Every finding on record at Ignite Medical Resort Round Rock, LLC

Based on interview and record review, the facility failed to ensure residents were free of significant medication errors for 1 of 3 residents (Resident #3) reviewed for medication errors. The facility failed to ensure nursing staff administered Resident #3's medication at the scheduled time. These failures could place all 3 residents at risk of their medications not being administered according to Physician's orders, getting their medications late, or not receiving the intended therapeutic benefits of their medications.Findings included: Record review of Resident #3's order summary report indicated Resident #3 had an order for Carbidopa-Levodopa Oral Tablet Disintegrating 25-100 MG. Give 1.5 tablet by mouth every 8 hours for Parkinson's. Please give at scheduled time. Notify provider if unable to give at scheduled time with start date 01/06/2026. Record review of Resident #3's Medication Administration Record, dated 01/01/2026-01/31/2026, indicated the following scheduled time for administration of Carbidopa-Levodopa Oral tablet 25-100 MG, give 1.5 tablet at 6:00 a.m., 2:00 p.m., and 10 p.m. Resident #3's MAR indicated all scheduled doses of Carbidopa-Levodopa Oral tablet 25-100 MG were administered to Resident #3 without specific time of administration indicated. Record review of facility's Medication Administration Audit Report for schedule dates 01/01/2026-01/28/2026 revealed Carbidopa-Levodopa Oral tablet 25-100 MG. Give 1.5 tablet by mouth three times a day for Parkinson's. One dose scheduled time at 0600 a.m. on 01/07/2025 was administered at 08:33 a.m.One dose schedule time at 2:00 p.m. on 01/08/2026 was administered at 3:15 p.m.One dose schedule time at 2:00 p.m. on 01/10/2026 was administered at 3:05 p.m.One dose schedule time at 2:00 p.m. on 01/19/2026 was administered at 4:00 p.m.One dose schedule time at 2:00 p.m. on 01/22/2026 was administered at 3:04 p.m. Record review of the NP's progress note for Resident #3, dated 01/06/2026, revealed that Resident #3's Family voices concerns of timing of carbidopa-levodopa, patient has been receiving his medication later than scheduled and has increased tremors. Discussed with nursing and will adjust order to reflect every 8 hours on specific times. Record review of Resident #3's face sheet, dated from 01/28/2026, indicated a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease with fluctuations (progressive neurodegenerative disorder caused by the loss of dopamine-producing brain cells, leading to movement issues like muscle tremors and stiffness), hypertension (a chronic condition with high blood pressure), and traumatic subarachnoid hemorrhage (bleeding into the space around the brain, most commonly caused by head injuries from accidents or falls). Record review of Resident #3's admission MDS assessment, dated 01/09/2026, revealed Resident #3's BIMS score of 15, indicating intact cognition. Record review of Resident #3's comprehensive care plan, revised 01/15/2026, indicated Resident #3 was on anti-Parkinsonian therapy for Parkinson's disease with interventions in place to administer anti-Parkinson's medications as ordered by physician. Monitor/document side effects and effectiveness every shift. During an interview on 1/28/2026 at 12:34 p.m. with the ADM, she stated that she did not have medication administration training as she was not a medical professional. She stated that nurses and medication aides were responsible for proper medication administration including administration scheduled medications according to physician's orders. She stated that the potential risk for not administering medications according to the physician's orders could be not treating residents' diagnoses properly. She stated that nursing leadership was responsible for monitoring proper medication administration at the facility. During an interview on 01/28/2026 at 1:02 p.m. with the VPCO, she stated that she had medication administration training annually. She was aware of right time as one of the significant characteristics of medication administration. She stated that medication aides and charge nurses were responsible for timely medication administration. She stated that most of the medications at the facility administered on the liberalized schedule: 07:00-10:00 a.m. (AM pass), 1:00-3:00 p.m. (mid-day pass), and 7:00 - 10:00 p.m. (PM pass). But certain medications, like seizure and Parkinson's medications, if ordered for specific times, should be administered according to physician's orders with following one hour before and one hour after scheduled time rule. She stated if medication was not administered to residents as ordered or administered late, it could affect residents' health conditions these medications were intended to treat. She stated that late administration of Carbidopa-Levodopa for Resident #3 could affect his Parkinson's disease. Interview with the DON was not attempted secondary to the DON was only two days in this role. During an interview on 01/23/2026 at 12:05 p.m. with the NP, she stated that Resident #3's health condition improved while he stayed at the facility, he was able to get up with therapy and walk in the hallway. She stated that she communicated with Resident #3 and his family, and they expressed the concern with medication administration timing specifically for his Parkinson's medication. She stated that she adjusted the administration time to specific three times a day times, and after that she did not hear any concerns from Resident #3 or his family during her weekly rounds. Record review of the facility's Medication Pass Policy and Procedure, undated, revealed Purpose: to ensure that all medications in the facility are administered safely, accurately, and in compliance with Texas law and regulatory requirements.3. Resident rights to timely and appropriate medication administration.Right Time: Administer the medication at the correct time and frequency, as ordered. Record review of facility's Medication Pass Policy and Procedure, undated, revealed that Med Pass: Scheduled administration of medications to residents. Medication Administration: Right Time - Administer the medication at the correct time and frequency, as ordered.

Based on observation, interview, and record review, the facility failed to ensure that each resident has the right to secure and confidential personal and clinical records for 2 of 23 residents (Resident #1 and Resident #2) on Kindle Unit of the facility reviewed for Privacy and Confidentiality. The facility failed to ensure Resident #2's clinical records were protected from being viewed by unauthorized persons when the CNA left Resident #2's personal information visible on the computer's screen at unattended charting station on Kindle Unit. The facility failed to ensure Resident #1's clinical records were protected from being viewed by unauthorized persons when the RN left Resident #1's personal information visible on the computer's screen on unattended NC on Kindle Unit. This failure could result in residents' personal information being exposed to unauthorized individuals. The findings included: Observation on 1/28/2026 at 9:09 a.m. revealed that the computer screen on the CNA's charting station on Kindle Unit was opened and unlocked with Resident #2's personal (plan of care) information displayed and visible to unauthorized individuals, including visitors or other residents. Unauthorized individuals were not present near the charting station at that time. During an interview on 1/28/2026 at 12:15 p.m. with the CNA, she stated that she had an in-service on HIPAA a few months ago and it included instructions not discussing residents' private clinical information with unauthorized individuals and to lock the computer screen when stepping away from the charting station. She stated that everybody who works with charting computers was responsible for closing it and locking it when not in attendance. She stated that she was called by another staff member to help with resident care, and she forgot to close the computer's screen. She stated that she was responsible for shutting down and locking the charting computer's screen when stepping away. She stated that leaving the screen unlocked with clinical information displayed on it could be harmful for residents as anybody can see it. Observation on 1/28/2026 at 10:00 a.m. revealed that the computer screen on the RN's NC on Kindle Unit was open and unlocked, with Resident #1's personal medical information (medication administration record) displayed and visible to unauthorized individuals, including visitors or other residents. Unauthorized individuals were not present near the RN's NC at that time. During an interview on 1/28/2026 at 10:05 a.m. with the RN, he stated that staff who worked with residents' personal information was responsible for shutting down the charting computers' screen when needed to leave. He stated that he received HIPAA training several months ago. RN stated that leaving a computer screen without locking the screen could lead to exposing residents' private medical information to unauthorized people and residents' privacy could be violated. During an interview on 1/28/2026 at 12:34 p.m. with the ADM, she stated that she had the HIPAA annual training which covered the importance of maintaining the residents' private information. She stated that whoever used the computer was responsible for shutting it down to ensure the residents' information was not visible. She stated that the potential risk for not shutting down charting computers could be a breach of residents' privacy. She stated that all staff complete HIPAA in-service at hire and annually through computer modules. She stated that the RN and the CNA completed their annual training. During an interview on 1/28/2026 at 1:02 p.m. with the VPCO, she stated that the facility's policy was to minimize the charting computers' screens when stepping away. She stated that if the screen was not minimized, someone could have unauthorized access to the private clinical information displayed on the screen. She stated that HIPAA in-service was provided to all employees at hire and annually through computer modules which include instructions on locking the computer screens. She stated that the person who works with residents' private clinical information should lock the screen before walking away. She stated that the potential negative effect was unauthorized disclosure of residents' private information. Record review of Resident #2's face sheet, dated 1/28/2026, revealed, a 95-years-old male originally admitted on [DATE] and readmitted on [DATE]. Resident's #1's diagnoses included acute posthemorrhagic anemia (a critical condition caused by rapid, significant blood loss), acute kidney failure the sudden, rapid loss of kidney function) and type 2 diabetes mellitus (a chronic condition characterized by insulin resistance, where body cells fail to use insulin properly, resulting in high blood sugar). Record review of Resident #1's face sheet, dated 1/28/2026, revealed, a 66-years-old female admitted on [DATE]. Resident's #1's diagnoses included type 2 diabetes mellitus (a chronic condition characterized by insulin resistance, where body cells fail to use insulin properly, resulting in high blood sugar), myopathy (muscle diseases characterized by structural or functional impairment, primarily causing weakness, fatigue, stiffness, and cramps) and polyneuropathy (a condition characterized by damage to multiple peripheral nerves, often causing symmetric numbness, tingling, weakness, and pain). Record review did not reveal HIPAA in-services completed and documented by the CNA and the RN before this incident. Record review of facility's Notice of Privacy Practices, dated 01/2026, revealed, This facility is required by the privacy regulations issued under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to maintain the privacy of each of our elder's medical information. Protecting the confidentiality of each elder's personal information has been, and always will be, a top priority for this facility. All staff members are trained to protect all health information and keep the information confidential at the time of employment prior to performing any/all assigned duties, at least annually and at any time a supervisors feel the staff member may need additional training.

Based on observation, interview, and record review, the facility failed to provide a resident or family group with private space for 1 of 1 resident council meetings reviewed for resident rightsThe facility failed to provide a private space for residents to meet during resident council meetings, exposing residents to loss of privacy.This failure could affect place residents by placing them at risk for loss of privacy and dignity. the Findings included:Record review of previous Resident Council Meetings Minutes, dated 10/23/2025,11/20/2025, 11/23/2025 revealed that Resident council meetings were regularly held in the facilities dining room.During an interview on 01/13/2026 at 10:00 AM revealed AD F had been trained in Resident Rights and in Abuse, Neglect, and Exploitation. AD F stated, Per the State of Texas Constitution, residents will not be denied their rights and residents should be able to make choices. AD F stated the topics previously addressed in past resident council meetings included: Protecting and valuing residents' private space, right to be free of reprisal from the facility, right to Respect and Dignity. AD F stated she was responsible for ensuring residents had a private place to meet.During a follow up interview and record review on 01/13/2026 at 11:35 a.m., AD F stated she was not aware of the privacy requirement for residents during resident council meetings. She stated, Now that you have highlighted the aspect of privacy, the dining room may not have been the best place to hold resident council meetings. She stated, I was thinking that the dining room was my only option. She stated, she understood that residents should be able to afford privacy while expressing their thoughts about the facility, and she believed the meetings should take place in the privacy of the conference room from then on.An interview on 01/15/2026 at 2:24 p.m. revealed the ADM's expectations for resident privacy was that they should have privacy to make complaints when attending the resident council meetings. The ADM stated the average length of stay for residents was 14 days, and the residents have other interests.During an interview on 01/15/2026 at 2:04 p.m., it was revealed that VPCO was trained in resident rights and the right of a resident to have privacy. She stated the policy was Residents are allowed to meet without staff present. She stated, if uninvited staff were walking through a room while residents were in a resident council meeting, they may not be as candid with their comments, complaints, or input at the meeting. She stated residents were allowed to present grievances to the facility, and resident council meetings should try to be held in a private place.Review of the facility's policy Resident Rights dated November 2021 Reflected, Residents of Texas nursing facilities have all the rights, benefits, responsibilities, and privileges granted by the Constitution and laws of this state and the United States. They have the right to be free of interference, coercion, discrimination, and reprisal in exercising these rights as citizens of the United States.Includes:Dignity and RespectFreedom of Choice You have the right to:Make your own choices regarding personal affairs, care, benefits, and services.Privacy and Confidentiality You have the right to:Privacy, including privacy during visits, phone calls and while attending to personal needs.Complaints You have the right to:Organize or participate in any group that presents residents' concerns to the administrator of the facility.Your rights may be restricted only to the extent necessary to protect you or others, or to protect the rights of others, particularly those rights relating to privacy and confidentiality.Policy: [facility] Resident Rights dated April 2022.Purpose: To ensure each resident is treated with dignity and respect. This includes providing activities and interactions from staff, temporary agencies or volunteers that is focused on assisting in maintaining and enhancing self- esteem, self- worth, individualizing goals, preferences, and choices. Care and services respect individuality while both honoring and valuing input.GuidelineOur facility environment encourages self-selection of individualized needs, care, and routines in a dignified and [NAME] way to respect preferences and full exercises of rights. Our residents have rights to a dignified existence, self - determination, and communication with and access to persons and services inside and outside the facility.Respect and Dignity.Protecting and valuing residents' private space:Knocking on doors and requesting permissions before entering and closing doors as requested.

Based on observation, interview, and record review, the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 5 of 8 residents (Resident #31, Resident #57, Resident #76, Resident #93, and Resident #94) reviewed for quality of life.1. The facility failed to ensure Resident #57, Resident #76, Resident #93, and Resident #94 received regular showers.2. The facility failed to ensure Resident #31, and Resident #94 were offered to have their facial hair removed.These failures placed residents at risk of having poor hygiene.Findings included:1. A record review of Resident #31's face sheet dated 1/14/2026 reflected an [AGE] year-old female admitted on [DATE] with diagnoses of congestive heart failure (end-stage heart disease), atrial fibrillation (abnormal heartbeat), chronic kidney disease, anxiety disorder, need for assistance with personal care, hypothyroidism (underactive thyroid), hypertension (high blood pressure), depression, hyperlipidemia and (high cholesterol), vascular dementia (cognitive disorder). A record review of Resident #31's MDS assessment dated [DATE] reflected a BIMS score of 7, which indicated moderately impaired cognition. Resident #31's MDS assessment reflected that she required moderate assistance with bathing and supervision or touching assistance with personal hygiene. A record review of Resident #31's care plan last revised on 1/13/2026 reflected that she had ADL self-care performance deficits and limitations in physical mobility. A record review of Resident #31's progress notes dated 1/02/2026-1/13/2026 reflected no documented refusals of care. A record review of Resident #31's POC Response History for bathing dated 1/14/2026 with a 30-day lookback period reflected no data.A record review of Resident #31's shower sheets reflected that she refused a shower on 1/02/2026, 1/06/2026, and 1/13/2026. Resident #31's shower sheets reflected that she received a shower on 1/03/2026 and 1/09/2026. During an observation and interview on 1/13/2026 at 12:43 PM, Resident #31 was observed sitting in her room. Resident #31 was observed to have a few wispy chin hairs about 0.5 inches in length. Resident #31 stated she had several chin hairs that she had not plucked yet. Resident #31 stated it would be nice if someone offered to help her with that.2. A record review of Resident #57's face sheet dated 1/14/2026 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of acute kidney failure, anemia, morbid (extreme) obesity, hypertension (high blood pressure), nonalcoholic steatohepatitis (fatty liver disease), type 2 diabetes (uncontrolled blood sugar), hyperlipidemia (high blood pressure), and glaucoma (eye disease). A record review of Resident #57's MDS assessment dated [DATE] reflected a BIMS score of 15, which reflected intact cognition. Resident #57's MDS assessment did not reflect data on her functional abilities. A record review of Resident #57's care plan last revised on 1/13/2026 reflected that she had ADL self-care performance deficits and limitations in physical mobility. Resident #57's care plan reflected she required substantial/maximal assistance with bathing and personal hygiene. A record review of Resident #57's progress notes dated 1/02/2026-1/14/2026 reflected no documented refusals of care. A record review of Resident #57's shower sheets reflected she refused a shower on 1/05/2026 and 1/12/2026. There was no documentation of showers offered during that period.During an observation and interview on 1/13/2026 at 10:45 AM, Resident #57 was observed sitting in her wheelchair in her room. Resident #57 stated she arrived at the facility on 1/02/2026 and it took the facility 7 days to bathe her. Resident #57 stated her family member had to come to the facility and intervened so that she could receive a shower. Resident #57 stated she refused a shower one time because it was 9:00 PM and she was already lying in bed comfortably for the night. Resident #57 stated she asked if she could have a shower the next day, and staff told her it would be 2-3 days until she could get one. Resident #57 was not sure which nurse stated this. Resident #57 stated she was due for a bath the day prior, on 1/12/2026, but no one came.3. A record review of Resident #76's face sheet dated 1/14/2026 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of displaced subtrochanteric fracture of left femur (broken leg), unspecified dementia (cognitive disorder), anxiety disorder, insomnia (inability to sleep), gastro-esophageal reflux disease (acid reflux), dysphagia (difficulty swallowing), and severe protein-calorie malnutrition. A record review of Resident #76's MDS assessment dated [DATE] did not reflect a BIMS score or data on her functional abilities. A record review of Resident #76's care plan last revised on 1/13/2026 reflected that she had ADL self-care performance deficits and limitations in physical mobility. Resident #76's care plan reflected that she required partial/moderate assistance with bathing and supervision or touching assistance with personal hygiene. A record review of Resident #76's progress notes dated 1/09/2026-1/14/2026 reflected no documented refusals of care. A record review of Resident #76's POC Response History for bathing dated 1/15/2026 with a 30-day lookback period reflected No Data Found. A record review of Resident #76's shower sheets reflected she refused a shower on 1/13/2026. There was no documentation of showers offered on other days.During an interview and observation on 1/13/2026 at 9:56 AM, Resident#76 was observed lying in bed. Resident #76's hair appeared oily. Resident #76 stated she wanted a shower and wondered when she would get one. Resident #76 stated she had not received a shower since arriving at the facility. Resident #76 stated she had not asked for a shower. 4. A record review of Resident #93's face sheet dated 1/15/2026 reflected an [AGE] year-old female admitted on [DATE] with diagnoses of metabolic encephalopathy (condition that causes brain dysfunction), unspecified dementia, hypertension (high blood pressure), fracture of left femur (leg), pubis (hip) and sacrum (spine), hyperlipidemia (high cholesterol), Alzheimer's disease (cognitive disease), and protein-calorie malnutrition.A record review of Resident #93's MDS assessment dated [DATE] reflected a BIMS score of 00, which indicated severe cognitive impairment. Resident #93's MDS assessment did not reflect data on her functional abilities. A record review of Resident #93's care plan last revised on 1/13/2026 reflected that she had ADL self-care performance deficits and limitations in physical mobility. Resident #93's care plan reflected she was dependent on staff for bathing and required substantial/maximal assistance with personal hygiene.A record review of Resident #93's progress notes dated 1/06/2026-1/15/2026 reflected no refusals of baths or showers. A record review of Resident #93's POC Response History for baths/showers dated 1/15/2026 with a 30-day lookback period reflected No Data Found.A record review of Resident #93's shower sheets reflected that she was given a shower on 1/08/2026. Resident #93's shower sheet dated 1/10/2026 reflected that she refused a shower and it was noted on her shower sheet that she liked day showers. Resident #93's shower sheet dated 1/15/2026 reflected she refused a shower.During an observation and interview on 1/13/2026 at 11:31 AM, Resident #93 was observed lying in bed. Resident #93 was non-interviewable. Resident #93's family member was present and stated that staff instructed her that Resident #93 would be a night shower but Resident #93 preferred day showers. Resident #93's family member stated she had requested several times that Resident #93 receive a shower during the day instead of at night since she had sundown syndrome. Resident #93's family members stated staff told her they would try to get Resident #93 on the schedule for day showers. Resident #93's family member stated that Resident #93 had only received one shower since arriving at the facility, and that was four days ago. Resident #93's family member stated she had requested a shower for Resident #93 the day prior, but Resident #93 had not received one. 5. A record review of Resident #94's face sheet dated 1/14/2026 reflected an [AGE] year-old female admitted on [DATE] with diagnoses of congestive heart failure (end-stage heart disease), type 2 diabetes (uncontrolled blood sugar), depression, anxiety, chronic kidney disease, lymphedema (swelling), and spinal stenosis (narrowing of spinal canal). A record review of Resident #94's MDS assessment dated [DATE] did not reflect a BIMS score or data on her functional abilities. A record review of Resident #94's care plan last revised on 1/10/2026 reflected that she had ADL self-care performance deficits and limitations in physical mobility. Resident #94's care plan reflected she required substantial/maximal assistance with bathing and partial/moderate assistance with personal hygiene. A record review of Resident #94's progress notes dated 1/09/2026-1/14/2026 reflected no documented refusals of baths or showers.A record review of Resident #94's POC Response History for showers/baths dated 1/14/2026 with a 30-day lookback period reflected No Data Found.A record review of Resident #94's shower sheet dated 1/09/2026 reflected that she refused a shower.Resident #94's shower sheets from January 2026 were requested on 1/15/2026 at 12:45 PM but were not provided prior to exit.During an observation and interview on 1/13/2026 at 12:04 PM, Resident #94 was observed in her room. Resident #94 stated she had not received a shower since she arrived at the facility (last Thursday). Resident #94 was observed to have facial hair on her chin. Resident #94 stated she used to tweeze her chin hair when she was at home. Resident #94 stated staff had not offered to help her groom her facial hair.During an interview on 1/14/2026 at 3:42 PM, LVN I stated showers were documented on sheets and electronically. During an interview on 1/14/2026 at 3:48 PM, LVN I stated when residents refused showers, the CNA would notify the nurse, and the nurse would ask the resident why they were refusing. LVN, I stated the nurse would then make a progress note in the resident's chart and notify the social worker. During an observation and interview on 1/15/2026 at 10:46 AM, CNA J stated that each CNA gave three showers a day and she stated CNAs went by a chart. CNA J then displayed the facility's shower schedule, which was organized by room number. CNA J stated residents were offered showers at least twice a week, but she would give them an extra shower if they needed one. CNA J stated that the facility's policy on grooming women with facial hair included shaving them any time they needed it. CNA J stated CNAs were responsible for bathing and grooming residents. CNA J stated, we do a lot of training. CNA J stated she was not sure when the last time Resident #76 had a shower, but that SC A oversaw the shower sheets and could look up when the resident's last shower was. CNA J stated she had not worked on Tuesday, but that Resident #76 would get a bath tomorrow. CNA J stated Resident #76's shower schedule was Tuesday and Friday nights. CNA J stated that Resident #31's shower days were Tuesday and Friday nights. An observation revealed CNA J walked into Resident #31's room, examined Resident #31's face, and then stated, I noticed some hairs there that I need to trim up today. CNA J stated she had not offered to remove Resident #31's facial hair in the past and she did not know whether other staff had offered. CNA J stated Resident #94's shower days were during the day on Mondays and Thursdays. CNA J stated she did not know the last time was Resident #94 was bathed, but that she was scheduled for one that same day. CNA J stated Resident #31 did not have a history of refusing baths. CNA J stated she had not offered to remove Resident #94's facial hair. An observation revealed CNA J walked into Resident #94's room, examined the resident, and said, she needs to be shaved today and that it was a little bunchy. CNA J stated Resident #57's showers were on Monday and Thursday evenings. CNA J stated she was not sure whether Resident #57 had refused showers in the past and she would have to look it up with [SC A] to see when Resident #57's last shower was. During an interview on 1/15/2026 at 12:31 PM, RN B stated she was not sure when Resident #93's last shower was, but that Resident #93 had been requesting showers during the day since it was cold at night. RN B stated refusals were documented on shower sheets and showers should be documented, but sometimes they don't document. RN B provided a sheet which reflected that Resident #93 had refused a shower on 1/10/2026. When asked if Resident #93 had been offered a shower since the 10th, RN B stated, yes. An observation revealed that RN B pulled up Resident #93 POC Response History for baths and it reflected no data. RN B stated Resident #93 may have been given a shower even if it was not documented. During an interview on 1/15/2026 at 12:45 PM, SC A stated that she was the CNA staffing coordinator and that she oversaw shower sheets. SC A stated CNAs were supposed to document showers in PCC and on the shower sheets. SC A stated, if it's not written, it didn't happen. SC A stated CNAs were supposed to ask three times if residents were refusing showers, then a nurse would need to sign the shower sheet if the resident still refused. During an interview on 1/15/2026 at 2:06 PM, the VPCO stated CNAs provided showers and tried to keep residents on a schedule. The VPCO stated grooming facial hair on women could be done during the shower depending on the patient. The VPCO stated we can offer that and it would be a shave. The VPCO stated CNAs were responsible for bathing and grooming residents at least twice a week. The VPCO stated we need to be documenting refusals and following up with the nurse. The VPCO stated nurses would sign shower sheets and try to get to the root cause as to why a resident did not want a shower. The VPCO stated showers were documented on PCC and on shower sheets, but there was no place in PCC to document grooming of facial hair. The VPCO stated that all staff had been trained upon hire and yearly through checkoffs and competencies. The VPCO stated that charge nurses monitored CNAs to ensure showers were being done. When asked what a potential negative outcome was if female residents had unwanted facial hair, the VPCO stated, they could be upset. When asked what a potential outcome was for residents if they did not receive regular showers/baths, the VPCO stated they could get upset or it could affect their progress.During an interview on 1/15/2026 at 2:26 PM, the ADM stated CNAs provide showers to residents twice a week either in the morning or in the afternoon. The ADM stated if residents wanted showers more frequently, staff should accommodate. The ADM stated she would try to find out if there was a policy on grooming facial hair on women. The ADM stated she expected staff to take note of facial hair on females, and it should be part of their ADL care. The ADM stated that staff were monitored to ensure showers and grooming were being done through leadership rounding with residents. The ADM stated showers were documented on sheets and she thought they documented in PCC. The ADM stated refusals were noted on the shower sheets. The ADM stated that all CNAs were trained as a part of their licensure and that it was addressed through orientation and in-services. The ADM stated residents with unwanted facial hair might feel embarrassed and we all feel better when we take a shower.Record review of the facility's policy titled ADL Policy dated November 2020 reflected the following: This facility will provide each resident with care, treatment, and services according to the resident's individualized care plan. Based on the individual resident's comprehensive assessment, facility staff will ensure that each resident's abilities in activities of daily living do not diminish unless circumstances of the resident's clinical condition demonstrate that the decline was unavoidable, including: Bathing. GroomingA record review of the facility's policy titled Resident Dignity dated November 2018 reflected the following: Policy: This facility will promote care for residents of the facility in a manner and in an environment that maintains and enhances each resident's dignity and respect in full recognition of the resident's individuality.Procedure: Residents will be groomed as they wish including hair care and styled, facial hair shaved/trimmed as the resident wishes, nail care as the resident chooses.

Based on observation, interview, and record review, the facility failed to prepare and distribute food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen and food sanitation.1. The facility failed to ensure the [NAME] used proper hand sanitation while preparing pureed foods. 2. The facility failed to ensure the DA D used proper hand sanitation prior to distributing food to residents' rooms. These failures could place residents, who receive food from the kitchen, at risk for food contamination and foodborne illness.Findings Included:An observation and interview on 01/13/2026 at 11:25 a.m., revealed the [NAME] cleaned and disinfected the robot coup blender after finishing a puree of Tamale pie. The [NAME] failed to wash her hands before putting clean gloves on. [NAME] completed a puree of refried beans, removed her gloves, and cleaned and sanitized the robot coup. [NAME] did not wash her hands between cleaning of robot coup and puree of rice. The [NAME] put gloves on and pureed rice and no handwashing after rice was pureed and gloves were removed. [NAME] stated she had training in food preparation and sanitation procedures. [NAME] stated the policy is to wash hands between kitchen and food preparation tasks.Observation/ interview on 01/15/2026 at 1:16 p.m., revealed DA D has been trained in food safety and sanitation. DA D stated he worked at the facility since August of 2025. He stated handwashing is to be performed before he leaves the kitchen to deliver food trays to the halls. Observed DA D failed to wash his hands prior to removing the food tray-cart from the kitchen to deliver food trays to the 100 hall. DA D stated the policy requires they sanitize our hands between tray delivery. During an interview on 01/14/2026 at 11:52 a.m., the RD stated her title is Dietary Specialist. She stated her responsibility is to meet with nursing staff and update residents' charts with new or changed nutritional and dietary needs. She stated she performs a kitchen sanitation audit 1 time per month, and she submits the findings to the facility staff. RD stated the policy for handwashing is posted at the designated wash sinks and it is her expectation that staff would wash hands between kitchen tasks, and before and after food preparation. She stated handwashing is essential for preventing food borne illness. During an interview on 01/14/2026 at 5:36 p.m., DM H (Corporate Dietary Manager) stated he was trained in culinary arts, dietary management, sanitation, and handwashing. He stated that the AC is the facility's Administrator. DM H explained that handwashing is to be done by all staff, and those who enter the kitchen, to prevent food borne illness. During an interview on 01/15/2026 at 2:04 p.m., the VPCO stated she was trained on kitchen sanitation and handwashing. She stated handwashing should be done when entering the kitchen and between tasks, using the soap dispenser and designated hand washing sinks in the kitchen. She stated there was no reason someone should not wash their hands per the handwashing policy. She stated if staff members do not wash hands between kitchen tasks, there could be cross contamination. Record Review of an in-service training on 10/15/2025 regarding Handwashing and Sanitation: proper Dishwashing & Storage and sanitation buckets.Record Review of kitchen staff certifications revealed. DM H Certified Dietary Manager and Certified Food Protection Professional. The [NAME] - Texas Food Service Handler certificationDA D - Texas Food Service Handler certification Review of the facility's policy for Food & Nutrition Services Sanitation & Food Safety Handwashing Policy reflected,Food and Nutrition services employees will practice safe food handling to prevent foodborne illness.Procedure: Food and nutrition services employees will thoroughly wash their hands and exposed areas of their arms with soap and water in the designated hand-washing sink at the following times: Upon entering the kitchen at the beginning of the shift Before engaging in food preparation. After touching anything unsanitary (garbage, dirty dishes) After touching bare human body parts other than clean hands and arms (example adjusting one's hairnet)Between removing gloves or aprons and before putting on new gloves or aprons.When switching between working with raw food and working with ready-to-eat food.Use of GlovesFood and nutrition service employees wear disposable gloves to avoid bare- hand contact with food.Use of disposable gloves shall be preceded by thorough hand washing with soap and water.

Based on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for reviewed for infection control.DA D did not sanitize his hands between each resident when passing meal trays for lunch. This failure could place the residents at risk of transmission of disease and infection.Findings included:Observation on 01/13/2026 at 12:50 PM of staff passing lunch trays to the resident rooms on the 100 Hall revealed DA D did not hand hygiene when leaving Resident #59's room. He took a tray from the cart to Resident #26's room, and no hand hygiene was conducted. DA D then returned to the cart and took a tray to Resident #38's room, and no hand hygiene was conducted. He returned to the cart and took a tray to Resident 67's room, and no hand hygiene was conducted. An interview on 01/13/2026 at 1:14 PM with DA D, who stated he had been trained to clean his hands with hand sanitizer between each resident when passing their lunch trays but stated he had been moving fast and had forgotten to sanitize his hands. DA D further stated he received training on hand hygiene and passing resident trays. DA D stated not conducting hand hygiene between each resident when passing meal trays could lead to infection. Interview on 01/15/26 at 1:53 PM with the VPCO revealed she was the infection preventionist for the facility. She also stated that normally the ADON and wound care nurse would also be the infection preventionist. The DON stated the policy for conducting handwashing/hand hygiene when providing care/passing meal trays included all staff were to be using hand sanitizer between each meal pass unless something happened and they needed to wash their hands. stated a negative outcome to the resident could be cross contamination. The DON stated Nurse leadership and herself were responsible for monitoring to ensure staff were conducting hand hygiene. The DON further stated the facility conducted monitoring to ensure staff were washing their hands by conducting spot checks, in-services, and checkoffs. She stated she did not know why the staff member did not conduct hand hygiene between each resident when passing meal trays. Review of the facility's Policy & Procedures on Hand Hygiene dated April 2023 reflected, Policy: All staff members will comply with current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines, as effective hand hygiene reduces the incidence of healthcare-associated infections (HAIs)Handwashing may also be used for routinely decontaminating hands in the following clinical situations: Before and after contact with inanimate objects including medical equipment in the immediate vicinity of the resident Indications for Alcohol-Based Hand Rub (ABHR):If hands are not visibly soiled, an alcohol-based hand rub may be used for routinely decontaminating hands in the following clinical situations: Before and after having direct contact with residents Before and after contact with inanimate objects including medical equipment in the immediate vicinity of the resident Before and after assisting a resident with eating

Based on observation and interviews, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 2 of 15 residents (Resident #22 and Resident #71) reviewed for resident rights. The facility failed to ensure Resident #22 and Resident #71's rooms were clean.This deficient practice could place residents at risk of feelings dissatisfaction.The findings were:Record review of Resident #22's face sheet, dated 01/14/2026, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #22 had diagnoses which included embolism and thrombosis (blood clots in blood vessels), atrial fibrillation (abnormal heart rhythm), dementia (memory, thinking, difficulty), need for assistance with personal care, muscle weakness, history of falls and unsteadiness on feet. Record review of Resident #22's MDS assessment, dated 01/05/2026, revealed Resident #22 had a BIMS score of 13 which indicated intact cognitive responses. Record review of Resident #22's admission care plan dated 12/31/2026 revealed [Resident #22] was at risk for falls related to history of falls and decreased mobility. The goal was [Resident #22] would remain free from injury related to falls. Interventions were when [Resident #22] attempts to stand, ask what they would like to do and then assist them to complete the task.Record review of Resident #71's face sheet, dated 01/14/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. [Resident #71] had diagnoses which included anxiety (feeling of uneasiness or worry), morbid (severe) obesity, need for assistance with personal care, difficulty in walking, pain due to trauma, and person injured in collision between other specified motor vehicles. Record review of [Resident #71]'s MDS, dated [DATE], revealed Resident #71 had a BIMS score of 15 which indicated intact cognitive responses. Record review of [Resident #71]'s admission care plan dated 12/24/2026 revealed [Resident #71] was at risk for falls related to impaired mobility, fractures, pain and post-surgical state. The goal was [Resident #71] would remain free from injury related to falls. An intervention was educating Resident #71 and family on need to call for assistance when transferring in and out of chair.Observation of [Resident #71]'s room on 01/13/2026 at 9:53 a.m., revealed the resident's room had paper on the floor, dirty socks on the floor, an empty medication cup under the bed and the bathroom had hair on the wall of the shower. Observation of [Resident #22]'s room on 01/13/2026 at 2:26 p.m., revealed there was a paper towel on the floor, small pieces of paper on the floor, and two spoons on the floor under her bed.Observation of [Resident #71]'s room on 01/13/2026 at 2:29 p.m., revealed her room still had paper on the floor, dirty socks on the floor, an empty medication cup under the bed and the bathroom still had hair on the wall of the shower. Observation of [Resident #71]'s room on 01/14/2026 at 8:22 a.m., revealed her room still had paper on the floor, dirty socks on the floor, an empty medication cup under the bed and the bathroom still had hair on the wall of the shower. An interview with [Resident #71] on 01/13/2026 at 9:56 a.m., she stated she did not know the last time housekeeping had come into her room to clean. She said housekeeping had not come in to sweep, mop, or clean her bathroom. She also said that her visitors would comment on how dirty her room was. She said she wanted housekeeping to come clean her room daily. An interview with [Resident #22] on 01/13/2026 at 2:29 p.m., revealed that her room was dirty because housekeeping had already come. She said housekeeping only cleaned the room once a day. She said that staff would not pick up anything and left it for housekeeping. An interview with the HKS on 01/15/2026 at 11:27 a.m., revealed she had been trained in resident rights. She said the housekeeping policy was if a room had a resident in it, staff were not to touch the bed. She said the housekeeping staff would take out the trash, clean the bathroom, sweep, mop and fill up the soap dispensers. She said housekeeping was responsible for cleaning the resident's rooms once a day. She said if housekeeping knew a resident dropped things often, the housekeeping staff would go back and retouch up the room. She said when housekeeping was not there, the staff should pick up trash on the floor. She also said depending on what the mess was, the staff would call housekeeping to come in and disinfect. She said if the residents' rooms were not cleaned, it could cause the resident to get sicker and cause germs in the room. She said the HKS was responsible for monitoring to ensure the residents' rooms were clean. She said the HKS monitored it by walking around and checking the resident's rooms to ensure they were clean. She said [Resident #22] and [Resident #71]'s rooms were probably dirty because the facility only had one housekeeper because the other housekeeper was out sick.An interview with the VPCO on 01/15/2026 at 2:07 p.m., revealed that she had been trained on resident rights. She said the housekeeping policy for cleaning the residents' rooms was the housekeeper had a spreadsheet of things they were to clean the residents' rooms. She said the rooms were cleaned daily. She said housekeeping was responsible for cleaning the resident's rooms. She also said CNAs could help pick up trash and keep the residents' rooms clean. She said a resident may get upset if their room was not cleaned or if their room was cluttered. She said the housekeeping supervisor monitored to ensure the residents' rooms were getting cleaned. She said the housekeeping supervisor monitored through an audit system. She said she did not know why [Resident #22] and [Resident #71]'s rooms had not been cleaned. During an interview with the ADM on 01/15/2026 at 2:27 p.m., she said the housekeeping policy was that the residents' rooms should be cleaned daily. She said the housekeeping staff were responsible for cleaning the resident's rooms. She said the nursing staff should be helping keep the residents' rooms tidy when housekeeping was not there. She said it depended on the resident on how it might affect them. She said some may not care, but it was standard that the staff had to keep the rooms clean. She said the housekeeping supervisor and the director of environmental services monitored to ensure the rooms were cleaned. She said the housekeeping supervisor and the director of environmental services monitored by doing rounds. She said she knew that residents' had been refusing things, but she was not sure if [Resident #22] or [Resident #71] had refused to let staff clean their rooms. Record review of the facility's Safe, Clean, Comfortable, Homelike Environment Policy dated 07/2025, revealed Management and Environmental Service staff provide homelike surroundings with access to personal living space. Staff will provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, functional, and comfortable interior.

Based on observation, interview, and record review, the facility failed to ensure drugs are stored properly and only authorized persons have access for 1 of 2 medication carts (TC #1) reviewed for pharmacy services.The facility failed to ensure TC #1 was locked, medications secured, and not accessible to other staff, residents, or visitors.This failure could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missing medications.Findings included:An initial walkthrough observation of the facility on 01/13/2026 at 09:01 a.m., revealed TC#1 was unlocked and unattended outside of a resident's room. A nurse was inside a resident's room with her back turned away from the treatment cart. The resident's door was cracked open about two inches. Residents were walking by the unlocked treatment cart. TC #1 contained residents prescribed creams. On top of the treatment cart was a bottle of wound cleaner solution and two packages of black foam wound dressings. One foam dressing was opened. LVN C came out of the room, introduced herself, went back into the room, closed the door all the way and did not lock the treatment cart. An interview with LVN C on 01/15/2026 at 10:26 a.m., revealed that she had been trained on medication storage. She said the medication/treatment cart policy was staff must lock the treatment cart anytime they walked away. She said the person who was working on the treatment cart was responsible for locking the cart. She said the treatment cart should be locked immediately after removing the medication from the cart and before walking away from the cart. She said if the treatment cart was left unlocked and unattended someone could get into the treatment cart and take medication from the cart. She said the clinical supervisor monitored by doing rounds and in-services. She said she left the medication cart unlocked because she walked in to talk to the resident. She said she locked it the second time when she came out of the resident's room. She said that the cart should have been locked when she walked back into the resident's room. An interview with the VPCO on 01/15/2026 at 2:07 p.m., revealed she had been trained on medication storage. She said the medication/treatment cart policy was staff must lock the cart any time the staff member was not using the cart. She said the team member who was assigned to the cart was responsible for ensuring the cart was locked. She said the treatment cart should always be locked outside when staff were in the cart providing care. She said if the treatment cart was left unlocked and unattended, someone might get some band aids out of the cart. She said nurse leaders monitored to ensure that staff were locking the medication/treatment carts. She said nurse leaders monitored by doing spot checks and rounds. She said LVN C left the treatment cart unlocked and unattended because she was dealing with a disgruntled resident and forgot.An interview with the ADM on 01/15/2026 at 2:22 p.m., revealed she had been trained on medication storage. She said the medication/treatment cart policy was that the cart should always be locked if the staff member was not in the cart or in sight of the cart. She said the medication aide or nurse on the medication/treatment cart was responsible for locking the cart. She said if the medication/treatment cart was left unlocked and unattended, it left items accessible to people who were not licensed to give medications. She said that the ADM and VPCO monitored to ensure staff were locking the medication/treatment carts. She said the ADM and VPCO monitored by doing rounds. She said that she did not know why LVN C left the treatment cart unlocked. During an interview with the ADM on 01/14/2026 at 1:29 p.m., the medication storage policy was requested.Record review of the facility's Medication Labeling and Storage policy dated January 2026, revealed the policy provided did not cover medication storage. The medication storage policy was not provided upon exit.

Based on observation, interview, and record review, the facility failed to be adequately equipped to allow residents to call for staff through a communication system that relays the call directly to a staff member or a centralized staff work area from toilet facilities for 1 of 1 resident rooms. (Resident #10's room [ROOM NUMBER]) reviewed for call lights.The facility failed to ensure emergency call lights in Resident #10's room's bathroom were operable.This failure could place residents at risk of injury, pain, hospitalization, and a diminished quality of life.Findings include:Record review of Resident #10's face sheet dated 10/05/25 indicated Resident #10 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included low back pain, pain in the right leg, and age-related osteoporosis (bone disease that occurs because of the aging process). Record review of Resident #10's annual MDS assessment has not been completed yet. Resident #10 required total assistance with toileting, personal hygiene, transfer, and bathing. Record review of Resident #10's Comprehensive Care Plan dated 10/10/25 reflected Resident #10 had ADL self-care performance deficits and limitations in physical mobility. Resident #10 requires assistance with all her ADL's. During an interview on 10/14/2025 at 10:27 PM, with Resident #10 in room [ROOM NUMBER], she stated that the call lights in the bathroom were not working. Resident #10 said she told someone about the call light not working, and she was told that someone was supposed to come and fix the call lights. Resident #10 said she cannot remember when she told someone or the name of the person that she spoke too about the call lights not working. Observation on 10/14/2025 at 10:35 AM, room [ROOM NUMBER] was observed to have two call lights in the bathroom next to the toilet. Upon pulling on the strings of both call lights in the bathroom, neither one of the call lights in the bathroom activated the call light system. During an observation and interview on 10/14/25 at 1:15 p.m., LNV A stated that call lights were to be checked randomly to make sure they were working. LVN A said that if a call light was not working, she would tell management. LVN A said that call lights were usually fixed right away. LVN A said if a call light was not working, a resident could be injured and stuck on the floor for a long period of time without care. During an observation and interview on 10/14/25 at 2:00 p.m., the DON stated that she was not aware that the call light in room [ROOM NUMBER] was not working. DON stated that there was no maintenance person at the facility, but they have hired a maintenance worker, and they will be starting in one week. DON said she was going to have Resident #10 moved to another room. DON said she has someone going to all the rooms to make sure all the call lights were working. DON said if a call light was not working then a resident could be seriously injured and left on the floor for an extended period. Record review of facility policy titled, Call Light - Ability to Use, Residents dated updated November 2024, reflected:1. The call light system is provided as a tool for residents to communicate with staff.2. Residents will be evaluated for the ability to use the call light on admission, quarterly and annually.3. If residents are determined to be physically unable to use call lights, alternative call buttons (touch, whistle, etc.) will be provided.

Based on interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals, to meet the needs of each resident for one of four residents (Resident #1) reviewed for pharmaceutical services. The facility failed to ensure Resident #1 received her Furosemide (given to help treat fluid retention) on 04/06/25 at 7:00 AM and 04/11/24 at 5:00 pm, Spironolactone (used to treat high blood pressure) on 04/06/25 at 7:00 AM and 05/11/25 at 5:00 PM, alprazolam (used to treat anxiety disorders) on 04/11/25 at 5:00 PM and 04/12/25 at 5:00 PM, Metronidazole (used to treat infections) on 04/11/25 at 5:00 PM, and Midodrine HCl (used to treat low blood pressure) on 04/11/25, 04/14/25, 04/19/25 and 04/20/25 at 5:00 PM. This deficient practice could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements, which could result in worsening or exacerbation of medical conditions. Findings included: Record review of Resident #1's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included spontaneous bacterial peritonitis (a bacterial infection of the ascitic fluid, the fluid that accumulates I the abdominal cavity, without a clear intra-abdominal cause), streptococcal infection (caused by bacteria in the Streptococcus [NAME]), and generalized anxiety disorder . Record review of Resident #1's, undated, care plan reflected a focus of resident was receiving antianxiety medications with intervention, administer anti-anxiety medications as ordered by physician. Record review of Resident #1's, undated, care plan reflected a focus of resident was receiving antianxiety medications with intervention, administer anti-anxiety medications as ordered by physician. Record review of the care plan reflected no care plan for refusal of medication or care. Record review of Resident #1's admission MDS dated [DATE] reflected a BIMS score of 15, indicating intact cognition. Record review of Resident #1's orders reflected Furosemide (given to help treat fluid retention [edema]) and swelling that is caused by congestive heart failure, liver disease, kidney disease, or other medical conditions) Oral Tablet 40MG give one table by mouth two times a day for Lasix (for the treatment of edema associated with congestive heart failure, cirrhosis of the liver, and renal disease, including the nephrotic syndrome) order date 04/05/25 no D/C date. Record review of Resident #1's MAR for April 2025 reflected Furosemide oral Tablet 40MG give one table by mouth two times a day for Lasix was not administered on 04/06/25 at 7:00 AM and 04/11/24 at 5:00 PM. Record review of Resident #1's orders reflected Spironolactone (used in combination with other medicines to treat high blood pressure [hypertension] and heart failure) oral Tablet 100 MG give 1 tabled by mouth two times a day for potassium sparring (medications that increase urine output without causing a lot of potassium in the urine) order date 04/05/25 no D/C date. Record review of Resident #1's MAR for April 2025 reflected Spironolactone Oral Tablet 100 MG give 1 tabled by mouth two times a day for potassium sparring was not administered on 04/06/25 at 7:00 AM and 05/11/25 at 5:00 PM. Record review of Resident #1's orders reflected alprazolam (used to treat anxiety disorders and panic disorder) oral tabled 0.5 MG give 1 tablet by mouth three times a day for anxiety order date 04/05/25, D/C date 04/12/2025. Record review of Resident #1's MAR reflected alprazolam oral tablet 0.5 MG give 1 tablet by mouth three times was not administered on 04/11/25 at 5:00 PM. Record review of Resident #1's orders reflected Metronidazole (used to treat skin infections, rosacea, and mouth infections, including infected gums and dental abscesses) oral tabled 500 MG give 1 tabled by mouth three times a day for antibiotic for 7 days. Record review of Resident #1's MAR reflected Metronidazole oral tablet 500 MG give 1 tablet by mouth three times a day was not administered on 04/11/25 at 5:00 pm. Record review of Resident #1's orders reflected Midodrine HCI (used to treat low blood pressure [hypotension]) oral tablet 10 MG give 1 tablet by mouth three times a day for hypertension (a condition where the force of blood pushing against your artery walls is consistently too high) order date 04/05/25 no D/C date. Record review of Resident #1's MAR reflected Midodrine HCI oral tablet 10 MG Give 1 tablet by mouth three times a day for hypertension was not administered on 04/11/25, 04/14/25, 04/19/25 or 04/20/25 at 5:00 PM. Interview on 05/03/25 at 2:51 PM with RN A revealed it was the responsibility of the charge nurse to make sure residents got their medications, and it was the responsibility of the person who administered the medications to indicated in the resident EMAR the medication was given. She said the negative effects of not showing the medications were the resident could potentially get the wrong dose if it was not documented properly. The negative effect of residents not getting the medication would be they would not receive the effects of the medication they needed. She said if there was a reason the medication was not administered to the resident, the reason should be documented either in the MAR or the resident's progress notes. Interview on 05/03/25 at 3:07 PM with LVN B revealed she administered Resident #1 her medications and she was aware Resident #1 suffered from anxiety. She said after she administered the resident's medications, she recorded it in the EMR. She revealed if the EMAR did not indicate the medication was administered in the EMAR, it could not be 100 percent confirmed the resident received the medication . She said if it was not documented, it was not administered. She said a negative effect of not giving a resident medication would depend on what medication was not given. She said if a resident was taking a scheduled blood pressure medication, and they did not receive their blood pressure medication, it could affect the resident's blood pressure. She said it was the facility's policy that when you were administering medication to a resident the administration of the medications were documented in the resident's EMAR. She said it was the responsibility of the person who administered the medication to make sure the resident got the medication. Interview on 05/03/25 at 4:18 PM with MT C revealed it was the responsibility of the medication aide or the person administering the medication to the resident to make sure the medication was administered. He said the negative effect if a medication was not administered was the resident could be sick. He said if residents did not receive their prescribed antibiotics, they would not get better. He said the negative effect if there was a blank on the EMAR indicated the medication was not administered and there was no proof the resident got the medication . Interview on 05/03/25 at 3:36 PM with CNO revealed it was the responsibility of the charge nurse to double check and confirm residents received their prescribed medications. He said if it was not documented the resident received the medication there was no way to confirm it was administered because the documentation was the primary source of confirmation. He said the possible negative effect if the resident did not receive the medication would depend on the type of medication that was not administered. If the medication was a pain medication that was no administered, the resident could be in pain but with routine medications, there would be minimal negative effects. He said it was the policy of the facility when medications were given, the administration of the medication was documented in the resident EMAR . Record review of the facility's Administration Medications, October 2024, reflected all medications are administered safely and appropriately to aid residents to help overcome illness, relieve, and prevent symptoms and help diagnosis. Hit 'prep' on the EMAR as the medication is prepared. Hit 'confirm on the EMAR once the medication is popped out. Remain with the resident to ensure that the resident swallows the medication. Once resident takes the medication, hit 'save' on the EMAR. If medication is not administered, record reason on the EMAR and notify physician or nurse practitioner. If the medication is given at a time different from the scheduled time, indicate the reason in the 'comment' section of the EMAR.

Based on interview and record review, the facility failed to ensure all residents were free from physical abuse for one (Resident #1) of seven residents reviewed for abuse in that: CNA B forced Resident #1 to have his vitals taken after he refused and used force to push Resident #1 on his back on 01/27/2025. Noncompliance existed from 01/27/2025 to 01/28/2025, but the facility corrected the noncompliance through re-training and assessment of staff, reviews of clinical information, and the immediate suspension of CNA B. Therefore, the findings are of past noncompliance. This deficient practice could place residents at risk of fear, physical injury and psychosocial harm. Findings included: Review of Resident #1's face sheet revealed a [AGE] year-old male admitted on [DATE] with diagnosis of pressure ulcer of sacral region (above tailbone), paraplegia (a condition that causes paralysis or loss of mobility in both legs), muscle weakness, and chronic pain (syndrome a condition characterized by persistent pain that lasts for at least three to six months and significantly impacts a person's life). Review of Resident #1's admission MDS assessment dated [DATE] reflected a BIMS score of 15 which indicated no cognitive impairment. Review of MDS functional abilities section reflected Resident #1 was dependent for toilet transfers, tub/shower transfers, going from lying to sitting on side of bed and for chair-to-bed/bed-to-chair transfers. Further review reflected Resident #1 required substantial/maximal assistance to go from sitting to lying. Review of Resident #1's care plan dated 01/09/2025 reflected that Resident #1 had an ADL self-care perform deficit and limitations in physical mobility. Interventions reflected Resident #1 was dependent and/or substantial/maximal assistance for siting to lying. Review of Resident #1's nursing progress notes dated 01/27/2025 by LVN A reflected Resident #1 was upset and wanted nurse to his room and complained of alleged abuse. LVN A stated she called the ED, spoke with HD and CNO was notified. Resident #1 was assessed head to toe and no bruising or marks were noted on Resident #1. Review of Resident #1's nursing progress note dated 01/29/2028 by ACNO reflected Resident was doing fine and received pain medication. Review of Resident #1's nursing progress note dated 01/28/2025 by CNO reflected ED, CNO, ACO interviewed Resident #1 regarding allegation of abuse and that Resident #1 felt safe at the facility. Review of Resident #1's MAR/TAR pain evaluation reflected no increased pain and appeared consistent with Resident #1's normal level of pain on 01/27/2025, 01/28/2025 and 01/29/2025. During an interview on 01/29/2025 at 10:31 AM, Resident #1 stated that there was an incident with CNA B on 01/27/2025 in the evening around 7:00 PM. Resident #1 stated that he asked CNA B to bring him coffee and when CNA B returned with his coffee, CNA B told Resident #1 she was going to take his vital signs. Resident #1 stated he was sitting in his bed watching television when CNA B returned and stated he did not want to have his vitals taken. Resident #1 stated CNA B told him you're going to give me the vitals and took his coffee and put it in the bathroom away from his reach. Resident #1 stated CNA B told him, he was not going to get the coffee until Resident #1 gave CNA B his vital signs. Resident #1 stated he again declined and stated he did not want his vital signs taken and asked CNA B for his coffee back. Resident #1 stated CNA B then snatched his call light, and television remote and threw his television remote across the room into his wheelchair. Resident #1 stated CNA B stated to Resident #1 that he was going to watch television without his coffee until Resident #1 let CNA B take his vital signs. Resident #1 stated that he had tucked his hands under his legs and then CNA B then grabbed his left arm and put the blood pressure cuff on his arm, crossed his arms over his chest and made an x with his arms and laid him on his back on his bed. Resident #1 stated he yelled at CNA B, and she stated if you want to act like a n*****, I'll show you how one acts. Resident #1 stated that CNA B then left the room and he called his nurse in and asked to speak with administration. Resident #1 stated CNO then called him and Resident #1 explained what happened and CNO stated it would be taken care of. Resident #1 stated the next morning, administration (ED, CNO, ACNO) talked to him about the incident. Resident #1 stated CNO told him that CNA B would no longer be working with him, and he had not seen her again since immediately after the incident. Resident #1 stated he felt CNA B's actions were abusive. Resident #1 stated he felt safe at the facility at the time of the interview. Resident #1 stated that he was unsure if anyone heard or was around but stated it was pretty loud between him and CNA B. During an interview via telephone on 01/29/2025 at 2:40 PM, CNA B stated that on 01/27/2028 she was required to take residents' vitals. CNA B stated she and Resident #1 had been messing around, playing throughout the week. CNA B stated on that day (01/27/2025) she and Resident #1 asked her to get him coffee. CNA B stated she returned to Resident #1's room and said she was going to give him his drink but asked that he give her vitals. CNA B stated she thought Resident #1 and her were messing around in a friendly manner. CNA B stated she put Resident #1's drink in the bathroom and she pretended she was going to walk out of the room. CNA B stated she got the blood pressure cuff around Resident #1's arm and believed Resident #1 allowed it. CNA B stated Resident #1 told her you know I am stronger than you and pushed his arms up. CNA B stated Resident #1 then frowned. CNA B stated she thought Resident #1 was getting serious and she took the blood pressure cuff and left his room. She stated that after thinking about it, she thought it was unprofessional but believed she and Resident #1 had a rapport. CNA B stated her hands were on Resident #1's arms but she was not applying pressure. CNA B stated when she took residents' blood pressure, she usually did not have her hands on the residents. She stated when she did that, Resident #1 was still smiling and then he leaned back and pushed his hands up and CNA B realized Resident #1 was no longer playing around. CNA B stated she was currently suspended and was sent home on 01/27/2025 CNA B stated she took Resident #1's call light and television remote, but she believed they were playing. CNA B stated she had to review policies when she started and it included abuse and neglect, and resident rights. CNA B stated Resident #1 could not walk or get out of bed. CNA B stated an example of physical abuse included hitting a resident, restraining a resident, and placing a call light out of their reach. CNA B stated she gave Resident #1 his call light back. Interview was attempted via phone call and text message with LVN A on 01/29/2025 at 11:22 AM and 12:12 PM. Requested CNO assistance with getting in touch with LVN A on 01/29/2025 at 12:20 PM. Phone call has not been returned as of 01/31/2025. During an interview on 01/29/2025 at 11:59 AM, LVN C stated that she worked with Resident #1 on 01/28/2025, the morning after the incident. LVN C stated that Resident #1 did not appear emotionally distressed, and he was up and ready for therapy. She stated that he had general pain and that his was normal for Resident #1. LVN C stated that residents had the right to refuse care. LVN C stated that she received training on abuse and neglect, and it included who to report allegations to, and when to report it. LVN C stated if she received a report of abuse, she would remove the staff from the resident, and report to the ED immediately. She stated that she would do a head-to-toe assessment and assess for any potential emotional changes. She stated that she was assigned to work with Resident #1 the morning after the incident and that the ED and CNO checked in with Resident #1 as well. LVN C stated that when she asked Resident #1 how he was doing, he told her he was doing okay and appeared normal. LVN C stated that Resident #1 is unable to walk and required a mechanical lift to get in and out of bed. During an interview on 01/29/2025 at 12:20 PM, CNO stated that he received a phone call Monday (01/27/2025) night from HD and LVN A. CNO stated that he received report from the HD that when CNA B returned with Resident #1's coffee, she asked to take his vitals and he declined. CNA B then placed his coffee in the restroom and asked Resident #1 again to take his vitals and Resident #1 again declined and asked for his coffee. CNA B then took his remotes and said if he did not allow his vitals to be taken, he was not going to get his coffee. Resident #1 had his hands under his legs and CNA B grabbed his arms and attempted to take his vitals and was able to get the blood pressure cuff on him. Resident #1 had reported he was tensing and said he was not going to let CNA B get his vitals and held his arms together and Resident #1 attempted to show CNA B he was stronger. It was then reported to CNO that CNA B said if Resident #1 did not give her his vitals, she was not going to care for him. CNO stated that CNA B was immediately suspended, and she was asked to leave the facility. CNO stated he informed LVN A that CNA B was suspended. CNO stated he instructed LVN A to ensure the resident had an assessment completed, pain medication in the event he needed them, and notify the on-call physician of the allegation and ensure there were no new injuries. CNO stated that Resident #1 stated CNA B was out of line and not being playful. CNO stated he spoke with CNA B and the first thing she told him was I'm sorry and CNA B stated she tried to get Resident #1 to take his vital signs and CNA B started to cry on the phone and again stated I'm sorry. CNO stated that CNA B told him she straightened Resident #1's arm to get his vitals. CNO stated on 01/28/2025, the ACNO, CNO and ED went to Resident 1's room to follow up with him. CNO stated Resident #1 told him, he felt safe. CNO stated there were no adverse reactions noted during this follow up. CNO stated that CNA B was still suspended and pending her statement. CNO stated CNA B did not come to the facility as scheduled on 01/29/2025 at 10:00 AM to provide her written statement for the facility's ongoing investigation. During an interview on 01/29/2025 at 12:56 PM, NP stated that he saw Resident #1 on 01/28/2025 and that the Resident #1 reported his pain was controlled, nothing unusual and there were no significant new complaints. NP stated that Resident #1 did not appear emotionally distressed. During an interview on 01/29/2025 at 1:50 PM, HD stated she was made aware of the concerns on 01/27/2025 in the evening, and she was asked to get a statement from Resident #1 by CNO. She stated that during the statement, Resident #1 was matter of fact and was not overly expressive. She stated he did not appear emotionally distressed. She stated she visited all residents the next morning (01/28/2025) and asked how they were treated and if there were any concerns. HD stated that all residents denied any issues with staff or care. During an interview on 01/29/2025 at 1:55 PM, ACNO stated that he completed in-servicing with each department regarding abuse and neglect. ACNO stated that he followed up with Resident #1 yesterday morning (01/28/2025) and no issues were noted. ACNO stated he checked in with residents around Resident #1's room and all denied issues or concerns. ACNO stated that Resident #1 appeared to be within his normal demeanor. During an interview on 01/29/2025 at 2:06 PM, the ED stated that she reported the incident to HHSC and also reported to police department. ED stated she was familiar with Resident #1 and worked with him at a previous facility. ED stated that she checked in on him after the incident and completed a psychosocial evaluation and he appeared fine and had no changed in appetite and mood was elevated. ED stated Resident #1 reported he was fine and thought it was a weird and strange the way CNA B interacted with him. ED stated Resident #1 felt safe and denied any injuries. ED stated Resident #1 was in wheelchair smiling, talking, and laughing. ED stated CNA B was currently suspended and was not taking the facility's phone calls. ED stated that CNA B had only been working two weeks and she was usually engaging with residents so the incident was surprising. ED stated that CNO spoke with CNA B regarding the incident on 01/27/2025. ED stated that Resident #1 could not reach his coffee because he was paralyzed. ED stated CNA B admitted to CNO that she moved Resident #1's coffee and tv remote and Resident #1 stated CNA B laid her body on him. ED stated that she believed Resident #1 and stated he was alert and orientated. During an interview on 01/29/2025 at 2:27 PM, CNA D stated she received training on abuse and neglect yesterday or the day before. CNA D stated that if any abuse was witnessed it should be reported immediately to the ED. She stated an example of physical abuse could be roughly handling a resident or leaving them on the toilet for too long. CNA D stated taking a resident's call light or remote was considered abuse, especially if they could not reach it. During an interview on 01/29/2025 at 4:29 PM, CNO stated that in-servicing was completed over abuse and neglect, regular check-ins were initiated with all residents and stated HD continued to check-in with all residents every day to ensure they are getting the care. CNO stated the investigation regarding CNA B was ongoing. CNO stated he expected staff to report all allegations immediately to ED, and if unable to reach her, they can reach out to him. He stated the nurse or CNO will complete an initial head-to-toe assessment, assess pain and if there is an alleged identified AP, CNO would assist with suspension. During an interview on 01/29/2025 at 4:29 PM, ED stated there were no other incidents or warning regarding concerns with CNA B. ED stated they rounded frequently on residents and there were guardian angel rounds with leadership staff. ED stated HD completed daily rounds and reports anything big or small. Review of CNA B employee filed revealed hire date of 01/14/2025 reflected abuse and resident rights policy was included. Abuse competency post test was completed by CNA B on 01/15/2025. Further review of posttest reflected that taking a resident's call light was considered a form of abuse. Review of facility in-service dated 01/28/2025 titled Abuse and Neglect reflected in-servicing was completed with each department (management, clinical, dietary, therapy) and included 40 staff members. In-servicing included abuse policy acknowledgement/post-test. Review of the facility's policy titled Abuse & Neglect with revision date of April 2024 revealed it is the policy of this facility to prohibit and prevent abuse, neglect and exploitation of residents and misappropriation of resident property . Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse included deprivation of goods or services that are necessary to attain or maintain physical, mental or psychosocial well-being by caretaker or individual.

Based on interview and record review, the facility failed to ensure residents received necessary treatment and services, consistent with professional standards of practice to promote wound healing and to prevent new pressure ulcers from developing for three (Resident #1, Resident #2, and Resident #3) of five residents reviewed for pressure injuries. The facility failed to: 1.) Ensure Resident #1 had wound care treatments until four days after being admitted . She missed seven wound care treatments in December 2024 and January 2025. 2.) Ensure Residents #2 and #3 had orders for the monitoring of their wound vacs (a negative pressure wound therapy) every shift. This failure could place residents at risk of improper wound management, the development of new pressure injuries, deterioration in existing pressure injuries, infection, and pain. Findings included: 1.) Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including type II diabetes, need for assistance with personal care, and chronic kidney disease. Review of Resident #1's admission MDS assessment, dated 12/30/24, reflected a BIMS was not conducted due to her rarely/never being understood. Section M (Skin Conditions) reflected she had one or more pressure ulcers/injuries. Review of Resident #1's admission care plan, dated 12/31/24, reflected she was at risk for further alteration in skin integrity, admitted with pressure ulcers, health conditions, and poor oral intake with an intervention of providing skin/wound treatments as ordered. Review of Resident #1's admission skin assessment, dated 12/23/24, reflected she had skin integrity issues on her RUE midline, discoloration to her bilateral buttocks, discoloration to her bilateral heels, discoloration to both feet and ankles, wound to her LUE, multiple wounds to her toes, and multiple pressure injuries to her sacral/coccyx (tailbone). Review of Resident #1's physician orders, undated with no start date, reflected to cleanse the L 2nd toe, L 3rd toe, L 4th toe, L 5th toe, and L great toe with NS or wound cleanser, pat dry, apply betadine and cover with dry dressing and PRN when soiled - one time a day for wound to toes. Review of Resident #1's physician orders, undated with no start date, reflected to cleanse the R and L heel with NS or wound cleanser, pat dry, apply betadine to site, and leave open to air one time a day for wounds to heels. Review of Resident #1's physician orders, undated with no start date, reflected to cleanse sacrum with NS or wound cleanser, pat dry, apply skin prep to peri wound, apply Medihoney to wound bed, cover with dressing and PRN when soiled one time a day for sacral wound. Review of Resident #1's December 2024 TAR reflected treatments for all of her wounds her wounds were provided on 12/27/24, 12/29/24, 12/30/24, and 12/31/24. Resident #1 was admitted to the facility with the wounds on 12/23/24. Review of Resident #1's December 2024 and January 2025 TARs reflected she missed wound care treatments for all of her wounds from 12/23/24 - 12/26/24, on 12/28/24, 01/02/25, and 01/05/25. 2.) Review of Resident #2's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including paraplegia (paralysis of the legs and lower body), chronic pain syndrome, and stage IV pressure ulcers to the sacral region and right and left buttock. Review of Resident #2's admission MDS assessment, dated 01/08/25, reflected a BIMS score of 15, indicating no cognitive impairment. Section M (Skin Conditions) reflected he had one or more pressure ulcers/injuries. Review of Resident #2's admission care plan, dated 01/03/25, reflected he was at risk for alterations in skin integrity with an intervention of encouraging/assisting with turning and repositioning every 2-3 hours. Review of Resident #2's physician orders, dated 01/14/25, reflected wound vacs to his right and left buttock - suction setting 125 mmHG, change (T/Th/S), Cleanse with wound cleanser; pat dry; skin prep peri wound; cut granufoam to fit wound bed. Apply transparent drape. Cut a small hole in the drape near the center for granufoam and place connecter pad directly over hole, connect tubing to vac canaster and turn on device. Ensure seal is patent and no leaks, patch if necessary - one time a day every Tuesday, Thursday, and Saturday. There was no order to monitor every shift. During an observation and interview on 01/15/25 at 12:58 PM revealed Resident #2's wound vac to be connected and running appropriately. He stated he had it put on on 01/13/25 and the staff would be replacing it the following day, 01/16/25. He stated the staff were tending to his wound and he had no concerns. Review of Resident #3's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including paraplegia, chronic pain syndrome, and unspecified staged pressure ulcers of his sacral region and left buttock. Review of Resident #3's EMR, on 01/15/25, reflected his 5-day MDS assessment had not been completed. Review of Resident #3's EMR, on 01/15/25, reflected his baseline care plan had not been completed. Review of Resident #3's physician orders, dated 01/14/25, reflected wound vac to his left ischium (bone of the lower back) - suction setting 155 mmHG, change (Monday and Thursday), Cleanse with wound cleanser; pat dry; skin prep peri wound; cut granufoam to fit wound bed. Apply transparent drape. Cut a small hole in the drape near the center for granufoam and place connecter pad directly over hole, connect tubing to vac canaster and turn on device. Ensure seal is patent and no leaks, patch if necessary - one time a day every Monday and Thursday. There was no order to monitor every shift. During an interview on 01/15/25 at 11:14 AM, the CNO stated a head-to-toe assessment should be completed by the admitting nurse upon admission and wound treatment orders should be implemented within 24 hours at the latest. He stated if a resident went four days without treatment orders after being admitted , that would not meet his expectations. He stated that could cause the wounds to possibly worsen. He stated residents with a wound vac should have orders to monitor it every shift. During an interview on 01/15/25 at 1:11 PM, the WCN stated the admitting nurse should ensure wound treatment orders were put in place within 24 hours of a residents' admission. She stated it would not meet her expectations for a resident to go 4-5 days without treatment orders. She stated that could be bad/detrimental and wounds could worsen. She stated residents with wound vacs should have orders to monitor every shift. She stated the nurses needed to monitor to make sure the machine was actually suctioning, making sure it still had a seal, and that there was no seepage or drainage. She stated that would be to ensure wounds were not worsening and also for infection control prevention. Review of an in-service conducted by the CNO, dated 11/27/24, reflected the nursing staff were in-serviced on skin assessments and their Skin Policy and Procedure. Review of the facility's Skin Policy and Procedure Policy, dated 03/2020, reflected the following: If the resident has, on admission, or develops pressure sore(s), he/she will receive necessary and appropriate treatment and services to promote healing, prevent infection and prevent further development of additional impaired skin integrity. A request for a policy on wound vacs was requested but not received prior to exiting.

Based on interviews and record review, the facility failed to consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 (Resident #1) of 6 residents reviewed for resident rights. 1. The facility failed to notify the MD or NP when Resident #1, who has a diagnosis of stage 5 kidney failure, complained of not being able to urinate. 2. The facility failed to notify the MD or NP when Resident #1, with a BIMS score of 15, began exhibiting erratic behaviors, changes in mental status, confusion, and agitation. 3. The facility failed to notify the MD, NP, or abuse coordinator when Resident #1 presented with bruises on her abdomen, back, legs, arms, and forehead . The failures resulted in an identification of an Immediate Jeopardy (IJ) on 11/13/24 at 2:49 PM. While the IJ was removed on 11/14/24 at 7:19 PM, the facility remained at a level of no actual harm with potential for more than minimal harm that is not immediate jeopardy at a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for delay in medical treatment, decline in health, and death. Findings included: Review of Resident #1's admission MDS assessment dated [DATE], reflected Section A (Identification Information) reflected a [AGE] year-old female admitted to the facility on [DATE]. Section I (Active Diagnoses) reflected diagnoses including left hemiplegia following cerebral infarct (weakness or paralysis on the left side of the body after a stroke), chronic kidney disease, muscle weakness, seizures, anxiety (intense and excessive worry and fear), and abnormalities of gait. The primary medical condition category was listed as stroke. Section B (Hearing, Speech, and Vision) reflected the resident's speech was clear and she made herself understood. Section C (Cognitive Patterns) reflected a BIMS score of 15 indicating intact cognition. Section E (Behavior) reflected no hallucinations (an experience involving the apparent perception of something not present) or delusions (Fixed, false conviction in something that is not real). Section E also reflected no verbal behaviors directed towards others, and no physical behaviors not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds). Section H (Bladder and Bowel) reflected the resident was continent of bowel and bladder. Section N (Medications) reflected the resident received anticoagulant and antiplatelet medications. Review of Resident #1's comprehensive care plan reflected a focus, initiated 10/30/24, of depressive symptoms with an intervention, Observe and report any changes in mental status, notify MD if any changes in mood, behavior and/or psychosocial status is observed. A focus, initiated 10/25/24, of risk for falls with interventions including, Follow facility fall protocol and, review information on past falls and attempt to determine cause of falls. Record possible root causes . A focus, initiated 10/25/24, reflected potential alteration in nutrition and hydration with interventions including, Monitor/document/report PRN any s/s of dehydration: decreased or no urine output and new onset confusion. A focus, initiated 10/25/24, for antianxiety medication reflected interventions including, Monitor/document/report PRN any adverse reactions to anti-anxiety therapy: .Confusion, impaired thinking and judgement, mania, hostility, rage, aggressive or impulsive behavior, hallucinations. A focus, initiated 10/25/24, for anticoagulant therapy reflected an intervention, Monitor/document/report PRN adverse reactions .sudden changes in mental status. The care plan did not address the resident's kidney disease. A focus initiated 11/04/24 reflected, The resident has a behavior problem of repeatedly putting herself on the floor (purposeful), throwing items on floor and breaking (plates, cups, etc.), yelling out loud, clogging toilet with paper towels. Goals included, Resident will show a decrease in negative behaviors by next review date and Will exhibit socially appropriate behaviors during review period. Interventions included, Approach resident appropriately when resident is hallucinating, delusional or expressing potentially harmful suspicions . Ask resident if these hallucinations/delusions are harmful to themselves in any way .Document resident's inappropriate behaviors when it occurs . If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and or unacceptable to the resident . Intervene as necessary to protect the rights and safety of others . Review of Resident #1's progress note dated 10/31/24 at 4:31 AM, written by LVN D reflected, .resident was sitting on the floor, states she woke up needing to use the restroom and was attempting to get up too quickly; bed was in low position with call light in reach, resident aware to call for help, VS WNL, denies pain, no s/s LE rotation, current anticoag rx [sic] on hold, denies hitting head, on neuro checks. Review of Resident #1's progress note dated 11/1/24 at 1:25 AM, written by LVN D, reflected Guest c/o 'not being able to urinate', bladder scan performed with no residual, noted in 24-hour report for in house NP. Review of Resident #1's progress note dated 11/1/24 at 9:44 PM reflected, fall f/u day 2/3: resident observed propelling self in hallway on unit, resident observed clogging toilets (toilet in her room and empty rooms) with paper towels, resident redirected multiple times nurse manager notified, maintenance order placed. Review of Resident #1's progress note dated 11/02/24 at 8:00 PM (created 11/03/24 at 1:03 AM), written by LVN K, reflected in part, .resident observed yelling out for help . Review of Resident #1's progress note dated 11/02/24 at 9:35 PM, written by LVN K (created 11/03/24 at 5:37 AM) reflected, Day 3/3 fall f/u bruises noted to abd, lower back, ble, bue, and forehead. The note does not reflect that the provider was notified of the bruises. Review of Resident #1's progress note dated 11/03/24 at 2:59 PM, written by LVN B, reflected in part, Guest noted from previous shift not having a good sleep yelling all night and breaking things and putting herself to the floor many times .the next day the pt continue breaking things and breakfast plates and cup and pulling the call light off the wall and continue throwing herself on the floor and yelling and the NP was called and the pt call 911 by herself and she was sent out for AMS and the pt has scattered bruising all over . Review of Resident #1's progress notes from 11/02/24 through 11/03/24, reflected no documentation that the provider was notified of bruising until the resident was sent out with EMS around 2:51 PM on 11/03/24. Additionally, there was no further information regarding her genitourinary status or that the provider was notified of the change in urinary status. There was no documentation that the provider was notified of the change in mental status or behaviors, or that Resident #1 was yelling out, yelling out all night, clogging toilets, breaking things, putting herself on the floor many times. The notes did not reflect that the provider was notified when the behaviors of throwing things, breaking things, pulling the call light off the wall, and throwing herself to the floor, and yelling continued to the next day. Review of an incident report dated 10/31/24 at 4:31 AM, reflected Resident #1's fall from the same date and time. Immediate actions taken included, Resident aware and reeducated to call for assistance when needing help . Mental Status reflected only the oriented to person box was checked. Predisposing Physiological Factors reflected the boxes for confused and impaired memory were checked. Predisposing Situation Factors reflected the boxes for behavior issues, during transfer and, ambulating without assist were checked. No notifications to the physician or responsible party were documented. Review of Resident #1's shower sheet dated 11/02/24, reflected scattered fading bruises. The time of the note is left blank. Lines on the body diagram indicated bruises on the abdomen, arms, and left leg. The form was signed by a CNA and a nurse. The nurse's signature is illegible. Review of Resident #1's Task: Bladder Continence, the resident was marked as continent five times from 10/26/24 through 10/30/24. On 11/01/24, she was marked as incontinent of bladder. Review of Resident #1's Transfer Form dated 11/03/24 at 2:59 PM reflected the resident was incontinent of bladder. Review of photos of Resident #1 taken in theER on [DATE] between 4:35 PM and 4:39 PM reflected the following: Face - two red bruises on her forehead and one on her left eyebrow. Abdomen - one purple/red bruise just below her umbilicus (belly button) and extending down towards the pubic bone, unable to visualize the bottom of the bruise due to positioning. The bruise is about 6 inches wide. A large deep purple hematoma (bruise) on the right abdomen flank is about 14 inches in width Review of the Change in Resident Condition policy revised 06/2022, reflected in part, To provide guidance on notification of the physician when there is a change of condition. 1. Should there be a significant change in the resident's physical, mental or emotional status, the attending physician should be notified. 2. If the attending physician does not respond within 30 minutes, contact the Medical Director. 3. If the Medical Director does not call within 30 minutes, contact the DON. It starts at about the level of the umbilicus, about 5 inches are visible, the bottom edge of the hematoma is covered by clothing. There was a tape measure visible lying across the wound in the in picture. Right upper leg - about 11 purple bruises on lateral (outside)/posterior (back) view. Right lower leg - about 8 purple bruises on posterior view Left lower leg - a purple bruise that starts a few inches below her knee and extends to just above the ankle, about 10 inches on anterior (front) view, tape measure visible in the photo. About 7 purple bruises are visible on the medial (inside) aspect of the leg and the large bruise on the anterior view extends to the medial aspect. Right foot - about 10 purple/red bruises on medial, lateral, dorsal (top), and plantar (bottom) surfaces. Laceration on dorsal surface. Left foot - about 6 purple/red bruises on lateral and dorsal surfaces. Right arm - about 3 purple bruises and one large deep purple/red bruise visible. Review of Resident #1's Emergency Provider Report from the ER, dated 11/03/24 at 5:52 PM, reflected in part, Presentation Chief Complaint - Altered Mental status. Stated complaint Left hip pain/confusion per EMS . presents with altered mental status and scattered bruising . speech nonsensical and unable to communicate effectively . Primary Impression: Altered Mental Status. Secondary Impressions: Anemia, Ecchymosis, History of completed stroke. Review of Resident #1's physician progress notes from the acute hospital dated 11/11/24 at 11:48 AM reflected in part, Patient was agitated on arrival to emergency room , required several doses of sedatives for agitation in emergency room . Per EMS report nursing staff at facility reported patient was hitting her own head against the wall and had frequent falls CT chest abdomen, and pelvis shows significant bladder distention. Markedly enlarged bilateral kidney with innumerable cyst . Hematoma in the subcutaneous fat in the lateral right mid to lower abdomen measuring 8.3 x 3.8 x 7.6 cm. Hemoglobin 6.1 on admission. Patient underwent 2 units of PRBC transfusion from extensive bruising all over the body. No evidence of GI bleed. Eliquis was discontinued, aspirin and Plavix continued. Acute metabolic encephalopathy resolved. Resident has some urinary retention, and a catheter was placed . Urinary tract infection, received Ceftriaxone 1 gram IV every 24 hours. Review of Resident #1's EMR including MDS assessment, progress notes, evaluations, and MARs dated from 10/25/24 through 11/03/26, did not reflect the physician was notified of a change in mental status, changes in mood, behavior and/or psychosocial status. There was no documentation that the physician was notified of hallucinations or delusions. During a telephone interview on 11/06/24 at 8:16 AM, Resident #1's FM stated the resident had called her on 11/02/24 and said she thought she had a UTI because she was not peeing, and she did not feel right. She stated they were on speaker phone and there was a staff member in the room. She stated she asked the other person in the room if the doctor was coming to see the resident and the other person replied, Yes. She stated she did not know if a doctor ever saw the resident about her complaint of not urinating. She stated she saw the resident the next day in the ER. She stated the resident went to the ER for altered mental status and multiple falls. She stated she was never notified of the falls. She stated she noticed, during phone calls and texts, the resident being more confused and irritable for the few days prior to going to the ER. She stated Resident #1 started having trouble writing a coherent text message. She stated the decline went on for days before Resident #1 called 911 to go to the hospital. During an interview on 11/06/24 at 2:28 PM, the VPCO stated the post fall assessment would have the documentation regarding the resident's status. She stated the nurses would document in the progress notes when a bruise was observed or noticed. She stated they would definitely investigate any bruises that could not be explained. She stated if an alert and oriented resident had falls and a change in behavior, her first thought was to get a UA as changes were often a sign of infection. During an interview on 11/07/24 at 10:33 AM, the MD stated she saw Resident #1 on 10/28/24. She stated she did not look under the clothes but there were no bruises on the visible skin. She stated she was not aware of extensive bruising. She stated the resident was on 3 different medications that could have caused her to bruise easily. She stated Resident #1's hemoglobin was 8.8 (hemoglobin, part of the blood, helps carry oxygen to all the vital organs, 12-17 is a normal level) on 10/23/24 at the acute hospital prior to her admission at this facility. She looked but did not see any blood results from the time the resident was in the facility. She stated she was not aware that the resident complained of not being able to urinate. She stated the resident had chronic kidney disease, but she had been urinating, as far as she knew, while at the facility. She stated the resident may not have been drinking enough, or her kidney disease may have worsened. She stated she expected to be notified of changes in condition when they occurred. She stated the resident was a good historian and would have been able to talk about the bruises and any problems with urination. She stated she was not notified of any erratic behavior other than the resident being upset that her daughter did not answer the phone. During an interview on 11/07/24 at 11:11 AM, the NP stated bruising may not occur right away if a resident fell or sustained an injury. The NP stated if a resident were on blood thinners and hit their head, to be safe, the resident would be sent out for evaluation. After viewing the picture of the abdominal bruise, the NP stated that bruise should have been reported immediately as the resident was on blood thinners. The NP stated she was not aware that the resident had complained of not being able to urinate. She stated she was not aware of the facility 24-hour report. She stated the on-call providers kept a report of the calls received. She reviewed the notes and stated she did not see an entry for Resident #1's urinary complaint. The NP stated she was notified of the erratic behavior when the nurse called her at 2:25 PM on 11/03/24. During an interview on 11/07/24 at 12:33, LVN B stated she had worked at the facility for about three years. She stated she first saw bruises on Resident #1's arm on 10/29/24 but did not work on the resident's hall until 11/01/24. She stated she noticed bruises on Resident #1's abdomen on 11/01/24. She stated because the resident was on blood thinners, she figured the resident was on anticoagulant injections while in the acute hospital and that was the reason for the bruises. She stated because they were old bruises, she did not report them. She stated the resident had scattered bruises all over her body. She stated on Saturday, 11/02/24, the resident was yelling and pulled the call light off the wall. She stated the resident was trying to call her daughter and was yelling about it. LVN B told the resident she would help her call her daughter shortly. When she returned to the room to help, the resident began yelling again and pushed her tray all the way out of her room; the yelling continued. LVN B stated she did not notify the doctor as the resident was just mad about her daughter not answering the phone. She stated on Sunday morning 11/03/24, she was told in report that Resident #1 had yelled all night. She stated the resident continued to yell, kept putting herself on the floor, and hit herself in the head with the phone. She stated it was very different behavior for this resident, but the resident was mad at her daughter. LVN B stated in the afternoon she explained to the resident that she would notify the provider to have her sent out. LVN B stated shortly after she got to the nursing station, the front desk called and asked her if she had called 911. The front desk told her 911 was on the phone about Resident #1 and she told them to come get her. LVN B stated, She heard me say I was going to send her out, so she went ahead and called 911. During an interview on 11/07/24 at 2:00 PM with the VPCO and CNO, the VPCO stated on 10/31/24, she was called to the room after Resident #1 was found sitting on the floor. She stated there was no facial bruising at that time. After seeing the picture of the bruise on Resident #1's abdomen/trunk/back, the CNO stated the bruise was from anticoagulant injections due to its location. The VPCO stated it was a new bruise because it had not changed colors. She stated she could not tell when or where the picture was taken so she could not verify the bruise was present while the resident was at the facility. During a telephone interview on 11/07/24 at 2:38 PM, Resident #1 stated she fell when she was at the facility. She stated, I tried to get help and they said they would be right back, and it was an hour. Resident #1 stated she was crawling around on her butt trying to get help. She stated they took their time to help. She stated one staff member told her they were going to kick her out if she kept acting up. She stated she had bruises on her arms which she sustained during the falls. She said she fell and hit her back. She stated the big bruise hurt and stated an ice pack would have helped. She stated she did not feel right and had trouble urinating, I thought I had a UTI. During an interview on 11/07/24 at 5:05 PM, the GM stated the nursing documentation should reflect the work they were doing. He expected documentation to be accurate and timely. He stated he expected the nurse to contact the MD, NP, or CNO if there was a change in condition or mental status. During an interview on 11/12/24 at 4:17 PM with the ACNO, he stated he had recently provided training on customer service, change of condition, and assessment. After review of Resident #1's abdominal flank bruise, he stated he expected the provider would have been notified of a bruise of that size. He stated if he saw the resident having behaviors, he would not necessarily notify the doctor if those behaviors caused the bruising. He stated if the resident was on blood thinners, he should notify the provider. He stated the provider should be notified if a resident had a change in status. During a telephone interview on 11/13/24 at 11:49 AM, CNA A stated on 10/31/24, Resident #1 was somewhat confused, so she checked on the resident every 30 minutes. She stated that was a change for the resident. She stated the resident had bruises, but the nurse had already assessed them. She stated there was just a small bruise on the resident's arm that the resident said came from a fall earlier in the day. The CNA stated she reported that bruise to the nurse, but the nurse said it would not show up that fast so it must have been an old bruise. During an interview on 11/13/24 at 1:06 PM, LVN B stated the change in Resident #1's mental status did not occur until Sunday 11/03/24. On Saturday (11/02/24) morning report, which she received from LVN D, she was told the resident was found on the floor. On Sunday morning in report, she was told other residents were mad because Resident #1 was making so much noise all night. She stated the resident had complained of pain the night before and they got a hip x-ray. She stated she did not remember ever being told in report that Resident #1 complained of not being able to urinate. She stated on the morning of 11/03/24 Resident #1 continued to yell and break things and throw herself on the floor. She stated the resident had bruises all over and she notified the provider to send the resident out. She stated she assessed the resident, and it was because her daughter did not answer the phone, that she was mad. Review of the Change in Resident Condition policy revised 06/2022, reflected in part, To provide guidance on notification of the physician when there is a change of condition. 1. Should there be a significant change in the resident's physical, mental or emotional status, the attending physician should be notified. 2. If the attending physician does not respond within 30 minutes, contact the Medical Director. 3. If the Medical Director does not call within 30 minutes, contact the DON. The VPCO was notified on 11/13/24 at 2:49 PM that an IJ had been identified and an IJ template was provided. The following POR was approved on 11/14/24 at 4:32 PM: Allegation of Credible Compliance F684 11/13/2024 November 13th, 2024 Immediate Interventions: 1. Notifications made to the Medical Director on 11/13/24 at approximately 4:00pm of the immediate jeopardy citation 2. Emergency meeting conducted with action plan developed. This occurred at 4:30pm on 11/13/24 Attendees: RN, VP of Clinical Operations Administrator RN, Assistant Director of Nursing Action Plan: Licensed nursing staff, certified medication aides, and certified nursing assistants in-serviced immediately on the facility policy and procedure for notification of change of condition and the abuse and neglect policy and procedure. Resident #1 has discharged from the facility and therefore a plan of correction cannot be accomplished. Current residents were assessed by licensed nursing staff for any changes of condition, including but not limited to their physical (including but not limited to skin integrity), mental and emotional status. No negative outcomes were obtained from these assessments. A root cause analysis was completed by the VP of Clinical Operations and incorporated into staff training and in-servicing, which includes notification of change of condition, and abuse and neglect policies and procedures. 3. Licensed nursing staff, certified medication aides, and certified nursing assistants were in-serviced on the change of condition policy and procedure, including but not limited to: changes in resident behavior, skin integrity changes, increased confusion, and genitourinary changes. The assistant director of nursing and nursing supervisor have provided in-service, education and compliance training with staff. - Changes of condition must be reported to the provider timely (within 30 min) if no response within 30 minutes the Medical Director will be notified. If the Medical Director does not respond within 30 minutes, the Director of Nursing will be contacted. - Documentation of changes of condition will be documented in the medical record within the nurse's shift. - Signs and symptoms of abuse or neglect, the Administrator will be notified immediately. - Allegations of abuse and neglect will be reported to all appropriate state and local entities by the Administrator in accordance with all state and federal regulations. 4. Meeting with the following managers to review Immediate Jeopardy on 11/13/24. We reviewed the notification of changes of condition policy and procedure, as well as the abuse and neglect policy and procedure. - Administrator - VP of Clinical Operations - Director of Rehabilitation - Assistant Director of Nursing - Nursing Supervisor - MDS Coordinator - Dietary Manager - Social Services Training: 1. RN Director of Nursing, to be in-serviced by RN [NAME] President of Clinical Operations. [Name] will be in-serviced on the notification of changes of condition policy and procedure, and the abuse and neglect policy and procedure. The VP of Clinical Operations ensures in-servicing and training tasks are provided and compliance is achieved. 2. An immediate in-service was initiated on 11/13/2024 by VP of Clinical Operations on change of condition notification and abuse and neglect. 3. Beginning 11/13/24 and on-going: A post-test will be completed by direct care nursing staff to ensure competency on notification of changes of condition and abuse and neglect. Staff must answer all questions correctly before returning to work. 4. New staff will receive in-servicing prior to orientation on the floor. PRN staff will not be allowed to work in the facility until they have completed in-service training and post-test. 5. A payroll report listing current employees will be used to track in-service completion. The VP of Clinical Operations will ensure this task is completed. Monitoring: 1. Nursing Administration (Director of Nursing, Assistant Director of Nursing) will interview and conduct skin assessments at random for residents residing in the facility, as well as review the electronic medical record to ensure compliance with the facility's abuse and neglect and notification of changes of condition policies to ensure compliance. This will occur daily for one week, then twice weekly for four weeks, and monthly thereafter. 2. Administrator, or appointed designee, will review this plan in its entirety in the Clinical Meeting scheduled 5 times per week (Monday through Friday) to monitor for compliance, and to make changes based on the interdisciplinary team's review and decision. This will be on-going. [Facility] requests that the measures we have implemented be reviewed and that our allegation of removal of jeopardy be accepted as of 11/13/24. The investigator monitored the Plan of Removal on 11/14/24 as followed: During interviews conducted on 11/14/24 between 4:39 PM and 7:00 PM, 3 CNAs, 2 LVNs, and 2 RNs from both shifts stated they were in-serviced on Abuse and Neglect and Change in Condition. Some staff reported they had the training on 11/13/24, while others reported the training on 11/14/24 prior to starting their shift. All staff stated the abuse coordinator was the GM. Staff stated any abuse had to be reported immediately. Staff reported taking a written test about abuse and neglect. Staff reported in-service and a written test regarding notification of changes. The staff stated the in-service covered reporting any change such as bruises, skin tears, complaints of difficulty urinating, behaviors, or pain. Staff stated the provider needed to be notified immediately. If the provider did not respond within 30 minutes, the medical director was notified. If no response from the medical director within 30 minutes, the CNO was notified. Documentation was to be completed as soon as possible but no later than the end of the shift. The staff stated the test was a multiple-choice test. They stated questions included, Which of the following incidents requires notification to the MD/NP? and, If the resident experiences a significant change, what actions must the nurse take? Review of the facility's Ad Hoc meeting agenda dated 11/13/24, reflected the Medical Director was notified. The VPCO, RN Supervisor, Director of Rehab, MDS Coordinator, DM, SS, and DCE attended the meeting. Review of the post-tests to ensure competency on notification of changes of condition and abuse and neglect was conducted. The test for change of condition contained seven multiple-choice questions. A sample of questions included, A charge nurse must notify the physician of the following: circle all that apply, Which of the following requires notification to the MD/NP? and, If a resident experiences a significant change in their physical, mental, or psychosocial status, which action must the charge nurse take? The Abuse post-test contained 10 True or False questions. A sample of the questions included, Everyone in the facility is responsible for watching for and reporting abuse. Taking away a resident's call light is considered a form of abuse. It is okay to swear in front of a resident if they are swearing too. The tests were taken by direct care nursing staff as well as staff from other departments. The tests reviewed were all passed with no concerns identified. Review of the Abuse in-service given by the VPCO, dated 11/13/24 reflected Notification to Abuse Coordinator (GM). The in-service contained 43 signatures. The Abuse & Neglect policy was attached. Review of the Change of Condition notification in-service given by the VPCO, dated 11/13/24 reflected Assessment and notification must be completed on any physical, mental or emotional changes. The Change of Condition Policy was attached. The sign-in sheet contained 43 signatures. Review of the payroll report listing current employees was reviewed. 18 nursing staff had completed the training. 4 general administrative staff had completed the training. An interview and skin assessment were conducted on all residents in house. A sample of 5 residents medical records reflected the residents were interviewed and a head-to-toe assessment was completed. No significant findings noted. The CNO was out of town but per the VPCO, he was trained verbally during a telephone call and would take the tests when he returned to duty. The VPCO was notified on 11/14/24 at 7:19 PM that the IJ had been removed. While the IJ was removed on 11/14/24 at 7:19 PM, the facility remained at a level of no actual harm with potential for more than minimal harm that is not immediate jeopardy at a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observations, interviews, and record reviews, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing for 1 (Resident #1) of 6 residents reviewed for quality of care. 1. The facility failed to assess the resident or notify the provider when Resident #1, who has a diagnosis of stage 5 kidney failure, complained of not being able to urinate. 2. The facility failed to assess Resident #1, notify the provider or the abuse coordinator when Resident #1, who was taking blood thinners and had a BIMS score of 15, presented with bruises all over her body, and began throwing herself on the floor, hitting herself on the head, yelling, and exhibiting erratic behaviors . 3. The facility failed to follow the care plan and notify the MD of changes in mental status, confusion, and agitation. 4. The facility failed to assist Resident #1 to transfer to the hospital on 11/03/24, before she called 911 and waited 27 minutes on the phone until EMS arrived. The failures resulted in an identification of an Immediate Jeopardy (IJ) on 11/13/24 at 2:49 PM. While the IJ was removed on 11/14/24 at 7:19 PM, the facility remained at a level of no actual harm with potential for more than minimal harm that is not immediate jeopardy at a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for not receiving intervention in a timely manner and a decline in health and hospitalization . Findings included: Review of Resident #1's admission MDS assessment dated [DATE], Section A (Identification Information) reflected a [AGE] year-old female admitted to the facility on [DATE]. Section I (Active Diagnoses) reflected diagnoses including left hemiplegia following cerebral infarct (weakness or paralysis on the left side of the body after a stroke), chronic kidney disease, muscle weakness, seizures, anxiety (intense and excessive worry and fear), and abnormalities of gait. The primary medical condition category was listed as stroke. Section B (Hearing, Speech, and Vision) reflected the resident's speech was clear and she made herself understood. Section C (Cognitive Patterns) reflected a BIMS score of 15 indicating intact cognition. Section E (Behavior) reflected no hallucinations or delusions. Section E also reflected no verbal behaviors directed towards others, and no physical behaviors not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds). Section H (Bladder and Bowel) reflected the resident was continent of bowel and bladder. Section N (Medications) reflected the resident received anticoagulant and antiplatelet medications. Review of Resident #1's comprehensive care plan reflected a focus, initiated 10/30/24, of depressive symptoms with an intervention, Observe and report any changes in mental status, notify MD if any changes in mood, behavior and/or psychosocial status is observed. A focus, initiated 10/25/24, of risk for falls with interventions including, Follow facility fall protocol and, review information on past falls and attempt to determine cause of falls. Record possible root causes . A focus, initiated 10/25/24, reflected potential alteration in nutrition and hydration with interventions including, Monitor/document/report PRN any s/s of dehydration: decreased or no urine output and new onset confusion. A focus, initiated 10/25/24, for antianxiety medication reflected interventions including, Monitor/document/report PRN any adverse reactions to anti-anxiety therapy: .Confusion, impaired thinking and judgement, mania, hostility, rage, aggressive or impulsive behavior, hallucinations. A focus, initiated 10/25/24, for anticoagulant therapy reflected an intervention, Monitor/document/report PRN adverse reactions .sudden changes in mental status. The care plan did not address the resident's kidney disease. A focus initiated 11/04/24 reflected, The resident has a behavior problem of repeatedly putting herself on the floor (purposeful), throwing items on floor and breaking (plates, cups, etc.), yelling out loud, clogging toilet with paper towels. Goals included, Resident will show a decrease in negative behaviors by next review date and Will exhibit socially appropriate behaviors during review period. Interventions included, Approach resident appropriately when resident is hallucinating, delusional or expressing potentially harmful suspicions . Ask resident if these hallucinations/delusions are harmful to themselves in any way .Document resident's inappropriate behaviors when it occurs . If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and or unacceptable to the resident . Intervene as necessary to protect the rights and safety of others . Review of Resident #1's admission Nursing Evaluation, dated 10/25/24 at 7:29 PM, reflected normal skin color on the resident's face, upper extremities, and lower extremities. The assessment note redness on the sacrum but no other skin integrity concerns. Review of Resident #1's physician order dated 10/25/24 reflected, Skin Checks Weekly every day shift every Saturday - Must open and document Skin Evaluation for each assessment (including no new areas found). Review of Resident #1's Medication/Treatment Administration Record for November 2024, reflected LVN B signed the Weekly Skin Evaluation as completed on 11/02/24. Review of Resident #1's Evaluation log from 10/25/24 through 11/03/24 reflected no Weekly Skin Evaluation was completed. Review of Resident #1's Order Summary Report for active orders as of 11/03/24, reflected the following medication orders: 10/28/24 Apixaban oral tablet 5mg by mouth two times a day for DVT PPX unsupervised self-administration. 10/25/24 Aspirin oral capsule 81mg by mouth on time a day for analgesics. 10/25/24 Clopidogrel Bisulfate oral tablet 75mg by mouth one time a day for hematological agents 10/25/24 Buspirone HCl oral tablet 5mg by mouth two times a day for antianxiety agents. Review of Resident #1's shower sheet dated 11/02/24, reflected scattered fading bruises. The time of the note is left blank. Lines on the body diagram indicated bruises on the abdomen, arms, and left leg. The form was signed by a CNA and a nurse. The nurse's signature is illegible. Review of Resident #1's progress note dated 10/31/24 at 4:31 AM, written by LVN D reflected, .resident was sitting on the floor, states she woke up needing to use the restroom and was attempting to get up too quickly; bed was in low position with call light in reach, resident aware to call for help, VS WNL, denies pain, no s/s LE rotation, current anticoag rx [sic] on hold, denies hitting head, on neuro checks. Review of Resident #1's progress note 10/31/24 at 12:30 PM (created 11/01/24 at 8:35 AM) written by the VPCO, reflected, . Staff member was informed guest called to say she fell in her room, upon entering room guest was observed sitting in an upright position on her buttock . no apparent injuries, no redness, swelling, bruising or abnormalities .denies hitting her head or any other area of her body . educated guest to call for assistance with any further transfers .verbalized understanding. Guest is her own r/p, clinical manager and MD notified as well. Review of Resident #1's progress note dated 11/1/24 at 1:25 AM, written by LVN D, reflected Guest c/o 'not being able to urinate', bladder scan performed with no residual, noted in 24-hour report for in house NP. Review of Resident #1's progress note dated 11/1/24 at 9:44 PM reflected, fall f/u day 2/3: resident observed propelling self in hallway on unit, resident observed clogging toilets (toilet in her room and empty rooms) with paper towels, resident redirected multiple times nurse manager notified, maintenance order placed. Review of Resident #1's progress note dated 11/02/24 at 8:00 PM, written by LVN K, reflected in part, .resident observed yelling out for help . The note did not reflect the provider being notified that the yelling out behavior was a change in mental status from being alert and oriented, with a BIMS score of 15, and able to make her needs known. Review of Resident #1's progress note dated 11/02/24 at 9:35 PM, written by LVN K (created 11/03/24 at 5:37 AM) reflected, Day 3/3 fall f/u bruises noted to abd, lower back, ble, bue, and forehead. The note does not reflect that the provider was notified of the bruises. Review of Resident #1's progress note dated 11/03/24 at 2:59 PM, written by LVN B, reflected in part, Guest noted from previous shift not having a good sleep yelling all night and breaking things and putting herself to the floor many times .the next day the pt continue breaking things and breakfast plates and cup and pulling the call light off the wall and continue throwing herself on the floor and yelling and the NP was called and the pt call 911 by herself and she was sent out for AMS and the pt has scattered bruising all over . Review of Resident #1's progress notes from 11/02/24 through 11/03/24, reflected no documentation that the bruises were assessed, or the provider notified of bruising until the resident was sent out with EMS around 2:51 PM on 11/03/24. Review of the incident report log from 08/01/24 through 11/06/24, reflected Resident #1 had two falls. The throwing herself to the floor was not documented on the incident list. Review of an incident report dated 10/31/24 at 4:31 AM, reflected Resident #1's fall from the same date and time. Immediate actions taken included, Resident aware and reeducated to call for assistance when needing help . Mental Status reflected only the oriented to person box was checked. Predisposing Physiological Factors reflected the boxes for confused and impaired memory were checked. Predisposing Situation Factors reflected the boxes for behavior issues, during transfer and, ambulating without assist were checked. No notifications were documented. Review of an incident report dated 10/31/24 at 12:30 PM, reflected Resident #1's fall from the same date and time. Immediate actions taken included, educated guest to call for assistance with any further transfers to decrease the risk of a fall. Page 1 of the report reflected the guest was alert and oriented x4. Page 2 of the report reflected the mental status as only oriented to person. No Predisposing Environmental or Physiological factors checked. Review of a text message from Resident #1 to a FM sent 11/01/24 at 10:30 PM, the resident texted, In short my pan s, I shit, I'm in sa diaper but, I'm in a dia diaper [sic] Review of Resident #1's Task: Bladder Continence, the resident was marked as continent five times from 10/26/24 through 10/30/24. On 11/01/24, she was marked as incontinent of bladder. Review of an undated document received in an email on 11/15/24 by the VPCO, regarding Resident #1's complaint of not being able to urinate, reflected in part, .The day shift licensed nurse worked with the resident has documented vital signs along with a pain assessment documented in the resident medical record. The resident did not verbally express any further concerns. As such, there was no indication from the residents or the nurse that additional follow-up was necessary at the time. The transfer form, included in the email, reflected the resident required assistance with toileting and was incontinent of bladder. Review of Resident #1's progress notes from 11/01/24 through 11/03/24, reflected no assessment of the cause for the incontinence and no further information regarding her genitourinary status. Review of Resident #1's progress notes dated 11/01/24 through 11/03/24 reflected no documentation that the provider was notified of the change in mental status or behaviors. The notes did not reflect that the nurse manager who was notified, followed up on the resident's change in mental status. Review of Resident #1's progress notes dated 10/31/24 through 11/03/24, up until the final entry, reflected no documentation that the provider was notified of yelling out, yelling out all night, clogging toilets, breaking things, putting herself on the floor many times. The notes do not reflect that the provider was notified when the behaviors of throwing things, breaking things, pulling the call light off the wall, and throwing herself to the floor, and yelling continued to the next day. Review of a screen shot from Resident #1's phone dated 11/03/24, reflected a phone call placed to 911 at 1:59 PM. The call lasted 27 minutes. Review of photos of Resident #1 taken in theER on [DATE] between 4:35 PM and 4:39 PM reflected the following: Face - two red bruises on her forehead and one on her left eyebrow. Abdomen - one purple/red bruise just below her umbilicus (belly button) and extending down towards the pubic bone, unable to visualize the bottom of the bruise due to positioning. The bruise is about 6 inches wide. A large deep purple hematoma (bruise) on the right abdomen flank is about 14 inches in width extending across her low back. It starts at about the level of the umbilicus, about 5 inches are visible, the bottom edge of the hematoma is covered by clothing. There was a tape measure visible lying across the wound in the in picture. Right upper leg - about 11 purple bruises on lateral (outside)/posterior (back) view. Right lower leg - about 8 purple bruises on posterior view Left lower leg - a purple bruise that starts a few inches below her knee and extends to just above the ankle, about 10 inches on anterior (front) view, tape measure visible in the photo. About 7 purple bruises are visible on the medial (inside) aspect of the leg and the large bruise on the anterior view extends to the medial aspect. Right foot - about 10 purple/red bruises on medial, lateral, dorsal (top), and plantar (bottom) surfaces. Laceration on dorsal surface. Left foot - about 6 purple/red bruises on lateral and dorsal surfaces. Right arm - about 3 purple bruises and one large deep purple/red bruise visible. Review of Resident #1's Emergency Provider Report, dated 11/03/24 at 5:52 PM, reflected in part, Presentation Chief Complaint - Altered Mental status. Stated complaint Left hip pain/confusion per EMS . presents with altered mental status and scattered bruising . speech nonsensical and unable to communicate effectively . Primary Impression: Altered Mental Status. Secondary Impressions: Anemia, Ecchymosis, History of completed stroke. Review of Resident #1's physician progress notes from the acute hospital dated 11/11/24 at 11:48 AM reflected in part, Patient was agitated on arrival to emergency room , required several doses of sedatives for agitation in emergency room . Per EMS report nursing staff at facility reported patient was hitting her own head against the wall and had frequent falls CT chest abdomen, and pelvis shows significant bladder distention. Markedly enlarged bilateral kidney with innumerable cyst . Hematoma in the subcutaneous fat in the lateral right mid to lower abdomen measuring 8.3 x 3.8 x 7.6 cm. Hemoglobin 6.1 on admission. Patient underwent 2 units of PRBC transfusion from extensive bruising all over the body. No evidence of GI bleed. Eliquis was discontinued, aspirin and Plavix continued. Acute metabolic encephalopathy resolved. Resident has some urinary retention, and a catheter was placed . Urinary tract infection, received Ceftriaxone 1 gram IV every 24 hours. Review of Resident #1's EMR including MDS assessment, progress notes, evaluations, and MARs dated from 10/25/24 through 11/04/26, did not reflect the resident was assessed for a change in mental status, changes in mood, behavior and/or psychosocial status, s/s of dehydration, reactions to anti-anxiety or anticoagulant medications. There was no documentation that the resident was assessed for hallucinations or delusions after the initial MDS assessment, or for possible causes of the altered mental status. During a telephone interview on 11/06/24 at 8:16 AM, Resident #1's FM stated the resident had called her on 11/02/24 and said she thought she had a UTI because she was not peeing, and she did not feel right. She stated they were on speaker phone and there was a staff member in the room. She stated she asked the other person in the room if the doctor was coming to see the resident and the other person replied, Yes. She stated she did not know if a doctor ever saw the resident about her complaint of not urinating. She stated she saw the resident the next day in the ER. She stated the resident went to the ER for altered mental status and multiple falls. She stated she was never notified of the falls. She stated she noticed, during phone calls and texts, the resident being more confused and irritable for the few days prior to going to the ER. She stated Resident #1 started having trouble writing a coherent text message. She stated the decline went on for days before she called 911 to go to the hospital. During an interview on 11/06/24 at 2:28 PM, the VPCO stated the post fall assessment would have the documentation regarding the resident's status. She stated the nurses would document in the progress notes when a bruise was observed or noticed. She stated they would definitely investigate any bruises that could not be explained. She stated if an alert and oriented resident had falls and a change in behavior, her first thought was to get a UA as changes were often a sign of infection. During an interview on 11/07/24 at 10:33 AM, the MD stated she saw Resident #1 on 10/28/24. She stated she did not look under the clothes but there were no bruises on the visible skin. She stated she was not aware of extensive bruising. She stated the resident was on 3 different medications that could have caused her to bruise easily. She stated Resident #1's hemoglobin was 8.8 (hemoglobin, part of the blood, helps carry oxygen to all the vital organs, 12-17 is a normal level) on 10/23/24 at the acute hospital prior to her admission at this facility. She looked but did not see any blood results from the time the resident was in the facility. She stated she was not aware that the resident complained of not being able to urinate. She stated the resident had chronic kidney disease, but she had been urinating, as far as she knew, while at the facility. She stated the resident may not have been drinking enough, or her kidney disease may have worsened. She stated she expected to be notified of changes in condition when they occurred. She stated the resident was a good historian and would have been able to talk about the bruises and any problems with urination. She stated she was not notified of any erratic behavior other than the resident being upset that her daughter did not answer the phone. During an interview on 11/07/24 at 11:11 AM, the NP stated for any unwitnessed fall, she expected the staff to ask the resident if they had hit their head. She stated bruising may not occur right away if a resident fell or sustained an injury. The NP stated if a resident was on blood thinners and hit their head, to be safe, the resident would be sent out for evaluation. After viewing the picture of the abdominal bruise, the NP stated that bruise should have been reported immediately as the resident was on blood thinners. She stated the bruise looked fresh and it may have happened when she threw herself on the floor. The NP stated she was not aware that the resident had complained of not being able to urinate. She stated she was not aware of the facility 24-hour report. She stated the on-call providers kept a report of the calls received. She reviewed the notes and stated she did not see an entry for Resident #1's urinary complaint. The NP stated she was notified of the erratic behavior when the nurse called her at 2:25 PM on 11/03/24. During an interview on 11/07/24 at 12:33, LVN B stated she had worked at the facility for about three years. She stated she first saw bruises on Resident #1's arm on 10/29/24 but did not work on the resident's hall until 11/01/24. She stated she noticed bruises on Resident #1's abdomen on 11/01/24. She stated because the resident was on blood thinners, she figured the resident was on anticoagulant injections while in the acute hospital and that was the reason for the bruises. She stated because they were old bruises, she did not report them. She stated the resident had scattered bruises all over her body. She stated on Saturday, 11/02/24, the resident was yelling and pulled the call light off the wall. She stated the resident was trying to call her daughter and was yelling about it. LVN B told the resident she would help her call her daughter shortly. When she returned to the room to help, the resident began yelling again and pushed her tray all the way out of her room. The yelling continued. LVN B stated she did not notify the doctor as the resident was just mad about her daughter not answering the phone. She stated on Sunday morning 11/03/24, she was told in report that Resident #1 had yelled all night. She stated the resident continued to yell, kept putting herself on the floor, and hit herself in the head with the phone. She stated it was very different behavior for this resident, but the resident was mad at her daughter. LVN B stated in the afternoon she explained to the resident that she would notify the provider to have her sent out. LVN B stated shortly after she got to the nursing station, the front desk called and asked her if she had called 911. The front desk told her 911 was on the phone about Resident #1 and I told them to come get her. LVN B stated, She heard me say I was going to send her out, so she went ahead and called 911. During an interview on 11/07/24 at 2:00 PM with the VPCO and CNO, the VPCO stated on 10/31/24 she was called to the room after Resident #1 was found sitting on the floor. She stated there was no facial bruising at that time. After seeing the picture of the bruise on Resident #1's abdomen/trunk/back, the CNO stated the bruise was from anticoagulant injections due to its location. The VPCO stated it was a new bruise because it had not changed colors. She stated she could not tell when or where the picture was taken so she could not verify the bruise was present while the resident was at the facility. During a telephone interview on 11/07/24 at 2:38 PM, Resident #1 stated she fell when she was at the facility. She stated, I tried to get help and they said they would be right back, and it was an hour. She stated she was crawling around on her butt trying to get help. They took their time to help me. She stated one staff member told her they were going to kick me out if I kept acting up. She stated she had bruises on her arms which she sustained during the falls. She said she fell and hit her back. She stated the big bruise hurt and stated maybe an ice pack would have helped. She stated she did not feel right and had trouble urinating, I thought I had a UTI. During an interview on 11/07/24 at 5:05 PM, the GM stated there were no competencies for the bladder scan . He stated there was a manual for the bladder scan machine itself. He stated nursing documentation varies from person to person. He stated the nursing documentation should reflect the work they were doing. He expected documentation to be accurate and timely. He stated the clinical management team was responsible to monitor documentation. He stated he expected the nurse to contact the provider or CNO if there was a change in condition or mental status. During an interview on 11/12/24 at 4:17 PM with the ACNO, he stated he had recently provided training on customer service, change of condition and assessment. He stated he had not provided any training on bladder scans. He stated if a resident complained of not being able to urinate, the nurse reached out to the provider, performed a straight cath, bladder scan, or whatever the provider ordered. He stated it would be case by case, but voiding should occur at least every 4-8 hours. He stated signs and symptoms of UTI could be itching, burning, frequency, or new onset confusion. He stated if there was a bladder scan with no residual, there was no need for follow up. He stated if it was him, he would have rescanned to ensure the initial reading was correct. He stated skin assessments were done upon admission and he believed the wound care nurse was responsible to complete the skin assessment. He stated the skin assessments were completed, he thought, weekly per the policy. He stated CNAs documented in the electronic record and completed shower sheets. The CNAs were expected to document and report any skin issues such as bruises, skin tears, or red areas. He stated residents could get bruised many ways and they could be self-inflicted if the resident was having behaviors. After review of Resident #1's abdominal flank bruise, he stated she may have sustained the bruise when she fell or threw herself on the floor. He expected the provider to be notified of a bruise of that size. He stated it looked new as he did not see any yellow or other signs of aging. He stated if he saw the resident having behaviors, he would not necessarily notify the doctor if those behaviors caused the bruising. He stated if the resident was on blood thinners, probably, he should notify the provider. During an interview on 11/13/24 at 11:08 AM, LVN C stated she was trained on performing a bladder scan when she worked at a hospital, but she had not had any recent training on the bladder scan. She stated the last time she worked with Resident #1, on 10/31/24, she was alert and oriented, and wheeling herself to the coffee shop in the lobby. She stated she completed a skin assessment that day as she helped the resident get dressed. She did not notice any bruises or skin impairment. She stated she did not document that skin assessment. During a telephone interview on 11/13/24 at 11:49 AM, CNA A stated on 10/31/24, Resident #1 was somewhat confused, so she checked on the resident every 30 minutes. She stated they had the bed in the low position, and she told her several times to call for assistance before getting up, but the resident kept getting up. She stated that was a change for the resident. She stated the resident had bruises, but the nurse had already assessed them. She stated there was just a small bruise on the resident's arm that the resident said came from a fall earlier in the day. The CNA stated she reported that bruise to the nurse but the nurse said it would not show up that fast so it must have been an old bruise. During an interview on 11/13/24 at 1:06 PM, LVN B stated the change in Resident #1's mental status did not occur until Sunday 11/03/24. On Saturday (11/02/24) morning report, which she received from LVN D, she was told the resident was found on the floor. On Sunday morning in report, she was told other residents were mad because Resident #1 was making so much noise all night. She stated the resident had complained of pain the night before and they got a hip x-ray. She stated she did not remember ever being told in report that Resident #1 complained of not being able to urinate. She stated on the morning of 11/03/24 Resident #1 continued to yell and break things and throw herself on the floor. She stated the resident had bruises all over and she notified the provider to send the resident out. She stated she assessed the resident, and it was because her daughter did not answer the phone, that she was mad. Multiple attempts to contact LVN D by telephone were made between 11/07/24 and 11/13/24. No return call was received prior to exit from the facility. Review of the Change in Resident Condition policy revised 06/2022, reflected in part, To provide guidance on notification of the physician when there is a change of condition. 1. Should there be a significant change in the resident's physical, mental or emotional status, the attending physician should be notified. 2. If the attending physician does not respond within 30 minutes, contact the Medical Director. 3. If the Medical Director does not call within 30 minutes, contact the DON. Review of the Post-Fall policy revised 05/2023, reflected in part, The LPN/RN will assess the resident for injury and give care/treatment needed at that time. Evaluating the resident's need for: First aid needs, Assessment will include vital signs, skin assessment, neurological assessment, ROM .pain .The LPN/RN notifies the physician of the fall and findings from his/her assessment. The physician makes the clinical decision to transfer resident to hospital or monitor and treat in facility. The Administrator and DON are notified of fall. Document circumstances, notification of medical doctor, family or responsible party, Administrator and Director of Nursing and findings from the assessment in the clinical record . Review of the Bladder Scan Protocol revised 09/2024 reflected, To ensure bladder scan orders are followed in accordance with physician orders. Policy/ Procedure: 1. Bladder scans may be initiated for residents experiencing signs and symptoms of urinary retention and/or recent catheter removal at the licensed nurse's discretion, provider notification will occur for abnormal results. 2. Post void residuals will be completed via a bladder scan device if available in accordance with physician orders . Review of the Skin Policy & Procedure dated 03/2020, reflected in part, The nurse will perform a full-body initial skin assessment to identify if the resident is at risk for a pressure ulcer within 24 hours of admission to the facility and weekly .The nurse will conduct a full-body skin assessment for each resident weekly to ensure no risks have developed .Each Direct Care Provider will examine each resident's total body skin with each bathing experience and will report any abnormalities to the nurse using the Skin Sheet. The VPCO was notified on 11/13/24 at 2:49 PM that an IJ had been identified and an IJ template was provided. The following POR was approved on 11/14/24 at 4:32 PM: Allegation of Credible Compliance F684 11/13/2024 November 13th, 2024 Immediate Interventions: 1. Notifications made to the Medical Director on 11/13/24 at approximately 4:00pm of the immediate jeopardy citation 2. Emergency meeting conducted with action plan developed. This occurred at 4:30pm on 11/13/24 Attendees: RN, VP of Clinical Operations Administrator RN, Assistant Director of Nursing Action Plan: Licensed nursing staff, certified medication aides, and certified nursing assistants in-serviced immediately on the facility policy and procedure for notification of change of condition and the abuse and neglect policy and procedure. Resident #1 has discharged from the facility and therefore a plan of correction cannot be accomplished. Current residents were assessed by licensed nursing staff for any changes of condition, including but not limited to their physical (including but not limited to skin integrity), mental and emotional status. No negative outcomes were obtained from these assessments. A root cause analysis was completed by the VP of Clinical Operations and incorporated into staff training and in-servicing, which includes notification of change of condition, and abuse and neglect policies and procedures. 3. Licensed nursing staff, certified medication aides, and certified nursing assistants were in-serviced on the change of condition policy and procedure, including but not limited to: changes in resident behavior, skin integrity changes, increased confusion, and genitourinary changes. The assistant director of nursing and nursing supervisor have provided in-service, education and compliance training with staff. - Changes of condition must be reported to the provider timely (within 30 min) if no response within 30 minutes the Medical D [TRUNCATED]

Based on interviews and record review the facility failed to maintain medical records on each resident in accordance with accepted professional standards and practices that are complete and accurately documented for 2 (Resident #1 and Resident #2) of 6 residents who were reviewed for administration. 1. The facility failed to accurately document the administration of Resident #1's anticoagulant medication from 10/28/24 through 11/05/24. 2. The facility failed to transcribe a wound care order 10/30/24 for Resident #2. These failures could place residents at risk of lack of desired effect of medications and treatments, and lack of wound healing. Findings included: 1. Review of Resident #1's admission MDS assessment dated [DATE], Section A (Identification Information) reflected a [AGE] year-old female admitted to the facility on [DATE]. Section I (Active Diagnoses) reflected diagnoses included left hemiplegia following cerebral infarct, chronic kidney disease, muscle weakness, seizures, anxiety, and abnormalities of gait. The primary medical condition category was listed as stroke. Section C (Cognitive Patterns) reflected a BIMS score of 15 indicating intact cognition. Review of Resident #1's face dated 11/06/24 reflected she discharged on [DATE]. Review of Resident #1's comprehensive care plan reflected a focus, initiated 10/25/24, for anticoagulant therapy reflected interventions, Administer anticoagulant medications as ordered by physician. Monitor for side effects and effectiveness every shift and Monitor/document/report PRN adverse reactions .sudden changes in mental status. Review of Resident #1's Order Summary Report for active orders as of 11/03/24, reflected the following medication order: 10/28/24 Apixaban oral tablet 5mg by mouth two times a day for DVT PPX unsupervised self-administration. Review of Resident #1's EMR revealed no assessment or physician's order for self-administration of medications. Review of Resident #1's MAR for October 2024 reflected, U-SA for the two doses due each day on 10/28/24, 10/29/24, 10/30/24, and 10/31/24. The chart codes reflected U=unknown Review of Resident #1's MAR for November 2024 reflected, U-SA for the two doses due each day on 11/01/24, 11/02/24, 11/03/24, 11/04/24, and 11/05/24. Review of Resident #1's Order Recap Report for orders between 10/25/25 and 11/06/24, did not reveal any orders to hold the anticoagulant medications. Review of Resident #1's progress note dated 10/31/24 at 4:31 AM, written by LVN D reflected, .resident was sitting on the floor, states she woke up needing to use the restroom and was attempting to get up too quickly; bed was in low position with call light in reach, resident aware to call for help, VS WNL, denies pain, no s/s LE rotation, current anticoag rx [sic] on hold, denies hitting head, on neuro checks. 2. Review of Resident #2's admission MDS assessment, dated 10/28/24, Section A (Identification Information) reflected a [AGE] year-old female admitted to the facility on [DATE]. Section I (Active Diagnoses) reflected her diagnoses included a hip fracture, pain due to internal orthopedic prosthetic device, unspecified fall, and hypertension. Section C (Cognitive Patterns) reflected a BIMS score of 15 indicating intact cognition. Section GG (Functional Abilities) reflected she required substantial/maximum assistance for sit to stand, chair to chair, and toilet transfers. Section M (Skin Conditions) reflected the resident had a surgical wound, received surgical wound care, and received applications of ointments/medications, and was at risk for pressure ulcers. Review of Resident #2's comprehensive care plan initiated 10/25/24, reflected in part, Focus: The resident is at risk for further alteration in skin integrity, left hip post-surgical. Goal: The resident will remain free of new skin impairment through the review date. Interventions: Apply barrier cream . Avoid scratching .Do not allow linens to be creased/folded .Educate resident/family the importance of changing positions .Encourage and assist with turning and repositioning every 2-3 hours . Provide skin/wound treatments as ordered. Review of the order summary for Resident #2 reflected in part, [name] hydrocolloid dressing to Right Buttock for denuded skin ordered 10/30/24 with no end date on the order. Review of Resident #2's November 2024 TAR reflected no order for the hydrocolloid dressing to her right buttock. During an observation and interview on 11/06/24 at 7:35 AM, Resident #2 stated she had an incision on her hip. She stated for a while, she had to beg the staff to come put a dressing over the incision because it was draining so much it got her sweater all bloody. She stated she did not recall any other treatments or wound care. During an interview on 11/07/24 at 12:33 PM, LVN B reviewed the order for Resident #1's Apixaban then stated, They must have clicked the wrong box when it was ordered because the resident did not give her own meds. She stated by looking at the MAR, she could not tell if the medication had been given . She stated she gave the medication because she remembered reading Eliquis 5mg po bid and it was the right time, so she gave the med. She stated if she saw an order that was not correct, she should have called the doctor for clarification. She stated when she clicked in the box after she administered the medication, the U-SA populated instead of her initials. She stated she did not notice the order was wrong because she quit reading the order after she verified the dose and time. She stated she gave the medication to the resident on 10/29/24, 11/01/24, 11/02/24, and 11/03/24. During an interview on 11/07/24 at 2:00 PM, the VPCO stated they did not have any residents who self-administered medications. She stated she did not know how that order got there. She stated the nurse that discovered an incorrect order was responsible to notify the provider for clarification. She stated she would have to check with the nurses to see if the medication was given to Resident #1. She stated she would look at the order for Resident #2's hydrocolloid dressing because she did not believe the resident had a wound that would require that type of dressing. During an interview on 11/07/24 at 4:56 PM, the VPCO stated she could not get the hydrocolloid dressing to populate on the TAR and was not sure why. She stated she did not know why the treatment was ordered. Review of the facility's Self Administration of Medications and Treatments policy, dated 11/2018, reflected in part, 1. Self administration of medications and treatments is determined by physician order after determining that the resident is able to self administer. 2. Medications and treatments for self administration are kept in a locked drawer in the resident room. 3. All medications and treatments that are self-administered are signed out in the MAR or TAR with the nurses initials . Review of the facility's Physician Orders policy, revised 05/2023, reflected in part, General: To clarify requirements and assure that all physicians' orders are valid and safe for patient care. Policy: 1. Orders may be called, hand-written, faxed, or electronically generated by physician . 3. After the authorized provider has completed the orders, the RN or LPN is responsible to promptly and accurately transcribe all written orders. The RN or LPN must include his/her signature, the date and time of the transcription and credentials . 4. Orders that are unclear must be clarified prior to implementation. Review of the facility's Administration of Medications policy, revised 04/2023, reflected in part, General: All medications are administered safely and appropriately to aid residents to and help in overcome Illness, relieve and prevent symptoms and help in diagnosis. Procedure . 3. Check medication administration record prior to administering medication for the right medication, dose, route, patient and time. 4. Read each order entirely. 5. Remove medication from drawer and read label three times; when removing from drawer, before pouring and after pouring . 14. Click confirm on the eMAR once the medication is removed from the package . 17. Remain with the resident to ensure that the resident swallows the medication. Once resident takes the medication, hit save on the eMAR. 18. If medication is not administered, record reason on the eMAR and notify physician or nurse practitioner. Observe the resident for medication side effects and inform the physician if any occur .

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 to help prevent the development and transmission of communicable disease and infection for 1 of 3 residents (Resident #2) reviewed for infection prevention and control. The facility failed to place Resident #2 on Enhanced Barrier Precautions when admitted on [DATE] with a surgical wound. The facility failed to ensure they made PPE available near or outside resident's rooms who were on EBP. These failures could place residents at risk for infections. Findings included: Review of Resident #2's admission MDS assessment, dated 10/28/24, reflected Section A (Identification Information) reflected a [AGE] year-old female admitted to the facility on [DATE]. Section I (Active Diagnoses) reflected her diagnoses included a hip fracture, pain due to internal orthopedic prosthetic device, unspecified fall, and hypertension. Section C (Cognitive Patterns) reflected a BIMS score of 15 indicating intact cognition. Section GG (Functional Abilities) reflected she required substantial/maximum assistance for sit to stand, chair to chair, and toilet transfers. Section M (Skin Conditions) reflected the resident had a surgical wound, received surgical wound care, and received applications of ointments/medications. Review of Resident #2's comprehensive care plan initiated 10/25/24, reflected in part, Focus: The resident is at risk for further alteration in skin integrity, Left hip post-surgical. Goal: The resident will remain free of new skin impairment through the review date. Interventions: Apply barrier cream .Avoid scratching .Do not allow linens to be creased/folded .Educate resident/family the importance of changing positions .Encourage and assist with turning and repositioning every 2-3 hours . Provide skin/wound treatments as ordered. The comprehensive care plan did not address Enhanced Barrier Precautions. Review of Resident #2's Wound Rounds assessment dated [DATE] at 11:53 AM reflected in part, site-right hip, type-surgical, classification-incision, exudate-serosanguineous. Review of Resident #2's Order Summary Report for active orders dated 10/30/24, reflected an order for Bordered Gauze 4x10 and 4x4 to left hip surgical site one time a day on even days. During observations on 11/6/24 between 6:11 AM and 6:58 AM, 9 EBP signs were observed on the doors of rooms 114, 125, 130, 132, 158, 159, 160, 163, and 165 . There was no PPE observed near or at the door of the rooms. After an observation of measuring the distance from the nurses' station to Resident #2's room door on 11/07/24 at 10:15 AM, the meter on the measuring wheel reflected the distance was 110 feet. An observation on 11/07/24 at 12:10 PM revealed a blue disposable isolation gown hung on a hook just inside room [ROOM NUMBER]. A sign indicating EBP was observed on the room door. During an observation and interview on 11/06/24 at 7:35 AM, Resident #2 stated she had an incision on her hip. She stated for a while, she had to beg the staff to come put a dressing over the incision because it was draining so much it got her sweater all bloody. She showed the dried blood stains on the sweater she was wearing. The stains lined up with the surgical cite. She stated she did not recall the staff ever wearing gowns when they provided care, Just their regular clothes. She stated the staff always wore gloves but did not always remove them before they left the room. During an interview on 11/6/24 at 6:11 AM, CNA A stated there was no one on her end of the hallway who required PPE during care. Her end of the hall included rooms [ROOM NUMBER]. She stated she wore gloves when providing care to all residents. She stated she had received training on infection control on the computer training system. During an interview on 11/06/24 at 6:13 AM, CNA F stated she had one resident who was on isolation and, You have to gown up when you go in that room but not any of the other rooms. During an interview on 11/06/24 at 6:18 AM, LVN D stated he had worked at the facility, before, as a CNA and returned as an LVN a couple of weeks ago. He stated he did not have the whole orientation training again. When asked about the process for EBP, he stated anyone with wounds or lines such as an IV, would be on EBP. He stated gloves, but not gowns, were required when care was provided to residents on EBP. He stated there were PPE carts in the supply room ready to go for any resident placed on isolation precautions. He stated a possible negative outcome of not wearing the correct PPE could be infection transfer or cross contamination. During an interview on 11/06/24 at 6:35 AM, LVN E stated she recently had training in infection control. She stated the training included hand hygiene and EBP. She stated if the resident had a wound, she had to wear gloves when care was provided. If the resident with the wound had MRSA, she also had to wear a gown. She stated PPE was kept in the supply room. She stated if the resident was on isolation, they kept the PPE in a cart at the room. She stated they re-used the disposable gowns, One gown, one resident, one shift unless the resident had MRSA or C-diff then they used a clean gown each time. She stated there were hooks in the room to hang the gowns. She stated an adverse outcome of not wearing the proper PPE could be the spread of germs. During an interview on 11/06/24 at 9:04 AM, the ACNO stated he was the Infection Preventionist. He stated he had been in the position since he started working at the facility 9 weeks ago. He stated they had one resident on isolation for C-diff and many residents on EBP. He stated everyone with a catheter, peg tube, wound, or IV was on EBP. He stated PPE was kept at the nurse's station and in central supply. He stated he would pull the log to see when infection control training was last done. He stated he was not sure what training rehires received. He stated he had not been using a log or tracking observations of hand hygiene or donning/doffing PPE. He stated they prided themselves on following the EBP protocol, but a negative outcome of not following infection control practices could be cross contamination. He stated residents with stage 3 wounds, or any surgical wound would be on EBP. He stated even if the surgical wound looked closed, it was better to err on the side of caution. During an interview on 11/06/24 at 1:20 PM, CNA H stated he recently had been trained on infection control. When asked to describe EBP, he stated, Some people came in with COVID, so you had to use the extra PPE . He stated a face mask, gown, and face shield were required. He stated PPE was kept in the supply room. During an interview on 11/06/24 at 2:27 PM, the VPCO stated it was her expectation that staff followed EBP. She stated the infection preventionist was responsible for training on infection control. She stated upon hire, EBP was incorporated with Infection Control training. She stated they completed annual skills checks and capability was assessed upon hire. She stated every month they had skill checkoffs on different topics. During an interview on 11/07/24 at 9:42 AM, the ACNO stated management all did rounding and monitored PPE usage. He stated they did not require a physician's order for EBP. He stated the nurse who completed the admission assessment was responsible for initiating the EBP when indicated. He stated it did not meet his expectations that a resident with a draining surgical wound was not on EBP. He stated Resident #2 moved from one hall to another hall and he assumed the EBP sign did not move with her to the new room. He stated it was about 90 feet from the nurse's station where the PPE was kept to Resident #2's door. He stated he considered that to be nearby. During an interview on 11/07/24 at 2:00 PM, the VPCO stated EBP was required for wounds that required a daily dressing. She stated some residents did not require daily dressing changes for their wounds. She stated she would have to look at Resident #2's orders to see if she needed to be on EBP. She stated they did not require an order for EBP because it was just a precaution and not isolation. She stated PPE was kept in the supply room and the nursing station, and it was available. She stated they did not reuse PPE. During an interview on 11/07/24 at 4:24 PM, CNA M stated she had not had much training since working there for three months. She stated when she provided care for residents who required EBP, she had to wear gloves and a gown. She stated she was not sure about reusing a gown but then stated, Well, I guess I would if I was going to be in the room several times, yes, it is okay to use the same gown for the shift. During an interview on 11/07/24 at 5:05 PM, the GM stated he expected staff to follow the infection control policies. He stated on or near the resident door could mean 100 to 150 feet or maybe up to 1000 feet if you looked up the definition of near in the dictionary. They did not put the PPE carts near the rooms in order to provide a more home-like environment. During an interview on 11/12/24 at 5:48 PM, the GM stated the guests in the facility were called guests because they were in the facility for a short period of time. He stated they were not referred to as residents because it was a temporary stay. When asked about the homelike environment he stated they did not have bins of PPE at the rooms because they wanted the facility to look more home-like than hospital-like. During an interview on 11/13/24 at 11:08 AM, LVN C stated they used EBP for residents with wound or dressing changes. She stated a gown and gloves were required if providing contact care to residents on EBP. She stated anyone with a line or wound was placed on EBP when they were admitted . She stated Resident #2 was not on EBP when the resident moved to a room on the hall where she worked. She stated the wound was open to air but there was one day when the wound leaked, and it had to be covered with a dressing. She stated the resident should have been put on EBP at that time. She stated, I should have changed her precautions, but I didn't. LVN C stated not wearing proper PPE or following precautions could lead to the spread of infection. During an interview on 11/13/24 at 10:22 AM, CNA G stated she worked with Resident #2 until she moved to another room on the hall. She stated the resident was not on EBP or isolation as far as she knew, she just wore gloves. Review of the facility's Infection Control policy, revised 05/2024, reflected in part, This facility will follow the Enhanced Barrier Precautions Policy for all MDRO infections. Review of the facility's Enhanced Barrier Precautions policy dated, 03/2024, reflected in part, This facility follows recommendations and guidance from the Centers for Disease Control in order to keep all residents safe from Healthcare Acquired Infections (HAI) . EBP: refers to an infection control intervention de signed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities . Wound: refers to any skin opening requiring a dressing such as for chronic wounds such as: pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers . Make PPE including gowns and gloves available near or outside resident's room . Staff will not wear the same gown and gloves for care of more than one resident or reuse the gown and gloves for the same resident . Residents will be maintained in EBP throughout the duration of the resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed the resident at higher risk . According to the CDC website, https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/ppe.html, accessed on 11/18/24, Make PPE, including gowns and gloves, available immediately outside of the resident room; Incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education.

Based on interview, and record review, the facility failed to provide the necessary treatment and services, based on the comprehensive assessment and consistent with professional standards of practice, to prevent development of pressure injuries for 4 (Resident #1, Resident #2, Resident #3, and Resident #4) of 4 residents reviewed for quality of care. 1. The facility did not prevent the development of one facility acquired Stage II pressure injury for Resident #3. 2. The facility failed to complete weekly skin assessments according to their policy for Residents # 1, 2, 3, and 4. These failures could place residents at risk for developing pressure ulcers or wounds. Findings included: Review of Resident #3's face sheet dated 11/12/2024 reflected an [AGE] year-old female admitted to the facility on [DATE] diagnoses included muscle weakness, need for assistance with personal care, other abnormalities of gait and mobility. It reflected Resident # 3 was discharged from the facility on 11/06/2024. Review of Resident #3's admission MDS assessment dated [DATE] reflected a BIMS score of 15 indicating no cognitive impairment. Review of Resident #3's care plan initiated 10/22/2024 reflected Resident #3 had ADL selfcare performance deficits and limitations in physical mobility. The resident was at risk for alteration in skin integrity. The resident had an alteration in musculoskeletal status related to left humerus fracture. It was also reflected Resident #3 was at risk for alteration in skin integrity. Review of Resident #3's initial skin assessment dated [DATE] reflected Resident #3 had no skin breakdown upon admission. The following were also reflected: The resident is at risk for alteration in skin integrity. Goal: The resident will remain free of new skin impairment through the review date Intervention: Apply barrier cream per facility protocol to help protect skin from excess moisture Intervention: Encourage/assist with turning and repositioning every 2-3 hours Intervention: Provide skin/wound treatments as ordered. Review of Resident #3's physician order dated 10/22/2024 reflected: Barrier Cream apply after incontinent episodes as needed. Review of facility's wound report dated 10/13/2024 to 11/11/2024 reflected Resident #3 had a wound that was identified on 11/05/2024 at her right gluteal fold, classified as trauma/skin stripping . Stage not applicable. Review of Resident #3's physician order dated 11/05/2024 reflected: Apply Hydrocolloid dressing to right gluteal fold skin tear after treatment with collagen. one time a day for wound care. Collagen to right gluteal fold one time a day for wound care. Review of Resident #3's local Home Health clinical records dated 11/08/2024 reflected Resident #3 had pressure ulcer right buttock, stage 2. During an interview on 11/12/2024 at 4:48 PM, Resident #3's family stated staff were leaving Resident # in her soiled brief for long periods and the resident was not being repositioned frequently. Resident #3's family also stated she spoke with facility's staff regarding not being changed frequently and concerns regarding Resident #3 developing pressure ulcers. Family stated a week and a half later Resident #3 was discharged home with a pressure ulcer. During an interview on 11/13/2024 at 10:14 am, CNA G stated skin breakdown was caused from sitting too long or laying too long or not being changed on time . CNA G also stated she worked with Resident #3, and Resident #3 needed assistance with repositioning. During an interview on 11/13/2024 at 11:08 am, LVN C stated Resident #3 had developed redness at Resident #3's buttock and the staff were applying barrier cream to the site. She also stated the area opened at her right-side buttocks just before Resident #3 was discharged from the facility. She stated not moving around, sitting for long, and not being able to reposition could cause skin breakdown. During an interview on 11/13/2024 at about 2:17 PM, the ACNO stated he did not expect a resident to develop skin breakdown. It could be moisture, sitting too long, and a million things. Review of Resident #1's face sheet dated 11/06/2024, reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included left hemiplegia following cerebral infarct, chronic kidney disease, muscle weakness, seizures, anxiety, and abnormalities of gait. It reflected the resident discharged [DATE]. Review of Resident #1's admission MDS assessment dated [DATE] reflected a BIMS score of 15 indicating no cognitive impairment. MDS also indicated Resident #1 was at risk for skin breakdown. Review of Resident #1's admission Nursing Evaluation, dated 10/25/2024 at 7:29 PM, reflected, redness on the sacrum but no other skin integrity concerns. Review of Resident #1's care plan initiated 10/25/2024 reflected Resident #1 was at risk for alteration in skin integrity, required assistance with ADLs, and had left hemi. Interventions included the following: Apply barrier cream per protocol, encourage good nutrition, encourage/assist with turning every 2-3 hours, monitor skin when providing care, and notify nurse of any changes. Review of Resident #1's physician order dated 10/25/2024 reflected, Skin Checks Weekly every day shift every Saturday - Must open and document Skin Evaluation for each assessment (including no new areas found). Review of Resident #1's Medication/Treatment Administration Record for November 2024, reflected LVN B signed the Weekly Skin Evaluation as completed on 11/02/2024. Review of Resident #1's Evaluation log from 10/25/24 through 11/03/2024 reflected no Weekly Skin Evaluation was completed. Review of Resident #2's face sheet date 11/06/2024, reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included hip fracture, pain due to internal orthopedic prosthetic device, unspecified fall, and hypertension. Review of Resident #2's admission MDS assessment, dated 10/28/24 reflected a BIMS score of 15 indicating no cognitive impairment. It was reflected Resident # 2 had surgical incision at left hip. Review of Resident #2's comprehensive care plan initiated 10/25/2024, reflected in part, Focus: The resident is at risk for further alteration in skin integrity, left hip post-surgical. Goal: The resident will remain free of new skin impairment through the review date. Interventions: Apply barrier cream .Avoid scratching .Do not allow linens to be creased/folded .Educate resident/family the importance of changing positions .Encourage and assist with turning and repositioning every 2-3 hours . Provide skin/wound treatments as ordered. Review of the physician order summary for Resident #2 dated 10/25/24 reflected in part, Skin checks Weekly every day shift every Saturday - Must open and document Skin Evaluation for each assessment (including no new areas found). Review of Resident #2's November 2024 MAR/TAR reflected the weekly skin evaluation was signed as completed on 11/02/2024 by RN L. Review of Resident #2's evaluation log reflected no Weekly skin check was completed on 11/02/2024. Review of Resident #3's face sheet dated 11/12/2024 reflected an [AGE] year-old female admitted to the facility on [DATE] diagnoses included muscle weakness, need for assistance with personal care, other abnormalities of gait and mobility. It reflected Resident # 3 was discharged from the facility on 11/06/2024. Review of Resident #3's admission MDS assessment dated [DATE] reflected a BIMS score of 15 indicating no cognitive impairment. Review of Resident #3's initial skin assessment dated [DATE] reflected Resident # 3 had no skin breakdown upon admission. Review of Resident #3's care plan initiated 10/22/2024 reflected Resident #3 had ADL selfcare performance deficits and limitations in physical mobility, the resident is at risk for alteration in skin integrity, the resident has an alteration in musculoskeletal status related to left humerus fracture (humerus is the long bone in the arm running from the shoulder to the elbow). It reflected Resident # 3 was discharged from the facility on 11/06/2024. Review of Resident #3's evaluation log (skin assessment) reflected no Weekly skin check was completed for Resident # 3 on 10/29/2024 or 11/05/2024. Review of Resident #3's clinical records reflected there was no other skin assessment noted for Resident # 3 on 10/29/2024 and 11/05/2024. Review of Resident #3's October's 2024 MAR/TAR reflected the weekly skin evaluation was signed as completed on 10/29/2024. Review of Resident #3's November 2024 MAR/TAR reflected the weekly skin evaluation was signed as completed on 11/05/2024 by LVN D. Review of Resident #4's face sheet dated 11/12/2024 reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of age-related osteoporosis (a condition in which bone strength weakens and is susceptible to fracture), other abnormalities of gait and mobility, muscle weakness. Review of Resident #4's admission MDS assessment dated [DATE] reflected a BIMS score of 15 indicating no cognitive impairment. It was reflected MDS had not address Resident #4's skin conditions. Review of Resident #4's care plan initiated 11/05/2024 reflected Resident #4 had ADL self-care performance deficits and limitations in physical mobility, resident was at risk for further alteration in skin integrity, right hip post-surgical incision, right lower leg skin tears, The resident had an alteration in musculoskeletal status related to right femur (the thigh bone) fracture s/p ORIF. Review of Resident #4's skin assessment dated [DATE] reflected right thigh front and right lower leg front, wound vac in place and multiple skin tears. Review of Resident #4's evaluation log reflected no weekly skin check was completed on 11/13/2024 . During an interview on 11/12/2024 at 4:17 PM, the ACNO stated skin assessment were supposed to be done on admission and weekly according to the facility's policy. He also stated all the management team members were responsible to ensure the assessments were completed . During an interview on 11/13/2024 at 11:08 am, LVN C stated skin assessments were done by the nurses and the nurses were prompted weekly on the electronic documentation system to do skin assessments. Review of facility's policy titled Skin Policy and procedure dated March 2020 reflected: [the facility] is committed to ensuring comprehensive skin assessment and treatments are implemented for all residents in accordance with all state and federal regulations. Based on the comprehensive assessment of the resident, facility clinical staff will ensure that the resident who enters the facility without pressure injury will not develop a pressure injury unless the resident's clinical condition demonstrates that the condition was unavoidable. o The licensed nurse and interdisciplinary team will assess and periodically reassess each resident's risk for developing a pressure ulcer and take action to address any identified risks. o the interdisciplinary team will create a written plan for the identification of risk for and prevention of pressure ulcers. o Identification and evaluation of risk factors of: o the nurse will conduct a full-body skin assessment for each resident weekly to ensure no risks have developed.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, and distribute food in accordance with professional standards for the facility's only kitchen reviewed for food service safety. 1. The facility failed to properly seal, label, and date foods stored in the kitchen's freezer, refrigerator , activity room snack bar, and walk-in cooler. 2. The facility failed to clean and sanitize the kitchen's only industrial can opener. 3. The HC failed to wear effective hair restraint while preparing food. This failure could have placed residents at risk of ingesting food borne pathogens, ingesting adulterated foods, and becoming ill. Findings Included: Record review and observation on 10/14/2024 at 9:05 AM of the facility's only kitchen revealed a sign on the small refrigerator/freezer (side by side) door, which reflected the correct way to fill out a food label. The sign indicated:1. Fill in the item name; 2. Current date/ Prep date: 3. Use by date was 6 days after prep date; 4. Your initials. Observations in the small freezer revealed an opened, yet re-sealed with a banana clip, bag of frozen tater tots without a label to signify date opened, or a use by date; a bag of frozen spicy black bean hamburger patties in an unsealed bag, without a label to signify date opened, or a use by date; a 1.5 foot by 2.5 foot metal sheet pan with 6 small plastic cups of a white liquid, wrapped in plastic wrap, and 43 small 2 ounce covered plastic cups of colorful mixed shapes of food, without a label to signify date prepared, or a use by date; a 2 quart square plastic container with a green lid, containing a red substance, without a label to signify date opened, or a use by date. Record review and observation on 10/14/2024 at 9:14 AM of the facility's walk-in cooler revealed a sign on the walk-in's door, which reflected the correct way to fill out a food label. The sign indicated:1. Fill in the item name; 2. Current date/ Prep date: 3. Use by date was 6 days after prep date; 4. Your initials. Observations in the walk-in cooler revealed a clear plastic medium sized container, with no lid, containing an assortment of items; 1 bottle of BBQ sauce; 1 box of bread sticks, 1 opened jar of banana peppers (dated 10/3/2024,) and 3 small plastic containers of a cubed cheese like item; none of the individual items in the clear plastic medium sized container, minus the jar of banana peppers, possessed a label to signify date opened, or a use by date; furthermore, the 1 opened jar of banana peppers (dated 10/3/2024,) was supposed to have been used by 10/9/2024. On a separate shelf, in the facility's walk-in cooler, there was an opened box of cooked chicken breasts (meaning unsealed and open to the air) without a label to signify date opened, or a use by date. On a separate shelf, there was an opened plastic bag (meaning unsealed and open to the air) of parmesan cheese (dated 10/8/2024); a 3 inch by 3 inch wide and 8 inch long rectangular slab of a cheese like substance, which was partially sealed (meaning unsealed and open to the air) without label to signify date opened, or a use by date. Observation and interview on 10/15/24 at 11:46 AM revealed the kitchen's only industrial can opener had a 1.5 inch by 1.5-inch mounting bracket attached to a metal food preparation table. The seams, where the 1.5 inch by 1.5-inch mounting bracket was attached to the table, had a black sticky substance in the cracks and crevices. The 1.5 inch by 1.5 inch by 10-inch-long metal shaft, which fit into the 1.5 inch by 1.5-inch mounting bracket had the same black sticky substance. On the top end of the 1.5 inch by 1.5 inch by 10-inch-long metal shaft, was a 6-inch-long handle mechanism. The 6-inch-long handle mechanism rotated a metal gear (like the size and shape of a hockey puck,) which in turn rotated a metal can. On the underside of the 6-inch-long handle mechanism, was a 1-inch piece of sharp metal, which ended at a point, which pierced the top of the can. Inside the metal gear, and on the 1-inch piece of sharp metal, was the same black sticky substance. Interview with the dishwasher, KA, revealed he did not remember the last time the industrial can opener was washed. Observations on 10/15/24 at 12:01 PM in the facility's only kitchen revealed HC preparing food. He was observed with effective hair restraint over his head, lower mouth, and neck, but he did not have any effective hair restraint covering his mustache. Observation on 10/15/2024 at 1:54 PM in the activity bar snack refrigerator, located on the side wall of the main dining room, revealed two bottles of ketchup and two bottles of yellow mustard. All 4 bottles were without a label to signify date opened, or a use by date. Observations on 10/16/24 at 1:07 PM in the facility's only kitchen revealed the HC without effective hair restraint. He was observed with effective hair restraint over his head, lower mouth, and neck, but he did not have any effective hair restraint covering his mustache. Interview and observation on 10/16/24 at 1:10 PM with the HC revealed the label and dating system, used by the kitchen staff, was designed to keep food from being held for too long and becoming unsafe to eat. The dating system indicated when the food was opened, or prepared, and when the fold was no longer to be used (or thrown away) if not used by the 6th day. Foods were supposed to be sealed tight, like in a bag or a container, to have protected them from exposure to the frigid air in the refrigerator, freezer, and walk-in cooler. Foods not properly sealed, and exposed to the air, could have begun to grow mold, grow bacteria, or become stale. If a resident ingested food that was moldy, or with bacteria, the resident was exposed to food borne pathogens. A safeguard in place to ensure food was properly sealed, labeled, and dated was a weekly walk through of the kitchen to spot check items for labels and safe storage. Observation of HC revealed he had effective hair restraint over his head, lower mouth, and neck, but he did not have any effective hair restraint covering his mustache. He stated hair restraints were provided to staff and were required to cover both the hair on the head and on the face. Each entrance to the kitchen had a small plastic box, attached the door frame, with disposable hair restraints. No one was allowed to enter the kitchen without their hair restraint. The HC stated it was hard to breathe at times, so he lowered the cloth fabric from his mouth and mustache. He was then observed raising the fabric covering his neck and lower mouth over his lips and to cover his mustache. He stated hair restraints were utilized to keep hair out of resident's food. The HC, stated He had not been corrected about his mustache hair restraint, from the KM. Having heard the verbal description of the facility's only industrial can opener, he acknowledged the industrial can opener could have been contaminated with food borne pathogens. At times, the facility served fruit from a can, which had been opened with the industrial can opener. Canned fruit did not get heated to 165 degrees for 15 seconds, which was the temperature to kill food borne pathogens. The canned fruit, or any other food items opened with the industrial can opener (not heated to 165 degrees for 15 seconds) could have been contaminated with a food borne pathogens. A resident who ingested food borne pathogens could have become sick. The effects of food borne pathogens could have caused a resident to have had an upset stomach, diarrhea, and unintended weight loss. The kitchen did not have a posted cleaning schedule for kitchen areas, or equipment. No tasks were assigned, cleaning was a team effort. Interview and record review on 10/16/24 at 3:15 PM with the KM revealed the policy of the facility's only kitchen was to follow time/temperature guidelines and make sure the food served to the residents was fresh, appealing, and met dietary requirements. She expected staff to securely wrap, or use a clean storage container, with the label system described in record review, 10/14/2024 at 9:05 AM. Record review of a cleaning schedule (undated,) provide by the KM during interview, instructed staff to wash the can openers, which meant the industrial can opener. The cleaning schedule had been posted on the wall in the kitchen, but its vertical edges curled inwards on both sides covering the instructions for cleaning. Kitchen staff were required to wear effective hair restraint prior to having entered to the kitchen. Effective hair restraint meant having covered hair on the head and facial hair, if applicable. The KM stated the hair restraint equipment, provided by the facility, was of sufficient design to cover hair, beards, and mustaches. Staff wore hair restraints, so the food did not get contaminated; foods not stored in appropriate time and temperature guidelines were at higher risk for the growth of food-borne pathogens. Residents exposed to contaminated food, or food-borne pathogens, were at risk of diarrhea, vomiting, stomach pain, and unintended weight loss. Interview on 10/16/24 at 3:47 PM with LVN P revealed a food-borne pathogen was a bacterium that grew on, and in, food that was not cooked, handled, or stored properly. Residents exposed to food borne pathogens were at risk to have experienced diarrhea, nausea, food poisoning, vomiting, dehydration, and unintended weight loss. Interview on 10/16/24 at 4:04 PM with the GM revealed she expected her kitchen staff to follow proper sanitization and proper food handling techniques. Kitchen staff was trained per policy. The failure for the kitchen staff to follow policy fell upon training and education. Record review of the facility's Infection Prevention & Control for Food Service Policy, dated 2022, revealed the facility stored, prepared, and distributed food in a sanitary manner to prevent food borne illness, cross contamination, and to assure infection prevention and control. Staff were instructed to wear effective hair restraint and a beard guard, if needed. Counters, equipment, and utensils were supposed to be washed, and rinsed, after each use, with a detergent solution. Food was supposed to be labeled, with a use by date. Record review of the Food and Drugs Administration 2022 Food Code, 1/18/2023 Edition, reflected guidance for Hair Restraints. Section 2-402 Hair Restraints indicated food employees were supposed to wear hair restraints, such as hats, hair coverings, nets, beard restraints, and clothing that covered body hair; Designed, and worn, to effectively keep their hair from contacting exposed food. Record review of the Food and Drugs Administration 2022 Food Code, 1/18/2023 Edition, reflected guidance for Reduced Oxygen Packaging. Annex 6, Food Processing Criteria indicated the shelf life of foods was based on storage temperature for a certain time and other factors of the food. Each package of food was supposed to display a [use-by date.] Record review of the Food and Drugs Administration 2022 Food Code, 1/18/2023 Edition, reflected guidance for Can Openers. Section 4-204.19 indicated the cutting, or piercing, surfaces of a can opener could directly contact food as the container was opened. These surfaces must be protected from contamination. Record review of the HC's food handler's card revealed it was current and was dated to expire on 6/27/2025. Record review of the KM's food handler card revealed it was current and was dated to expire on 5/18/2028. Record review of the KM's associate degree, in the Culinary Arts, revealed it was effective as of 3/31/2017.

Based on observations, interviews, and record reviews, the facility failed to provide, based on the comprehensive assessment and care plan and preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being for 3 of 7 Residents (Resident #32, Resident #152, and Resident #154) reviewed for facility activities. 1. The facility failed to post the activity schedule in a prominent location, visible to residents and responsible parties. 2. The facility failed to hold activities that were on the activity schedule. 3. The facility failed to complete Resident #152's Activity Assessment. 4. The facility failed to perform Resident #154's Activity Assessment within the facility's required completion period. 5. The facility failed to provide Resident #32, Resident #152, and Resident #154 a monthly activity calendar. This failure could have placed the residents at risk of isolation, depression, missed opportunities to work on fine motor skills, and a diminished quality of life. Findings Included: Observations on 10/14/2024 at 10:00 AM of the facility entrance, the facility hallways, and the facility information board did not display a resident activity schedule. Observations and record review on 10/14/2024 at 2:30 PM in the dining room did not reveal the AD providing the daily activity, which was supposed to be crafts. Record review of the activity calendar, provided at entrance conference, revealed the activity was scheduled to occur at 2:30 PM. Observations on 10/15/24 at 9:00 AM of the facility entrance, the facility hallways, and the facility information board did not display a resident activity schedule. Observations and record review on 10/15/2024 at 10:30 AM in the dining room did not reveal the AD providing the daily activity, which was supposed to be painting. Record review of the activity calendar, provided at entrance conference, revealed the activity was scheduled to occur at 10:30 AM. Resident #32 Record review of Resident #32's AR, dated 10/15/2024, reflected a [AGE] year-old woman, who admitted to the facility on [DATE]. She was diagnosed with Fracture of Right Lower Leg, an Anxiety Disorder (which was a mental health condition marked by heightened responses (worry) to certain situations and stimuli), a Bi-Polar Disorder (which was a mood disorder marked by elevated moods and de-elevated moods), and Major Depression (which was a mental condition characterized by depressed mood, loss of pleasure, or interest in life). Record review of Resident #32's Admission MDS assessment, dated 10/7/2024 reflected the resident had a BIMS Score of 15. A BIMS Score of 15 indicated the resident had no cognitive impairment. The resident's mood interview indicated the resident felt down, depressed, or hopeless 2 to 6 days over the course of the last 2 weeks. Resident felt it was very important to do things with groups of people and somewhat important to do her favorite activities. Record review of Resident #32's Activity Assessment, dated 10/7/2024, revealed the resident felt it was very important to do things with groups of people and somewhat important to do her favorite activities. The resident's leisure activities were card games, creative arts, learning/education, music, and parties/social. Other information gathered indicated an interest in bingo and painting. Record review of Resident #32's CCP reflected an area of Focus for leisure activities, initiated on 10/7/2024. The Goal initiated on 10/8/2024 indicated the resident would participate in their leisure activities as desired. The Interventions provided, initiated on 10/7/2024, listed card games, creative arts, learning/education, and parties/social. Interview and observation on 10/15/2024 at 2:50 PM with Resident #32 revealed she was unaware of activities at the facility. Resident #32 stated she had not received a copy of the activity calendar for the month of October 2024. Not knowing about the activities at the facility made her feel frustrated and isolated. She had not been approached by staff to remind her of any activity. She was alert and oriented to place and time. Observations of Resident #32's room did not reveal an activity calendar. Resident #154 Record review of Resident #154's AR, dated 10/15/2024, reflected a [AGE] year-old woman, who admitted to the facility on [DATE]. She was diagnosed with Acute Respiratory Failure (which was condition of the lungs having caused an inability for oxygen to enter the body) and Acquired Absence of Left Leg Below Knee. Record review of Resident #154's Admission MDS assessment, dated 10/10/2024, reflected the resident had a BIMS Score of 15. A BIMS Score of 15 indicated the resident had no cognitive impairment. Section F. Preferences for Customary Routines and Activities had not been completed. Record review of Resident #154's Activity Assessment, located on the Assessment Page in PCC (Point Click Care,) the facility's documentation platform, reflected Resident #154's Activity Interview was due on 10/11/2024 and was 4 days overdue. Interview and observation on 10/15/24 at 4:34 PM with Resident #154 revealed she was not aware of activities provided by the facility. She had not received an activity calendar in her room, nor had staff informed her to attend any activities. She was unaware they had activities to do. She stated she felt aggravated that she had not been informed. She felt like she was cooped up in the room all day. She was alert and orientated to place and time. Observation of Resident #154's room did not reveal an activity calendar. Resident #152 Record review of Resident #152's AR, dated 10/15/2024, reflected a [AGE] year-old woman, who admitted to the facility on [DATE]. She was diagnosed with Depression (which was a mental condition characterized by depressed mood, loss of pleasure, or interest in life) and an anxiety disorder (which was a mental health condition marked by heightened responses of worry to certain situations and stimuli). Record review of Resident #152's Admission MDS assessment, dated 10/15/2024, reflected the resident had not yet been assessed for a BIMS Score. Section F. Preferences for Customary Routines and Activities had not been completed. Record review of Resident #152's Activity Assessment, located on the Assessment Page in PCC reflected Resident #152's Activity Interview was opened, but was unedited, on 10/15/2024. The Activity Assessment was blank. Record review of Resident #152 CCP, with an admitted [DATE], did not reveal a care area section for Activities. Interview and observation on 10/15/24 at 4:39 PM with Resident #152 revealed she had not been informed about activities at the facility. She did not know there were scheduled activities and she had not received an activity calendar. She was disappointed there were no activities to do and even more so when she learned the facility was supposed to have provided them. She did not get reminders from staff since her arrival. Observation of her room did not reveal an activity calendar. Observations on 10/16/24 at 11:00 AM of the facility entrance, the facility hallways, and the facility information board did not display a resident activity schedule. Interview and Record review on 10/16/24 at 11:48 AM with the AD revealed she had been the AD at the facility for the last 8 months. She did not have any certificate, nor had she attended any formal training, for the position. The AD, stated new residents were supposed to have been assessed for activities in Section F of the MDS. The AD stated she either looked at the Assessment Page in PCC for the dates the assessments were due or the MDS Nurse, MDSN, would tell her. There were no Activity Calendars posted on the walls, or on any information boards, in the facility. Record review of the facility's welcome packet revealed 10 pages of facility information but no information about activities. The AD acknowledged there was no information about activities in the welcome packet; she had not asked to be included in the facility's welcome packet. The AD stated she had not provided residents with a copy of the activity calendar. The activity (crafting) planned for Monday, 10/14/2024 at 2:30 PM in the dining room, was canceled due to staffing shortages; the activity (painting) planned for Tuesday, 10/15/2024 at 10:30 AM in the dining room, was canceled due to a resident council meeting 4 hours later that same day. The AD stated activities for residents were important because activities got the residents out of their rooms, promoted socialization, helped fine motor skills, and kept them active. Without activities, the residents may have become isolated, or depressed, and would have missed opportunities for work on their fine motor skills. A safeguard in place, to ensure residents were informed of activities, was a daily room visit. Staff would tell the resident about activities and wrote those names down, to know who to collect at the scheduled time. The lists were not kept on file. The AD stated the facility had not been meeting the standards of the facility's Activity Policy. Interview on 10/16/24 at 2:37 PM with GM revealed the current AD was trained and supervised by the SAD, who was over multiple facilities in the region. The AD had not had a great deal of experience with activities, but the facility thought she was a good fit, since residents liked her. She had not taken an Activity Director Course. The GM stated morning rounds, a daily administrative walk through of the facility, was performed daily to let residents know of activities. Benefits for the residents having attended activities highlight social interaction, increased joy, and practice with fine motor skills; The GM deferred any questions to negative outcomes due to the lack of activities. Record review of the facility's activity calendar, for the month of October 2024, revealed a planned activity for each day of the month. Record review of the facility's Activity Policy, dated November 2020, revealed group activities will be offered to all residents and guests. Residents will be offered a variety of activities based on their preferences. A calendar of activities will be made available to all residents upon admission and each month thereafter.

Based on observations, interviews, and record reviews, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good grooming and personal hygiene for 1 of 7 Residents (Resident #33) reviewed for ADL care. The facility failed to provide grooming services, in the form of nail care, for Resident #33. This failure could have placed residents at risk of scratches, infections, or lowered self-esteem. Findings Included: Record review of Resident #33's AR, dated 10/14/2024, reflected an [AGE] year-old woman, who admitted to the facility on [DATE]. She was diagnosed with Dementia (which was a disease that affected memory, thought, and interfered with daily life), Acquired Absence of Left Finger (left index), the Need for Assistance with Personal care, and Diabetes Mellitus Type 2 (which was a condition of the body that disrupted how the body used sugar for fuel). Record review of Resident #33's Admission MDS assessment, dated 10/8/2024, reflected the resident had a BIMS Score of 12. A BIMS Score of 12 indicated the resident had moderate cognitive impairment. The resident had impairment on one side of their upper extremities (shoulder, elbow, wrist, and hand.) The resident had no impairment in either lower extremity (hip, knee, ankle, and foot.) The resident required partial/moderate assistance with personal hygiene (The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face, and hands) which meant the helper provided less than half the effort while the resident completed the greater portion of the activity. Record review of Resident #33's CCP reflected an area of Focus area for ADL Care, initiated on 10/1/2024, evidenced by ADL Care Self-Performance Self Deficits. The Goal, initiated on 10/1/2024 indicated the resident would improve self-care. The Intervention, initiated on 10/1/2024, delegated nursing home staff to perform personal hygiene, resident was dependent. Record review of Resident #33's Order Summary Report indicated an order, start date of 10/5/2024 for weekly skin checks (every Saturday night.) Interview and observation on 10/14/24 at 12:34 PM of Resident #33 revealed her in her room and sitting in a wheelchair watching television. The room was free from clutter and odors. She stated she was doing alright. She was alert and orientated to place and time. Observations revealed a recent amputation of her left index finger. Closer inspection revealed her thumb nail extended 1/2 inch past the fingertip, middle finger fingernail (if she had five fingers) was 1/4 inch past the fingertip and jagged, her ring finger fingernail extended 3/4 inches past the fingertip, and her pinky finger fingernail was 1/2 inch past the fingertip. He right hand thumbnail extended 1/2 inch past the fingertip, her index finger fingernail was short and extended 1/8 inch past the fingertip, but curled down towards the fingertip, her middle finger fingernail was 3/4 inch past the fingertip, her ring finger fingernail extended 3/4 inches past the fingertip, and her pinky finger fingernail was 1/2 inch past the fingertip. Resident did not want to complain about her fingernail length, but felt they were too long and needed to be trimmed. Observations on 10/16/24 at 8:56 AM revealed Resident #33's fingernails had not been trimmed (matching the observation on 10/14/2024 at 12:34 PM). She was indifferent about her nails having been neglected. She was not aware staff were supposed to have been helping her with her nail hygiene, but overall felt she deserved more attention to her nails. Interview and record review on 10/16/24 at 9:28 AM with CNA M revealed residents who are bathed/showered were observed for skin abnormalities, which included the need for nail care. The resident either had a documented paper shower observation sheet, or the services were documented in PCC (the facility's documentation platform). Record review of the facility's binder of shower sheet observations, which was located at the nurse's station, did not contain a shower sheet for Resident #33. Interview on 10/16/24 at 9:36 AM with LVN O, revealed some residents received paper shower observation sheets or the shower observations were documented in PCC. Interview on 10/16/24 at 9:44 AM with CNA N revealed residents who received showers/baths received observation of skin and body, which were either documented in PCC or on a paper shower observation sheet. Observations of CNA N having searched PCC for shower/skin observations did not reveal shower observation documentation for Resident #33. Interview and observations on 10/16/24 at 10:02 AM with RN Q, revealed Resident #33 was a diabetic and licensed nursing staff would have been enlisted to perform nail care for diabetic residents. RN Q expected the CNA staff to document the skin observations, to include the need for nail care, on a paper shower observation sheet. Observations of RN Q having searched PCC for any documentation, revealed PCC did not allow for elaborations of shower observations. The options for CNA staff were limited to either yes-meaning task performed, or No-meaning task not performed. The risks for residents, with long or jagged fingernails, were scratches, infections, and lowered self-esteem. Safeguards in place to identify the need for nail care were regular rounds, paper shower observation sheets, and staff awareness. Interview on 10/16/24 at 10:13 AM with LVN O revealed she approached Resident #33, in her room, for a nail observation. She stated Resident #33 did not want her nails cut. LVN O, stated Resident #33 responded with the offer of nail care with, No. Not at all. Even though Resident #33 refused nail care on 10/16/24 at 10:13 AM, LVN O stated there should have been documentation of the refusal having been obtained prior to today, 10/16/2024. Observation and interview on 10/16/24 at 10:26 AM with Resident #33 revealed her being taken to physical therapy in her wheelchair. Resident #33 stated she did not refuse nail care and stated, I did not say no, I was in the bathroom when they asked. I do want my nails cut. Interview on 10/16/24 at 10:13 AM with LVN O revealed she revisited Resident #33's nail care. She stated she misunderstood Resident #33 earlier on room visit on 10/16/24 at 10:13 AM. Her revisit resulted in Resident #33 having desired to have her nails cut. Interview on 10/16/24 at 2:52 PM with the GM revealed she expected her staff to assess the need for grooming and let the resident make the choice to whether they wanted the service performed. If the resident's choice to refuse nail care ever reached the point of an accident, the facility staff would speak to the medical provider to address the concern. The GM deferred questions that pertained to negative consequences of long, or jagged nails, as they were of a clinical nature. Record review of the facility's ADL Policy, dated November 2020, revealed the facility would provide each resident with care, treatment, and services. The policy included: bathing, dressing, grooming, transferring, locomotion, ambulation, toileting, eating, and communication.

Based on interview and record review, the facility failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections to the extent possible for one (Resident #1) of three residents reviewed for foley catheter care. The facility failed to monitor/document Resident #1's (who has a history of urine retention) urine output for three days (09/11/24 - 09/13/24). On 09/14/24 an I/O catheter removed 700 CCs of urine and he was sent out to the hospital the following day due to swelling to his groin, the foley not draining, and his urine being cloudy with clots of pus. This failure could place residents at risk of UTIs, urine retention, bladder rupture, or hospitalization . Findings included: Review of Resident #1's undated face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including urinary tract infection, severe sepsis (a serious condition in which the body responds improperly to an infection), acute kidney failure, type II diabetes, and neuromuscular dysfunction of the bladder (what happens when the relationship between the nervous system and bladder function is disrupted by injury or disease). As of 09/24/24, Resident #1 was still in the hospital. Review of Resident #1's admission MDS Assessment, dated 09/12/24, reflected a BIMs of 8, indicating a moderate cognitive impairment. Section H (Bladder and Bowel) reflected he had an indwelling catheter and required intermittent catheterization. Review of Resident #1's admission care plan, dated 09/12/24, reflected he had a urinary catheter and was at risk of complications associated with F/C placement with an intervention of monitoring/recording/reporting to MD for s/sx of UTI: pain, burning, blood-tinged urine, cloudiness, no output . It further reflected he had the potential for alterations in nutrition and hydration with an intervention of monitoring/documenting/reporting PRN and any s/sx of dehydration: decreased or no urine output . Review of Resident #1's hospital medical records, dated 08/25/24, reflected the following: .CT Abd showed urinary distention . Bilateral hydronephrosis (excess urine accumulation in the kidneys) secondary to large urinary bladder distention . Review of Resident #1's NP A assessment, dated 09/10/24, reflected the following: . On exam today, [Resident #1] is seen lying down in bed, [FM B] at bedside. [Resident #1] is sleepy, HOH, forgetful-on-RA-noted tenderness to suprapubic area with palpation and has abdominal distension on exam-as per [FM B] the Foley was discontinued from the hospital since he was pulling on it-will order bladder scan with orders for I/O cath . Review of Resident #1's NP A assessment, dated 09/12/24, reflected the following: . [Resident #1] is more alert today, HOH, forgetful-on RA-[Resident #1] was retaining urine and Foley has been placed . GU: Foley CDI to bedside drainage with dark yellow urine Review of Resident #1's physician order, dated 09/12/24, reflected Foley Catheter Care to include anchoring tubing and checking skin integrity every shift and PRN. There were no orders for the reason for the catheter, size of catheter, or monitoring the input/output of urine. Review of Resident #1's progress note, dated 09/14/24 and documented by LVN C , reflected the following: This nurse reported to on call Dr [sic] that [Resident #1]'s urine output was cloudy with flakes and pus in urine bag. Foley was removed due to leakage and I&O cath was completed for 700 and reported to on call physician. N/O for Rocephin (antibiotic) 1 gm q24hrs x7 days . Review of Resident #1's progress note, dated 09/15/24 and documented by LVN C, reflected the following: This nurse noticed swelling in [Resident #1]'s groin area, attempted to I&O due to leakage with foley and not draining, was able to drain 100 cc from [Resident #1] but very cloudy and clots of pus draining out. Dr was notified of swelling and unable to drain, order to send out to hospital (hospital name) . During an interview on 09/24/24 at 11:08 AM, NP D stated she was not Resident #1's NP while he was at the facility . She stated if a resident had a foley catheter, there should be separate orders for foley care, emptying the bag every 6-8 hours, stat lock placement, and recording the output of urine. She stated if a resident had a history of urine retention it was even more important to have orders for monitoring output to show that the foley was working properly and that output was getting charted. She stated the importance of the orders was to ensure care was getting done and monitoring input/output. She stated a possible negative outcome of not having these orders could be reoccurring UTIs. During a telephone interview on 09/24/24 at 12:56 PM, NP A stated she had been Resident #1's NP while he was at the facility. She stated he had a catheter in the hospital but he kept trying to pull it out so the hospital removed it and he was admitted to the facility without one. She stated she first saw him on 09/10/24 and she could tell he was retaining urine so she gave orders for a foley to be placed. She stated once a resident has a foley catheter in place, the staff are no longer expected to conduct bladder scans because they should be monitoring and documenting urine output to ensure the resident was not retaining urine. She stated it was particularly important to monitor Resident #1's urine output because urine retention was one of his problems when he was in the hospital. She stated a negative outcome of not monitoring/documenting urine output/input could lead to complications such as a UTI, bladder rupture, and higher risk for infection. She stated Resident #1 already had a history of sepsis from UTIs in the past. She stated it was her expectation that urine output be monitored every shift . During a telephone interview on 09/24/24 at 2:09 PM, the MD stated when a resident had a foley catheter they should have orders for routine foley care, assessing that the bag is situated below the bladder, and more medical stuff. He stated monitoring urine output was important because it could help determine if a resident is going into renal failure or if their kidneys are shutting down. He stated if the bladder did not feel full and the resident was not producing a lot of urine, they could also be dehydrated. He stated a negative outcome of not monitoring urine output depended on what the underlying issue was. He stated urine retention could lead to UTIs, damaged kidneys, and distention of the bladder. During an interview on 09/24/24 at 3:50 PM, the VPCS stated the nurses were responsible for ensuring all orders (for catheter care) were in the residents' EMR. She stated orders for a foley catheter would include care every shift, what type of foley, and fluid restrictions. She stated a negative outcome of not monitoring urine output could not be determined because foley catheters were not meant to be a long-term intervention. Review of the facility's Catheterization of Urinary Bladder Policy, dated November 2018, reflected the following: A catheter is placed in the bladder when it is needed to prevent urinary retention . . 19. Output should be recorded every shift only with a physician order, 20. Make sure the physician order sheet contains an order for the catheter specifying reason, size of catheter and balloon and to change the bag PRN.

Based on interviews and record reviews, the facility failed to ensure a resident was free of any significant medication errors for 1 (Resident #1) of 5 residents reviewed for pharmacy services. The facility failed to ensure Resident #1's scheduled medications were acquired and administered. Resident #1 was not given ceftriaxone (antibiotic used to treat bacterial infections) for a total of 4 times within the dates of 07/09/2024 to 07/11/2024, staff did follow up with the pharmacy for the antibiotics, staff did not communicate with the NP of the lack of antibiotics and missed medications, and staff did not communicate the missed doses to the administration. This failure resulted in the Resident #1's being sent to the hospital to have consistent antibiotic treatment, and to treat Bacteremia (bacteria in the blood stream) and ventriculitis (inflammation of the ventricles in the brain). An IJ was identified on 07/18/2024. The IJ Template was provided to the facility on [DATE] at 06:35 p.m. While the IJ was removed on 07/19/2024, the facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy. This failure could place residents at risk of not receiving their scheduled medications in an accurate and timely manner to promote healing and to meet the needs and care of resident. Findings Included: Review of Resident #1's face sheet, dated 07/18/2024, revealed a [AGE] year-old-female. admitted to the facility on [DATE] and discharged on [DATE]. Resident #1's face sheet further revealed diagnoses of other Encephalitis (An inflammation of the brain usually caused due to infection that causes flu like symptoms), Encephalomyelitis (term for inflammation of the brain and spinal cord), and Bacteremia (the presence of bacteria in the bloodstream)/ventriculitis inflammation of ventricles in the brain). Record review of Resident #1's orders, dated 07/18/2024, revealed two discontinued orders for: Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy), order date: 07/09/2024, start date: 07/09/2024 Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy) until 07/18/2024, order date: 07/09/2024, start date: 07/09/2024, end date: 07/18/2024 Record review of Resident #1's July MAR (Medication Administration Record), dated 07/18/2024, revealed: Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy), order date: 07/09/2024 1038 (10:38 a.m.), D/C (Discontinued) Date: 07/10/2024 0608 (06:08 a.m.). With administer times at 0900 (09:00 a.m.) and 2100 (09:00 p.m.). Further review revealed: Tuesday 07/09/24 a charting code of 09 at 2100 (09:00 p.m.) Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy) until 07/18/2024 23:59 (11:59 p.m.), D/C (Discontinued) Date: 07/12/2024 at 1548 (03:48 p.m.). With administer times at 0900 (09:00 a.m.) and 2100 (09:00 p.m.). Further review revealed: Wednesday 07/10/2024 a charting code of 09 at 0900 (09:00 a.m.), and 2100 (09:00 p.m.) Thursday 07/11/2024 a charting code of (x) at 0900 (09:00 a.m.), and a charting code of a check mark 2100 (09:00 p.m.) Friday 07/12/2024 a charting code of (x) at 0900 (09:00 a.m.), and a charting code of (x) at 2100 (09:00 p.m.) Further review of Resident #1 July MAR (Medication Administration Record) revealed a Chart Codes/Follow up table, a charting code of a check mark is listed as administered. Additional review of Resident #1's July MAR (Medication Administration Record), on page 30: Ceftriaxone Sodium Intravenous Solution Reconstituted, scheduled time: 07/11/2024 2100 (09:00 p.m.), administered time: 07/11/2024 2320 (11:20 p.m.), administered by LVN B, route intravenously, and location of Admin arm-right. Record review of Resident #1's July MAR revealed Resident #1 was administered Ceftriaxone Sodium Intravenous one time from the dates of 07/09/2024 to 07/12/2024. Record review of Resident #1's Progress Notes, dated 07/18/2024, revealed: Note, effective date: 07/09/2024 2022 (08:22 p.m.), type: Emar (electronic medication administration), note text: Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy) pending pharmacy delivery. Note, effective date: 07/10/2024 1007 (10:07 a.m.), type: Emar (electronic medication administration), note text: Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy) until 07/18/2024 23:59 (11:59 p.m.) PT (patient) pulled IV (Intravenous) line out. Note, effective date: 07/10/2024 1600 (04:00 p.m.), type: Emar (electronic medication administration), note text: Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy) until 07/18/2024 23:59 (11:59 p.m.) pending pharmacy delivery. Note, effective date: 07/10/2024 2253 (10:53 p.m.), type: Emar (electronic medication administration), note text: Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy) until 07/18/2024 23:59 (11:59 p.m.) Medication pending arrival to facility. Note, effective date: 07/11/2024 1810 (06:10 p.m.), type: Emar (electronic medication administration), note text: Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy) until 07/18/2024 23:59 (11:59 p.m.) Not Available. Note, effective date: 07/12/2024 0947 (09:47 a.m.), type: Emar (electronic medication administration), note text: Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy) until 07/18/2024 23:59 (11:59 p.m.) med order pending, call pharmacy. Record review of Resident #1's NP Progress note, dated 07/12/2024, revealed an HPI (History of Present Illness) Related to this Visit, notified this AM (Morning) by nursing staff that pt (Patient) has not received IV (Intravenous) abx (Antibiotic) ceftriaxone since admission d/t (Determine that) Pharmacy carrier not delivering med to facility. No previous staff or nursing notified this NP (Nurse Practitioner) that med had not been delivered since pt's (Patient's) admission. This NP (Nurse Practitioner) called and notified attending MD (Medical Doctor) and notified her of the situation. pt (Patient) sent to ER (emergency room ) to ensure pt restarted on abx (Antibiotic). Spoke to pt's Family #1 in pt's room and notified family that pt has not received her IV (Intravenous) abx and will be sending pt back to ER. MD stated his frustrations with facility and wanted pt immediately sent out, which this NP explained was already in the process. Record review of Resident #1's hospital records, dated 07/18/2024, revealed Resident #1 an admitted to the hospital on 07/12/2024, with no discharge date , with a chief complaint missed antibiotic. Further review of Resident #1's hospital records revealed an Assessment/Plan note: this 91-yeard-old female with past medical history of diabetes type 2 dementia, and haemophiles influenza (bacteria that can cause severe infection) on ceftriaxone was brought from skilled nursing facility. 1. Bacteremia (the presence of bacteria in the bloodstream)/ventriculitis inflammation of ventricles in the brain). Continue ceftriaxone 2 g (grams) every 12 hour till (until) 7/20 Interview on 07/18/2024 at 11:24 a.m., RN A stated that she worked the day shift when Resident #1 arrived on 07/09/2024, Resident #1 arrived between 3pm to 4pm. RN A stated that she remembered Resident #1 because of her antibiotics (Ceftriaxone) and she was scheduled to receive her medications twice, 9am and 9pm as that was how the orders was listed. RN A stated she admitted Resident #1, her antibiotics were not in house, RN A stated she ordered them from the pharmacy, as Resident #1's admitting records from the hospital revealed Resident #1 received her first dose of the antibiotic and Resident #1 next dose would be at 9pm. RN A stated she passed this information down to the next nurse on shift, as she would be off duty from 07/10/2024 to 07/12/2024. RN A returned to work on 07/12/2024 and reviewed Resident #1 medication administration and discovered that Resident #1 had missed doses of Ceftriaxone and had only received one dose on 07/11/2024 at 9pm. RN A stated when she inquired on the missed antibiotics, she was told the medications have not arrived in the facility. RN A stated she informed the ACNO, and NP of the missed doses. RN A stated that staff should have followed up with the pharmacy for the medications, inform the DON or ACNO, and notify the MD or NP of the missing antibiotics to look for alternatives. RN A stated that there we risk associated with the missed dosages as it could lead to an infection in Resident #'s blood. RN A stated Resident #1 was sent to the ER per the NP orders as the NP was seriously concerned of Resident #1 not receiving the antibiotics. Interview on 07/18/2024 at 12:27 p.m., LVN A stated she worked the floor as a charge nurse during Resident #1 stay on 07/11/2024. LVN A stated that Resident #1 antibiotics (Ceftriaxone) were not available that day. LVN A stated she checked the Ekit that day and there was no Ceftriaxone available. LVN A stated she marked it on the MAR as a 9, listed as other because the antibiotic was not available. LVN A stated that if there are missed doses, we contact the MD or NP, there is a procedure to follow up with the pharmacy and notify the DON or ACNO. LVN A stated, I screwed up, I admit it, I did not call the pharmacy because I thought it would be delivered later that day, and I did not call the NP. It was so busy that day, I'm sorry. LVN A stated the risks of Resident #1 not having her antibiotics would be the increased risk of infection. Interview on 07/18/2024 at 01:48 p.m., LVN B stated she worked during Resident #1's time at the facility and remembered her. LVN B confirmed that Resident #1 antibiotics are administered intravenously. LVN B stated that on Wednesday night (07/10/2024), she did not see Resident #1's Ceftriaxone in the cart, LVN B added she did not look in the Ekit that night. LVN B stated in Resident #1's MAR she coded it as 9 as she did not want to lie and say she administered the Ceftriaxone. LVN B stated on Thursday night (07/11/2024) Resident #1 did not have her Ceftriaxone in the cart, LVN B asked another nurse to look in the Ekit, and a dose of Ceftriaxone was available. LVN B stated she successfully administer Resident#1's antibiotic (Ceftriaxone), that is why she marked it with a checkmark. LVN B stated, I take full accountability, didn't check the ekit, and didn't call, I didn't call the pharmacy, I was thinking it (Ceftriaxone) was on its way here, I was thinking it was, that's why I put a medication pending arrival in the progress note, I didn't call the NP, the DON or ACNO, I should have but it was busy those nights. LVN B stated the risk of not Resident #1 not having her Ceftriaxone was, the risk of not getting better, of not healing, the risk of infection, and the risk of the resident (Resident #1) not going home as planned, I'm sorry. Interview on 07/18/2024 at 03:09 p.m., NP stated that she was only told that Resident #1 did not receive the scheduled antibiotic Ceftriaxone on 07/12/2024, the day I sent her to the ER. NP stated she was informed by RN A. NP stated she informed the MD, we were not happy, because staff did not give her Ceftriaxone, and we were not informed. NP added Resident #1 missed many doses, and when she was informed, I wanted to assure Resident #1 received her Ceftriaxone, that is the reason she had to send her to the ER. NP stated, the antibiotics (Ceftriaxone) was important for this patient, this was the main reason she was here to treat her infection, she had an infection in her brain that was treated at hospital, to assure that the infection won't come back and keep ravaging this patient, the antibiotics (Ceftriaxone) had to be consistent, and continued at the facility. the NP added, even with one dose she (Resident #1) received it could lead to serious harm, she (Resident #1) could have gone septic, sending to her hospital was ensuring she doesn't go septic and have drastic harm done to her (Resident #1). Interview on 07/18/2024 at 04:00 p.m., DON stated staff were required to look in the Ekit, if medications are not available staff are to notify the resident's providers, to look for alternative medications or treatments, or to make appropriate adjustments. The DON stated that the process and procedures are here to keep residents safe and to also offer options for our facility to treat residents. The DON confirmed she was not notified of Resident #1's missed doses (Ceftriaxone) within the dates of 07/09/2024 to 07/11/2024. Interview on 07/18/2024 at 04:13 p.m., ACNO stated if no medications are available in the medication cart or the Ekit, staff should follow up with pharmacy, there two routes of delivery. If the medication does not come in from pharmacy, and there is no reason given from the pharmacy, staff are supposed to tell the DON, ADM, GM, ACNO. ACNO stated staff are supposed to follow up and call doctor or NP to see if there are alternatives. ACNO stated she recalled Resident #1 because she was on antibiotics (Ceftriaxone). ACNO stated she was informed on Friday (07/12/2024) approximately at 10:40 a.m., she informed the GM, and a pharmacy follow up would be completed. ACNO stated that she was informed that Resident #1 had missed two days without her (Resident #1) antibiotics. ACNO stated that staff should have notified, her, DON, GM that first day the Ceftriaxone had not come in and if Resident #1 did not receive the antibiotic. ACNO stated she verbally educated LVN A on the process of calling administration on 07/12/2024, but no in-services completed. ACNO stated, The antibiotic (Ceftriaxone), was important, if there were missed doses, it would interfere with her (Resident #1's) healing. Interview on 07/18/2024 at 05:39 p.m., GM stated staff are to contact the providers if there are no medications available for any reason, providers are to offer adjustments or alternatives for the missing medications, staff are to contact the pharmacy directly as well to work with them to have those medications delivered. GM added if the pharmacy is not able to deliver the medication, staff are to contact his or her supervisors and inform them of the situation. GM stated if the process is not followed, there are risk to residents not receiving the desired and appropriate treatments. GM stated she was not informed by staff of Resident #1 missed dosages of antibiotics (Ceftriaxone) within the dates of 07/09/2024 to 07/11/2024. GM stated she was informed by the ACNO on 07/12/2024, and she immediately followed up with the pharmacy that day. Record Review of the Facility's Medication Ordering and Receiving from Pharmacy/Ordering and Receiving Non-Controlled Medications, dated 01/23, reflected the Policy: Medications and related products are received from the provider pharmacy on a timely basis. The nursing care center maintains accurate reds of medication order and receipt. Procedures: 1. Section E: New Medications, expect for emergency or stat medications, are ordered as follows: If the first dose of medication is scheduled to be given before the next regularly scheduled pharmacy delivery, please telephone or transmit the medication orders to the pharmacy immediately upon receipt. Inform the pharmacy of the need for prompt delivery. Timely delivery of new orders is required so that medication administration is not delayed. If available, the emergency kit is used when the resident needs a non-controlled medication prior to pharmacy delivery. 1. Section F: Stat and emergency medications; except for Controlled Substances are ordered as follows: During regular pharmacy hours, the emergency or stat order is transmitted to the pharmacy immediately upon receipt. Such medications are delivered and administer in a timely manner. Emergency/STAT medication order then medication is not available in the emergency kit: An emergency/STAT order is placed with the provider pharmacy and the pharmacy is called by nursing staff to request the STAT. The requested medication(s) will be delivered in a timely manner. Subsequent doses are scheduled according to nursing care center policy on medication administration. Record Review of the Facility's Administration of Medications, dated 04/2023, revealed General statement, All medications are administered safely and appropriately to aid resident to and help overcome illness, relieve and prevent symptoms and help in diagnosis. The GM was notified on 07/18/2024 at 06:35 p.m., that an IJ situation was identified due to the above failures and the IJ template was provided. The POR (Plan of Removal) was accepted on 07/19/2024 at 03:37 p.m., and included: On 7/18/24 an abbreviated survey was initiated on 7/18/24 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate Jeopardy resident health and safety. The notification of Immediate Jeopardy states as follows: F755 - The facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological) to meet the needs of a resident, this resulted in Resident #1 missing dosages of ceftriaxone. 1. Corrective Action for residents affected by the deficient practice: a. Resident #1 had been discharged from the facility on 7/12/2024. 2. How other residents having the potential to be affected be identified and what corrective action(s) will be taken: a. Residents admitted to the facility have the potential to be affected by the identified deficient practice. Education was given to DON and GM by Chief Clinical Officer on 7/18/2024. Inservice will start 7/18/2024 and be completed by all fulltime staff by 7/19/2024 and be conducted by director of nursing (DON), general manager (GM) to all Fulltime, part time, PRN nurses and certified medication aides (CMA). Training for all new hires, PRN and part time employees will be completed prior to start of shift. Post test will be conducted after Inservice. Topic will include: i. Proper ordering/reordering medications process - will review the pharmacy policy section 3.2 entitled Medication Ordering and Receiving From Pharmacy Provider ii. Proper Protocol for all Facility Nurses and medication aides for bullet points 1,2, and 3. when medication is unavailable - 1. Check Medication expensing machine and IV E-kit immediately. Nurses & CMAs. 2. Contact pharmacy immediately. Nurses & CMAs. 3. Notify DON and/or GM for escalation Within 1 hour of calling pharmacy. Nurses & CMAs. 4. Within 1 hour after notifying DON and/or GM, notify physician to request for alternative orders. ONLY for nurses 5. Document and carry out provider's instructions immediately. ONLY for nurses iii. Proper Protocol for all Facility Nurses and Medication aides of notification tree if medication is unavailable - 1. DON Contact information is posted in med room 2. Contact GM Contact information is posted in Med Room 3. Contact assigned provider ONLY for nurses iv. Contents of medication dispensing machine and IV E-kits - see Attachment A b. Inservices will be reinforced via the bulletin board of the electronic health records as well as live documents sent via text message. Inservice will be required to be completed prior to start of shift. There will be post test given and graded by CNO and/or GM c. Nursing staff initiated a MAR-to-Cart audit of all in-house residents on 7/18/2024 to ensure medications are available and to order/reorder medications that are not available in the medication carts. This will be completed by 7/19/2024. 3. Measures that will be put in place or systemic changes that will be made to ensure the deficient practice(s) does not recur: a. The medication lists of all new admissions will be matched with actual medications the following day by DON and or designee starting 7/20/2024 and will be ongoing process. Medications should be available by next delivery period and/or within 24 hours of order entry. If a medication is scheduled prior to pharmacy scheduled delivery run, nurses or certified medication aides are to pull first dose from the IV-ekit or medication delivery machine. Then follow regular delivery for the next dose. If medications are not available on the medication dispensing machine, the nurses and certified medication aides are expected to call for STAT delivery. List of medications available on the medication dispensing machine was posted by DON on 7/18/2024 in the medication rooms. 4. Monitoring performance: a. DON and/or designee will complete a daily audit of medications for new admissions, starting 7/20/2024 until 8/1/2024. Then will be reduced to weekly x 2 weeks ending 8/15/2024. Then move to random new admit medication audits until 8/30/2024. b. If there is missing medication, DON and/or designee will ensure that the notification tree was activated beginning 7/18/2024 and will be ongoing process. c. Findings will be discussed weekly starting 7/19/2024 between GM, DON and/or designee and VP of clinical operations and will continue weekly until 8/15/2024. There was an ADHOC QAPI meeting held on 7/18/2024 with the General Manager, Administrator, Director of Nursing, Medical Director, Pharmacy Director, Chief Clinical Officer, and Regional VP of Clinical, after the IJ was called. Findings will also be presented during monthly QAPI meeting x3 months. The Survey Team monitored the Plan of Removal on 07/19/2024 Observations on 07/19/2024 from 08:30 a.m. to 03:30 p.m., revealed nursing staff received in-service training from GM and DON on topics of Proper ordering/reordering medications process, contacting administration, and systematic changes to assure accuracy of orders and medications. Record review on 07/19/2024 revealed daily audit of medications for new admissions, and MAR-to-Cart audit of all in-house residents. Record review on 07/19/2024 revealed ADHOC QAPI meeting held on 7/18/2024 with the General Manager, Administrator, Director of Nursing, Medical Director, Pharmacy Director, Chief Clinical Officer, and Regional VP of Clinical Record review on 07/19/2024 revealed in-services completed for 12 staff on topics of Proper ordering/reordering medications process, contacting administration, and systematic changes to assure accuracy of orders and medications. Further record review revealed graded post-test for staff, no failures. Interview on 07/19/2024 at 03:41 p.m., LVN C stated she has taken in-services on 07/18/2024 at PM shift, on topics of Proper ordering/reordering medications process, contacting administration, providers to inform of any missing medications to seek immediate interventions and alternatives, and systematic changes to assure medications and orders accuracy. LVN C stated she has taken the post-test and confirmed completion and passed. Interview on 07/19/2024 at 03:47 p.m., RN B stated he has taken in-services on 07/18/2024 at PM shift, on topics of Proper ordering/reordering medications process, contacting administration, providers to inform of any missing medications to seek immediate interventions and alternatives, and systematic changes to assure medications and orders accuracy. RN B stated he has taken the post-test and confirmed completion and passed. Observation and interview on 07/19/2024 at 03:53 p.m., LVN D was observed calling the pharmacy on medications delivery. LVN D stated she has taken in-services on 07/19/2024 at AM shift, on topics of Proper ordering/reordering medications process, contacting administration, providers to inform of any missing medications to seek immediate interventions and alternatives, and systematic changes to assure medications and orders accuracy. LVN D stated she has taken the post-test and confirmed completion and passed. Interview on 07/19/2024 at 04:09 p.m., CMA A stated she he has taken in-services on 07/19/2024 at AM shift, on topics of Proper ordering/reordering medications process, contacting administration, notifying nurses to follow process of provider notifications to seek immediate interventions and alternatives. CMA A stated she has taken the post-test and confirmed completion and passed. Interview on 07/19/2024 at 04:36 p.m., ACNO stated she has taken in-services on 07/19/2024 at AM shift, on topics of Proper ordering/reordering medications process, contacting administration, providers to inform of any missing medications to seek immediate interventions and alternatives, and systematic changes to assure medications and orders accuracy. ACNO stated she has taken the post-test and confirmed completion and passed. ACNO stated daily audit of medications for new admissions, and MAR-to-Cart audit of all in-house residents completed and will continue. Phone call Interview on 07/19/2024 at 04:39 p.m., LVN B stated she has taken in-services on 07/19/2024 over phone with DON, on topics of Proper ordering/reordering medications process, contacting administration, providers to inform of any missing medications to seek immediate interventions and alternatives, and systematic changes to assure medications and orders accuracy. LVN B stated she has taken the post-test and confirmed completion and passed. Phone call Interview on 07/19/2024 at 04:43 p.m., LVN A stated she has taken in-services on 07/19/2024 at AM shift, on topics of Proper ordering/reordering medications process, contacting administration, providers to inform of any missing medications to seek immediate interventions and alternatives, and systematic changes to assure medications and orders accuracy. LVN A stated she has taken the post-test and confirmed completion and passed. Interview on 07/19/2024 at 04:49 p.m., the DON stated the Chief Clinical Officer educated her and the GM on topics of Proper ordering/reordering medications process on 7/18/2024, ADHOC QAPI meeting held on 7/18/2024 with the General Manager, Administrator, Director of Nursing, Medical Director, Pharmacy Director, Chief Clinical Officer, and Regional VP of Clinical, and in-service started 07/18/2024 after IJ identified on topics of [NAME] ordering/reordering medications process, for all Fulltime, part time, PRN nurses and certified medication aides (CMA), as needed for all new hires, PRN and part time employees will be completed prior to start of shift. DON stated daily and random audits will continue to assure compliance. Interview on 07/19/2024 at 04:59 p.m., GM stated Chief Clinical Officer educated her and DON on topics of Proper ordering/reordering medications process on 7/18/2024, ADHOC QAPI meeting held on 7/18/2024 with the General Manager, Administrator, Director of Nursing, Medical Director, Pharmacy Director, Chief Clinical Officer, and Regional VP of Clinical, and in-service started 07/18/2024 after IJ identified on topics of [NAME] ordering/reordering medications process, for all Fulltime, part time, PRN nurses and certified medication aides (CMA), as needed for all new hires, PRN and part time employees will be completed prior to start of shift. DON stated daily and random audits will continue to assure compliance. The GM was notified on 07/19/2024 at 05:27 p.m. that the Immediate Jeopardy was removed. While the IJ was removed on 07/19/2024, the facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy.

Based on interviews and record reviews, the facility failed to provide pharmaceutical services, including accurate acquiring, and administering of all drugs and biologicals to meet the needs for 1 (Resident #1) of 5 residents reviewed for pharmacy services. The facility failed to ensure Resident #1's scheduled medications were acquired and administered. Resident #1 was not given ceftriaxone (antibiotic used to treat bacterial infections) for a total of 4 times within the dates of 07/09/2024 to 07/11/2024, staff did follow up with the pharmacy for the antibiotics, staff did not communicate with the NP of the lack of antibiotics and missed medications, and staff did not communicate the missed doses to the administration. This failure resulted in the Resident #1's being sent to the hospital to have consistent antibiotic treatment, and to treat Bacteremia (bacteria in the blood stream) and ventriculitis (inflammation of the ventricles in the brain). An IJ was identified on 07/18/2024. The IJ Template was provided to the facility on [DATE] at 06:35 p.m. While the IJ was removed on 07/19/2024, the facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. This failure could place residents at risk of not receiving their scheduled medications in an accurate and timely manner to promote healing and to meet the needs and care of resident. Findings Included: Review of Resident #1's face sheet, dated 07/18/2024, revealed a [AGE] year-old-female. admitted to the facility on [DATE] and discharged on [DATE]. Resident #1's face sheet further revealed diagnoses of other Encephalitis (An inflammation of the brain usually caused due to infection that causes flu like symptoms), Encephalomyelitis (term for inflammation of the brain and spinal cord), and Bacteremia (the presence of bacteria in the bloodstream)/ventriculitis inflammation of ventricles in the brain). Record review of Resident #1's orders, dated 07/18/2024, revealed two discontinued orders for: Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy), order date: 07/09/2024, start date: 07/09/2024 Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy) until 07/18/2024, order date: 07/09/2024, start date: 07/09/2024, end date: 07/18/2024 Record review of Resident #1's July MAR (Medication Administration Record), dated 07/18/2024, revealed: Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy), order date: 07/09/2024 1038 (10:38 a.m.), D/C (Discontinued) Date: 07/10/2024 0608 (06:08 a.m.). With administer times at 0900 (09:00 a.m.) and 2100 (09:00 p.m.). Further review revealed: Tuesday 07/09/24 a charting code of 09 at 2100 (09:00 p.m.) Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy) until 07/18/2024 23:59 (11:59 p.m.), D/C (Discontinued) Date: 07/12/2024 at 1548 (03:48 p.m.). With administer times at 0900 (09:00 a.m.) and 2100 (09:00 p.m.). Further review revealed: Wednesday 07/10/2024 a charting code of 09 at 0900 (09:00 a.m.), and 2100 (09:00 p.m.) Thursday 07/11/2024 a charting code of (x) at 0900 (09:00 a.m.), and a charting code of a check mark 2100 (09:00 p.m.) Friday 07/12/2024 a charting code of (x) at 0900 (09:00 a.m.), and a charting code of (x) at 2100 (09:00 p.m.) Further review of Resident #1 July MAR (Medication Administration Record) revealed a Chart Codes/Follow up table, a charting code of a check mark is listed as administered. Additional review of Resident #1's July MAR (Medication Administration Record), on page 30: Ceftriaxone Sodium Intravenous Solution Reconstituted, scheduled time: 07/11/2024 2100 (09:00 p.m.), administered time: 07/11/2024 2320 (11:20 p.m.), administered by LVN B, route intravenously, and location of Admin arm-right. Record review of Resident #1's July MAR revealed Resident #1 was administered Ceftriaxone Sodium Intravenous one time from the dates of 07/09/2024 to 07/12/2024. Record review of Resident #1's Progress Notes, dated 07/18/2024, revealed: Note, effective date: 07/09/2024 2022 (08:22 p.m.), type: Emar (electronic medication administration), note text: Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy) pending pharmacy delivery. Note, effective date: 07/10/2024 1007 (10:07 a.m.), type: Emar (electronic medication administration), note text: Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy) until 07/18/2024 23:59 (11:59 p.m.) PT (patient) pulled IV (Intravenous) line out. Note, effective date: 07/10/2024 1600 (04:00 p.m.), type: Emar (electronic medication administration), note text: Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy) until 07/18/2024 23:59 (11:59 p.m.) pending pharmacy delivery. Note, effective date: 07/10/2024 2253 (10:53 p.m.), type: Emar (electronic medication administration), note text: Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy) until 07/18/2024 23:59 (11:59 p.m.) Medication pending arrival to facility. Note, effective date: 07/11/2024 1810 (06:10 p.m.), type: Emar (electronic medication administration), note text: Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy) until 07/18/2024 23:59 (11:59 p.m.) Not Available. Note, effective date: 07/12/2024 0947 (09:47 a.m.), type: Emar (electronic medication administration), note text: Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy) until 07/18/2024 23:59 (11:59 p.m.) med order pending, call pharmacy. Record review of Resident #1's NP Progress note, dated 07/12/2024, revealed an HPI (History of Present Illness) Related to this Visit, notified this AM (Morning) by nursing staff that pt (Patient) has not received IV (Intravenous) abx (Antibiotic) ceftriaxone since admission d/t (Determine that) Pharmacy carrier not delivering med to facility. No previous staff or nursing notified this NP (Nurse Practitioner) that med had not been delivered since pt's (Patient's) admission. This NP (Nurse Practitioner) called and notified attending MD (Medical Doctor) and notified her of the situation. pt (Patient) sent to ER (emergency room ) to ensure pt restarted on abx (Antibiotic). Spoke to pt's Family #1 in pt's room and notified family that pt has not received her IV (Intravenous) abx and will be sending pt back to ER. MD stated his frustrations with facility and wanted pt immediately sent out, which this NP explained was already in the process. Record review of Resident #1's hospital records, dated 07/18/2024, revealed Resident #1 an admitted to the hospital on 07/12/2024, with no discharge date , with a chief complaint missed antibiotic. Further review of Resident #1's hospital records revealed an Assessment/Plan note: this 91-yeard-old female with past medical history of diabetes type 2 dementia, and haemophiles influenza (bacteria that can cause severe infection) on ceftriaxone was brought from skilled nursing facility. 1. Bacteremia (the presence of bacteria in the bloodstream)/ventriculitis inflammation of ventricles in the brain). Continue ceftriaxone 2 g (grams) every 12 hour till (until) 7/20 Interview on 07/18/2024 at 11:24 a.m., RN A stated that she worked the day shift when Resident #1 arrived on 07/09/2024, Resident #1 arrived between 3pm to 4pm. RN A stated that she remembered Resident #1 because of her antibiotics (Ceftriaxone) and she was scheduled to receive her medications twice, 9am and 9pm as that was how the orders was listed. RN A stated she admitted Resident #1, her antibiotics were not in house, RN A stated she ordered them from the pharmacy, as Resident #1's admitting records from the hospital revealed Resident #1 received her first dose of the antibiotic and Resident #1 next dose would be at 9pm. RN A stated she passed this information down to the next nurse on shift, as she would be off duty from 07/10/2024 to 07/12/2024. RN A returned to work on 07/12/2024 and reviewed Resident #1 medication administration and discovered that Resident #1 had missed doses of Ceftriaxone and had only received one dose on 07/11/2024 at 9pm. RN A stated when she inquired on the missed antibiotics, she was told the medications have not arrived in the facility. RN A stated she informed the ACNO, and NP of the missed doses. RN A stated that staff should have followed up with the pharmacy for the medications, inform the DON or ACNO, and notify the MD or NP of the missing antibiotics to look for alternatives. RN A stated that there we risk associated with the missed dosages as it could lead to an infection in Resident #'s blood. RN A stated Resident #1 was sent to the ER per the NP orders as the NP was seriously concerned of Resident #1 not receiving the antibiotics. Interview on 07/18/2024 at 12:27 p.m., LVN A stated she worked the floor as a charge nurse during Resident #1 stay on 07/11/2024. LVN A stated that Resident #1 antibiotics (Ceftriaxone) were not available that day. LVN A stated she checked the Ekit that day and there was no Ceftriaxone available. LVN A stated she marked it on the MAR as a 9, listed as other because the antibiotic was not available. LVN A stated that if there are missed doses, we contact the MD or NP, there is a procedure to follow up with the pharmacy and notify the DON or ACNO. LVN A stated, I screwed up, I admit it, I did not call the pharmacy because I thought it would be delivered later that day, and I did not call the NP. It was so busy that day, I'm sorry. LVN A stated the risks of Resident #1 not having her antibiotics would be the increased risk of infection. Interview on 07/18/2024 at 01:48 p.m., LVN B stated she worked during Resident #1's time at the facility and remembered her. LVN B confirmed that Resident #1 antibiotics are administered intravenously. LVN B stated that on Wednesday night (07/10/2024), she did not see Resident #1's Ceftriaxone in the cart, LVN B added she did not look in the Ekit that night. LVN B stated in Resident #1's MAR she coded it as 9 as she did not want to lie and say she administered the Ceftriaxone. LVN B stated on Thursday night (07/11/2024) Resident #1 did not have her Ceftriaxone in the cart, LVN B asked another nurse to look in the Ekit, and a dose of Ceftriaxone was available. LVN B stated she successfully administer Resident#1's antibiotic (Ceftriaxone), that is why she marked it with a checkmark. LVN B stated, I take full accountability, didn't check the ekit, and didn't call, I didn't call the pharmacy, I was thinking it (Ceftriaxone) was on its way here, I was thinking it was, that's why I put a medication pending arrival in the progress note, I didn't call the NP, the DON or ACNO, I should have but it was busy those nights. LVN B stated the risk of not Resident #1 not having her Ceftriaxone was, the risk of not getting better, of not healing, the risk of infection, and the risk of the resident (Resident #1) not going home as planned, I'm sorry. Interview on 07/18/2024 at 03:09 p.m., NP stated that she was only told that Resident #1 did not receive the scheduled antibiotic Ceftriaxone on 07/12/2024, the day I sent her to the ER. NP stated she was informed by RN A. NP stated she informed the MD, we were not happy, because staff did not give her Ceftriaxone, and we were not informed. NP added Resident #1 missed many doses, and when she was informed, I wanted to assure Resident #1 received her Ceftriaxone, that is the reason she had to send her to the ER. NP stated, the antibiotics (Ceftriaxone) was important for this patient, this was the main reason she was here to treat her infection, she had an infection in her brain that was treated at hospital, to assure that the infection won't come back and keep ravaging this patient, the antibiotics (Ceftriaxone) had to be consistent, and continued at the facility. the NP added, even with one dose she (Resident #1) received it could lead to serious harm, she (Resident #1) could have gone septic, sending to her hospital was ensuring she doesn't go septic and have drastic harm done to her (Resident #1). Interview on 07/18/2024 at 04:00 p.m., DON stated staff were required to look in the Ekit, if medications are not available staff are to notify the resident's providers, to look for alternative medications or treatments, or to make appropriate adjustments. The DON stated that the process and procedures are here to keep residents safe and to also offer options for our facility to treat residents. The DON confirmed she was not notified of Resident #1's missed doses (Ceftriaxone) within the dates of 07/09/2024 to 07/11/2024. Interview on 07/18/2024 at 04:13 p.m., ACNO stated if no medications are available in the medication cart or the Ekit, staff should follow up with pharmacy, there two routes of delivery. If the medication does not come in from pharmacy, and there is no reason given from the pharmacy, staff are supposed to tell the DON, ADM, GM, ACNO. ACNO stated staff are supposed to follow up and call doctor or NP to see if there are alternatives. ACNO stated she recalled Resident #1 because she was on antibiotics (Ceftriaxone). ACNO stated she was informed on Friday (07/12/2024) approximately at 10:40 a.m., she informed the GM, and a pharmacy follow up would be completed. ACNO stated that she was informed that Resident #1 had missed two days without her (Resident #1) antibiotics. ACNO stated that staff should have notified, her, DON, GM that first day the Ceftriaxone had not come in and if Resident #1 did not receive the antibiotic. ACNO stated she verbally educated LVN A on the process of calling administration on 07/12/2024, but no in-services completed. ACNO stated, The antibiotic (Ceftriaxone), was important, if there were missed doses, it would interfere with her (Resident #1's) healing. Interview on 07/18/2024 at 05:39 p.m., GM stated staff are to contact the providers if there are no medications available for any reason, providers are to offer adjustments or alternatives for the missing medications, staff are to contact the pharmacy directly as well to work with them to have those medications delivered. GM added if the pharmacy is not able to deliver the medication, staff are to contact his or her supervisors and inform them of the situation. GM stated if the process is not followed, there are risk to residents not receiving the desired and appropriate treatments. GM stated she was not informed by staff of Resident #1 missed dosages of antibiotics (Ceftriaxone) within the dates of 07/09/2024 to 07/11/2024. GM stated she was informed by the ACNO on 07/12/2024, and she immediately followed up with the pharmacy that day. Record Review of the Facility's Medication Ordering and Receiving from Pharmacy/Ordering and Receiving Non-Controlled Medications, dated 01/23, reflected the Policy: Medications and related products are received from the provider pharmacy on a timely basis. The nursing care center maintains accurate reds of medication order and receipt. Procedures: 1. Section E: New Medications, expect for emergency or stat medications, are ordered as follows: If the first dose of medication is scheduled to be given before the next regularly scheduled pharmacy delivery, please telephone or transmit the medication orders to the pharmacy immediately upon receipt. Inform the pharmacy of the need for prompt delivery. Timely delivery of new orders is required so that medication administration is not delayed. If available, the emergency kit is used when the resident needs a non-controlled medication prior to pharmacy delivery. 1. Section F: Stat and emergency medications; except for Controlled Substances are ordered as follows: During regular pharmacy hours, the emergency or stat order is transmitted to the pharmacy immediately upon receipt. Such medications are delivered and administer in a timely manner. Emergency/STAT medication order then medication is not available in the emergency kit: An emergency/STAT order is placed with the provider pharmacy and the pharmacy is called by nursing staff to request the STAT. The requested medication(s) will be delivered in a timely manner. Subsequent doses are scheduled according to nursing care center policy on medication administration. Record Review of the Facility's Administration of Medications, dated 04/2023, revealed General statement, All medications are administered safely and appropriately to aid resident to and help overcome illness, relieve and prevent symptoms and help in diagnosis. The GM was notified on 07/18/2024 at 06:35 p.m., that an IJ situation was identified due to the above failures and the IJ template was provided. The POR (Plan of Removal) was accepted on 07/19/2024 at 03:37 p.m., and included: On 7/18/24 an abbreviated survey was initiated on 7/18/24 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an Immediate Jeopardy resident health and safety. The notification of Immediate Jeopardy states as follows: F755 - The facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological) to meet the needs of a resident, this resulted in Resident #1 missing dosages of ceftriaxone. 1. Corrective Action for residents affected by the deficient practice: a. Resident #1 had been discharged from the facility on 7/12/2024. 2. How other residents having the potential to be affected be identified and what corrective action(s) will be taken: a. Residents admitted to the facility have the potential to be affected by the identified deficient practice. Education was given to DON and GM by Chief Clinical Officer on 7/18/2024. Inservice will start 7/18/2024 and be completed by all fulltime staff by 7/19/2024 and be conducted by director of nursing (DON), general manager (GM) to all Fulltime, part time, PRN nurses and certified medication aides (CMA). Training for all new hires, PRN and part time employees will be completed prior to start of shift. Post test will be conducted after Inservice. Topic will include: i. Proper ordering/reordering medications process - will review the pharmacy policy section 3.2 entitled Medication Ordering and Receiving From Pharmacy Provider ii. Proper Protocol for all Facility Nurses and medication aides for bullet points 1,2, and 3. when medication is unavailable - 1. Check Medication expensing machine and IV E-kit immediately. Nurses & CMAs. 2. Contact pharmacy immediately. Nurses & CMAs. 3. Notify DON and/or GM for escalation Within 1 hour of calling pharmacy. Nurses & CMAs. 4. Within 1 hour after notifying DON and/or GM, notify physician to request for alternative orders. ONLY for nurses 5. Document and carry out provider's instructions immediately. ONLY for nurses iii. Proper Protocol for all Facility Nurses and Medication aides of notification tree if medication is unavailable - 1. DON Contact information is posted in med room 2. Contact GM Contact information is posted in Med Room 3. Contact assigned provider ONLY for nurses iv. Contents of medication dispensing machine and IV E-kits - see Attachment A b. Inservices will be reinforced via the bulletin board of the electronic health records as well as live documents sent via text message. Inservice will be required to be completed prior to start of shift. There will be post test given and graded by CNO and/or GM c. Nursing staff initiated a MAR-to-Cart audit of all in-house residents on 7/18/2024 to ensure medications are available and to order/reorder medications that are not available in the medication carts. This will be completed by 7/19/2024. 3. Measures that will be put in place or systemic changes that will be made to ensure the deficient practice(s) does not recur: a. The medication lists of all new admissions will be matched with actual medications the following day by DON and or designee starting 7/20/2024 and will be ongoing process. Medications should be available by next delivery period and/or within 24 hours of order entry. If a medication is scheduled prior to pharmacy scheduled delivery run, nurses or certified medication aides are to pull first dose from the IV-ekit or medication delivery machine. Then follow regular delivery for the next dose. If medications are not available on the medication dispensing machine, the nurses and certified medication aides are expected to call for STAT delivery. List of medications available on the medication dispensing machine was posted by DON on 7/18/2024 in the medication rooms. 4. Monitoring performance: a. DON and/or designee will complete a daily audit of medications for new admissions, starting 7/20/2024 until 8/1/2024. Then will be reduced to weekly x 2 weeks ending 8/15/2024. Then move to random new admit medication audits until 8/30/2024. b. If there is missing medication, DON and/or designee will ensure that the notification tree was activated beginning 7/18/2024 and will be ongoing process. c. Findings will be discussed weekly starting 7/19/2024 between GM, DON and/or designee and VP of clinical operations and will continue weekly until 8/15/2024. There was an ADHOC QAPI meeting held on 7/18/2024 with the General Manager, Administrator, Director of Nursing, Medical Director, Pharmacy Director, Chief Clinical Officer, and Regional VP of Clinical, after the IJ was called. Findings will also be presented during monthly QAPI meeting x3 months. The Survey Team monitored the Plan of Removal on 07/19/2024 Observations on 07/19/2024 from 08:30 a.m. to 03:30 p.m., revealed nursing staff received in-service training from GM and DON on topics of Proper ordering/reordering medications process, contacting administration, and systematic changes to assure accuracy of orders and medications. Record review on 07/19/2024 revealed daily audit of medications for new admissions, and MAR-to-Cart audit of all in-house residents. Record review on 07/19/2024 revealed ADHOC QAPI meeting held on 7/18/2024 with the General Manager, Administrator, Director of Nursing, Medical Director, Pharmacy Director, Chief Clinical Officer, and Regional VP of Clinical Record review on 07/19/2024 revealed in-services completed for 12 staff on topics of Proper ordering/reordering medications process, contacting administration, and systematic changes to assure accuracy of orders and medications. Further record review revealed graded post-test for staff, no failures. Interview on 07/19/2024 at 03:41 p.m., LVN C stated she has taken in-services on 07/18/2024 at PM shift, on topics of Proper ordering/reordering medications process, contacting administration, providers to inform of any missing medications to seek immediate interventions and alternatives, and systematic changes to assure medications and orders accuracy. LVN C stated she has taken the post-test and confirmed completion and passed. Interview on 07/19/2024 at 03:47 p.m., RN B stated he has taken in-services on 07/18/2024 at PM shift, on topics of Proper ordering/reordering medications process, contacting administration, providers to inform of any missing medications to seek immediate interventions and alternatives, and systematic changes to assure medications and orders accuracy. RN B stated he has taken the post-test and confirmed completion and passed. Observation and interview on 07/19/2024 at 03:53 p.m., LVN D was observed calling the pharmacy on medications delivery. LVN D stated she has taken in-services on 07/19/2024 at AM shift, on topics of Proper ordering/reordering medications process, contacting administration, providers to inform of any missing medications to seek immediate interventions and alternatives, and systematic changes to assure medications and orders accuracy. LVN D stated she has taken the post-test and confirmed completion and passed. Interview on 07/19/2024 at 04:09 p.m., CMA A stated she he has taken in-services on 07/19/2024 at AM shift, on topics of Proper ordering/reordering medications process, contacting administration, notifying nurses to follow process of provider notifications to seek immediate interventions and alternatives. CMA A stated she has taken the post-test and confirmed completion and passed. Interview on 07/19/2024 at 04:36 p.m., ACNO stated she has taken in-services on 07/19/2024 at AM shift, on topics of Proper ordering/reordering medications process, contacting administration, providers to inform of any missing medications to seek immediate interventions and alternatives, and systematic changes to assure medications and orders accuracy. ACNO stated she has taken the post-test and confirmed completion and passed. ACNO stated daily audit of medications for new admissions, and MAR-to-Cart audit of all in-house residents completed and will continue. Phone call Interview on 07/19/2024 at 04:39 p.m., LVN B stated she has taken in-services on 07/19/2024 over phone with DON, on topics of Proper ordering/reordering medications process, contacting administration, providers to inform of any missing medications to seek immediate interventions and alternatives, and systematic changes to assure medications and orders accuracy. LVN B stated she has taken the post-test and confirmed completion and passed. Phone call Interview on 07/19/2024 at 04:43 p.m., LVN A stated she has taken in-services on 07/19/2024 at AM shift, on topics of Proper ordering/reordering medications process, contacting administration, providers to inform of any missing medications to seek immediate interventions and alternatives, and systematic changes to assure medications and orders accuracy. LVN A stated she has taken the post-test and confirmed completion and passed. Interview on 07/19/2024 at 04:49 p.m., the DON stated the Chief Clinical Officer educated her and the GM on topics of Proper ordering/reordering medications process on 7/18/2024, ADHOC QAPI meeting held on 7/18/2024 with the General Manager, Administrator, Director of Nursing, Medical Director, Pharmacy Director, Chief Clinical Officer, and Regional VP of Clinical, and in-service started 07/18/2024 after IJ identified on topics of [NAME] ordering/reordering medications process, for all Fulltime, part time, PRN nurses and certified medication aides (CMA), as needed for all new hires, PRN and part time employees will be completed prior to start of shift. DON stated daily and random audits will continue to assure compliance. Interview on 07/19/2024 at 04:59 p.m., GM stated Chief Clinical Officer educated her and DON on topics of Proper ordering/reordering medications process on 7/18/2024, ADHOC QAPI meeting held on 7/18/2024 with the General Manager, Administrator, Director of Nursing, Medical Director, Pharmacy Director, Chief Clinical Officer, and Regional VP of Clinical, and in-service started 07/18/2024 after IJ identified on topics of [NAME] ordering/reordering medications process, for all Fulltime, part time, PRN nurses and certified medication aides (CMA), as needed for all new hires, PRN and part time employees will be completed prior to start of shift. DON stated daily and random audits will continue to assure compliance. The GM was notified on 07/19/2024 at 05:27 p.m. that the Immediate Jeopardy was removed. While the IJ was removed on 07/19/2024, the facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy.

Based on interviews and record reviews, the facility failed to inform the resident's Physician or Nurse Practitioner when there was a need to alter treatment significantly for 1 (Resident #1) of 5 residents reviewed for pharmacy services. The facility failed to ensure Resident #1's scheduled medications were acquired and administered. Resident #1 was not given ceftriaxone (antibiotic used to treat bacterial infections) for a total of 4 times within the dates of 07/09/2024 to 07/11/2024, staff did follow up with the pharmacy for the antibiotics, staff did not communicate with the NP of the lack of antibiotics and missed medications, and staff did not communicate the missed doses to the administration. This failure resulted in the Resident #1's being sent to the hospital to have consistent antibiotic treatment, and to treat Bacteremia (bacteria in the blood stream) and ventriculitis (inflammation of the ventricles in the brain). An IJ was identified on 07/18/2024. The IJ Template was provided to the facility on [DATE] at 06:35 p.m. While the IJ was removed on 07/19/2024, the facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy. This failure could place residents at risk of not receiving their scheduled medications in an accurate and timely manner to promote healing and to meet the needs and care of resident. Findings Included: Review of Resident #1's face sheet, dated 07/18/2024, revealed a [AGE] year-old-female. admitted to the facility on [DATE] and discharged on [DATE]. Resident #1's face sheet further revealed diagnoses of other Encephalitis (An inflammation of the brain usually caused due to infection that causes flu like symptoms), Encephalomyelitis (term for inflammation of the brain and spinal cord), and Bacteremia (the presence of bacteria in the bloodstream)/ventriculitis inflammation of ventricles in the brain). Record review of Resident #1's orders, dated 07/18/2024, revealed two discontinued orders for: Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy), order date: 07/09/2024, start date: 07/09/2024 Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy) until 07/18/2024, order date: 07/09/2024, start date: 07/09/2024, end date: 07/18/2024 Record review of Resident #1's July MAR (Medication Administration Record), dated 07/18/2024, revealed: Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy), order date: 07/09/2024 1038 (10:38 a.m.), D/C (Discontinued) Date: 07/10/2024 0608 (06:08 a.m.). With administer times at 0900 (09:00 a.m.) and 2100 (09:00 p.m.). Further review revealed: Tuesday 07/09/24 a charting code of 09 at 2100 (09:00 p.m.) Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy) until 07/18/2024 23:59 (11:59 p.m.), D/C (Discontinued) Date: 07/12/2024 at 1548 (03:48 p.m.). With administer times at 0900 (09:00 a.m.) and 2100 (09:00 p.m.). Further review revealed: Wednesday 07/10/2024 a charting code of 09 at 0900 (09:00 a.m.), and 2100 (09:00 p.m.) Thursday 07/11/2024 a charting code of (x) at 0900 (09:00 a.m.), and a charting code of a check mark 2100 (09:00 p.m.) Friday 07/12/2024 a charting code of (x) at 0900 (09:00 a.m.), and a charting code of (x) at 2100 (09:00 p.m.) Further review of Resident #1 July MAR (Medication Administration Record) revealed a Chart Codes/Follow up table, a charting code of a check mark is listed as administered. Additional review of Resident #1's July MAR (Medication Administration Record), on page 30: Ceftriaxone Sodium Intravenous Solution Reconstituted, scheduled time: 07/11/2024 2100 (09:00 p.m.), administered time: 07/11/2024 2320 (11:20 p.m.), administered by LVN B, route intravenously, and location of Admin arm-right. Record review of Resident #1's July MAR revealed Resident #1 was administered Ceftriaxone Sodium Intravenous one time from the dates of 07/09/2024 to 07/12/2024. Record review of Resident #1's Progress Notes, dated 07/18/2024, revealed: Note, effective date: 07/09/2024 2022 (08:22 p.m.), type: Emar (electronic medication administration), note text: Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy) pending pharmacy delivery. Note, effective date: 07/10/2024 1007 (10:07 a.m.), type: Emar (electronic medication administration), note text: Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy) until 07/18/2024 23:59 (11:59 p.m.) PT (patient) pulled IV (Intravenous) line out. Note, effective date: 07/10/2024 1600 (04:00 p.m.), type: Emar (electronic medication administration), note text: Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy) until 07/18/2024 23:59 (11:59 p.m.) pending pharmacy delivery. Note, effective date: 07/10/2024 2253 (10:53 p.m.), type: Emar (electronic medication administration), note text: Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy) until 07/18/2024 23:59 (11:59 p.m.) Medication pending arrival to facility. Note, effective date: 07/11/2024 1810 (06:10 p.m.), type: Emar (electronic medication administration), note text: Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy) until 07/18/2024 23:59 (11:59 p.m.) Not Available. Note, effective date: 07/12/2024 0947 (09:47 a.m.), type: Emar (electronic medication administration), note text: Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy) until 07/18/2024 23:59 (11:59 p.m.) med order pending, call pharmacy. Record review of Resident #1's NP Progress note, dated 07/12/2024, revealed an HPI (History of Present Illness) Related to this Visit, notified this AM (Morning) by nursing staff that pt (Patient) has not received IV (Intravenous) abx (Antibiotic) ceftriaxone since admission d/t (Determine that) Pharmacy carrier not delivering med to facility. No previous staff or nursing notified this NP (Nurse Practitioner) that med had not been delivered since pt's (Patient's) admission. This NP (Nurse Practitioner) called and notified attending MD (Medical Doctor) and notified her of the situation. pt (Patient) sent to ER (emergency room ) to ensure pt restarted on abx (Antibiotic). Spoke to pt's Family #1 in pt's room and notified family that pt has not received her IV (Intravenous) abx and will be sending pt back to ER. MD stated his frustrations with facility and wanted pt immediately sent out, which this NP explained was already in the process. Record review of Resident #1's hospital records, dated 07/18/2024, revealed Resident #1 an admitted to the hospital on 07/12/2024, with no discharge date , with a chief complaint missed antibiotic. Further review of Resident #1's hospital records revealed an Assessment/Plan note: this 91-yeard-old female with past medical history of diabetes type 2 dementia, and haemophiles influenza (bacteria that can cause severe infection) on ceftriaxone was brought from skilled nursing facility. 1. Bacteremia (the presence of bacteria in the bloodstream)/ventriculitis inflammation of ventricles in the brain). Continue ceftriaxone 2 g (grams) every 12 hour till (until) 7/20 Interview on 07/18/2024 at 11:24 a.m., RN A stated that she worked the day shift when Resident #1 arrived on 07/09/2024, Resident #1 arrived between 3pm to 4pm. RN A stated that she remembered Resident #1 because of her antibiotics (Ceftriaxone) and she was scheduled to receive her medications twice, 9am and 9pm as that was how the orders was listed. RN A stated she admitted Resident #1, her antibiotics were not in house, RN A stated she ordered them from the pharmacy, as Resident #1's admitting records from the hospital revealed Resident #1 received her first dose of the antibiotic and Resident #1 next dose would be at 9pm. RN A stated she passed this information down to the next nurse on shift, as she would be off duty from 07/10/2024 to 07/12/2024. RN A returned to work on 07/12/2024 and reviewed Resident #1 medication administration and discovered that Resident #1 had missed doses of Ceftriaxone and had only received one dose on 07/11/2024 at 9pm. RN A stated when she inquired on the missed antibiotics, she was told the medications have not arrived in the facility. RN A stated she informed the ACNO, and NP of the missed doses. RN A stated that staff should have followed up with the pharmacy for the medications, inform the DON or ACNO, and notify the MD or NP of the missing antibiotics to look for alternatives. RN A stated that there we risk associated with the missed dosages as it could lead to an infection in Resident #'s blood. RN A stated Resident #1 was sent to the ER per the NP orders as the NP was seriously concerned of Resident #1 not receiving the antibiotics. Interview on 07/18/2024 at 12:27 p.m., LVN A stated she worked the floor as a charge nurse during Resident #1 stay on 07/11/2024. LVN A stated that Resident #1 antibiotics (Ceftriaxone) were not available that day. LVN A stated she checked the Ekit that day and there was no Ceftriaxone available. LVN A stated she marked it on the MAR as a 9, listed as other because the antibiotic was not available. LVN A stated that if there are missed doses, we contact the MD or NP, there is a procedure to follow up with the pharmacy and notify the DON or ACNO. LVN A stated, I screwed up, I admit it, I did not call the pharmacy because I thought it would be delivered later that day, and I did not call the NP. It was so busy that day, I'm sorry. LVN A stated the risks of Resident #1 not having her antibiotics would be the increased risk of infection. Interview on 07/18/2024 at 01:48 p.m., LVN B stated she worked during Resident #1's time at the facility and remembered her. LVN B confirmed that Resident #1 antibiotics are administered intravenously. LVN B stated that on Wednesday night (07/10/2024), she did not see Resident #1's Ceftriaxone in the cart, LVN B added she did not look in the Ekit that night. LVN B stated in Resident #1's MAR she coded it as 9 as she did not want to lie and say she administered the Ceftriaxone. LVN B stated on Thursday night (07/11/2024) Resident #1 did not have her Ceftriaxone in the cart, LVN B asked another nurse to look in the Ekit, and a dose of Ceftriaxone was available. LVN B stated she successfully administer Resident#1's antibiotic (Ceftriaxone), that is why she marked it with a checkmark. LVN B stated, I take full accountability, didn't check the ekit, and didn't call, I didn't call the pharmacy, I was thinking it (Ceftriaxone) was on its way here, I was thinking it was, that's why I put a medication pending arrival in the progress note, I didn't call the NP, the DON or ACNO, I should have but it was busy those nights. LVN B stated the risk of not Resident #1 not having her Ceftriaxone was, the risk of not getting better, of not healing, the risk of infection, and the risk of the resident (Resident #1) not going home as planned, I'm sorry. Interview on 07/18/2024 at 03:09 p.m., NP stated that she was only told that Resident #1 did not receive the scheduled antibiotic Ceftriaxone on 07/12/2024, the day I sent her to the ER. NP stated she was informed by RN A. NP stated she informed the MD, we were not happy, because staff did not give her Ceftriaxone, and we were not informed. NP added Resident #1 missed many doses, and when she was informed, I wanted to assure Resident #1 received her Ceftriaxone, that is the reason she had to send her to the ER. NP stated, the antibiotics (Ceftriaxone) was important for this patient, this was the main reason she was here to treat her infection, she had an infection in her brain that was treated at hospital, to assure that the infection won't come back and keep ravaging this patient, the antibiotics (Ceftriaxone) had to be consistent, and continued at the facility. the NP added, even with one dose she (Resident #1) received it could lead to serious harm, she (Resident #1) could have gone septic, sending to her hospital was ensuring she doesn't go septic and have drastic harm done to her (Resident #1). Interview on 07/18/2024 at 04:00 p.m., DON stated staff were required to look in the Ekit, if medications are not available staff are to notify the resident's providers, to look for alternative medications or treatments, or to make appropriate adjustments. The DON stated that the process and procedures are here to keep residents safe and to also offer options for our facility to treat residents. The DON confirmed she was not notified of Resident #1's missed doses (Ceftriaxone) within the dates of 07/09/2024 to 07/11/2024. Interview on 07/18/2024 at 04:13 p.m., ACNO stated if no medications are available in the medication cart or the Ekit, staff should follow up with pharmacy, there two routes of delivery. If the medication does not come in from pharmacy, and there is no reason given from the pharmacy, staff are supposed to tell the DON, ADM, GM, ACNO. ACNO stated staff are supposed to follow up and call doctor or NP to see if there are alternatives. ACNO stated she recalled Resident #1 because she was on antibiotics (Ceftriaxone). ACNO stated she was informed on Friday (07/12/2024) approximately at 10:40 a.m., she informed the GM, and a pharmacy follow up would be completed. ACNO stated that she was informed that Resident #1 had missed two days without her (Resident #1) antibiotics. ACNO stated that staff should have notified, her, DON, GM that first day the Ceftriaxone had not come in and if Resident #1 did not receive the antibiotic. ACNO stated she verbally educated LVN A on the process of calling administration on 07/12/2024, but no in-services completed. ACNO stated, The antibiotic (Ceftriaxone), was important, if there were missed doses, it would interfere with her (Resident #1's) healing. Interview on 07/18/2024 at 05:39 p.m., GM stated staff are to contact the providers if there are no medications available for any reason, providers are to offer adjustments or alternatives for the missing medications, staff are to contact the pharmacy directly as well to work with them to have those medications delivered. GM added if the pharmacy is not able to deliver the medication, staff are to contact his or her supervisors and inform them of the situation. GM stated if the process is not followed, there are risk to residents not receiving the desired and appropriate treatments. GM stated she was not informed by staff of Resident #1 missed dosages of antibiotics (Ceftriaxone) within the dates of 07/09/2024 to 07/11/2024. GM stated she was informed by the ACNO on 07/12/2024, and she immediately followed up with the pharmacy that day. Record Review of the Facility's Medication Ordering and Receiving from Pharmacy/Ordering and Receiving Non-Controlled Medications, dated 01/23, reflected the Policy: Medications and related products are received from the provider pharmacy on a timely basis. The nursing care center maintains accurate reds of medication order and receipt. Procedures: 1. Section E: New Medications, expect for emergency or stat medications, are ordered as follows: If the first dose of medication is scheduled to be given before the next regularly scheduled pharmacy delivery, please telephone or transmit the medication orders to the pharmacy immediately upon receipt. Inform the pharmacy of the need for prompt delivery. Timely delivery of new orders is required so that medication administration is not delayed. If available, the emergency kit is used when the resident needs a non-controlled medication prior to pharmacy delivery. 1. Section F: Stat and emergency medications; except for Controlled Substances are ordered as follows: During regular pharmacy hours, the emergency or stat order is transmitted to the pharmacy immediately upon receipt. Such medications are delivered and administer in a timely manner. Emergency/STAT medication order then medication is not available in the emergency kit: An emergency/STAT order is placed with the provider pharmacy and the pharmacy is called by nursing staff to request the STAT. The requested medication(s) will be delivered in a timely manner. Subsequent doses are scheduled according to nursing care center policy on medication administration. Record Review of the Facility's Administration of Medications, dated 04/2023, revealed General statement, All medications are administered safely and appropriately to aid resident to and help overcome illness, relieve and prevent symptoms and help in diagnosis. The GM was notified on 07/18/2024 at 06:35 p.m., that an IJ situation was identified due to the above failures and the IJ template was provided. The POR (Plan of Removal) was accepted on 07/19/2024 at 03:37 p.m., and included: On 7/18/24 an abbreviated survey was initiated on 7/18/24 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy resident health and safety. The notification of Immediate Jeopardy states as follows: F755 - The facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological) to meet the needs of a resident, this resulted in Resident #1 missing dosages of ceftriaxone. 1. Corrective Action for residents affected by the deficient practice: a. Resident #1 had been discharged from the facility on 7/12/2024. 2. How other residents having the potential to be affected be identified and what corrective action(s) will be taken: a. Residents admitted to the facility have the potential to be affected by the identified deficient practice. Education was given to DON and GM by Chief Clinical Officer on 7/18/2024. Inservice will start 7/18/2024 and be completed by all fulltime staff by 7/19/2024 and be conducted by director of nursing (DON), general manager (GM) to all Fulltime, part time, PRN nurses and certified medication aides (CMA). Training for all new hires, PRN and part time employees will be completed prior to start of shift. Post test will be conducted after Inservice. Topic will include: i. Proper ordering/reordering medications process - will review the pharmacy policy section 3.2 entitled Medication Ordering and Receiving From Pharmacy Provider ii. Proper Protocol for all Facility Nurses and medication aides for bullet points 1,2, and 3. when medication is unavailable - 1. Check Medication expensing machine and IV E-kit immediately. Nurses & CMAs. 2. Contact pharmacy immediately. Nurses & CMAs. 3. Notify DON and/or GM for escalation Within 1 hour of calling pharmacy. Nurses & CMAs. 4. Within 1 hour after notifying DON and/or GM, notify physician to request for alternative orders. ONLY for nurses 5. Document and carry out provider's instructions immediately. ONLY for nurses iii. Proper Protocol for all Facility Nurses and Medication aides of notification tree if medication is unavailable - 1. DON Contact information is posted in med room 2. Contact GM Contact information is posted in Med Room 3. Contact assigned provider ONLY for nurses iv. Contents of medication dispensing machine and IV E-kits - see Attachment A b. Inservices will be reinforced via the bulletin board of the electronic health records as well as live documents sent via text message. Inservice will be required to be completed prior to start of shift. There will be post test given and graded by CNO and/or GM c. Nursing staff initiated a MAR-to-Cart audit of all in-house residents on 7/18/2024 to ensure medications are available and to order/reorder medications that are not available in the medication carts. This will be completed by 7/19/2024. 3. Measures that will be put in place or systemic changes that will be made to ensure the deficient practice(s) does not recur: a. The medication lists of all new admissions will be matched with actual medications the following day by DON and or designee starting 7/20/2024 and will be ongoing process. Medications should be available by next delivery period and/or within 24 hours of order entry. If a medication is scheduled prior to pharmacy scheduled delivery run, nurses or certified medication aides are to pull first dose from the IV-ekit or medication delivery machine. Then follow regular delivery for the next dose. If medications are not available on the medication dispensing machine, the nurses and certified medication aides are expected to call for STAT delivery. List of medications available on the medication dispensing machine was posted by DON on 7/18/2024 in the medication rooms. 4. Monitoring performance: a. DON and/or designee will complete a daily audit of medications for new admissions, starting 7/20/2024 until 8/1/2024. Then will be reduced to weekly x 2 weeks ending 8/15/2024. Then move to random new admit medication audits until 8/30/2024. b. If there is missing medication, DON and/or designee will ensure that the notification tree was activated beginning 7/18/2024 and will be ongoing process. c. Findings will be discussed weekly starting 7/19/2024 between GM, DON and/or designee and VP of clinical operations and will continue weekly until 8/15/2024. There was an ADHOC QAPI meeting held on 7/18/2024 with the General Manager, Administrator, Director of Nursing, Medical Director, Pharmacy Director, Chief Clinical Officer, and Regional VP of Clinical, after the IJ was called. Findings will also be presented during monthly QAPI meeting x3 months. The Survey Team monitored the Plan of Removal on 07/19/2024 Observations on 07/19/2024 from 08:30 a.m. to 03:30 p.m., revealed nursing staff received in-service training from GM and DON on topics of Proper ordering/reordering medications process, contacting administration, and systematic changes to assure accuracy of orders and medications. Record review on 07/19/2024 revealed daily audit of medications for new admissions, and MAR-to-Cart audit of all in-house residents. Record review on 07/19/2024 revealed ADHOC QAPI meeting held on 7/18/2024 with the General Manager, Administrator, Director of Nursing, Medical Director, Pharmacy Director, Chief Clinical Officer, and Regional VP of Clinical Record review on 07/19/2024 revealed in-services completed for 12 staff on topics of Proper ordering/reordering medications process, contacting administration, and systematic changes to assure accuracy of orders and medications. Further record review revealed graded post-test for staff, no failures. Interview on 07/19/2024 at 03:41 p.m., LVN C stated she has taken in-services on 07/18/2024 at PM shift, on topics of Proper ordering/reordering medications process, contacting administration, providers to inform of any missing medications to seek immediate interventions and alternatives, and systematic changes to assure medications and orders accuracy. LVN C stated she has taken the post-test and confirmed completion and passed. Interview on 07/19/2024 at 03:47 p.m., RN B stated he has taken in-services on 07/18/2024 at PM shift, on topics of Proper ordering/reordering medications process, contacting administration, providers to inform of any missing medications to seek immediate interventions and alternatives, and systematic changes to assure medications and orders accuracy. RN B stated he has taken the post-test and confirmed completion and passed. Observation and interview on 07/19/2024 at 03:53 p.m., LVN D was observed calling the pharmacy on medications delivery. LVN D stated she has taken in-services on 07/19/2024 at AM shift, on topics of Proper ordering/reordering medications process, contacting administration, providers to inform of any missing medications to seek immediate interventions and alternatives, and systematic changes to assure medications and orders accuracy. LVN D stated she has taken the post-test and confirmed completion and passed. Interview on 07/19/2024 at 04:09 p.m., CMA A stated she he has taken in-services on 07/19/2024 at AM shift, on topics of Proper ordering/reordering medications process, contacting administration, notifying nurses to follow process of provider notifications to seek immediate interventions and alternatives. CMA A stated she has taken the post-test and confirmed completion and passed. Interview on 07/19/2024 at 04:36 p.m., ACNO stated she has taken in-services on 07/19/2024 at AM shift, on topics of Proper ordering/reordering medications process, contacting administration, providers to inform of any missing medications to seek immediate interventions and alternatives, and systematic changes to assure medications and orders accuracy. ACNO stated she has taken the post-test and confirmed completion and passed. ACNO stated daily audit of medications for new admissions, and MAR-to-Cart audit of all in-house residents completed and will continue. Phone call Interview on 07/19/2024 at 04:39 p.m., LVN B stated she has taken in-services on 07/19/2024 over phone with DON, on topics of Proper ordering/reordering medications process, contacting administration, providers to inform of any missing medications to seek immediate interventions and alternatives, and systematic changes to assure medications and orders accuracy. LVN B stated she has taken the post-test and confirmed completion and passed. Phone call Interview on 07/19/2024 at 04:43 p.m., LVN A stated she has taken in-services on 07/19/2024 at AM shift, on topics of Proper ordering/reordering medications process, contacting administration, providers to inform of any missing medications to seek immediate interventions and alternatives, and systematic changes to assure medications and orders accuracy. LVN A stated she has taken the post-test and confirmed completion and passed. Interview on 07/19/2024 at 04:49 p.m., the DON stated the Chief Clinical Officer educated her and the GM on topics of Proper ordering/reordering medications process on 7/18/2024, ADHOC QAPI meeting held on 7/18/2024 with the General Manager, Administrator, Director of Nursing, Medical Director, Pharmacy Director, Chief Clinical Officer, and Regional VP of Clinical, and in-service started 07/18/2024 after IJ identified on topics of [NAME] ordering/reordering medications process, for all Fulltime, part time, PRN nurses and certified medication aides (CMA), as needed for all new hires, PRN and part time employees will be completed prior to start of shift. DON stated daily and random audits will continue to assure compliance. Interview on 07/19/2024 at 04:59 p.m., GM stated Chief Clinical Officer educated her and DON on topics of Proper ordering/reordering medications process on 7/18/2024, ADHOC QAPI meeting held on 7/18/2024 with the General Manager, Administrator, Director of Nursing, Medical Director, Pharmacy Director, Chief Clinical Officer, and Regional VP of Clinical, and in-service started 07/18/2024 after IJ identified on topics of [NAME] ordering/reordering medications process, for all Fulltime, part time, PRN nurses and certified medication aides (CMA), as needed for all new hires, PRN and part time employees will be completed prior to start of shift. DON stated daily and random audits will continue to assure compliance. The GM was notified on 07/19/2024 at 05:27 p.m. that the Immediate Jeopardy was removed. While the IJ was removed on 07/19/2024, the facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy.

Based on interviews and record reviews the facility failed to ensure a resident who displays or is diagnosed with mental disorder or psychosocial adjustment disorder receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for 1 of (Resident # 1) 1 residents reviewed for suicidal ideation in that: The failed to monitor Resident #1 closely after verbalizing to multiple staff members that she wanted to die on 06/26/2023 and Resident #1 attempted suicide on 06/26/2023 at about 2:50 p.m. and was sent to the local hospital ER. An Immediate Jeopardy (IJ) situation was identified on 07/07/2023 at 5:20 p.m. While the IJ was removed on 07/11/2023 at 13:5012 p.m., the facility remained out of compliance at a scope of isolated with no actual harm with the potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice placed residents at risk for accidents, a diminished quality of life and suicide. Findings included: Review of Resident #1's undated face sheet revealed a [AGE] year-old female with admitted [DATE]. Diagnoses included altered mental status, unspecified, urinary tract infection, and depression. Review of Resident #1's physician order dated 06/22/2023 reflected: Psychologist or Psychiatrist to evaluate and treat as needed. Review of Resident #1's 5-days MDS assessment dated [DATE] revealed a BIMS score of 00, which indicated severe cognitive impairment. Review of Resident #1's care plan dated 06/23/2023 revealed the resident had an ADL self-care performance deficit and limited physical mobility, the resident had a psychosocial wellbeing problem, and was a full code (f a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive). The care plan also reflected the resident was having adjustment issues and voiced she wanted to die, staff witnessed guest attempting to harm self when entered room initiated on 06/26/2023. Review of Resident #1's Progress note dated 06/23/2023 at 12: 37 p.m. written by the OT reflected During OT evaluation, patient stated to OT I don't want to live and refused to use oxygen despite education and reflected of recommended medical intervention. Review of Resident #1's NP progress notes dated 06/23/2023 written by NP B reflected: Notified by therapy that patient is refusing to wear oxygen and is saying that she is ready to die. She is satting (oxygen level) in the 80s without nasal cannula, does not appear to be short of breath, however. Patient has very poor English, but she is telling me that she is old and should not have lived this long anyway. Extensive emotional support offered. We discussed that she should be able to make progress and go back home but she says she does not want to try. Denies any plans of actively hurting herself. PHQ-9 Screening: In the past two weeks, how often have you been bothered by any of the following problems? 0 = not at all 1 = several days 2 = more than half the days 3 = nearly every day 1. little interest or pleasure in doing things? 3 2. Feeling down, depressed, or hopeless? 3 9. Thoughts that you would be better off dead, or of hurting yourself in some way? 2 Review of Resident #1's PHQ9 (The 9-question Patient Health Questionnaire is a diagnostic tool introduced in 2001 to screen adult patients in a primary care setting for the presence and severity of depression. It rates depression based on the self-administered Patient Health Questionnaire) assessment conducted by the social worker dated 06/26/2023 at 9:34 a.m. reflected a score of 15, Moderately Severe Depression (staff Observation). It was also reflected Resident #1 answered yes to the question state that life isn't worth living, wishes for death, or attempts to harm self-symptom presence and state that life isn't worth living, wishes for death, or attempts to harm self-symptom presence 2-6 days. Review of Resident #1's Progress notes dated 06/26/2023 at 12:02 pm written by LVN A reflected Guest requested to speak with family. Called guest family for guest to speak. Left room with guest sitting in wheelchair on the phone with speaking with family. Then observed guest banging phone on bedside table repeatedly stating get me out of here. why am I here. I'm going to kill myself. I just want to die. Reported to DONNCO. Guest still on phone with family member. NCO states will notify social work. Review of Resident #1's incident report dated 06/26/2023 at 2:50 p.m. reflected Resident #1 was found by social services sitting in a wheelchair in her bathroom with the call light cord wrapped and tied around her neck. The Resident was unable to give description of incident. Continuously states she wants to kill herself. Review of Resident #1's progress notes dated 06/26/2023 at 2:56 pm written by the Social Worker reflected: This writer was walking down the hallway and noticed that guest's light was red, this writer knocked and then entered the room. This writer called out and didn't see the guest in bed- as I turned into the bathroom this writer found the guest with the emergency cord wrapped and tied around her neck. The writer ran into the hallway and found two therapists to come assist. The two therapists followed this writer into the guest's room/bathroom where they untied her cord. This writer informed DON that guest needed to be sent out for a Psych Eval. Review of Resident #1's progress notes dated 06/26/2023 at 2:57 p.m. written by the PT reflected: entered pt's room approximately 10:40AM pt. stating Give me a knife, I want to kill myself, throw me out the window. Reported to DOR who then immediately reported at 10:50AM to social worker and administration. Later in the day passing by pt.'s room approx. 2:55PM social worker asking for help due to pt. wrapping call light cord around neck in bathroom. Review of Resident #1's progress notes dated 06/26/2023 at 3:01 p.m. written by the DOR reflected: At 10:50am PT notified me that pt. made reports of wanting to kill herself and just die. Immediately notified SW and GM about guest's reports and ensured a referral had been made to psychology services and for following up. Review of Resident #1's MDS dated [DATE] reflected It was noted Resident #1 was discharged on [DATE]. During an interview on 07/07/2023 at 11:04 a. m. the PT stated Resident #1 expressed not wanting to live during therapy initial evaluation on 06/23/2023 and the Director of Rehabilitation was notified immediately. The PT stated the DOR notified the GM, DON and Social Services. The PT stated on 06/26/2023 Resident #1 asked her (PT) to give her a knife or throw her out through the window along with the trash, and Resident #1 stated she wanted to kill herself. The PT stated, she left Resident #1 in the room by herself to notify the Director of therapy. The PT stated, I guess it was not safe to leave her (Resident #1) by herself in the room. The PT stated later that day, at about 2:55 p.m. she was approached by the Social Worker asking for help for Resident #1. The PT stated when she walked into Resident #1's room, Resident #1 had the cord from the call light around her neck, but not completely. The PT stated she then wheeled Resident #1 to the nurse's station and notified LVN A of the incident. During an interview on 07/07/2023 at 11:21 a.m. LVN A stated on 06/26/2023 at about 08:00 am was the first day she heard Resident #1 verbalize wanting to die. LVN A stated while Resident #1 was on the phone with family, she heard Resident #1 telling family she wanted to kill herself. LVN A stated she notified the DON and the ADON about Resident #1's behavior. LVN A stated staff were going back and forth to Resident #1's room due to Resident #1 being agitated, banging the phone on the table, yelling, and screaming out loud. LVN A stated everyone knew about Resident #1's behavior and Resident #1's room door was kept opened. LVN A stated she was on her break when the Social Worker found Resident #1 in the restroom with the cord from the call light around her neck. LVN A stated Resident #1 was taken to the nurse's station after the incident and Resident #1 made multiple attempts hitting her forehead, motion of stabbing herself and attempts to hit staff. During an interview on 07/07/2023 at 11:49 a.m. the Social Worker stated on 6/26/23, she saw a flashing red light from Resident #1's room. The social worker stated she called out Resident #1's name and she did not respond. The social worker stated Resident #1 was found in the restroom in her room with the cord from the call light in the restroom around her (Resident #1) neck and the resident was pulling on the cord. The Social Worker stated she ran out for help and saw 2 therapy staff one of which was the PT. The Social worker stated the therapy staff took the cord from around Resident #1's neck. The Social Worker stated maybe 2 hours prior to the incident, the DOR sent a group text to she (social Worker) and the GM that Resident #1 made a statement of wanting to die. The Social worker stated she was going to make a referral to Psych but Resident # 1 attempted suicide before she could. The social Worker stated during her initial assessment with Resident #1, Resident #1 had depression noted. During an interview on 07/07/2023 at 12:19 p.m. the DOR stated she was notified by the PT on 06/23/2023 that Resident #1 expressed being depressed and she immediately notified the Social Worker and the GM. The DOR stated during one of Resident #1's treatment sessions, on the morning of 06/26/2023 Resident #1 asked that the PT give her a knife and throw her out with the trash. The DOR stated she immediately notified the GM and the social worker. If a resident says she does not want to live, it should be taken seriously that is serious. The DOR stated usually the first time a resident expressed wanting to harm themselves the DON and NP were notified. The DOR stated, You know it is not uncommon for people to express the need of wanting to kill themselves, I just make my report and those who are trained to take care of it, takes care of it. On the day she was sent out, that was the day she was expressing more of a direct suicidal ideation. During an interview on 07/07/2023 at 12:35 p.m. the DON stated she was made aware of the initial statement made by Resident #1 on 06/23/2023 and she assessed Resident #1, but she did not document her assessment. The DON stated she was made aware the second time Resident #1 verbalized she wanted to die on 06/26/2023. The DON stated staff were monitoring the resident by making frequent rounds. The DON stated the facility did not provide one on one monitoring due to staffing. The DON stated she could not say why Resident #1 was not sent out after verbalizing the second time that she wanted to die since the facility was not able to provide one on one monitoring. During an interview on 07/07/2023 at 3:42 p.m. NP B stated she was notified on 06/23/2023 by therapy and nursing that Resident #1 verbalized not wanting to live. NP B stated she assessed Resident #1, and Resident stated she did not want to live. NP B stated Resident # 1 had no plan, was weak at the time, could not move, had no strength, and could not carry out what she was saying. NP B stated Resident #1's statement was passive and had no plan and if Resident #1 had a plan, she would have spoken to the DON to follow the facility's protocols regarding suicide. During an interview on 07/07/2023 at 5:29 p.m. the GM stated she only heard about Resident #1 wanting to die on 06/26/2023. The GM stated the procedure to follow for a resident with suicidal ideation was reflected on the behavior monitoring policy. The GM stated, I did not know she had said it earlier. Now I am understanding why it was an IJ. We have the behavioral monitoring policy, if a resident has a plan, we will send them to the hospital for evaluation and monitoring. During an interview on 07/10/2023 at 10:48 a.m. NP C stated NP B informed her on 06/23/2023 sent her a communication that Resident #1 wanted to die but had no plans. NP C stated she worked on 06/26/2023 and was not made aware Resident #1 continued to have suicidal ideation until after the incident. NP C stated if she was made aware, she would have assessed Resident #1, and if she was suicidal, she would have sent Resident #1 to the ER for immediate psychiatric consult. NP C stated they can try to monitor but this was not the right setting for them, and sending the resident out was better. NP C stated Resident #1 should have been assessed; it was not the best thing to leave Resident #1 by herself in the room. During an interview on 07/10/2023 at 11:13 a.m. the ADON stated on 06/23/2023 he was told by the PT Resident #1 did not want to wear her oxygen. He stated he went to assess Resident #1 and she was sating (oxygen level) in 93-94% on room air and the family stated Resident #1 did not wear oxygen at home. The ADON stated LVN A did not notify him on 06/26/2023 about Resident #1 verbalizing that she wanted to die. The ADON stated the next time he heard of Resident #1 wanting to die was after she attempted to kill herself. The ADON stated, If I had known prior, I was going to notify the GM, DON made sure Resident #1 was safe, have someone to watch her, initiate one on one visit, notify the physician, family, if she got violent, we would activate 911. Review of the facility's policy titled BEHAVIOR EMERGENCY POLICY revised 04/2023 reflected: The goal of the facility is to provide a safe, secure environment. To foster a safe environment, a consistent staff approach to behavioral problems and emergencies are necessary. Responsible Party: Nursing Staff, Social Services, GM. Policy The goal is to use the least restrictive behavioral interventions and move through the steps at increments necessary to maintain a safe environment. No forms of seclusions are permitted, however, separation from other residents or staff is allowed for a short period of time to reduce agitation. Staff should remain calm and professional at all times. Demonstrate empathy and offer reassurance of safety: I understand your situation, you are safe here, you don't need to be afraid, etc. Set verbal limits: please keep your voice down, stop swinging your arms, etc. Escort to private area - a quiet room with decreased external stimulation for a short amount of time may help calm the resident and provides privacy. Initiate 1:1 observation/monitoring as needed until the resident is calm. Offer medication - utilize physician order for a medication explaining to the resident how the medication will help them. Notify physician for transfer to emergency room for evaluation of behavioral disturbance. If resident becomes violent to staff or others, call 911 for outside intervention. After the incident, document in the nursing notes: a. The president's behavior and/or symptoms at the onset. b. The events and/or reasons potentially contributing to the president's behavior. c. An assessment of the resident. d. Each intervention utilized. e. Notification of family/physician and subsequent orders Review of the facility's policy titled Behavioral Monitoring dated July 2020 reflected: To ensure behavioral monitoring is completed in accordance with all state and federal requirements. Responsible Party: GM, DON Policy/Procedure: 1. Residents that are exhibiting behaviors, and/or that are receiving psychotropic medications will have behavioral monitoring completed by licensed facility nursing staff. 2. Behavioral monitoring may be completed on paper or within the facility electronic medical record. 3. Behavioral monitoring may include but isn't limited to the type(s) of behaviors being exhibited, non-pharmacological interventions attempted prior to administering medications, and the outcome of the non-pharmacological and/or pharmacological interventions. 4. Residents who are exhibiting new and/or increased behaviors that are not improving with non-phar-macological and/or pharmacological interventions may be referred to psychiatric and/or psychology services for further treatment interventions. 5. In the event the resident is exhibiting suicidal and/or homicidal ideations, the physician will be notified and increased intensive staff monitoring implemented until the resident can be transferred to a higher level of care. This was determined to be an Immediate Jeopardy (IJ) on 07/07/2023 at 5:20 p.m. The General Manager and DON were notified. The General Manager was provided with the IJ template on 07/07/2023 at 5:20 p.m. The following Plan of Removal submitted by the facility was accepted on 07/10/2023 at 3:12 p.m.: Plan of Removal Immediate Jeopardy On 07/07/2023 an abbreviated survey was initiated at the facility. On 07/07/2023 the surveyor provided an Immediate Jeopardy (IJ) notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. The notification of Immediate Threat states as follows: F742-The facility failed to ensure each resident received adequate supervision and assistance to prevent accidents for one of (Resident # 1) one residents reviewed for suicidal ideation. Action: Resident #1 was sent to the emergency room for further psychiatric evaluation on 6/26/2023. She did not recall the incident during her ER evaluation. She was not admitted and transferred to another SNF on that same day. Action: All active residents currently in the facility had PHQ-9 (Patient Health Questionnaire) screening done by Director of Care Transitions and/or Designee. Any resident scoring 10 or higher (which indicates moderate depression) has been referred to psych services on July 10th, by Director of Care Transitions and/or Designee. On July 10th, Director of Care Transitions or nurse/designee notified physician, responsible party, Director of Nursing and GM. Behavior Monitoring Policy and/or Behavior Emergency Policy were followed based on specific resident behaviors. These team members will be involved in setting up a safe plan if resident voices suicidal ideations voiced during PHQ-9 intake that would include 1:1 monitoring until resident is transferred to hospital and removing any items that could be used by resident as harm (silverware, shoelaces, call light cords, etc.). Staff to be notified of resident safety plan requirements until discharged . The PHQ-9 is a questionnaire that is administered with MDS Assessment cycle which includes change of condition. It can be used at any time to determine if resident is experiencing depression and there is not a requirement on who is able to conduct the PHQ-9 with residents. Start Date:7/8/2023 Completion Date: 7/8/2023 by midnight Responsible: Director of Care Transitions (Social Worker) and/or Designee Action: All staff including GM and Director of Nursing have received training on reporting of resident threat to self/voicing suicidal ideations immediately utilizing our Behavior Emergency Policy and Behavioral Monitoring Policy by 7/8/23. Any staff on leave/agency/prn to be in-serviced prior to return to duty. The Behavior Emergency Policy and the Behavior Monitoring Policy will be followed when residents experience suicidal ideation. Start Date: 7/8/2023 Completion Date: 7/8/2023 Responsible: GM and Director of Nursing Services (trained by Regional Clinical Support for the facility prior to training facility staff) Action: Director of Nursing has conducted health and welfare rounds on all in house residents on 7/8/2023 and then will continue completing health and welfare rounds on all in house residents by DON/designee: daily for 2 weeks, weekly for 1 month, and randomly thereafter. DON was trained by Regional Clinical Support on 7/8/2023. All results reported to monthly QAPI committee on July 10th, for review of trends and action as needed. If suicidal ideations are voiced during rounds, DON/Designee will notify physician, responsible party, the GM and Director of Care Transitions immediately. The Behavior Emergency Policy and the Behavior Monitoring Policy will be followed when residents voice suicidal ideations. These team members will be involved in setting up a safe plan when resident voices suicidal ideations voiced during health and wellness rounds or at any time to any staff member that would include 1:1 monitoring until resident is transferred to hospital and ensuring a safe environment removing any items that could be used by resident as harm (silverware, shoelaces, call light cords, etc.). QAPI Committee includes, Medical Director, DON, GM, Social Services, Environmental Services, HR, Pharmacist. Any residents that have suicidal ideations during initial rounds on 7/8/2023 will be discussed with the GM, DON, and Directors of Care Transitions for safety plan. Care plans to be initiated and physician and responsible party to be notified immediately. Start Date: 7/8/2023 Completion Date: 7/8/2023 for initial rounds; then ongoing Responsible DON/Designee Action: All residents admitted with a diagnosis of depression and/or psychotropic medications will be referred to psych services within 72 hours of admitting by Director of Nursing or Director of Care Transitions or designee. Prior to psych services referral, Director of Care Transitions or DON or designee will notify physician, responsible party and GM immediately if resident is voicing suicidal ideations. These team members will be involved immediately in setting up a safe plan based which could include but are not limited to referral to psych services, 1:1 monitoring, transfer to hospital and ensuring a safe environment for resident. Psych services typically visit on a weekly basis for neuropsych evaluations can be expedited as needed. Any resident voicing suicidal ideations will be provided with 1:1 monitoring until transferred to hospital and will remain in a safe environment in which any items that could be used as harm will be removed (silverware, shoelaces, call light cords, etc). Start Date: 7/8/2023 Completion Date: ongoing Monitoring of the plan of removal was completed on 07/11/2023 and revealed the following: During an interview on 07/11/2023 at 11:26 a.m. LVN A stated she was on what serviced on what to do in a suicidal situation. LVN A stated they were to notify the DON and the GM. LVN A stated the Resident was not to be left alone, they should be placed on 1:1 care/monitoring. LVN A stated the resident should be in an environment that is safe and free from anything that could be used potentially to harm themselves. During an interview on 07/11/2023 at 11:54 a.m. LVN D stated she was in-serviced on 07/10/2023 on suicidal ideations. LVN D stated when a resident was having suicidal ideation, she would call the DON and the GM, and notify the doctor and the social worker for psych evaluation. LVN D stated she would continue to monitor the resident, make sure the resident is given plastic silverware only, the call light would be taken away from the resident, and the resident would be monitored visually. monitoring. LVN D stated she would not leave the resident in a room when they were expressing to harm themselves. LVN D stated, you cannot assume a resident would not kill themselves after they have verbalized it. During an interview on 07/11/2023 at 12:17 p.m. CNA E stated she was in-serviced on 07/10/2023 on suicidal ideations. She stated she had to make sure she stayed with the resident and called the DON. During an interview on 07/11/2023 at 12:35 p.m. CNA F stated she was in-serviced on 07/10/2023 on who to notify when a resident verbalized harming self and how to keep a resident safe. CNA F stated If someone made a statement to harm themselves or physically harm themselves, they would be put on one-on-one supervision in a safe area in their room. She stated she would try to get more information from the resident and call her supervisor to intervene but would never leave the resident alone. During an interview on 07/11/2023 at 12:46 p.m. the Social Worker stated she was in-serviced on 07/10/2023 on Residents with suicidal ideations. The social Worker stated if a resident verbalized wanting to kill self or not wanting to be here, she would ask the resident if they had a plan. The social worker stated it was important for whoever getting the information to alert the DON, ADON, the GM and her (Social Worker). The Social Worker stated, when alerted by another staff of a resident having suicidal ideation, she would discuss feelings with the resident and based on the findings the resident would be transferred to the ER. During an interview on 07/11/2023 at 12:58 p.m. the DOR stated on 07/10/2023 she was in-serviced on the Behavior monitoring policy, and how to respond to the resident when they were having suicidal or homicidal ideation. The DOR stated she would try to figure out the trigger., and seclude the resident as needed. The DOR stated for residents with suicidal ideations, no seclusion was needed, empathy, least restrictive modification. The DOR stated they were trained who to notify by following the tree/chain of command, including the GM, DON, ADONANCO, and social workers. The DOR stated she was responsible to in-service therapy staff as they got back to work. The DOR stated the DON and GM were in-servicing other staff as they came back to work. During an interview on 07/11/2023 at 1:54 p.m. the PT stated she was in-serviced by the DOR on 07/10/2023 regarding the behavioral modification process. The PT stated if a resident expressed suicidal ideation, the DOR, GM and the DON were to be notified, and do not leave the resident by themselves. Record review of the facility's Inservice, dated 07/07/2023, reflected the following trainings were instructed by the DOO and participants were the DON and the GM. Suicidal Ideation and Behavioral Monitoring During an interview on 07/11/2023 at 1:23 p.m. the DON stated she and the GM were in-serviced on 07/07/2023 by the DOO regarding Behavioral monitoring and Residents with suicidal ideation, the process and mechanism of action and her responsibilities when a Resident verbalized suicidal ideation. The DON stated she initiated the in-services for all other staff on 07/08/2023. The DON stated she, the GM, the DOR and the ADON were responsible to make sure all staff were in-serviced prior to working their shifts. The DON stated she completed Health and Welfare Resident Audits on all Residents on 07/08/2023, 07/09/2023, and 07/10/2023; and the ones for 07/11/2023 were in progress. During an interview on 07/11/2023 at 1:38 p.m. the GM stated she and the DON were in-serviced on 07/07/2023 by the DOO regarding Behavioral monitoring and Residents with suicidal ideation, the process, and her responsibilities when a Resident verbalized suicidal ideation. The GM stated the 2 policies were reviewed, when a resident verbalized suicidal ideation, the staff would call for help and never leave the resident alone. The GM stated the nurses would assess the resident and notify the RP, Physician, and initiate one-on-one monitoring until the resident was transferred to the ER. Record review of the facility's Inservice, dated 07/08/2023, reflected the following trainings were instructed by the DON and the GM and the participants were all other staff in the facility. Behavioral Emergency Policy. Adequate supervision and assistance to prevent accidents Record review of facility's POR documentations reflected Health and Welfare Resident Audits were completed on all Residents on 07/08/2023, 07/09/2023, and 07/10/2023 by the DON. Record review of facility's POR documentations reflected 36 Residents BIMS and PHQ9 assessments were completed by the Social Worker The GM was informed the Immediate Jeopardy was removed on 07/11/2023 at 1:50 p.m. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.