #1 had 4 of the 5 risk factors listed on the form. · According to this form, there was no physician order for [REDACTED].>· The date listed for explaining the risks/benefits of the use of siderails was [DATE]. There were no signatures of the family giving consent for the use of the side rails, nor was there a signature of the staff completing the form. Record review of Nurse's note for Resident #1 dated [DATE] at 12:02 a.m., documented the following: CNA (name) alerted this nurse that pt was crying & that she (CNA) needed assistance. Arrived @ pt's room & noted pt had slid out of bed on to fall mat on the floor, right side leaning up against bed frame, & res was tightly gripping right side rail with her arm. Both CNA (name) & this nurse assisted res to reposition to a position of comfort, then res was assisted up onto the bed. Res then repositioned for comfort in the bed. Assessment done by this nurse. No delayed injuries, bruises, cuts or other open areas noted. All needs met @ this time. Bed down, call light within resident's reach. WCTM. (Written by LVN A) Record review of Nurse's note written by RN D on [DATE] at 12:57 am documented the following: Upon notification from (LVN E), resident had been found lying with her legs and lower body were off the right side of the bed in a crouching like position while her head and upper body remained on the bed. Upon getting assistance to place resident back in the bed, it was noted that the resident was blue and no pulse or respirations were noted. After verifying that the resident was a DNR, no resusitation (sic) measures were taken. Upon assessing, death was pronounced at 2043 (8:43 pm) by this nurse. DON notified. NP (F) notified of residents death. Record review of the incident report written by LVN E, with an incident date of [DATE] at 8:30 pm, documented the following: Found Res (Resident #1) hanging from her neck from the rails. She was blue. Her neck and jaw was (sic) hinged on the rail. Her right arm was under her. She was slumped and hanging. During an observation and interview at 1:40 pm on [DATE] with Resident #3, she was in her room, on the far bed by the window. She was lying on her bed watching TV. She said her roommate, Resident #1, passed away recently. Resident #3 said she was in the room when it happened, but the curtain was closed, and she didn't see anything. When describing what she heard when Resident #1 passed away, Resident #3 said Resident #1 used to snore loudly but this time she was making a really loud snoring noise. Resident #3 was about to press her call light to get Resident #1 some help but a nurse came in to give her some medicine. Resident #3 told the nurse Resident #1 was making strange noises and to check on her. A short time later, Resident #3 was told Resident #1 had passed away. Resident #3's ¼ bedrails were down on the sides of her bed. She said the staff put them up at bed time and put them down during the day. She said it has been that way since she was admitted a couple of months ago. During an observation on 1:45 pm on [DATE] of Resident #1's bed, none of the mattress retainers (metal clips attached to the bed frame on each corner of the bed to hold the mattress in place) were up to hold the mattress securely in place and the mattress could slide lengthwise and sideways on the frame of the bed. The ¼ bedrails were loose when wiggled side to side (towards the bed and away from the bed) giving movement of 1 inch on the right bedrail and ½ inch movement on the left bedrail (from the position of standing, looking at the bed). When the mattress was up against the right bedrail and the right bedrail was not moved there was a ¾ inch gap between the mattress and right bedrail. When the mattress was slid over against the left bedrail and the right bedrail was pushed away from the bed, there was a 3-inch gap between the right bedrail and the mattress. During an interview with CNA B at 2:06 pm on [DATE], she said she worked the day shift starting at 7:00 am on [DATE], the morning after Resident #1 expired. She was told by CNA C, who worked the night shift and witnessed Resident #1 entrapped between the bedrail and mattress, that Resident #1's head was caught between the bedrail and bed, and she choked to death. Resident #1 had been checked on 1 ,[DATE] hours prior to being found like that. CNA B said to ask the Maintenance Director about the monitoring of bed rails to make sure they are tight, she thought he oversaw bedrail maintenance. When asked if anyone else was responsible for checking the tightness of the bedrails, CNA B said it would be a good idea if the CNAs checked the bedrails but the don't. During an interview and observation, in an unoccupied room with Maintenance Director at 4:36 pm on [DATE], Maintenance Director confirmed he was responsible for the installation and maintenance of the beds, including the bedrails. When asked how often he inspects the bedrails, he said every month. When asked to describe what is done when he inspects the beds and the tightness of the bedrails, he demonstrated in the unoccupied room, his routine. He said he visually looks at the bedrails. When asked how he can visually determine how tight the bedrail is to the bed frame, he said he looks at the bolt to see if it is coming out. He said he does not physically grab the bedrail and shake it side to side from the bed. He will see if it is loose going towards the up and down position, but not side to side. When discussing the mattress retainers that were in the down position on the bed, therefore not securing the mattress in place, MA said he was not sure if they should be in the up position or not. He said he doesn't check the mattress retainers as part of his inspection. At 4:47 pm on [DATE], the DON and ADM were asked to come into the unoccupied room with the Maintenance Director. When ADM, DON and the Maintenance Director were shown how much movement there was when the mattress was not secure, and the bedrails were not tightly secured to the bed frame, they did not think the amount of movement was significant. The DON said she was more concerned with the risk of skin tears the mattress retainers could cause than a resident's head becoming entrapped between the mattress and the bedrail. The Maintenance Director said the manufacturer wouldn't make the retainers go down if they wanted them to be up, he thought they were optional. The ADM said he thought the facility was following the Manufacturer's recommendations and specifications. He said they have an outside agency come out to inspect the bed annually in addition to the Maintenance Director's monthly inspections. ADM said they couldn't have done anything different to prevent what happened to Resident #1. During an interview with CNA C at 5:45 pm on [DATE], she said she was doing hydration rounds, handing out snacks, and answering call lights on the evening of [DATE]. When she stepped out of a Resident's room, LVN [NAME] called out for help from Resident #1's room. When CNA C entered Resident #1's room, she saw her sitting on floor on the fall matt with her face wedged between the mattress and rail. Resident #1 had no signs of life. CNA C assisted LVN [NAME] getting Resident #1 back onto the bed. CNA C said the last time she checked on Resident #1 was between 7:15 pm - 7:20 pm and she was sleeping. About 8:20 pm is when she went back in the room with LVN E. No one else went in Resident #1's within that time. Resident #3, her roommate, was in there but she keeps the curtain was closed between them. During an interview with LVN [NAME] at 5:56 pm on [DATE], she said came to work at 7:00 pm and went around and checked on each resident, as is her normal routine. When she checked on Resident #1, she was in bed, asleep on her back. LVN [NAME] saw the CNAs delivering ice water to all residents. LVN [NAME] then got her computer work done, got the med cart and treatment cart ready to make rounds and administer medications. LVN [NAME] said Resident #3, Resident #1's roommate, needed some medication. When she entered their room, she noticed Resident #1 was laying funny on her side. LVN [NAME] quickly gave Resident #3 her medications and went to check on Resident #1. LVN [NAME] said she could see Resident #1 was hanging from her neck and her body was crumpled to the floor. LVN [NAME] said she tried to get her up but couldn't. She went out into the hall and got a CNA to come help. They both lifted her up onto the bed. She was purple and blue. Had sputum bubbles coming out of her mouth. She tried to arouse her but couldn't. There was no pulse. LVN [NAME] said she then went to get RN D to pronounce Resident #1's death. RN D was working on Hall 4. RN D checked for a pulse and said she was gone. During an interview with Maintenance Director on [DATE] at 8:04 am, Maintenance Director provided documentation showing the last time he inspected Resident #1's bed was (MONTH) 10, 2019. The name of the form was Maintenance/Housekeeping Policies and Procedures - Patient/Resident Room Checklist. The section titled, Bed frames, mattresses, bed rails (if applicable) documented the following tasks but the tasks did not include ensuring the mattress was snug against the mattress retainers or that the bed rails/assist bars were tightly secure to the bracket as their policy stated. This Checklist only documented the following: With bed in the highest position, inspect all pivot point rivets. If rivets are broken, remove and replace with bolt and double nuts. Verify Inspection locking mechanism on all bed brakes. Verify that bed rails operate and lock in the desired position. Leave the bed in the lowest position with the bed brakes locked. Verify that bed rails or mattresses obtained separately from the bed frame are compatible. Inspect bed control panel covering for signs of damage where liquids cold (sic) leak in and inspect beds power cord, cord plug and wall plug for damage. Maintenance Director confirmed this was part of his visual inspection he does of the beds he demonstrated the day before. At 8:30 am on [DATE], an interview was held with the outside agency that the ADM and DON said comes out annually to inspect the beds. The contractor confirmed his agency comes to the facility annually. He reported that they service medical devices at the facility including the facility's oxygen concentrators, lifts, AED, suction machine, grounding checks on beds, and calibration of wheelchair scales. He reported that they only check the grounding and electrical wires of the beds, they do not check the maintenance any of the mechanical parts of the beds. The contractor reported that the beds are not considered medical devices for the purposes of his company, which is why they only check electrical grounding and wiring on them. They only do this as a general safety measure since residents sleep on them. During an interview at 9:56 am on [DATE] with Maintenance Director, he was shown the manufacturer's handbook for the facility beds (provided by facility) and was asked what his interpretation was regarding the retainer bars at the head and the foot of the beds; if they should be engaged in the up position. He reported he feels like usage of the retainers was optional. He was unable to indicate anything in the manual that led him to believe the writers were implying that they were optional and repeatedly stated that he just feels that the retainers were optional. After reviewing the maintenance inspection information in the manual, he said he feels as though he is fulfilling the inspection requirements, although reported he has no documentation to prove it other than his monthly sign check-off log. When asked why he did not tell surveyors about doing many of the things on the inspection lists when he walked surveyors through his bed maintenance procedure yesterday, he reported he does a visual inspection to check welds, fasters, and bolts for looseness claiming he does not have to handle them manually to determine if they are loose or worn. During an interview with the ADM on [DATE] at 10:25 am, he was shown the manufacturer's manual for the facility beds. He was shown the assembly instruction and asked how he interprets the manufacturer's intentions for the mattress retainers in the assembly instruction, and whether the retainers should be in the up position and engaged. He stated, I don't think it's a must. He stated he feels that way because the document uses the word should which to him implies the retainers are optional. He reported the mattresses stay in place and there is very little maneuvering room for the mattresses. ADM was then shown the maintenance recommendations in the manufacturer's manual and asked if he feels the facility is fulfilling the inspection and maintenance requirements in the manual. He stated it looks pretty good to me. We pretty much cover it. During an interview on [DATE] at 2:15 pm with RN D, she reported she was the RN on duty the night Resident #1 passed away. She reported the LVN [NAME] was working that night and came running and hollering down the hall requesting assistance. RN D reported that when she entered the room, the Resident #1 was already in the bed on her left side, and CNA C stated she had no pulse. RN D said they rolled the resident onto her back. She felt no pulse or breathing, verified no heart beat or respirations, verified DNR, pronounced the resident dead, and notified DON and NP F. RN D reported that LVN [NAME] had told her the resident was found on the floor and that she and CNA C moved the resident to a bed. During an interview with the DON at 3:03 pm on [DATE], she said Resident #1 was found with her lower body off the side of her bed and her head and neck were between the assist bar and mattress. Resident #1 had no signs of life and the RN that was working that night pronounced her death at 8:43 pm. DON said they call them assist bars not siderails. She said their policy calls them siderails though. After the Resident #1's incident, she went thru the facility and measured all the beds for the distance between the assist bars and mattresses. DON assessed everyone to see if they used them for bed mobility or transfers, specific for each person's ability. Maintenance Director took off the assist bars not being used. DON got consents for the Residents using the assist bars. She is starting to add the use of the assist bars to the Residents' care plans as well. She got physicians' orders for assist bars for everyone for in the event they use them, like a standing order. During an interview with the DON at 3:13 pm on [DATE] she produced a copy of the facility's policy titled, Bed rails and side rails, Installation and Use. When asked if this policy was being followed since they call them assist bars, she wouldn't answer. In an attempt to clarify that we were talking about the same piece of equipment attached to the bed frames, she confirmed that we were. During another interview with the DON at 5:09 pm on [DATE], when asked if Resident #1 had a more recent assessment for bedrails since [DATE], she said no. When asked if she followed their policy on how often residents should be assessed for bedrails, she said she never considered them bedrails because they don't call them bedrails at this facility, they call them assist bars. She said she is now following the Federal Regulations for bedrails and will be reassessing each resident quarterly, annually, and after a significant change in condition. She said prior to this incident, she was only assessing residents upon admission. Since this incident, DON said all the Residents have been reassessed for the use of bedrails/assist bars. Record review of the facility's Bed Rails and Side Rails, Installation and Use policy and procedure, with a revision date of [DATE] documented the following: Policy: The facility will ensure the correct installation, use and maintenance of bed rails/side rails when their use is determined to be appropriate for the patient/resident. Procedures: 2. The resident will be evaluated for the risk of entrapment prior to installation. 4. The risks and benefits of bed rails/side rails will be reviewed with the resident and/or responsible party and consent will be obtained prior to the installation of bed rails/side rails. 6. Facility will install and maintain bed rails/side rails per the manufacturer's recommendations and specifications for the duration of use. 7. Qualified staff will assess the patient/resident for continued use of bed rails/side rails at a minimum of quarterly, annually and with significant change. Record review of the facility's Medical Bedframe Owner's Manual, REV 003, documented the following: ENTRAPMENT WARNING Accurate assessment of the patient and monitoring of correct maintenance and use of equipment are required to prevent entrapment . Make sure the mattress is the correct size for the bed frame and the assist bars are secure to the frame to decrease the risk of entrapment. ASSEMBLY Mattress Retainer Adjustment Mattress Retainer is designed to keep the mattress in place on the sleep surface. Determine what the length of bed you will need to use. Please read important information on Mattress Retainer and follow instructions on installation. If you are using a 80 bed frame you will need to move the head and foot section mattresses retainers to the 80 slots which is the middle position. The remaining mattress retainers on the perimeter of the sleep deck should be moved in the upward position. Place the mattress on mattress support deck. The mattress should now be snug against all of the mattress retainers. (However, observations showed the mattresses were found to be easily moved because these retainers were not in use.) ASSIST BAR ASSEMBLY Tighten knobs until Assist Bar is secure against the bracket. If Assist Bar is loose continue to tighten until it is secure. WARNING Patient entrapment with assist bars may cause injury or death. To prevent patient entrapment the mattress must fit bed frame and side rails snugly. (However, observations showed the bed rails were loose and could be wiggled from side to side.) Please follow the manufacturer's instructions and monitor patient frequently. QUARTERLY MAINTENANCE CHECK Inspect bed and Assist Bars/Rails bolts, if loose tighten and if missing replace. PATIENT SAFETY Patients who have problems with memory, sleeping, incontinence, pain, uncontrolled body movement, or who get out of bed and walk unsafely without assistance, must be carefully assessed for the best ways to keep them from harm, such as falling. Assessments by the patient's health care team will help to determine how best to keep the patient safe. Potential risks of bed rails may include: Strangling, suffocating, bodily injury or death when patients or part of their body are caught between rails or between the bed rails and mattress. When bed rails are used, perform an on-going assessment of the patient's physical and mental status; closely monitor high-risk patients. Consider the following: reduce the gaps between the mattress and side rails. The ADM, DON, and CSD were notified on [DATE] at 5:22 pm that an Immediate Jeopardy situation had been identified due to the above failures. The facility submitted their Plan of Removal on [DATE] at 10:00 pm. The facility's Plan of Removal was accepted on [DATE] at 11:58 a.m. and included: Residents identified that utilize the bed rails/assist bars will have the following protocol initiated: Physician order will be obtained for the resident to utilized bed/rails/assist bars for bed mobility and/or transfers; An evaluation for the bed rail/assist bars will be completed by a licensed nurse. Care Plan will be updated to reflect the use of bed rails/assist bars for bed mobility and /or transfers; Consent will be completed for use and signed by the Resident or Responsible Party/Power of Attorney; The bed rails/assist bars, bed frames and mattresses were evaluated by the maintenance director and the administrator for compatibility and proper functionality. This was completed on (MONTH) 17, 2019 and repeated on (MONTH) 20, 2019. The Maintenance Director's evaluations completed on (MONTH) 20, 2019 included lifting the mattress for the evaluation and engaging as necessary the mattress retainers. The Maintenance Director evaluation of the bed rail/assist bars for excessive movement with tightening of the bolts as well as other areas of the bed rails/assist bars per manufacturers recommendation. Licensed nurses and Certified nursing assistants were re-educated by the clinical consultant and the Director of Nursing regarding: The process of conduction an evaluation for the use of bed rails/assist bars upon admission, quarterly and with significant change including identifying risks for entrapment; gaps between the mattress and bed rail/assist bars, mattress sliding or not fitting properly Reporting to maintenance or the administrator for addressing promptly if a risk for entrapment is identified. This re-education will be completed by (MONTH) 21, 2019. Any Licensed nurse or Certified Nursing Assistant not receiving this re-education by this date will receive prior to next scheduled shift. This information will be presented in New Hire Orientation. The Maintenance Director and the Administrator were re-educated by the Vice President of Plant Operations regarding conducting a regular inspection of bed frames, mattresses, and bed rails/assist bars as part of a regular maintenance program to identify areas of possible entrapment. This was completed on (MONTH) 20, 2019. On [DATE] at 4:01 pm, the surveyor confirmed the plan of removal had been implemented sufficiently to remove the Immediate Jeopardy by: Reviewed updated resident assessments/evaluations for bed rails/assist bars, physician orders, care plans, consents. Observed 18 beds with bed rails/assist bars. They were no longer loose but fit tightly on the bed frames. The mattresses were secured within the mattress retainers. Interviewed 5 nurses, 1 MA, and 5 CNAs. They all said they had been an in-serviced on the process of conducting an evaluation for the use of bed rails/assist bars upon admission, quarterly and with significant change in condition including identifying risks for entrapment; gaps between the mattress and bed rails/assist bars, mattress sliding or not fitting properly. If there was any concern with the bed, bed rails/assist bars, or mattress, they would notify the Maintenance Director. On [DATE] at 4:01 pm, the ADM, DON, and CSD were informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at an isolate incident of actual harm, due the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review; it was determined the facility failed to ensure Resident #3 was not neglected when Resident #3 fell on ce on 07/04/2017 and twice on 07/06/2017, with her second fall on 07/06/2017 resulting in a [MEDICAL CONDITION]. There were no interventions in place for Resident #3 to prevent her falls. Resident #3 did not have the chair alarm in place (initiated after her fist fall at the facility) when she was found on the floor, and the examination revealed a [MEDICAL CONDITION]. The facility's failure to ensure each resident remained free of neglect could place 77 residents requiring 1-2 person assistance with transfers at risk for falls, pain, bruising, cuts, lacerations, blood loss, broken bones, head injuries, coma and death. Findings include: Record review of Resident #3's clinical record revealed Resident #3 is a [AGE] year old female with an admission date of [DATE]. She was discharged on [DATE] after a fall and [MEDICAL CONDITION]. She has [DIAGNOSES REDACTED]. Resident #3 does not have a MDS as her admission and discharge MDS were not due at the time of the investigation. While reviewing the physician orders [REDACTED]. 07/01/2017 at 01:18 p.m.: Resident is a fall risk. While reviewing the nursing notes for Resident #3, it stated: 07/06/2017 at 06:45 a.m.: Resident voiced she got up and started to losing her balance and decided to sit herself on the floor .bed and chair alarm in place. (The bed/chair alarm were initiated after her fall on 07/03/2017). No mention of the bed or chair alarm is made in the fall documentation on 07/06/2017 at 08:20 p.m. While reviewing the facility incident report for Resident #3's fall on 07/04/2017, it stated: Resident was found on the floor. She sustained no injuries, and a bed/chair alarm were initiated to prevent future falls. During an interview on 07/07/2017 at 11:30 a.m., DON confirmed Resident #3 was admitted after a fall at home to rehab to get stronger so she could go to surgery. He confirmed Resident #3 fell [DATE] and a bed and chair alarm was initiated to prevent falls. He confirmed Resident fell on [DATE] at 06:45 a.m., and the bed and chair alarms were documented to be in place and functioning. He confirmed Resident #3 fell on [DATE] at approximately 8 p.m., and sustained a [MEDICAL CONDITION]. He was unable to remember if the chair alarm was in place at the time Resident #3 fell and fractured her hip. He confirmed he was not notified of the serious injury (of unknown origin) until approximately 02:30 a.m. (approximately 4 hours later). During an interview on 07/07/2017 at 1:49 p.m., LVN A confirmed Resident #3 had fallen twice on 07/06/2017 and once on 07/04/2017. She confirmed Resident #3 was to have a bed/chair alarm due to her cognitive impairment and multiple falls. She confirmed Resident #3 was admitted for an injury to her arm due to a fall at home. On 07/06/2017 about 08:00 p.m., LVN A was passing evening medications, she stated she heard yelling from the Resident's room. She went to the room and found the Resident #3 on the floor. After examining Resident #3, LVN A was pretty sure she had a broken hip. The on-call physician was notified. Resident #3 was transferred to the local hospital, and a [MEDICAL CONDITION] was confirmed. LVN A confirmed Resident #3 was up in a chair without a chair alarm. She stated, I should have checked to make sure she had it (chair alarm) on when I came on. LVN A confirmed the injury occurred approximately 08:00 p.m. on 07/06/2017, and she did not report the injury to administration until approximately 02:30 a.m. on 07/07/2017. During an interview on 07/07/2017 at 03:20 p.m., DON confirmed no fall care plan was in place for Resident #3 prior to its completion today. He confirmed no additional bed/chair alarm policies are in the fall management policies, and stated, those are our fall policies. While reviewing the facility's Fall Management What you need to know, dated 2015, it stated: Other Interventions to Manage Fall Risk -Use of bed/chair alarms only when deemed beneficial. Preventative Strategies to Reduce Risk of Falls C. Environmental -Furnishings -Chair Alarms -Has experienced one or more falls from a chair or wheelchair -One or more falls ambulating shortly after leaving chair or found on floor by chair. While reviewing the facility's policy for Abuse Prohibition, dated, 2016, it stated: Policy: 1. The facility's Leadership prohibits neglect . 2. Ensure that all alleged violations involving abuse, neglect, exploitation, mistreatment, including injuries of unknown source ., are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury . Definitions: 6. Neglect is the failure of the facility, its employees or service providers to provide goods or services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Prevention: 5. Ongoing assessments, care planning, and monitoring of those patients/residents with special needs that may lead to neglect, for example: C. History of self-injury; E. Patients/residents requiring excessive nursing care or staff. Review of the CMS Form 672 Resident Census and Conditions of Residents, dated 07/07/2017, documented a census of 99, with 77 residents requiring assistance with transfers.

Based on interview and record review; it was determined the facility failed to implement its policies and procedures that prohibit and prevent abuse, neglect, and exploitation, and misappropriation of resident property for 1 of 5 residents reviewed for abuse, neglect and misappropriation (Resident #3). Resident #3 was found on the floor and examination revealed a [MEDICAL CONDITION]. LVN A failed to report the serious injury of unknown origin as directed by the facility's Abuse, Neglect and Misappropriation Policy. The facility's failure to implement its policies and procedures that prohibit and prevent abuse, neglect, and exploitation, and misappropriation of resident property could place 77 residents requiring 1-2 person assistance with transfers at risk for abuse, neglect, exploitation, falls, pain, bruising, cuts, lacerations, blood loss, broken bones, head injuries, coma and death. Findings include: While reviewing the facility's policy for Abuse Prohibition, dated, 2016, it stated: Policy: 1. The facility's Leadership prohibits neglect . 2. Ensure that all alleged violations involving abuse, neglect, exploitation, mistreatment, including injuries of unknown source ., are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury . Definitions: 6. Neglect is the failure of the facility, its employees or service providers to provide goods or services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Prevention: 5. Ongoing assessments, care planning, and monitoring of those patients/residents with special needs that may lead to neglect, for example: C. History of self-injury; E. Patients/residents requiring excessive nursing care or staff. Record review of Resident #3's clinical record revealed Resident #3 is a [AGE] year old female with an admission date of [DATE]. She was discharged on [DATE] after a fall and [MEDICAL CONDITION]. She has [DIAGNOSES REDACTED]. Resident #3 does not have a MDS as her admission and discharge MDS were not due at the time of the investigation. While reviewing the physician orders [REDACTED]. 07/01/2017 at 01:18 p.m.: Resident is a fall risk. While reviewing the nursing notes for Resident #3, it stated: 07/06/2017 at 06:45 a.m.: Resident voiced she got up and started to losing her balance and decided to sit herself on the floor .bed and chair alarm in place. (The bed/chair alarm were initiated after her fall on 07/03/2017). No mention of the bed or chair alarm is made in the fall documentation on 07/06/2017 at 08:20 p.m. While reviewing the facility incident report for Resident #3's fall on 07/04/2017, it stated: Resident was found on the floor. She sustained no injuries, and a bed/chair alarm were initiated to prevent future falls. During an interview on 07/07/2017 at 11:30 a.m., DON confirmed Resident #3 was admitted after a fall at home to rehab to get stronger so she could go to surgery. He confirmed Resident #3 fell [DATE] and a bed and chair alarm was initiated to prevent falls. He confirmed Resident fell on [DATE] at 06:45 a.m., and the bed and chair alarms were documented to be in place and functioning. He confirmed Resident #3 fell on [DATE] at approximately 8 p.m., and sustained a [MEDICAL CONDITION]. He was unable to remember if the chair alarm was in place at the time Resident #3 fell and fractured her hip. He confirmed he was not notified of the serious injury (of unknown origin) until approximately 02:30 a.m. (approximately 4 hours later). During an interview on 07/07/2017 at 1:49 p.m., LVN A confirmed Resident #3 had fallen twice on 07/06/2017 and once on 07/04/2017. She confirmed Resident #3 was to have a bed/chair alarm due to her cognitive impairment and multiple falls. She confirmed Resident #3 was admitted for an injury to her arm due to a fall at home. On 07/06/2017 about 08:00 p.m., LVN A was passing evening medications, she stated she heard yelling from the Resident's room. She went to the room and found the Resident #3 on the floor. After examining Resident #3, LVN A was pretty sure she had a broken hip. The on-call physician was notified. Resident #3 was transferred to the local hospital, and a [MEDICAL CONDITION] was confirmed. LVN A confirmed Resident #3 was up in a chair without a chair alarm. She stated, I should have checked to make sure she had it (chair alarm) on when I came on. LVN A confirmed the injury occurred approximately 08:00 p.m. on 07/06/2017, and she did not report the injury to administration until approximately 02:30 a.m. on 07/07/2017. During an interview on 07/07/2017 at 03:05 p.m., ADON confirmed the initial care plan for Resident #3 should be completed within 24 hours of her admission on 07/01/2017. She confirmed the care plan should be updated after every fall. She confirmed she failed to complete an initial care plan and update the care plan after each fall. She stated, I know it's not an excuse, but I am new to this position. During an interview on 07/07/2017 at 03:20 p.m., DON confirmed no additional bed/chair alarm policies except those in the fall management policies, and stated, those are our fall policies. While reviewing the facility's policy for Fall Management, dated 07/01/2017, it stated: 1. The facility will identify which resident who is at risk for falls and will care plan and implement interventions to manage falls. While reviewing the facility's Fall Management What you need to know, dated 2015, it stated: Care planning a fall -With each fall, (the) care plan must be updated. While reviewing the facility's Fall Management What you need to know, dated 2015, it stated: Other Interventions to Manage Fall Risk -Use of bed/chair alarms only when deemed beneficial. Preventative Strategies to Reduce Risk of Falls C. Environmental -Furnishings -Chair Alarms -Has experienced one or more falls from a chair or wheelchair -One or more falls ambulating shortly after leaving chair or found on floor by chair. Review of the CMS Form 672 Resident Census and Conditions of Residents, dated 07/07/2017, documented a census of 99, with 77 residents requiring assistance with transfers.

Based on interview and record review; it was determined the facility failed to ensure adequate supervision and assistive devices for each resident to prevent accidents for 1 of 5 residents (Resident #3) reviewed for falls. Resident #3 did not have a chair alarm in place when she fell and sustained a fractured hip. The facility's failure to ensure each resident received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being could place 77 residents requiring 1-2 person assistance with transfers at risk for falls, pain, bruising, cuts, lacerations, blood loss, broken bones, head injuries, coma and death. Findings include: Record review of Residents #3's clinical record revealed Resident #3 is a [AGE] year old female with an admission date of [DATE]. She was discharged on [DATE] after a fall and fractured hip. She has [DIAGNOSES REDACTED]. Resident #3 does not have a MDS as her admission and discharge MDS were not due at the time of the investigation. While reviewing the physician orders [REDACTED]. 07/01/2017 at 01:18 p.m.: Resident is a fall risk. While reviewing the nursing notes for Resident #3, it stated: 07/06/2017 at 06:45 a.m.: Resident voiced she got up and started to losing her balance and decided to sit herself on the floor .bed and chair alarm in place. (The bed/chair alarm were initiated after her fall on 07/03/2017). No mention of the bed or chair alarm is made in the fall documentation on 07/06/2017 at 08:20 p.m. While reviewing the facility incident report for Resident #3's fall on 07/04/2017, it stated: Resident was found on the floor. She sustained no injuries, and a bed/chair alarm were initiated to prevent future falls. During an interview on 07/07/2017 at 11:30 a.m., DON confirmed Resident #3 was admitted after a fall at home to rehab to get stronger so she could go to surgery. He confirmed Resident #3 fell [DATE] and a bed and chair alarm was initiated to prevent falls. He confirmed Resident fell on [DATE] at 06:45 a.m., and the bed and chair alarms were documented to be in place and functioning. He confirmed Resident #3 fell on [DATE] at approximately 8 p.m., and sustained a fractured hip. He was unable to remember if the chair alarm was in place at the time Resident #3 fell and fractured her hip. He confirmed he was not notified of the serious injury (of unknown origin) until approximately 02:30 a.m. (approximately 4 hours later). During an interview on 07/07/2017 at 1:49 p.m., LVN A confirmed Resident #3 had fallen twice on 07/06/2017 and once on 07/04/2017. She confirmed Resident #3 was to have a bed/chair alarm due to her cognitive impairment and multiple falls. She confirmed Resident #3 was admitted for an injury to her arm due to a fall at home. On 07/06/2017 about 08:00 p.m., LVN A was passing evening medications, she stated she heard yelling from the Resident's room. She went to the room and found the Resident #3 on the floor. After examining Resident #3, LVN A was pretty sure she had a broken hip. The on-call physician was notified. Resident #3 was transferred to the local hospital, and a hip fracture was confirmed. LVN A confirmed Resident #3 was up in a chair without a chair alarm. She stated, I should have checked to make sure she had it (chair alarm) on when I came on. LVN A confirmed the injury occurred approximately 08:00 p.m. on 07/06/2017, and she did not report the injury to administration until approximately 02:30 a.m. on 07/07/2017. During an interview on 07/07/2017 at 03:05 p.m., ADON confirmed the care plan for Resident #3 should be updated after every fall. She confirmed she failed to update the care plan after each fall. She stated, I know it's not an excuse, but I am new to this position. During an interview on 07/07/2017 at 03:20 p.m., DON confirmed no fall care plan was in place for Resident #3 prior to its completion today. He confirmed no additional bed/chair alarm policies are in the fall management policies, and stated, those are our fall policies. While reviewing the facility's policy for Fall Management, dated 07/01/2017, it stated: 1. The facility will identify which resident who is at risk for falls and will care plan and implement interventions to manage falls. While reviewing the facility's Fall Management What you need to know, dated 2015, it stated: Care planning a fall -With each fall, (the) care plan must be updated. While reviewing the facility's Fall Management What you need to know, dated 2015, it stated: Other Interventions to Manage Fall Risk -Use of bed/chair alarms only when deemed beneficial. Preventative Strategies to Reduce Risk of Falls C. Environmental -Furnishings -Chair Alarms -Has experienced one or more falls from a chair or wheelchair -One or more falls ambulating shortly after leaving chair or found on floor by chair. Review of the CMS Form 672 Resident Census and Conditions of Residents, dated 07/07/2017, documented a census of 99, with 77 residents requiring assistance with transfers.