Every finding on record at Ivy Creek Wellness & Rehabilitation

Based on interview and record review the facility failed to immediately inform the resident, consult with the resident's physician and notify, consistent with his or her authority, the resident representative(s) when there was a significant change in the resident's physical, mental, or psychosocial status in either life-threatening condition of clinical complications for one of eight residents (Resident #1) reviewed for resident rights. The facility failed to notify Resident #1's FM when she refused meals on 6/20/2026, 6/21/2026, 6/22/2026, 6/23/2026, 6/24/2026, and 6/25/2026. This failure could place residents at risk of a decreased quality of life and risk of not having their responsible party represent them in medical and care decisions.Findings include: Review of Resident #1's face sheet dated 6/30/2026 reflected she was a [AGE] year-old female admitted on [DATE] with diagnoses that included: type 2 diabetes (blood sugar regulation disorder), chronic kidney disease (progressive decline of kidney function), chronic obstructive pulmonary disease (a progressive lung condition that causes breaking difficulties), chronic pain, and cognitive impairment (problems with memory, attention, language or judgment that go beyond normal aging). Review of Resident #1's quarterly MDS assessment reflected a BIMS score of 2 suggesting severe cognitive impairment. Review of Resident #1's physician's orders reflected an order dated 4/10/2026 for hospice to evaluate and start treatment. Review of Resident #1's Care plan for May 2026 reflected the focus: Resident refuses to eat meals or drink fluids consistently, placing self at risk for dehydration, weight loss and nutritional deficiencies. Interventions included: Assist [resident] with meals, document meal and fluid intake daily, engage resident in social dining, and involve resident in food choices. Review of Resident #1's Progress notes dated 6/20/2026 to 6/30/2026 reflected no nursing entries related to refusal of meals or that FM was notified of refusals. Review of Resident #1's Plan of Care [sic] Response History reflected resident refused meals on:6/20/2026 - lunch6/21/2026 - breakfast6/22/2206 - breakfast and dinner6/23/2026 - all meals6/24/2026 - breakfast and lunch6/25/2026 - breakfast and lunch. During an interview on 6/30/2026 at 2:18 pm, Hospice Nurse (HN) stated Resident #1 will frequently refuse care, bathing, wound care, medication and meals. She stated Resident #1's capacity to refuse is questionable. When staff try to provide care, she will get upset, yell, curse at staff and then refuse care. HN stated she has seen staff bringing meals in and offering it to Resident #1 and she will refuse, when they try to feed her, she gets upset. She stated since Resident #1 has been on hospice services she has gone from eating to not eating much at all,. She stated this is was part of the process of overall natural decline; Resident #1 is was being asked if she is was hungry and she says no. HN stated she has tried to feed Resident #1 herself and she has refused to eat. HN stated she was not aware the facility was not notifying the FM when meals were refused. During an interview on 7/1/2026 at 1:17 pm, FM stated they were not aware Resident #1 had been refusing so many meals lately. She stated when FM was notified previously, they would try to come up to the facility with food and try to get the resident to eat. FM stated they have not gotten any calls in at least a month that Resident #1 was refusing meals. FM stated because of Resident #1's dementia she will get irritated and won't want to eat. She stated they do have a camera in the room and if they see her refusing a meal, the family will intervene and bring her food. FM stated if they don't catch it on the camera, they have no way of knowing she has refused, because the facility is not notifying them. FM stated she had no idea Resident #1 had missed that many meals since 6/20/2026 and she was very upset the facility had not called. During an interview on 7/1/2026 at 10:16 am, MD stated she was familiar with Resident #1 who was on hospice and frequently refused care. She stated it is normal for a resident near end of life to refuse care and refuse meals. She stated staff should be documenting refusals of care or eating and notifying appropriate FM and nursing staff. She stated she noted Resident #1 was weighed in April, but typically once they go on hospice she does not feel they need weight checks. MD stated she was aware that Resident #1 was refusing to be weighed. During an interview on 7/1/2026 at 1:52 pm, DON stated if a resident refused a meal, staff should offer a supplement and let the nurse know. She stated if the resident still refuses when the nurse tries, it should be documented in the EMR and call FM. She stated Resident #1's FM wasn't to be notified if there are any refusals and staff need to notify FM. DON stated she used to be able to go in there and get Resident #1 to agree to care, agree to would wound care, agree to eat a meal, but now she will not do anything - Resident #1 doesn't want to be bothered, she wants to be left alone. Review of facility policy. , Resident Rights revised 8/2020 reflected: All residents have a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility including those specified in this policy. The Facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment, that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The Facility will protect and promote the rights of the resident and provide equal access to quality of care regardless of diagnosis, severity of condition, or payment source. C. Choose a physician and treatment and participate in decisions and care planning, including involving representatives and considering personal and cultural preferences;D. Be fully informed and participate in his/her treatment including being fully informed in a language that he or she can understand of his/her total health status including his/her medical condition;

Based on interview and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 resident (Resident #2) of 3 residents reviewed for accidents and hazards The nursing facility failed to ensure there was appropriate supervision to prevent Resident #2 from going missing on 6/28/2026 for 30-40 minutes resulting in sunburn to his scalp, arms, legs and face. This failure could place residents at risk of serious injuries from falls, heat-related emergencies from heat exposure and injuries from traffic accidents.Findings include: Review of Resident #2's face sheet dated 6/30/2026 reflected he was a [AGE] year-old male admitted on [DATE] with diagnoses that included: Alzheimer's disease (a progressive brain disorder that destroys memory and thinking skills), anxiety disorder, hyperlipidemia (elevated levels of cholesterol in the blood), major depressive disorder (depression), and insomnia (inability to sleep). Review of Resident #2's quarterly MDS assessment dated [DATE] reflected he had a BIMS score of 99 indicating he was unable to complete the interview. Under section C - Cognitive patterns staff indicated Resident #2 had both long term and short-term memory problems. Review of Resident #2's annual MDS assessment dated [DATE] reflected he had a BIMS score of 8 suggesting moderate cognitive impairment. Review of Resident #2's progress notes on 6/30/2026 at 1:08 pm reflected no progress notes for 6/28/2026 regarding resident being missing from the facility. Review of Resident #2's skin assessment dated [DATE] at 2:02 pm, reflected the following: Type of skin impairment: top of scalp - sunburn; other - bilateral forearms; other - bilateral lower extremities. Review of Resident #2's elopement assessment dated [DATE] reflected a score of 1 indicating a category or of no risk. During an interview on 6/28/2026 at 12:00 pm Resident #2 stated he wanted to go for a walk to go to church and the gate was open, so he left. Resident stated he was not hurt just sunburned. He stated he got a ride back with a staff person and then they checked him over. He stated they gave him drinks and watched him. During an interview on 6/28/2026 at 1:14 pm, FM stated they had arrived at the facility on 6/28/2026 at 12:30 pm to visit Resident #2. They went to his room, and he was not in his room. FM checked with staff and they were not able to locate Resident #2 in the building. FM stated about 20 minutes later Resident #2 arrived back at the facility, after being delivered by another staff member. FM stated Resident #2 had been at the facility since September of 2025 and had never left the building. During an interview on 6/30/2026 at 12:30 pm, DON stated she was aware of Resident #2 going missing on 6/28/2026. She stated Resident #2 had been seen by staff about 12:15 and was discovered missing when they delivered his lunch tray to his room around 12:30pm. DON stated Resident #2 had no history of being exit seeking or saying he wanted to leave the facility. She stated his recent elopement assessment indicated he was low risk. DON stated with Resident #2 leaving the facility and going missing - he could have been hit by a vehicle, he could fall (resident had no history of falls), dehydration, or heat exhaustion. During an interview on 6/30/2026 at 3:24 pm, Nurse A stated she was working on day shift on 6/28/2026 when Resident #2 went missing. She stated he had been seen walking back and forth to the dining room about 12:10-12:15 pm, then when they went to deliver his lunch tray in his room, they could not find him. She stated they started looking through the facility for him and could not locate him, but about that time, HKPS called her and told her she found him down the road and was bringing him back in her car. She stated she completed a skin assessment and noted he had sunburn to both arms and the top of his head and face but no other injuries. During an interview on 6/30/2026 at 5:07 pm, HKPS stated on 6/28/2026 at about 12:45 pm, she saw Resident #2 while she was driving down the street away from the facility. She stated she found him on the opposite side of the street from the facility several blocks down. HKPS stated she pulled over in a parking lot and asked Resident #2 to get in her car so she could take him back and he did. HKPS stated she called the facility and spoke to the charge nurse, Nurse A, and told her she had Resident #2 and was bringing him back to the facility. During an interview on 7/1/2026 at 8:48 am, ADM stated she was aware of Resident #2's incident on 6/28/2026. She stated Resident #2 had no history of exit seeking behaviors or expressing a desire to leave. She stated he was able to walk out the magnetic gate on the patio because someone failed to close it properly. She stated they had Maintenance look at the gate after the incident, and it was functioning properly ADM stated they were in the process of changing out the keypad on the gate to make it more secure and keep staff from using it as an entrance or exit. She stated in-services with staff have been done to ensure the patio gate is not used by staff. During an interview on 7/1/2026 at 9:15 am, the Maintenance Director stated he was aware of the incident on 6/28/2026 when Resident #2 walked out of the patio gate. He stated he came up to the facility on 6/28/2026 and inspected the gate and it was working properly. He stated the only thing he could think of is maybe a staff member went through the gate and did not let make sure it closed and the magnetic latch caught. He stated they were in the process of changing out the keypad right now and upgrading the locking mechanism. He added that only leadership would have the code to prevent staff from using the gate to go in and out. During an interview on 7/1/2026 at 10:16 am, MD stated she was never notified of Resident #2 going missing on 6/28/2026, but she was told the NP was notified and gave orders for Resident #2. She stated to her knowledge Resident #2 did not have any wandering or exit seeking behaviors and had a low elopement risk score when he was assessed back in March 2026. MD stated Resident #2 had a diagnosis of Lewy Body Dementia and cognition levels could fluctuate from day to day and even during the day. MD stated he could have been seriously injured being out in the heat in his confused state. During an interview on 7/1/2026 at 11:23 am, NP stated she was aware of the event with Resident #2 on 6/28/2026. She stated Resident #2 did not have a history of wandering or trying to leave the facility and had been stable for quite some time with no noted exit seeking behaviors. She added he had been assessed back in March 2026 for elopement and was a very low risk. She stated the potential harm to the resident by walking away from the facility during the day would have been extreme heat related conditions - heat exhaustion, heat stroke, dehydration which could lead to electrolyte imbalances. Review of facility policy Wandering & Elopement revised 8/2020 reflected: The Facility will identify residents at risk for elopement and minimize any possible injury as a result of elopement. Further: I. The Licensed Nurse, in collaboration with the Interdisciplinary Team (IDT), will assess residents upon admission, readmission, quarterly, and upon identification of significant change in condition to determine their risk of wandering/elopement.II. The resident's risk for elopement and preventative interventions will be documented in theresident's medical record, and will be reviewed and re-evaluated by the IDT upon dm ssreadmission, quarterly, and upon change in condition. A facility policy on Supervision of Residents was requested on 6/30/2026 at 10:41 and again on 7/1/2026 at 2:47 pm but not provided prior to exit on 7/1/2026.

Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately but not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for one of eight (Resident #2) residents reviewed for reporting abuse and neglect. The nursing facility failed to report to the state agency that Resident #2 was missing on 6/28/2026 for 30-40 minutes resulting in sunburn to his scalp, arms, legs and face. This failure could place residents at risk of serious injuries from falls, heat-related emergencies from heat exposure and injuries from traffic accidents.Review of facility policy Abuse Prevention and Prohibition Program dated revised October 24, 2022, reflected I. Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property. D. Facility will report allegations of. use, neglect, exploitation, mistreatment, injuries of unknown source, misappropriation of resident property, or other incidents that qualify as a crime.i. Immediately but no later than 2 hours after forming the suspicion - if the alleged violation involves abuse or results in serious bodily injury to the state surveyagency, adult protective services, law enforcement, and the Ombudsman (if applicable per state regulation).ii. No later than 24 hours after forming the suspicion - if the alleged violation (e.g. misappropriation of property, neglect) does not involve abuse and does not result in serious bodily injury to the state survey agency, adult protective services, law enforcement, and the Ombudsman. Review of Provider Letter PL 2024-14, titled Abuse, Neglect, Exploitation, Misappropriation of Resident Property and Other Incidents that a Nursing Facility (NF) Must Report to the Health and Human Services Commission (HHSC) with date issued: August 29, 2024 reflected: 2.1 Incidents that a NF Must Report to HHSC A NF must report to CII the following types of incidents, in accordance with applicable state and federal requirements: Abuse Neglect Exploitation Death due to unusual circumstances4 A missing resident Misappropriation Drug theft Suspicious injuries of unknown source Fire Emergency situations that pose a threat to resident health and safety8 Communicable disease situations that are an unusual or abnormal event that poses a threat to resident health and safety Review of facility policy Wandering and Elopement dated revised 8/2020 reflected: PurposeTo enhance the safety of residents of the facility and VII. Response to Resident ElopementG. The facility will make necessary reports to state agencies. Resident #2 Review of Resident #2's face sheet dated 6/30/2026 reflected he was a [AGE] year-old male admitted on [DATE] with diagnoses that included: Alzheimer's disease (a progressive brain disorder that destroys memory and thinking skills), anxiety disorder, hyperlipidemia (elevated levels of cholesterol in the blood), major depressive disorder (depression), and insomnia (inability to sleep). Review of Resident #2's quarterly MDS assessment dated [DATE] reflected he had a BIMS score of 99 indicating he was unable to complete the interview. Under section C - Cognitive patterns staff indicated Resident #2 had both long term and short-term memory problems. Review of Resident #2's annual MDS assessment dated [DATE] reflected he had a BIMS score of 8 suggesting moderate cognitive impairment. Review of Resident #2's progress notes on 6/30/2026 at 1:08 pm reflected no progress notes for 6/28/2026 regarding resident being missing from the facility. Review of Resident #2's skin assessment dated [DATE] at 2:02 pm, reflected the following: Type of skin impairment: top of scalp - sunburn; other - bilateral forearms; other - bilateral lower extremities. Review of Resident #2's elopement assessment dated [DATE] reflected a score of 1 indicating a category or of no risk. During an interview on 6/28/2026 at 12:00pm Resident #2 stated he wanted to go for a walk to go to church and the gate was open, so he left. Stated he was not hurt just sunburned. He stated he got a ride back with a staff person and then they checked him over. He stated they gave him drinks and watched him. During an observation on 6/28/2026 at 12:00pm Resident #2 was observed to have redness to the back of his neck, above the collar line and below the hairline, redness on head/face, and redness on his arms; legs were not visualized as Resident #2 had pants on. During an interview on 6/28/2026 at 1:14 pm, FM stated they had arrived at the facility on 6/28/2026 at 12:30 pm to visit Resident #2. They went to his room, and he was not in his room. FM checked with staff and they were not able to locate Resident #2 in the building. FM stated about 20 minutes later Resident #2 arrived back at the facility, after being delivered by another staff member. FM stated Resident #2 had been at the facility since September of 2025 and had never left the building. During an interview on 6/30/2026 at 12:30 pm, DON stated she was aware of Resident #2 going missing on 6/28/2026. She stated Resident #2 was assessed when he returned to the building and had some mild sunburn but no serious injuries and did not complain of any pain or injuries. DON stated Resident #2 had no history of being exit seeking or saying he wanted to leave the facility. She stated his recent elopement assessment indicated he was low risk. DON stated with Resident #2 leaving the facility and going missing - there was serious potential for harm - he could have been hit by a vehicle, he could have stepped off a curb and fell, dehydration, heat exhaustion; could have gotten, heat stroke and became disoriented. She stated any and all of those could have been life threatening. During an interview on 6/30/2026 at 3:24 pm, Nurse A stated she was working on day shift on 6/28/2026 when Resident #2 went missing. She stated he had been seen walking back and forth to the dining room about 12:10-12:15 pm, then when they went to deliver his lunch tray in his room, they could not find him. She stated they started looking through the facility for him and could not locate him, but about that time, HKPS called her and told her she found him down the road and was bringing him back in her car. She stated she assessed Resident #2 when he got back and noted some light sunburn to his arms, face, scalp and legs, but no other injuries. She stated she called the NP and notified her of what happened and NP gave orders for over-the-counter aloe to treat his sunburn, some labs and a urinalysis. The NP also told her to make sure Resident #2 was encouraged to hydrate. She stated by the time all this was done, it was close to shift change, so she passed on all the information to the oncoming nurse but forgot to put in any progress notes about the incident. She stated she completed a skin assessment and noted he had sunburn to both arms and the top of his head and face. During an interview on 6/30/2026 at 5:07 pm, HKPS stated on 6/28/2026 at about 12:45 pm, she saw Resident #2 while she was driving down the street away from the facility. She stated she found him on the opposite side of the street from the facility several blocks down. HKPS stated she pulled over in a parking lot and asked him where he was going, and he said he was going for a walk. She stated she asked Resident #2 to get in her car so she could take him back and he did. HKPS stated she called the facility and spoke to the charge nurse, Nurse A, and told her she had Resident #2 and was bringing him back to the facility. She stated Resident #2 was wearing a white t-shirt and long flannel type lounge pants. She stated he looked hot but did not complain of any injuries. During an interview on 7/1/2026 at 8:48 am, ADM stated Resident #2's incident was not an elopement - he failed to sign out. ADM also stated resident had never signed themselves out before and had only left with family. ADM stated, technically he was missing for about 30-40 minutes. She stated a missing resident incident should have been reported to the state agency and it was her responsibility to report it. She stated she spoke to the corporate consultant, and they decided it didn't need to be reported because it wasn't an elopement. She stated per their policy, any incident that occurs, they go to their consultant at corporate for guidance and that is what she did. ADM stated there were several environmental risk factors with Resident #2 being missing including the extreme heat, the sun, and traffic conditions on a 4-lane roadway. ADM stated there was a potential for serious injury due to the environmental factors and the timing was fortunate in that there wasn't much traffic and a staff member saw him and brought him back to the facility quickly. During an interview on 7/1/2026 at 10:16 am, MD stated she was never notified of Resident #2 going missing on 6/28/2026, but the NP was the provider that was notified and gave orders for Resident #2. MD stated Resident #2 had a diagnosis of Lewy Body Dementia and cognition levels could fluctuate so much from day to day and even during the day. She stated her concerns for Resident #2 being missing and out in the heat in the middle of the day for 30-40 minutes would be dehydration, heat exhaustion, he could have gotten hurt from falling and injuring himself. She stated he could have been seriously hurt, and it was not a good situation for him to be in with his mental status. MD stated he could have been seriously injured being out in the heat in his confused state and some injuries could have potentially been life threatening. During an interview on 7/1/2026 at 11:23 am, NP stated she was aware of the event with Resident #2 on 6/28/2026. She stated nursing staff called her and she gave verbal orders for topical aloe vera for his sunburn, told staff to make sure he hydrates and get a urinalysis and labs done. She stated Resident #2's labs and urinalysis came back all within normal parameters. She stated Resident #2 has been very stable for a long time. She stated the potential harm to the resident by walking away from the facility during the day would have been extreme heat related conditions - heat exhaustion, heat stroke, dehydration which could lead to electrolyte imbalances. She added, in extreme measures these could lead to heart failure, which in extreme circumstances could lead to death.

Based on interview and record review, the facility failed to keep residents free from misappropriation of property for 2 of 6 residents (Resident #1 and Resident #2) reviewed for misappropriation in that: On 1/30/2025 the facility discovered Resident #1 had 60 tablets of 7.5/325 mg hydrocodone tablets missing On 2/2/2026, the facility discovered Resident #2 had 30 tablets of 10 mg hydrocodone missing This failure could place residents at risk of not receiving the intended therapeutic benefit of the medications and could result in worsening or exacerbation of chronic medical conditions, and hospitalization. Findings included: Resident #1 Review of Resident #1's face sheet dated 2/5/2026 reflected a [AGE] year-old female admitted on [DATE] with diagnoses that included: hemiplegia and hemiparesis following cerebral infarction (weakness and paralysis following a stroke), contracture right hand, contracture left hand, vascular dementia (decline in cognitive function caused by impaired blood flow to the brain), and chronic pain syndrome. Review of Resident #1's quarterly MDS assessment dated [DATE], reflected she was rarely/never understood and had both short term and long-term memory problems. Further, it reflected her cognitive skills for daily decision making were severely impaired Review of Resident #1's care plan dated 2/6/2026 reflected: Focus: I require pain management [related to] diabetic neuropathy, contractures, deconditioning, and muscle spasms; Medication: Baclofen, Gabapentin, Hydrocodone with interventions of at risk for increased pain related to a drug discrepancy; administer analgesia per orders. Give 1/2 hour before treatments or care. Review of Resident #1's physician's orders reflected an active order for:Hydrocodone-Acetaminophen Oral Tablet 7.5-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet via PEG-Tube three times a day for pain -Order Date- 01/06/2026 Review of Resident #1's narcotic count sheet reflected on 1/6/2026 64 tablets were received by LVN A Review of pharmacy manifest dated 1/5/2026 reflected 124 tablets of Hydrocodone-Acetaminophen Oral Tablet 7.5-325 MG were received for Resident #1 by LVN A. Resident #2 Review of Resident #2's face sheet dated 2/6/2026 reflected a [AGE] year-old male admitted on [DATE] with diagnoses that included: paraplegia (partial or complete paralysis of the lower half of the body), Type 2 Diabetes (blood sugar regulation disorder), heart disease, muscle wasting and atrophy, and major depressive disorder. Review of Resident #2's quarterly MDS assessment reflected he had a BIMS of 14 suggesting no cognitive impairment. Review of Resident #2's care plan dated 2/6/2026 reflected the Focus: I am at risk for pain secondary to muscle spasms [related to] paraplegia secondary to a spinal injury from a [gun shot wound] and [related to] neuropathy secondary to diabetes complications. Medication: Tylenol #3, Gabapentin, Biofreeze with interventions of Provide PRN medications as indicated. Review of Resident #2's physician's orders reflected an active order for Hydrocodone-Acetaminophen Oral Tablet 10-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 6 hours as needed for pain -Order Date- 12/28/2025. Review of Resident #2's narcotic count sheet for January reflected on 1/5/2026 60 tablets of tablets of Hydrocodone-Acetaminophen Oral Tablet 10-325 MG were received an unknown staff - signature missing. Review of Pharmacy manifest dated 1/5/2026 reflected 90 tablets of Hydrocodone-Acetaminophen Oral Tablet 10-325 MG were received for Resident #2 by LVN B. During an interview on 2/6/2026 at 9:30 am, the DON stated a nurse went to reorder Resident #1's narcotic medication and the pharmacy told her it was too soon. She investigated and discovered that LVN A had received the Hydrocodone-Acetaminophen Oral Tablet 7.5-325 MG on the narcotic count sheet, and the quantity was changed from 124 to 64 tablets. The facility suspects that LVN A was the one that made the change but there were no witnesses. She stated Resident #1 did not go without pain medication at that time. The DON stated while they were reviewing the narcotic count sheets, they discovered Resident #2 was missing 30 tablets of Hydrocodone-Acetaminophen Oral Tablet 10-325 MG. She stated there was no name written in the received box on the narcotic count sheet, just a date and an amount, but the handwriting looked like LVN A. Again, there were no witnesses. Resident #2 did not go without pain medication at that time either. She stated she interviewed LVN B, who received Resident #2's narcotic medication from the pharmacy and she stated she handed the medication off to LVN A. She stated nursing staff were following the existing policy at that time but since then, they have changed their policy on how narcotic medications will be received and distributed to the medication carts. The new process requires two nurses to receive medications and two nurses to put the medications in the cart - both nurses will sign and date the narcotic count sheets when received and put away. During an interview on 2/6/2026 at 1:51 pm, the ADM stated his expectations regarding the receipt of narcotics was that two nurses will sign for delivery, both nurses go to the cart and put meds away, then both log it, secure it and sign the sheet. They should make sure the count sheet was accurate with no cross outs and if there were any changes made to the narcotic label on the count sheet, they should immediately notify the DON or ADM. He stated when narcotic medications are not available for residents, they might be unable to control their pain or control their anxiety - they might need it to calm down. During an interview on 2/6/2026 at 2:51 pm, the MD stated his expectations regarding the management and receipt of narcotics in general that there would be zero errors, no diversion and no missing medications. He stated with diversion there was a potential of misuse, or an overdose, a danger of meds not being available and a lack of pain control for the residents. He stated he is pleased with the facility's implementation of a different process, and they recently changed pharmacies - the new pharmacy's system has more up to date technology, and it was a good move. During an interview on 2/6/2026 at 3:15 pm, the DON stated her expectations regarding the receipt of narcotics was that staff would adhere to the rules regarding getting meds from the pharmacy, storing of meds, passing keys and signing the narcotic sheets as required. She stated when narcotic medications are not available residents could have increased pain or anxiety. During an interview on 2/6/2026 at 3:40 pm, Resident #2 stated he was aware of the missing medications, but it did not affect him in any way. He stated he had no concerns with care at the facility, and his pain was being managed. Attempts to reach LVN A by phone calls and text for an interview were unsuccessful. Review of facility policy Abuse, Neglect and Exploitation dated 4/11/2025 reflected It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Definition:Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent. Policy Explanation and Compliance Guidelines:1. The facility will develop and implement written policies and procedures that:a. Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property;b. Establish policies and procedures to investigate any such allegations; andc. Include training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriate of resident property, reporting procedures, and dementia management and resident abuse prevention

Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food and nutrition services. The facility failed on 07/22/2025 to ensure dietary CK 2 used proper hand hygienewore gloves while plating food for service on the line. The facility failed on 07/22/2025 to ensure CK 1 wore a beard net while preparing food for the residents. The facility failed on 07/22/2025 to ensure dietary CK 1 washed his hands or changed his gloves while preparing pureed food for the residents and in between tasks. The facility failed on 07/22/2025 to ensure dietary CK 1 cleaned and sanitized the food processer in between pureed food items. These failures could place residents at risk for food contamination and/or foodborne illness. In an observation on 07/22/2025 at 9:35 AM of the facility's only kitchen revealed CK 1 was near the food preparation table preparing food and was not wearing a beard net. CK 1 had a visible beard and mustache no more than one inch in length.In an observation on 07/22/2025 at 10:39 AM of the facility's only kitchen revealed CK 1 was in the kitchen near the food preparation table, and three compartment sink area with his beard net pulled below his bottom lip. CK 1 was wearing gloves while moving about touching other surfaces (food processor, kitchen sink handles, sink, food processor) in the kitchen without changing his gloves after encountering different surfaces and then resumed his food handling with the same gloves.Observation on 07/22/2025 at 11:00 AM, revealed CK 1's beard net was pulled below his bottom lip while preparing pureed chicken with chicken broth. CK 1 washed the food processor in the three-compartment sink, rinsed it with running water, but did not sanitize it. CK 1 proceeded to puree broccoli using the food processor and repeated the same process. CK 1 then proceeded to puree garlic bread with the unsanitized food processor. CK 1 then grabbed a dirty towel with food particles and brown spots off the dirty cart. CK 1 wiped down the food processor base and food preparation area with the same dirty towel. During the entire process of pureeing the chicken, broccoli, and garlic bread, dietary CK 1 did not change his gloves or wash his hands in between tasks.In an observation on 07/22/2025 at 11:20 AM CK 1 was near the stove and food preparation area with his beard net pulled below his bottom lip. In an observation on 07/22/2025 at 11:45 AM, CK 2 did not put on gloves before preparing trays on the serving line. In an interview on 07/22/2025 at 10:39 AM with the DM, she stated the kitchen staff was to always wear gloves and hair/beard nets when preparing food, which included the puree food process. She stated all staff were required to change their gloves and wash hands in between tasks and whenever they touched anything contaminated. This was to avoid cross contamination and sanitation issues. She stated if the kitchen staff were moving about touching other surfaces in the kitchen while preparing food, they must change gloves, wash their hands, and put on new gloves. She stated the food processor should go in the dish washer to be cleaned and sanitized in between uses. She stated the food processor base should be cleaned after each use with soap and water. She stated the staff had sanitizing buckets, one with soap and water and one with water kept under the cooking station. She stated the staff should be pulling the clean towel out of the soapy water and sanitizing the equipment after each use, and when done staff should put the dirty towel in the dirty bin. She stated a potential negative outcome of not using proper washing and sanitizing between pureed food items was there could be cross contamination, the resident could get sick, or it could affect the integrity of the meal.In an interview on 07/22/2025 at 12:15 PM, CK 2 stated she did not put gloves on before preparing trays on the serving line. She stated she was trained on proper hand hygiene. She stated all staff should be washing hands and wearing gloves on the serving line. She stated she was trained to wash and sanitize the blender in between pureed items. She stated the proper technique for cleaning and sanitizing the blender was to use the three-compartment sink to wash with soap and water and air dry in between pureed items. She stated a potential negative outcome of not properly washing and sanitizing the blender in between puree food items was food poisoning and cross contamination. She stated anyone that entered the kitchen was supposed to wear the appropriate hair and beard net to prevent hair from falling into food. She stated she had been trained but did not recall the date.In an interview on 07/22/2025 at 12:30 PM, CK 1 stated he did not change his gloves while preparing food for the residents. He stated he was required to change his gloves and wash hands in between tasks and after touching anything contaminated. He stated the germs on his gloves may spread to the food. He stated he did not wash and sanitize the food processor in between pureed items, and he was running behind on time. He stated the proper technique for cleaning and sanitizing the food processor was to use the three-compartment sink to wash with soap and water and air dry in between pureed items. He stated a potential negative outcome of not properly cleaning and sanitizing the food processor was the residents could get sick. He stated his beard, and mustache was short, and he did not think he needed a beard net with his beard and mustache being short. He stated he was trained but did not recall the date.Record review of facility's undated food processor cleaning policy reflected 1. Disassemble Unplug the food processor from the power outlet. Carefully detach all removable parts: the lid, feeder tube, blade, and bowl.2. Clean the parts Remove large food particles: Rinse the bowl, lid, and blade under warm water to eliminate any remaining food particles. Handwashing: Wash the bowl, lid, blade, and pusher with warm, soapy water and a soft cloth or sponge. Hard -to-reach areas: Utilize a nylon or soft bristled brush to thoroughly clean crevices and areas around the blade that are difficult to access. Base and Power Cord: Wipe down the base and power cord with a damp, soapy cloth. Never immerse the base in the water or any other liquids.3. Sanitize After washing, rinse all parts (except the motor base) with clean water to remove any soapy residue. Sanitize the food contact surface with an approved sanitizer, such as a diluted bleach solution, following the manufacturer's instructions for concentration and contact time. Optional: In a three-compartment sink, immerse the disassembled items in the third sink, which contains hot water (at least 117 degrees) for 30 seconds, or use a properly prepared chemical sanitizing solution.Important consideration for nursing homes PPE: Staff should wear appropriate PPE, including gloves, when handling food during the cleaning process to further minimize the risk of contamination.Following these cleaning and sanitation procedures for food processors and other kitchen equipment will help maintain a safe and hygienic environment for the residents and staff in the nursing home. Change gloves between the line and the dirty station/sinks. Wash processor between each food item change. 3 compartment sinks, soap, rinse, sanitize, and return between each food itemRecord review of FDA food code dated 2022 revealed 2-402 hair restraints reflected2-402.11 Effectiveness(A) Except as provided in (B) of this section, Food Employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed Food; clean Equipment, Utensils, and Linens; and unwrapped Single-Service and Single-Use Articles.Record review of the facility's policy titled ‘Kitchen Sanitation', dated 2023, reflected It is the policy of the facility to ensure kitchen sanitation is completed by the kitchen staff per shift, per day. It is up to the facility to ensure facility equipment is cleaned and sanitized.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the transmission of communicable diseases and infections for 4 of 4 residents (Residents #15, #25, #34, and #70) and 1 of 1 laundry carts reviewed for infection control. The facility failed on 07/21/2025 to ensure laundry staff handled and stored linens during transport in a manner to ensure cleanliness, protect from dust, and to prevent cross-contamination and the spread of infections. The facility failed on 07/22/2025 to ensure MA-A sanitized reusable equipment (BP cuff) between Residents #15, #25, #34, and #70. This failure could place residents at risk for development of communicable diseases and infections that could diminish a residents' quality of life. Findings included: Record review of Resident #15's undated face sheet, revealed she was a [AGE] year-old female admitted [DATE] with diagnoses of Hypothyroidism (low thyroid), Ocular Hypertension, Hypertension (High BP in the eye), and Schizophrenia (mental illness). Record review of Resident #15's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, which indicated the resident's cognitive ability was not impaired. Record review of Resident #15's Care Plan, reflected a Focus area was initiated for Hypertension on 10/2/15 and revised on 6/20/25 with a goal to have no side effects from BP medications. Resident #15's interventions included to check BP. Record review of Resident #25's undated face sheet, revealed she was a [AGE] year-old female admitted [DATE] with diagnoses of Congestive Heart Failure, Kidney Transplant, Hypertension, and Chronic Obstructive Pulmonary Disease (lung disease). Record review of Resident #25's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, which indicated the resident's cognitive ability was not impaired. Record review of Resident #25's Care Plan, reflected a Focus area was initiated for Hypertension on 2/11/25 with a goal to remain free from symptoms of Hypertension. Resident #25's interventions included to give anti-hypertensive medications and monitor for side effects. Record review of Resident #34's undated face sheet, revealed he was a [AGE] year-old male admitted [DATE] with diagnoses of Hemiplegia (paralysis on 1 side), Bipolar Disorder (mood disorder), Hypertension, and Cerebral Infarct (stroke).Record review of Resident #34's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 08, which indicated the resident's cognitive ability was moderately impaired. Record review of Resident #34's Care Plan, reflected a Focus area was initiated for Hypertension on 2/12/25 with a goal to remain free from symptoms of hypertension. Resident #34's interventions included to give anti-hypertensive medications and monitor for side effects. Record review of Resident #70's undated face sheet, revealed he was a [AGE] year-old male admitted [DATE] with diagnoses of Multiple Sclerosis (muscle weakening disease), Elevated [NAME] Blood Cell Count, Hypertension, and Elevated Liver Enzyme Levels. Record review of Resident #70's chart reflected that his MDS assessment had not been completed yet related to his recent admission date. Record review of Resident #70's Care Plan, reflected a Focus area was initiated for Hypertension on 7/22/25 with a goal to remain free from complications. Resident #70's interventions included to monitor and document blood pressure readings. Observation on 7/21/25 at 12:42 PM revealed LS-A pushing the laundry cart down the hall on the [NAME] Nursing Unit. The top of the cart was covered with a cloth, but the sides were completely uncovered and open to the air on both sides. Residents and visitors were observed moving down the hall also. Multiple resident's hanging clothes were observed in the exposed area of the cart. Observation on 7/22/25 at 8:56 AM revealed MA-A passing medications. She picked up the blood pressure cuff without cleaning it and entered Resident #34's room and proceeded to take his blood pressure. Upon returning to the medication cart, she placed the uncleaned blood pressure cuff on the top of the cart near the area she was preparing medications. She proceeded to give him his medications then performed hand hygiene but did not clean the cuff. Observation on 7/22/25 at 9:10 AM revealed MA-A passing medications. She picked up the uncleaned blood pressure cuff and entered Resident #70's room and proceeded to take his blood pressure. Upon returning to the medication cart, she placed the uncleaned blood pressure cuff on the top of the cart near the area she was preparing medications. She proceeded to give him his medications then performed hand hygiene but did not clean the cuff. Observation on 7/22/25 at 9:31 AM revealed MA-A passing medications. She picked up the uncleaned blood pressure cuff and entered Resident #25's room and proceeded to take her blood pressure. Upon returning to the medication cart, she placed the uncleaned blood pressure cuff on the top of the cart near the area she was preparing medications. She proceeded to give the resident her medications then performed hand hygiene but did not clean the cuff. Observation on 7/22/25 at 9:36 AM revealed MA-A passing medications. She picked up the uncleaned blood pressure cuff and entered Resident #15's room and proceeded to take her blood pressure. Upon returning to the medication cart, she placed the uncleaned blood pressure cuff on the top of the cart near the area she was preparing medications. She proceeded to give the resident her medications then performed hand hygiene but did not clean the cuff. In an interview on 7/22/25 at 9:45 AM MA-A stated that she forgot to clean the blood pressure cuff between residents. She stated the policy is to clean the cuff to prevent from spreading infections between residents. In an interview on 7/21/25 at 12:42 PM, LS-A stated that only the top of the linen cart had to be covered. She stated that small undergarments were delivered in the closed bin drawers below. She stated the policy of the facility was to just cover the top of the cart and she denied any concerns/risk with the exposed linens. In an interview on 7/23/25 at 4:10 PM, LM stated the policy on delivering linens/clothes to residents was to bring in all the resident's clothes on a cart that was covered all the way around. She stated it was important to keep linens covered to prevent cross contamination and the negative outcome to residents if linens were not covered was residents could catch infections and get sick. In an interview on 7/23/25 at 4:24 PM, CNA-A stated, the policy on delivering linens/clothes to residents was to bag them and transfer them to their room. She stated it was important to keep linens covered to keep germs and bacteria from cross contaminating the clothing and the negative outcome to residents if linens were not covered was, they could get sick because ultimately they would be exposed to germs and bacteria. She stated the policy on cleaning reusable equipment (BP Cuffs) between residents was to wipe the BP cuff with the sanitizing wipes provided and wait the appropriate time to use. She stated it was important to clean the cuffs to prevent cross contamination and the negative outcome to residents if cuffs were not cleaned was the resident could get sick from cross contamination. In an interview on 7/23/25 at 4:30 PM, MA-C stated the policy on cleaning reusable equipment (BP Cuffs) between residents was to sanitize the cuff between each resident. He stated this was important to prevent spread of infections and the negative outcome to residents if the cuffs were not cleaned was residents could get infections from other residents and get sick. In an interview on 7/23/25 at 4:35 PM, RN-A stated the policy on delivering linens/clothes to residents was to keep carts covered. She stated it was important to keep linens covered for Infection control and the negative outcome to residents if linens were not covered was, they could be exposed to germs and infectious material and get sick. She stated the policy on cleaning reusable equipment (BP Cuffs) between residents was to clean between each resident and let the cuff sit for the designated kill time. She stated it was important to clean the cuffs because if not residents could get sick. In an interview on 7/22/25 at 4:45 PM, the DON stated the policy on delivering linens/clothes to residents was to deliver them covered. She stated this was important for infection control and the negative outcome to residents if linens were not covered was they could get infections. She stated the policy on cleaning reusable equipment (BP Cuffs) between residents was to clean between each resident with an approved cleanser and follow the guidelines for the number of minutes to wait before reuse. She stated it was important to clean the cuffs to keep infections down and not doing so could possibly give residents infections. In an interview on 7/23/25 at 5:02 PM, the ADM stated the policy on delivering linens/clothes to residents was to deliver covered in bags or on a fully covered cart. She stated it was important to keep linens covered for infection control and to keep linens clean until they were delivered. She stated the negative outcome to residents if linens were not covered could be exposure to dirt and it could make residents sick. She stated the policy on cleaning reusable equipment (BP Cuffs) was to clean them between each resident. She stated the policy was to sanitize all equipment between every use. She stated it was important to clean the cuffs to prevent residents from getting sick from exposure to germs.A record review of the facility's undated policy titled, Infection Prevention and Control Program reflected the following:All reusable equipment requiring cleaning or disinfection shall be cleaned in accordance with current procedures governing soiled or contaminated equipment. Non-sterile supplies are stored and maintained as clean prior to use.Laundry staff shall handle and transport linens to prevent spread of infection.Clean linens shall be delivered to resident care units on covered linen carts with covers down.

Based on observation, interview, and record review the facility failed to ensure a resident with limited range of motion and limited mobility receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion and appropriate services, equipment, and assistance to maintain or improve mobility for 1 of 6 residents (Resident #22) reviewed for ROM and mobility, in that:The facility failed on 4/25/2025 to ensure Resident #22 continued to receive OT services that were signed off on by the MD on the resident's initial OT evaluation. This failure placed residents at risk of not maintaining their highest practicable physical, mental, and psychosocial well-being. Review of Resident #22's comprehensive MDS assessment dated [DATE] reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included stroke (when blood supply to part of the brain is suddenly reduced, leading to brain cell death and/or permanent damage), high blood pressure, diabetes mellitus (chronic disease where the body does not produce enough insulin), hemiplegia (paralysis) or hemiparesis (weakness on one side of the body). His BIMS score was a 00, indicating severe cognitive impairment. In Section GG - Functional Abilities, for the tasks of sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, he was indicated as being Dependent- Helper does all of the effort, resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. For the task of roll left and right he was indicated as requiring Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.Review of Resident #22's comprehensive care plan last revised 6/29/2025 reflected he had an ADL self-care performance deficit with a goal that he would improve his current level of function in bed mobility, transfers, eating, dressing, toilet use, and personal hygiene. An intervention of Notify DOR of need for ST/PT/OT evaluation and treatment as per MD orders was listed. He was not care planned for refusing any services.Review of Resident #22's physician's orders, active as of 7/23/2025, reflected the following standing (a written protocol that allows the healthcare team to perform specific clinical tasks without needing a physician's order) orders: PT to eval and treat on admission OT to eval and treat on admission ST to eval and treat on admissionReview of Resident #22's Occupational Therapy Evaluation & Plan of Treatment dated 4/18/2025 reflected diagnoses of cerebral infarction due to thrombosis of left anterior cerebral artery (blockage of blood flow to the front part of the brain) and muscle weakness. The reason for referral listed stated, Patient was referred to OT d/t recent admission to this facility. Patient presents with decreased: bed mobility, activity tolerance, and ROM LUE. Patient will benefit from OT to address these deficits and maximize overall QOL.The treatment approaches included: therapeutic exercises, neuromuscular reeducation, group therapeutic procedure, occupational therapy evaluation: moderate complexity, therapeutic activities, and self-care management training. The Frequency was for 12 time periods, for a duration of 30 days, with an intensity of daily, and the certification period was for 4/18/2025-5/17/2025. The following goals were listed: Patient will perform L UE strengthening exercises x 8-10 minutes, in order to improve strength for bed mobility.Patient will tolerate 5-7 minutes PROM to R UE, in order to improve ROM and prevent contracture.Patient will safely perform bed mobility tasks with Mod (A) with use of siderails for use of compensatory strategies in order todecrease risk for skin breakdown.Patient/caregivers will demonstrate 85% accuracy for safety/compensatory strategies for bed mobility.These were signed off on by the medical director on 4/21/2025 and it stated, I certify the need for these medically necessary services furnished under this plan of treatment while under my care from 4/18/2025 through 5/17/2025.In an observation on 7/21/2025 at 11:18 AM with Resident #22 he was observed to not be responding to the state surveyors' questions with words, rather he was using his left hand to move his thumb in a sideways or upwards movement to indicate a thumbs-up when asked if he felt okay, was being treated well by staff, and if he participated in activities. In a confidential interview the person stated that when Resident #22 first admitted , they thought the facility was going to be giving the resident rehabilitation to regain his functions, but there seemed to be no improvement with the resident's abilities. They stated that staff report that the resident refused therapy. This person stated that every time they visit the resident would be lying in the same position in bed. They confirmed that the resident had right side paralysis, and that his Medicaid had not been approved yet, and the facility would not do anything until that was approved. In an interview on 7/22/2025 at 4:22 PM with the DOR she stated that Resident #22 had been ‘Medicaid pending' since his admission on [DATE], indicating that certain corporate procedures had to be followed to get the resident's therapy visits financially covered while his insurance was awaiting approval. She stated that she thought Resident #22 had rehabilitation potential for contracture management, to prevent more contractures, and she confirmed that he was not receiving any services at the time. His initial OT evaluation was conducted on 4/18/2025 and he had only received 5 visits between the time period of 4/18-4/25. When asked by the state surveyor if the facility conducted ‘facility authorizations' for residents who could benefit from rehab, but were still Medicaid pending, she stated that yes, the facility did do them, and that rehab would authorize 5 visits, but it was a corporate rule to only allow 5 residents a month, unless it was determined an additional resident really needed it. She stated that if a resident were to exhaust their 5 visits, they could be picked back up based on IDT meetings and then the ADM would approve the additional visits. In an interview with the BOM on 07/23/2025 at 11:46 AM she stated that Resident #22's Medicaid application was denied in error, and that their back office had re-submitted the necessary documentation recently. She stated that based on her experience his application would be approved. When asked about therapy, she stated that corporate does allow 5 initial therapy visits, and if the DOR felt the residents needed more, she could get more approved. In a follow up interview with the DOR on 07/23/2025 at 11:55 AM she stated that Resident #22 was not able to position the way he needed to, and he was only able to use his left hand to thumbs up or down when answering questions. The therapy goals would have helped him achieve being able to roll side to side and to use his bed rails for repositioning. She stated he still needed more therapy to continue being able to work toward those goals. When asked why he was not currently receiving therapy, she stated that she planned to pick him back up soon, and that the residents only got a certain amount of approved therapy visits. She also stated they were short staffed and the staff she had, already had full caseloads. She stated that she was the only full-time staff for about 4 months, so it was hard to keep additional people on case loads. She tried to prioritize residents with falls, contractures, decreased strength, and ADLs. She stated that it was up to her discretion, and if she felt like he needed more therapy she could go through the steps of the policy, and she confirmed that she felt he needed more therapy. However, she felt she did not have the resources to continue providing him therapy previously, because most of her staff worked PRN. She stated that a negative outcome of the resident not receiving therapy services was an overall decrease in quality of life, inability to do for oneself, and not reaching their full potential with ADLs. In an observation on 07/23/2025 at 12:11 PM Resident #22 was observed to require extensive assistance by the DOR by her having to place both of her hands under his left side back to prop him up to assist him in being able to turn and reach for his right-side bed rail. The resident lifted his left arm to reach the right bed rail and once he made contact, he grabbed it but made no attempt to maneuver his body. In a follow up interview with the DOR on 07/23/2025 at 12:13 PM she stated that when Resident #22 was receiving therapy services he would sometimes refuse, but they would attempt to come back 3 times before scheduling the visit for another day, and he did receive all 5 of his initial visits. She stated that the goal would have been (if he were to have continued therapy services) for him to have had better bed mobility, by reaching for items on his bedside table, repositioning, and assisting staff with ADLs. In an interview on 07/23/2025 at 1:59 PM with the DOO she stated that therapy was to be offered in 2-week increments (rather than 5 days) for residents on Medicaid pending status. She further clarified that the 1st 2 approved weeks, the administrator signed off for approval, the next 2 weeks, she (DOO) would sign off for approval and then the following 3 weeks, the Senior VP ofOperations signed off for approval. She stated that she would provide re-education to staff. In an interview on 07/23/2025 at 3:50 PM with the DON she stated she had only been working at the facility for 5 days, but that Resident #22 could have been experiencing no overall improvement in his well-being or quality of life due to not receiving necessary rehab services. Review of the facility's Medicaid Therapy Tracker policy dated 2/2025 revealed, If your facility has identified a need for therapy interventions on a Medicaid only resident, the following approval process will be implemented. 1st approval - request in writing the resident, reason for the request, which disciplines will be involved and frequency/duration of services. This step will also require the Administrator's signature. 2nd approval - request in writing the resident, reason for the request, which disciplines will be involved and frequency/duration of services. This step will also require the Administrator's and Regional's signature. 3rd Approval- request in writing the resident, reason for the request, which disciplines will be involved and frequency/duration of services. This step will also require the Administrator's, Regional's and Sr VP of Operations signature.This form will be submitted monthly to the Regional and Sr VP of Operations. Services should not be rendered until all required signatures are obtained.Review of the facility's undated Resident Rights policy revealed, 8. Safe Environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 2 of 3 medication carts reviewed (East Cart, 1 [NAME] Back Cart). The facility failed to ensure narcotic logs on the East Cart and 1 [NAME] Back Cart were completely filled out and were not missing nurse signatures from 7/19/25-7/21/25.This failure could place residents at risk of drug outages due to drug diversions and poor inventory control which could result in the diminished health and well-being of residents.Findings included: Observation on 7/22/25 at 4:20 PM of the East Medication Cart Narcotic Log revealed 2 shifts with no narcotic counts recorded and 2 other shifts with partially completed entries. The 7/19/25 6PM line was missing a time and a signature of the off-going nurse for the count. The 7/20/25 6AM and 6PM shifts were both completely blank, indicating that 2 nurses failed to sign or count narcotics for those shifts. The 7/21/25 8AM line had only the signature of the oncoming medication aide and was missing a nurse's signature. Observation on 7/22/25 at 5:00 PM of the 1 [NAME] Back Medication Cart Narcotic Log revealed that the line for 7/20/25 6:05 PM had a blank box where the on-coming nurse should have signed. In an interview on 7/22/25 at 4:37 PM the DON stated that her expectations were that counts be completed prior to passing the narcotic keys every shift. She was not aware the counts had been missed prior to us discussing it and she denied knowing why they were missed. In an interview on 7/22/25 at 4:39 PM MA-B stated 2 agency nurses worked on the East Hall from 6 PM on 7/19/25- 6 AM on 7/21/25. She stated the nurses working on the shifts involved were LVN-A and LVN-B. She denied having any knowledge on why they did not sign out the narcotic count. In an interview on 7/23/25 at 4:30 PM MA-C stated the policy was for 2 nurses to count narcotics and sign the narcotic sheet. He stated it was important to count the narcotics with 2 people to verify and have a witness that the count was correct. He stated the negative outcome if count was missed was that narcotics could be short or missing, and residents could be neglected on their medications. He stated Agency nurses passed medications for the day and night shifts on the East Hall for the 7/19/25. and 7/20/25 shifts. In an interview on 7/23/25 at 4:35 PM RN-A stated, the policy was for 2 nurses to count narcotics and sign the narcotic sheet. She stated it was important to count the narcotics with 2 people to decrease chances of narcotic diversions and safely confirm that narcotics were not missing. She stated not counting narcotics could affect residents if a medication supply was low and a resident could not get their medications. In an interview on 7/23/25 at 4:45 PM the DON stated, the policy was for 2 nurses to count narcotics and sign the narcotic sheet between shift changes. She stated staff could not go home or take the narcotic keys until narcotics were counted and documented. She stated it was important to count the narcotics with 2 people to verify the count was correct. She stated not counting could affect residents if medications were diverted and the medication count was off. She stated, if that happened, then the medication may not be available for the resident, or it could cause a medication dosage error by leading to a missed dose or a duplicated dose. She stated the rule was that if they did not document something, then it was assumed it didn't happen. She stated that this morning she had tried to call the agency nurses that did not sign out but they had not called her back. In an interview on 7/23/25 at 5:02 PM the ADM stated the policy was to count narcotics at shift change and record the count on the log. She stated count should be done by 2 people, so no one could take narcotics. She stated it could affect residents by making them miss medications they needed. In an interview on 7/23/25 at 5:23 PM MA-A stated in a telephone interview with the DON present, that RN-A counted with her on 7/21/25 at 8 AM. In an interview on 7/23/25 at 5:30 PM, RN -A stated she did count with MA-A on 7/21/25 at 8 AM and she must have forgotten to sign the sheet. Interview on 7/23/25 at 6:09 PM attempted with LVN-B but she did not answer, and the phone would not accept a message. No call back was received. In an interview on 7/23/25 at 6:20 PM LVN-A stated she worked the weekend shifts for 7/19/25 at 6 PM-7/21/25 at 6 AM. She stated she did not remember why they didn't sign off the narcotic sheets. She stated they did count each day, and she counted with a facility staff nurse. She stated it was important to count with 2 people to prevent medications from being stolen and to catch if a wrong medication had been given. She stated that she did not think missing counts would affect residents. A record review of the facility policy titled; Controlled Substance Administration & Accountability dated 2025 reflected the following:All controlled substances obtained from a non-automated medication cart are recorded on the designated usage form. Written documentation must be clearly legible with all applicable information provided. For areas without automated dispensing systems, two licensed nurses account for all controlled substances and access keys at the end of each shift.

Based on observation, interview, and record review the facility failed to implement their established policy regarding smoking, smoking areas, and smoking safety for 1 (Resident #49) of 8 residents reviewed for smoking. The facility failed to inform Resident #49 of the facility's smoking policy prior to 7/21/2025.The facility failed on 7/21/2025 to maintain a clean smoking area for staff and residents. These failures could result in unwanted fire hazards and pose safety risks to residents and staff. Findings included:Review of Resident #49's comprehensive MDS assessment dated [DATE] reflected a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included, amputation, anemia, coronary artery disease (narrowed or blocked arteries caused by plague buildup), diabetes, high cholesterol, hyperlipidemia (high levels of fats in the blood), mild cognitive impairment, and limitation of activities due to disability. Her BIMS score was an 11, indicating she had moderate cognitive impairment. In Section J - Health Conditions, Resident #49 was marked as ‘Yes' for J1300 Current Tobacco Use. Review of Resident #49's care plan dated last revised 7/7/2025 reflected that she was care planned for an intervention of Encourage resident to refrain from smoking. due to a diagnosis of coronary artery disease related to hypercholesterolemia (high cholesterol). There was no indication Resident #49 had been informed of the smoking policy.In an observation on 7/21/2025 at 1:49 PM of a smoking break, Resident #49 had a pouch where her smoking materials were kept, and there were no cigars observed. Resident #49 was observed going up to a male resident and asking him for a cigar, when the AD interrupted and stated they could not do that. The smoking area was observed to be littered with cigarette butts and cigar wrappers. Additionally, cigarette butts were observed to be in plant pots by one of the facility's exit doors. In an interview on 07/21/2025 at 1:57 PM with the AD who was providing the smoke break to residents she stated that she provided smoke breaks to residents at 1:45 and 4pm daily when she worked. She stated that she would think it was housekeeping or maintenance's responsibility to clean up the cigarette butts off the ground. She stated that a fire could happen if the butts were put out and/or left in the plant pots and stated that it did look bad out there due to the trash and cigarette butts on the ground. Resident #49 usually smoked [a certain brand] and she came out during every smoke break. When shown a copy of the list of smokers provided to the state survey team, which did not include the name of Resident #49, and asked how she knew if the resident was permitted to smoke, she stated that it was communicated to her from nursing, who conducted the safe smoking assessments. She stated that Resident #49 was newly admitted to the facility, and the DON told the AD that the smoking policy was in the resident's admission packet, when asked if Resident #49 was aware of the smoking rules.In an interview on 07/22/2025 at 12:04 PM with Resident #49 she stated she was never informed of the rules about smoking or that she could not share, until 7/21/25 when the AD stated she could not borrow a cigar from a male resident because the state was present. She stated that her FM would bring her cigars when she ran out or she would ask another resident who smoked the same brand, and they would lend her one. In a follow up interview on 07/23/2025 at 3:24 PM with the AD she stated that Resident #49 would borrow cigars from any resident who smoked the same type as her. She confirmed the name of the resident whom Resident #49 was observed asking from during the 1:45 PM smoke break on 7/21, and that Resident #49 had in the past borrowed from him. She stated that it was the responsibility of the staff providing the smoke break to inform all smokers of the rules. When asked why residents should not share smoking materials, she stated that it was due to incidents years ago where residents would borrow from others after stating they would return the favor, or pay the loaner back, and fail to follow through on those promises, which led to problems, so the policy was put into place. In an interview on 07/23/2025 at 3:40 PM with the DON she stated that she had only been working at the facility for 5 days, however, if a resident was not compliant with the smoking policy, the staff would address it.Review of the facility's undated Smoking policy revealed, Residents are prohibited from sharing or loaning tobacco products to others.Review of the facility's undated Resident Rights policy revealed, 6. Information and communication. The resident has the right to be informed of his or her rights and of all rules and regulations governing resident conduct and responsibilities during his or her stay in the facility. 8. Safe Environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the transmission of communicable diseases and infections for 5 of 5 residents (Residents #27, #11, #20, #38 and #17) reviewed for infection control. 1. The facility failed to ensure CMA performed proper hand hygiene when passing medications. 2. The facility failed to ensure CMA sanitized equipment according to infection control guidelines. This failure could place residents at risk for development of communicable diseases and infections. Findings were: 1. Record review of Resident #27's face sheet, dated 06/12/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #27 had diagnoses which included Muscle wasting, Heart disease, Chronic Obstructive Pulmonary Disease (lung disease). Depression and Anxiety Disorder. Record review of Resident #27's quarterly MDS, dated [DATE], reflected a BIMS of 15, which indicated the resident's cognition was intact. Record review of Resident #27's Care Plan reflected on 3/15/20 a Focus was initiated for risk of infection. 2. Record review of Resident #11's face sheet, dated 06/11/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #11 had diagnoses which included Schizophrenia, (mental illness) COPD (lung disease), Anemia, Anxiety Disorder, Hypertension (high blood pressure) and Deficiency of Specified B group vitamins. Record review of Resident #11's quarterly MDS, dated [DATE], reflected a BIMS score of 15, which indicated the resident's cognition was intact. Record review of Resident #11's Care Plan reflected on 3/15/20 a Focus was initiated for risk of infection. The Care plan also reflected Resident #11 had a risk for shortness of breath and respiratory distress due to her diagnosis of COPD. 3. Record review Resident #20's face sheet, dated 06/12/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #20 had diagnoses which included Alzheimer's Disease (Dementia), Hypertension (high blood pressure), Muscle Wasting, Seizures, Vascular Dementia, Bipolar (mood disorder) and Stroke. Record review Resident #20's quarterly MDS, dated , 05/26/24, reflected a BIMS score of 11, which indicated the resident had moderate cognitive impairment. Record review of Resident #20's Care Plan reflected on 12/20/22 a Care Plan Focus was initiated for self-care deficit related to stroke, weakness and deconditioning. 4. Record review of Resident #38's face sheet, dated 06/12/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #38 had diagnoses which included COPD (lung disease), Pneumonia, Malnutrition, Respiratory (Breathing) Failure, Heart Failure and Dependence on Supplemental Oxygen. Record review of Resident #38's quarterly MDS, dated [DATE], reflected a BIMS score of 07, which indicated the resident had severe cognitive impairment. Record review of Resident #38's Care Plan reflected on 1/31/24 a Focus was initiated for respiratory failure with a goal to remain free from complications of asthma and interventions planned to encourage prompt treatment of any respiratory infections. 5. Record review of Resident #17's face sheet, dated 06/14/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #17 had diagnoses which included Heart Disease, COPD (lung disease), Post Traumatic Stress Disorder and Muscle Weakness. Record review of Resident #17' quarterly MDS reflected a BIMS score of 09, which indicated the resident had moderate cognitive impairment. Record review of Resident #17's Care Plan reflected on 9/26/23 a Focus was initiated for asthma with a goal to remain free from complications of asthma and interventions planned to encourage prompt treatment of any respiratory infections. Observation on 6/12/24 at 8:44 a.m. revealed MA went to Resident #27's room with a blood pressure cuff to check his vitals. She returned to the medication cart and placed blood pressure cuff on the top of the medication cart without sanitizing it. The MA proceeded to administer Resident #27's medications, then returned to the medication cart to start the next resident's medications without sanitizing the blood pressure cuff. Her hands were sanitized. Observation on 6/12/24 at 9:00 a.m. revealed MA prepared medications for Resident #11 on top of the medication cart. The blood pressure cuff she had not sanitized was still on the top of the medication cart on which she was working. She then proceeded to take Resident #11's blood pressure. After administering Resident #11's medications, she returned the blood pressure cuff to the top of the medication cart without sanitizing it. MA performed hand hygiene on her hands. Observation on 6/12/24 at 9:04 a.m. revealed MA prepared medications for Resident #20 on top of the medication cart. The blood pressure cuff she had not sanitized was still on the top of the medication cart, on which she was working. The MA then proceeded to take Resident #20's blood pressure with the blood pressure cuff. After administering Resident #20's medications, she returned the blood pressure cuff to the top of the medication cart without sanitizing it. The MA did not wash or sanitize her hands after leaving the resident's room. Observation on 6/12/24 at 9:23 a.m. revealed MA entered Resident #38's room without performing hand hygiene to ask if he was ready for his medications. Resident was on his cell phone, so she agreed to come back for his medications. She removed the breakfast tray from his room. MA did not perform hand hygiene after disposing of the tray. The blood pressure cuff she had not sanitized remained on her cart. Observation on 6/12/24 at 9:26 a.m. revealed MA entered Resident #17's room to see if she was ready for medication. The resident was not ready for her medications. MA left the room and washed her hands. The un-sanitized blood pressure cuff remained on her cart. In an interview on 6/12/24 at 09:40 a.m., the MA stated she missed hand hygiene between a couple of rooms. She stated she, wondered if she should be cleaning the blood pressure cuff. She stated infection control was important to prevent the spread of infections between residents and examples of potential spread would be scabies or C. Diff. (Clotridoides Difficile Colitis) infections. In an interview on 6/13/24 at 03:05 p.m., the DON stated the facility knew hand hygiene, and it was expected. The policy was to sanitize hands with alcohol gel if not visibly soiled or wash hands if visibly soiled. The DON stated she gave hand hygiene in-services often and did monthly hand hygiene competencies. She stated the policy was for staff to disinfect equipment between residents and they are expected to do that. The DON stated the potential outcome of not doing hand hygiene and disinfecting equipment was potential outbreak of infections. In an interview on 6/13/24 at 03:12 p.m., the ADON stated the policy was to sanitize hands with alcohol gel if they were not soiled and to use soap and water if hands were soiled. The ADON stated she gave frequent in-services on this and randomly asked staff to demonstrate how to wash hands properly. She stated the policy on disinfecting equipment was to disinfect based on kill time that was indicated on the disinfecting wipes. The ADON said she gave regular in-services on disinfecting equipment. The ADON stated the potential outcome of not doing hand hygiene and disinfecting equipment was possible transfer of infections to residents. In an interview on 6/13/24 at 03:18 p.m. the ADM stated the policy on hand hygiene between residents was to clean hands with soap and water if soiled or use 70% alcohol if not soiled. The ADM stated they gave regular in-services on hand hygiene and disinfecting equipment between residents. She stated equipment should be disinfected between residents every single time. The ADM stated the potential outcome of not doing hand hygiene and disinfecting equipment was germs and disease could be spread to others. In an interview on 6/13/24 at 03:25 p.m., CNA-C stated the policy on hand hygiene between residents was to wash hands. She stated they were regularly in-serviced on hand hygiene and sanitizing equipment. CNA-C stated they had a disinfecting spray they could use on equipment between residents. She stated the potential outcome of not doing hand hygiene and disinfecting equipment was they could get in trouble for not doing it and residents could get infections. CNA-C stated they always had supplies to do hand hygiene and sanitizing the equipment. Record review of the facility's, undated, policy titled, Hand Hygiene reflected All staff will perform proper hand hygiene procedures to prevent the spread of infections to other personnel, residents, and visitors .Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table . either hand washing, or Alcohol Based Hand Rub is indicated in the following circumstances: Between resident contacts After handling contaminated objects Before preparing or handling medications Record review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment dated 03/01/22, reflected Reusable items are cleaned and disinfected or sterilized between residents. The policy categorized blood pressure cuffs as non-critical items which can be decontaminated where they are used.

Based on interview and record review the facility failed to ensure residents had the right to send and receive mail, and to receive letters, packages, and other materials delivered to the facility for the resident through the means other than a postal service for 11 of 11 confidential residents reviewed for weekend mail delivery. The facility failed to ensure residents received their mail on the weekend. This failure could place residents at risk of not receiving mail in a timely manner and could result in a decline in residents' psychosocial well-being and quality of life. Findings include: During a confidential group interview 11 of 11 residents stated mail was not distributed on Saturdays. They stated mail did not get delivered until Monday or even picked up until Monday. The residents stated they had spoken to different [unnamed] staff about the issue but were told nobody was there who could deliver it on the weekend . In an interview on 06/13/24 at 02:39 PM with the SW, she said she was not aware of anyone who was assigned to deliver mail on the weekend. She said other than nursing staff she was not sure who worked on the weekend who would be able to deliver the mail and didn't think it got delivered. In an interview on 06/13/24 at 02:50 PM with the BOM, she stated the facility did not have anyone on weekends to deliver mail. The BOM said staff knew to put any weekend mail in her box, and she would deliver it to the residents when she came in on Monday. The BOM said she was not sure if it was a resident right to receive mail on the weekends and was not aware of the section which included weekend mail delivery under the Residents [NAME] of Rights. The BOM said she was sure there could be a potential negative outcome such as residents getting upset if they were expecting a package, but she said all mail whether it was a check or other envelope that was coming in on the weekend was held and not delivered until the Monday upon her return . She believed it was due to cutting back and not having a weekend receptionist. In an interview on 06/13/24 at 03:44 PM with the ADM, she stated it was her expectation the residents mail was being delivered on the weekend, and that it was a resident right to receive weekend mail delivery. The ADM stated currently they did not have anyone specific assigned to deliver mail on the weekends . She stated they currently had the mail delivered to the BOM's box. The ADM stated not delivering mail to residents on the weekend is a resident rights issue but not life or death. She said it was however the residents right to receive mail in a timely manner and they would review the process for a CNA to deliver the weekend mail. Record review of the facility's, undated, Resident Rights policy reflected: Information and communication: The resident has the right to be informed of his or her rights and of all rules and regulations governing resident conduct and responsibilities during his or her stay in the facility. - The resident has the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the resident through a means other than a postal service, including the right to: o Privacy of such communications consistent with this section; and o Access to stationary, postage, and writing implements at the residents own expense.

Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food and nutrition services. The facility failed to ensure the kitchen staff cleaned and sanitized the blender in between pureed food items. This failure could place residents at risk for food contamination and foodborne illness. Findings include: Observation of the kitchen on 06/11/24 at 10:02 AM revealed [NAME] E pureeing mixed vegetables for lunch. The mixed vegetables were pureed and placed in an appropriate container. Once the puree vegetables were completed, [NAME] E took the blender to the three-compartment sink. [NAME] E rinsed the blender with water and air dried the container. [NAME] E did not wash with soap or sanitize the blender. [NAME] E left the blender lid on the counter where the puree vegetables were. [NAME] E placed cooked beef inside the blender, with the unwashed blender lid that had mixed vegetable residue on the top. [NAME] E placed the beef in an appropriate holding container. [NAME] E took the blender and the lid to the three compartments sink and rinsed the blender and the lid with water. [NAME] E did not sanitize the blender or blender lid. [NAME] E continued with puree mashed potatoes with the non-sanitized blender. In an interview on 06/11/2024 at 10:30AM, [NAME] E stated she was trained to wash and sanitize the blender in between pureed items but said she forgot. [NAME] E stated the proper technique for cleaning and sanitizing the blender was to use the three-compartment sink to wash it and air dry in between pureed items. She stated a potential negative outcome of not properly cleaning and sanitizing the blender was the residents could get sick . In an interview on 06/12/2024 at 11:00 AM, the DM stated, the expectation for washing and sanitizing the blender was to use the three compartments sink in between food items and use a sanitation wipe if the dish could not be washed in water. She stated a potential negative outcome of not using proper washing and sanitizing between pureed food items was there could be cross contamination, the resident could get sick, or it could affect the integrity of the meal. In an interview on 06/13/2024 at 3:02 PM, [NAME] F stated he was trained to wash and sanitize the blender in between pureed items. [NAME] F stated the process for cleaning and sanitizing the blender was to use the three-compartment sink. He stated a potential negative outcome of not properly washing and sanitizing the blender in between puree food items was food poisoning and cross contamination could occur. In an interview on 06/13/2024 at 3:30 PM, the ADM stated the expectation for the blender was that it was properly cleaned and sanitized in between food items. She stated a potential negative outcome would be cross contamination or illness. Record review of the facility's policy Kitchen Sanitation, dated 2023, reflected it is the policy of the facility to ensure kitchen sanitation is completed by the kitchen staff per shift, per day. It is up to the facility to ensure facility equipment is cleaned and sanitized.

Based on observation, interview and record review the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 1 of 5 residents (Resident #40) reviewed for physical environment. The facility failed to ensure Resident #40 had a working call light in the room. This failure could place residents at risk of not being able to get assistance when needed. Findings include: Record review of Resident #40's face sheet, dated 06/13/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included pulmonary embolism (a blood clot in the lung that creates a blockage) without acute cor pulmonale (enlarged ventricle), cognitive communication deficit, unspecified atrial fibrillation (irregular and rapid heart rhythm that can lead to a stroke, heart failure or other complications), and dementia (loss of cognitive function that interferes with daily life) in other diseases classified elsewhere- unspecified severity- without behavioral disturbance, psychotic disturbance-,mood disturbance and anxiety ((A group of symptoms that affects memory, thinking and interferes with daily life.). Record review of Resident #40's quarterly MDS assessment, dated 04/01/24, reflected a BIMS score of 04, which indicated severe cognitive impairment. Section GG for functional abilities reflected Resident #40 was completely dependent on personal hygiene and toileting; and required maximal assistance with dressing and showers. Record review of Resident #40's care plan, last revised 06/14/24, reflected Falls Risk- [Resident #40] is at risk for falls related to dependence upon staff to provide assistance for stability to complete ADL's, functional incontinence and poor safety awareness secondary to cognitive impairment. Interventions for the identified problem in the care plan included, - Anticipate and meet the resident's needs. - Be sure the residents call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. An observation and interview on 06/11/24 at 01:44 PM revealed Resident #40 in her bed with the call light cord observed at the bedside to the right of the resident. The call light cord was frayed and hung by a thin white cable, and a black cable was observed completely severed from the push-button end of the cord. Resident #40 was asked to test the call light and upon pushing the button it was observed neither the green light at the base of the call light, nor the light outside of Resident #40's room was activated. Resident #40 stated she was not sure how long the call light had been out because she usually just waited for staff to enter her room to ask for assistance, she said they checked on her frequently. An observation and interview on 06/11/24 at 01:52 PM revealed LVN A attempt to push Resident #40's call light to test for functionality; the call button was pushed, and the call light was observed not functioning in the room or flashing outside of the resident's room. LVN A stated this is the first time she noticed the call light not functioning but it was probably due to the frayed wires. She was unable to determine how long the call light was damaged prior to that moment. LVN A stated a negative outcome to Resident #40 not having a functioning call light would be the resident could sit there wet or soiled due to needing staff assistance with incontinent care. LVN A stated she would promptly report it to maintenance to have it resolved and was observed bringing Resident #40 a hand bell to ring if she needed assistance in the meantime. In an in interview on 06/13/24 at 03:32 PM with the DON, she stated it was her expectation that residents call lights were functioning and placed within reach of the residents to call for help as needed. She stated functionality was tested by MNT, but nursing staff also did rounds to check for placement. The DON stated a resident having a non-functioning call light was negligence because they could not be getting their needs met. The DON said after the problem with Resident #40 was identified they did an audit of all residents to ensure their call lights were functioning. No major concerns were identified though the audit. In an interview on 06/13/24 at 03:44 PM with the ADM she stated it was her expectation all residents had a functioning call light in reach to call for help as needed. She said if anyone identified a concern with a call light staff were required to let MNT know. The ADM stated they had Angel Rounds which is a system where the heads of the departments check on functionality and placement of call lights in resident's rooms daily. The ADM stated a negative outcome to residents not being able to call for assistance would be the residents not getting the help they need which could potentially lead to a fall in some residents. In an interview on 06/13/24 at 04:00 PM with MNT, he stated the residents call lights were checked for functionality and placement every morning during Angel Rounds. He also stated if a concern was identified staff were required to immediately let him know. The MNT said there was a maintenance system they had that would also prompt him to complete a full call light system audit regularly. The MNT said as soon as the problem was identified with Resident #40, she was given a hand bell and the call light cord was replaced later the same day. The MNT said a negative outcome to a resident not having a functioning call light could potentially lead to a fall with injury. Record review of the facility's, undated, policy titled Call Lights: Accessibility and Timely Response reflected: The purpose of this policy is to assure the facility is adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. - Ensure the call light system alerts staff members directly or goes to a centralized staff work area.

Based on observation, interview and record review the facility failed to ensure, based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 2 resident (Resident #31) reviewed for quality of care. The facility failed to ensure Resident #31's wound care orders were followed daily. This failure could place residents at risk for worsening of wounds, development of infections, and possible loss of the highest practicable level of functioning. Findings include: Record review of Resident #31's face sheet, dated 06/13/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #31 had diagnoses which included Muscle Wasting, Stroke, Chronic Kidney Disease, Gangrene (dead body tissue) and Hypertension (High blood pressure). Record review of Resident #31's Quarterly MDS reflected a BIMS score of 7, indicated the resident's cognition was severely impaired. Record review of Resident #31's Care Plan, reflected a Focus was initiated for open area related to her auto immune disease on her right dorsal shin. This area heals and then reopens at times. The Care Plan Focus was revised on 3/12/24. On 5/1/24 the goal was revised to reflect a goal for her shin to heal without complications. Record review of Resident #31's orders reflected a wound treatment order to be done one time daily with a start date of 6/7/24 at 6:00 pm and a revision date of 6/12/24. Record review of Resident #31's TAR reflected an order beginning on 6/7/24 to provide daily wound care. The order is: Open area to RLE: Cleanse with normal saline, pat dry, apply Silver Alginate, cover with non-adherent dressing daily one time a day for treatment for open area. The TAR reflected no dressing changes were marked as performed for 6/7-6/12/24. The first date charted as wound treatment performed was 6/13/24. Record Review on 6/13/24 at 08:48 a.m. revealed Resident #31's TAR reflected a RLE dressing change charted as completed on 6/13/24 at 5:12 a.m. by agency nurse. On the TAR, the order had a start date on 6/7/24 and a revision date of 6/12/24. The TAR documented 6/13/24 at 05:12 a.m. dressing change was the first dressing change marked as completed and there were no notes which indicated why the dressing changes were not charted for 6/7/24 to 6/12/24. Observation on 06/11/24 at 10:45 a.m. revealed Resident #31 had a dressing on her right lower extremity with no date or initials to indicate when it was last changed. Observation on 06/12/24 at 01:58 p.m. revealed Resident #31 had a dressing on her right lower extremity with no date or initials to indicate when it was last changed. Observation on 6/13/24 at 8:44 a.m. revealed Resident #31 had a dressing on her right lower extremity with no date or initials to indicate when it was last changed. The dressing was a clean, flat, approximately 2x2 inch white gauze dressing covered with a clear dressing. The dressing edges were well adhered to skin with no signs of normal deterioration to the dressing. Skin redness extended past the dressing on the resident's right side and above the dressing edges. Unable to determine if redness was small amount of dried blood or scraped skin abrasion only. No drainage or signs of infection were observed on or around the dressing. Record Review on 6/13/24 at 08:48 a.m. revealed Resident #31's TAR reflected a RLE dressing change charted as completed on 6/13/24 at 5:12 a.m. by agency nurse. On the TAR, the order had a start date on 6/7/24 and a revision date of 6/12/24. The TAR documented 6/13/24 at 05:12 a.m. dressing change was the first dressing change marked as completed and there were no notes which indicated why the dressing changes were not charted for 6/7/24 to 6/12/24. Observation on 6/13/24 at 9:49 a.m. revealed LVN-B changed the dressing on Resident #31's right lower extremity according to orders and facility policy. The uncovered wound revealed an approximate wound area at its largest points were 3.5 inches width by 3.0 inches height. The wound appeared as a red abrasion with a small center spot approximately 1.5 mm radius and 1 mm deep (about the size of a pen tip) with a white dry center. Small, scabbed areas appeared across the red area. There was no drainage or signs of infection observed. In an interview on 6/11/24 at 10:45 a.m., Resident #31 stated the last time the dressing was changed on her right lower extremity was 3 days ago after her Saturday shower. In an interview on 6/12/24 at 01:58 p.m., Resident #31 stated the nursing staff had not come in to change the dressing since yesterday. In an interview on 6/13/24 at 08:48 a.m., LVN-B stated the last time a dressing change could be determined by looking at the date on the dressing and by looking in the electronic chart on the TAR. She said the TAR showed the dressing had already been changed on 6/13/24 at 05:12 a.m. by the night nurse. She stated the order was written to start on 6/7/24 and revised on 6/12/24. LVN-B stated the TAR showed the 6/13/24 at 05:12 a.m. dressing change was the first dressing change completed and there were no notes which indicated why the dressing changes were not completed for 6/07/24 to 6/12/24. In an interview on 6/13/24 at 08:54 a.m., Resident #31 stated, I think the dressing was changed the day before yesterday when I showered. The resident stated the dressing was not changed at 5:12 a.m. today. In an interview on 6/13/24 at 08:56 a.m., DON stated she instructed the staff to wait and do the dressing today with the State Surveyor. The DON stated an agency nurse was assigned to Resident #31 and she was sure the dressing was not changed this morning at 5:12 a.m. The DON stated she would research the order and dressing change history charted. In a joint interview on 6/13/24 at 09:43 a.m. with the DON and the ADON they stated they did daily Fail-Safe Risk Rounds to confirm orders were not missed. The DON stated she was responsible for auditing records to ensure wounds were done. She stated the audit was done but this one order was not caught due to a recent computer change. The DON stated a section of the electronic health record called the WAR was inactivated, but the staff nurse inadvertently entered the order into the WAR, so it did not show in the audit nor the treatment record. The DON also stated the staff were in serviced on the computer changes and the correct process to enter orders prior to the change. The ADON stated she did additional audits, and she caught the problem on 6/12/24 and corrected the order. The DON instructed LVN-B to change the dressing because it was not currently dated, and dressings needed to be dated. In a joint interview on 6/13/24 at 12:05 p.m. with the DON and the ADON, the DON stated an audit was done on all of agency nurse assignment and all task she signed as completed were verified as completed except the dressing change for Resident #31. The ADON stated an audit was done on the WAR tab for all of June and all orders were previously corrected by the ADON with no treatments missed for any residents except Residents #31's dressing change. In an interview on 6/13/24 at 2:38 PM, Resident #31 stated she did not remember if she told anyone about the missed dressing changes. Resident #31 stated the dressings were done on shower days and shower days were Saturday (6/8/24) Tuesday (6/11/24) and Thursday (6/13/24). In an interview on 6/13/24 at 2:36 p.m. the MDR stated the facility notified him some of Resident #31's dressing changes were missed. He stated, they always let me know anytime an order is not done or if there is a problem. The MDR stated the wound had not worsened but the concern if a wound was not treated properly was always a risk of infection. In an interview on 6/13/24 at 03:05 p.m., the DON stated her expectation was wound orders be implemented correctly and placed in the right tab. She stated wound care should be charted in the electronic health record and the dressing should be dated to track when dressing changes were done. The DON stated the potential outcome if wound care was missed was the wound could get worse or develop an infection. The DON stated the computer department was permanently correcting the problem with the WAR so no orders could be entered into that tab. In an interview on 6/13/24 at 03:12 p.m., the ADON stated her expectation was wound orders be completed per physician orders and if questions arose the staff should reach out to her for help. She stated wound care should be charted in the electronic health record and the dressing should be dated and initialed. The ADON stated the potential outcome if wound care was missed was infections. In an interview on 6/13/24 at 03:18 p.m., the ADM stated her expectation was wound care orders should be implemented and followed. The ADM stated the care should be recorded in the correct place under the correct tab. She stated the potential outcome if wound care was missed was that wounds could worsen and cause further health issues. In an interview on 6/13/24 at 03:25 p.m., CNA-C stated the CAN's reported wounds to the nurses. She stated that if wound care was missed infections could develop. Record review of the facility's, undated, policy titled; Wound Treatment Management reflected: It is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders . Wound treatments will be provided in accordance with physician orders . Treatment will be documented in the Treatment Administration Record or in the electronic health record.

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs for one (Resident #1) of five residents reviewed for care plans, in that: The facility failed to care plan Resident #1's history of illegal drug abuse. On 12/25/23, Resident #1 went unresponsive and was diagnosed with a Fentanyl overdose in the hospital. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 12/28/23 at 2:47 PM. While the IJ was removed on 12/29/23 at 6:15 PM, the facility remained out of compliance at a severity of actual harm at a scope of isolated that is not Immediate Jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk of a drug overdose, hospitalization , or death. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including inhalant abuse (a broad range of household and industrial chemicals whose volatile vapors or pressurized gases can be concentrated and breathed in via the nose or mouth to produce intoxication), nicotine dependence, personal history of traumatic brain injury, major depressive disorder, and other psychoactive substance dependence. Review of Resident #1's admission MDS assessment, dated 09/15/23, reflected a BIMS of 12, indicating a moderate cognitive impairment. Section G (Functional Status) reflected he was completely dependent for ADLs. Review of Resident #1's quarterly care plan, dated 09/28/23, reflected he presented with primary diagnosis of depression and bipolar with an intervention of ensuring all needs were met. There was nothing in the care plan reflected he had a history of drug abuse. Review of Resident #1's admission summary, dated 09/06/23, reflected the following: Lifestyle: Resident/family member report currently uses or HX of alcohol use. [Resident #1] has a history of smoking in past. Smoked, drank, abused drugs at an early age in life. Review of Resident #1's progress notes in his EMR, dated 12/25/23 at 11:36 PM and documented by RN C, reflected the following: Nurse called ER to get updated, [Resident #1] is being admitted d/t / opioid overdose, [Resident #1] tested positive for opioids and Fentanyl. [Resident #1] has current orders for opioids however does not have an order for Fentanyl. Review of Resident #1's hospital discharge paperwork, dated 12/25/23, reflected the following: Chief Complaint: [Resident #1] presets with Altered Mental Status HPI: .who presented to ED for evaluation of acute encephalopathy (a group of disorders that affect the brain and cause confusion, memory loss, or other mental changes) which began last night. Per chart review this afternoon nursing staff noticed [Resident #1] was not acting like himself and was more lethargic. Reportedly [nursing staff] are worried [Resident #1]'s family was giving him extra medications or narcotics . In ER [Resident #1] was medicated with multiple doses of Narcan (a drug used to treat known or possible opioid overdose), woke up had GCS 15 . Now requiring Narcan drip. Further workup revealing: UA consistent with infection, UDS + opiates and Fentanyl. Mental status: obtunded (dazed, desensitized), withdraws to pain. Principal Diagnosis: Opioid overdose Review of Resident #1's EMR, on 12/28/23, reflected no admission paperwork, documents from his previous SNF , history and physical, or nurse practitioner notes. During an interview on 12/29/23 at 2:37 PM, Resident #1 stated he did not ask anyone for fentanyl or any illegal drugs, and no one, not facility staff or family member, gave him anything he did not recognize. He stated he started feeling off before his family arrived for a visit. He stated at lunch, his food was going everywhere but into his mouth. He stated after his family arrived, he felt the highest he had ever felt in his life. He stated when he went to the hospital back at the beginning of December, he did not feel high like he had this most recent incident. He stated no one brings him drugs and staff do not offer him drugs. During a telephone interview on 12/28/23 at 10:11 AM, Resident #1's FM A state he and two other family members came to pick up Resident #1 on 12/25/23 around 5:00 PM. He stated RN C showed them to his room where he immediately noticed something was off with Resident #1. He stated he seemed to be heavily medicated, had a blank stare, and was mumbling. He stated this was unlike him as he was normally very communicative. He stated he asked RN C, You all had not noticed he was like this? He stated RN C said no and left the room. He stated it was very unnerving no one had noticed Resident #1's change in condition as it was obvious something was wrong with him. He stated it looked like someone had given him drugs as he was acting high. He stated Resident #1 was sent to the hospital earlier in the month for similar symptoms and wondered if someone had drugged him then, too. During an interview on 12/28/23 at 10:59 AM, the ADM stated he was notified of Resident #1's Fentanyl overdose on the morning of 12/26/23. He stated he was told by RN C that family members came to visit him on 12/25/23 and spent some time in his room and then stated they were going to take him out for Christmas dinner. RN C told him the family pushed him down the hallway to leave and she (RN C) asked them to sign him out first. RN C told him that an aide noticed Resident #1 did not look right. RN C told him the aide got RN C and she determined he needed to be sent to the hospital. He stated he got kicked out of his previous facility for smoking marijuana. He stated he did not believe drugs were pushed on him, rather that he asked for them. When asked if there was any kind of investigation conducted, he stated he was waiting until he could interview Resident #1 once he returned from the hospital because that would be the main source of his investigation. He stated he had seen Resident #1 a few times on 12/25/23 during the day and he was his normal self. He stated he was not sure if he had any other visitors that day but did regularly have friends that visited him in the facility. He stated he had noticed that not all visitors signed in the visitor log when they entered the facility. He stated he planned on [NAME] the three family members that visited him that day. The ADM stated the MDSC was primarily responsible for ensuring the accuracy of care plans. He stated it was important to individualize the care plans to each resident to ensure the highest quality of care to avoid any potential minor or major harm. He stated he would assume Resident #1's drug history was not in his care plan due to it not having happened while he had been residing at the facility. During an observation and interview on 12/28/23 at 11:41 AM, the Receptionist stated she worked Monday - Friday from 8:00 AM - 5:00 PM. She stated there was not a receptionist that worked on weekends and she did not work on Christmas Day. She stated visitors were to sign-in in their Visitor Logbook, and she pointed across the lobby to a binder. Record Review of the Visitor Logbook in the lobby, from 12/01/23 - 12/28/23, reflected no documented visitors for Resident #1. During an interview on 12/28/23 at 11:49 AM, LVN D stated she did not work on Christmas Day, but is almost always Resident #1's nurse on days she was working at the facility. She stated he often had visitors such as friends and family that would come by. She stated she had never heard of him requesting illegal substances of any kind. During a telephone interview on 12/28/23 at 1:31 PM, Resident #1's FM B stated that the current hospitalization was the second mysterious incident that has happened to Resident #1 at this facility. He stated on 12/08/23 he was sent to the hospital with the same symptoms, but a drug test was not performed. He stated the family members that visited him on 12/25/23 were family members from the other side of the family. He stated an incident like these two had not happened before at any other facility and Resident #1 had been residing in nursing facilities for over [AGE] years. He stated at most nursing facilities, you had to sign in when you entered, and this facility did not do that. He stated there is a book but no one enforced the rule. He stated he had never signed in and no one had ever asked who he was. He stated Resident #1 did have a history of drug abuse which is what led to him needing nursing facility care. He stated he asked Resident #1 at the hospital if he requested drugs and he responded, Why would I request something that could kill me? During a telephone interview on 12/28/23 at 2:11 PM, RN C stated she was working on 12/25/23 when Resident #1 had to be sent to the hospital. She stated during the day he was acting normal and there was nothing out of the usual. She stated in the evening, three family members that she had never seen before came to see him and stated they were going to take him home for Christmas. As they made their way down the hall, she yelled for someone to sign him out first. She stated an aide, who she could not remember who it was, told her that Resident #1 did not look right. She stated she went and assessed him and he was slumped in his wheelchair, was ashy white, eyes were dilated, and he could not talk - which was out of the norm for him. She stated his oxygen level was 81% and she told the family she was calling 911. She stated since the symptoms were very similar to the symptoms he experienced in early December , she requested that a drug test be conducted in the ER. During an interview on 12/28/23 at 2:24 PM, the ADM stated he could not find any admission documents or documents from Resident #1's previous facility. He stated he was an Interim ADM and was not working at the facility when Resident #1 was admitted . He stated the Admissions Coordinator that worked at the facility at that time no longer worked there. During an interview on 12/29/23 at 4:25 PM, the MDSC stated she was responsible for all resident care plans. She stated she looked at what was triggering from the MDS, medications that needed monitoring, diagnoses, and behaviors. She stated not having any interventions for Resident #1 regarding his history of drug abuse was an over-sight and was missed. Review of the facility's Comprehensive Care Plans Policy, dated 01/01/23, reflected the following: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The ADM was notified on 12/28/23 at 2:47 PM that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 12/29/23 at 11:31 AM: F656 - The facility must develop and implement a comprehensive person-centered care plan for each resident. On 12/28/2023 an abbreviated survey was initiated at (facility). On 12/29/2023 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 to resident health and safety. The notification of Immediate Jeopardy states as follows: Resident #1 is a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including TBI, cocaine dependence (in remission), and bipolar disorder. Interview with the ADM revealed that on 12/25/23 around 5:00 PM, three of Resident #1's family members came to visit. Approximately 20 minutes later the family was pushing him down the hallway towards the exit to take him to dinner when a CNA noticed that he did not look like himself. The CNA went and got the nurse who observed him to be sedated, have low O2 sats, and was unresponsive. Resident #1 was immediately sent to the hospital. Due to him having a similar episode earlier in the month, the nurse requested that a drug test be conducted at the ER. The results showed fentanyl and THC in the resident's system. Per the ADM, Resident #1 has a history of drug use and was kicked out of his old facility for smoking marijuana. He stated they did not investigate the incident because it was his belief that the family brought in the drugs, due to the resident being fine during the day until the family arrived. Interviews with staff revealed Resident #1 has family and friends visiting him often. Review of the Visitor Log at the entrance of the facility reflected no visitors had signed in for this resident for the month of December. There is nothing in Resident #1's CP regarding a history of drug use/addiction, so no interventions were in place. Review of the facility's ANE Policy reflects that the facility will implement policies and procedures to prevent neglect. Facility Response: Immediate Action 1. Action: Resident returned from the hospital and assessed by licensed nurse and care plan updated by MDS Nurse. Current interventions include scheduling a care conference, scheduled for 12/29/2023 at 3:00 pm with resident and responsible party to discuss current interventions put into place to prevent reoccurrence (1) Observe resident(s) for signs and symptoms of drug use, change in level of consciousness, excessive sedation, speech impairment. Any findings to be reported to administrator/designee, medical director, and responsible party and (2) Educate resident(s) on the adverse effects that illegal drugs could have on their overall health condition. Resident is receiving Psychiatry Services. Referral for face-to-face visit requested by MDS nurse. Start Date: 12/28/2023 Completion Date: 12/28/2023 at 5:35 p.m. Responsible: MDS Nurse and Charge Nurse Identification of Resident(s) Affected or Likely to be Affected: Action: Review of all residents ICD-10 codes completed by MDS nurse for identification of other residents with illicit drug history to ensure care plans are in place. 1 other resident identified and care plan updated by MDS nurse. Start Date: 12/28/2023 Completion Date: 12/29/2023 at 12:00 p.m. Responsible: MDS Nurse Action to Prevent Occurrence/Recurrence: Action 1: Interim Director of Nursing and MDS Nurse educated to ensure care plans are in place and interventions are present for all current residents with a history of drug addiction (through audit only 2 residents identified with a history of drug addiction) and all future admissions with a history/current drug abuse will have a history of drug abuse care plan initiated, with interventions, per regulation. New admissions with a history of drug abuse will be identified through their referral paperwork or upon admission assessment. State Date: 12/29/2023 Completion: 12/29/2023 at 2 p.m. Responsible: [NAME] President of Clinical Operations Action 2: All facility staff educated on Illegal Drug Use Policy and immediately reporting any illegal drugs found in a resident's room or on the facility grounds to the administrator/designee immediately. The administrator/designee will call the proper authorities, initiate an investigation, report to HHSC if warranted, and will notify the DON/MDS to ensure a care plan is initiated/updated and interventions are in place. The Administrator, Interim DON, VP of Clinical Operations, and the MDS nurse will educated all facility staff prior to working their next scheduled shift. The Administrator, Interim DON, and/or the MDS nurse will educate all new staff prior to working their first shift. Start date: 12/29/2023 Completion: 12/29/2023 by 12 p.m. Responsible: Administrator, Interim DON, [NAME] President of Clinical Operations, MDS nurse and/or designee Action for Monitoring for Compliance: Action: MDS nurse to complete weekly audits of residents ICD-10 codes for current illicit drug use and/or history and ensure it is care planned weekly x 4 weeks. Administrator/designee will document on the morning stand up form, any residents with a new diagnosis of illicit drug use 5 days a week x 4 weeks (Monday to encompass Friday - Sunday). The VP of clinical operations will validate daily stand-up forms weekly x 4 weeks. All new admissions identified as having a history of drug addiction, the MDS Coordinator will initiate a care plan and ensure interventions are in place. VP of Clinical Operations will audit weekly all new admission for illegal drug use and validate care plan includes drug use history. At a minimum the QAPI committee will review all education and all audits surrounding deficient practice. Start Date: 12/28/2023 Completion: 12/29/2023 by 12 p.m. Responsible: Administrator, Interim DON, MDS nurse, and or/designee Action: Ad Hoc QAPI Notified Medical Director of IJ template and action items to lower the immediacy. Start Date: 12/29/2023 Completion Date: 12/29/2023 @ 12 p.m. Responsible: Administrator, Medical Director, [NAME] President of Clinical Operations The Surveyor monitored the POR on 12/29/23 as followed: Observation on 12/29/23 at 2:24 PM revealed a sign on the entrance door that read ATTENTION ALL STAFF AND VISITORS: ILLICIT DRUGS ARE NOT PERMITTED TO BE BROUGHT INTO THE FACILITY OR GIVEN TO ANYONE AT THE FACILITY. During interviews on 12/29/23 from 2:58 PM - 5:55 PM with one HSKA, three LVNs, one MA, and two CNAs revealed they were all in-serviced before their shifts on illegal drugs not be allowed in the facility, on the facility's Illegal Drug Use Policy and immediately reporting any illegal drugs found in a residents room or on the facility grounds to the Administrator immediately, the signage posted on all entrance/exit doors regarding no illegal drugs were to be brought in, and the new visitor sign-in process. Observation on 12/29/23 at 3:32 PM revealed a visitor logbook at the nurses' station that was highly visible. There was a large sign that read ALL VISITORS MUST SIGN IN AT THE NURSES STATION. Review of an in-service entitled Illegal Drug Signage conducted by the MDSC, dated 12/28/23, reflected staff were educated on the following: There is a sign posted at the entrance for all staff and visitors that illicit drugs are not permitted to be brought into the facility or given to anyone in the facility. Review of an in-service conducted by the VPCO , dated 12/28/23, reflected staff were educated on the following: Anytime we receive information from outside entities or facility staff and/or visitors regarding illegal drug use the investigation must be started immediately and reported to the Police Department and HHSC if warranted. Review of the facility's Ad Hoc QAPI meeting, dated 12/28/23, reflected the following were in attendance: ADM, VPCO, RDO, and MD. Review of an in-service conducted by the VPCO, dated 12/29/23, reflected the MDSC was educated on the following: All residents diagnoses are part of the care plan and should be included with interventions. In morning meeting review of all new diagnosis of illicit drug use are to be care planned immediately. You must let the ADM know in morning meeting of any residents with a new diagnosis of illicit drug use. Review of Resident #1's updated care plan, dated 12/29/23, reflected he had a history of illicit drug use with interventions of notifying the NP if there is a change in condition and to set up appointment with psychiatric services. While the IJ was removed on 12/29/23 at 6:15 PM, the facility remained out of compliance at a severity of actual harm at a scope of isolated that is not Immediate Jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure that all alleged violations of abuse, neglect, exploitation, or misappropriation of property were thoroughly investigated in order to prevent further potential abuse, neglect, exploitation or misappropriation while the investigation was in progress for one (Resident #1) of five residents reviewed for abuse and neglect, in that: The facility failed to investigate after Resident #1 was diagnosed with a Fentanyl overdose on 12/25/23. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 12/28/23 at 2:47 PM. While the IJ was removed on 12/29/23 at 6:15 PM, the facility remained out of compliance at a severity of actual harm at a scope of isolated that is not Immediate Jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk of a drug overdose, hospitalization , or death. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including inhalant abuse (a broad range of household and industrial chemicals whose volatile vapors or pressurized gases can be concentrated and breathed in via the nose or mouth to produce intoxication), nicotine dependence, personal history of traumatic brain injury, major depressive disorder, and other psychoactive substance dependence. Review of Resident #1's admission MDS assessment, dated 09/15/23, reflected a BIMS of 12, indicating a moderate cognitive impairment. Section G (Functional Status) reflected he was completely dependent with ADLs. Review of Resident #1's quarterly care plan, dated 09/28/23, reflected he presented with primary diagnosis of depression and bipolar with an intervention of ensuring all needs were met. Review of Resident #1's admission summary, dated 09/06/23, reflected the following: Lifestyle: Resident/family member report currently uses or HX of alcohol use. [Resident #1] has a history of smoking in past. Smoked, drank, abused drugs at an early age in life. Review of Resident #1's progress notes in his EMR, dated 12/25/23 at 11:36 PM and documented by RN C, reflected the following: Nurse called ER to get updated, [Resident #1] is being admitted d/t / opioid overdose, [Resident #1] tested positive for opioids and Fentanyl. [Resident #1] has current orders for opioids however does not have an order for Fentanyl. Review of Resident #1's hospital discharge paperwork, dated 12/25/23, reflected the following: Chief Complaint: [Resident #1] presets with Altered Mental Status HPI: .who presented to ED for evaluation of acute encephalopathy (a group of disorders that affect the brain and cause confusion, memory loss, or other mental changes) which began last night. Per chart review this afternoon nursing staff noticed [Resident #1] was not acting like himself and was more lethargic. Reportedly [nursing staff] are worried [Resident #1]'s family was giving him extra medications or narcotics . In ER [Resident #1] was medicated with multiple doses of Narcan (a drug used to treat known or possible opioid overdose), woke up had GCS 15 (The highest possible GCS score is 15, and the lowest is 3. A score of 15 means you were fully awake, responsive and have no problems with thinking ability or memory). Now requiring Narcan drip. Further workup revealing: UA consistent with infection, UDS + opiates and Fentanyl. Mental status: obtunded (dazed, desensitized), withdraws to pain. Principal Diagnosis: Opioid overdose Review of Resident #1's physician orders in his EMR, on 12/28/23, reflected no order for Fentanyl or any other opioids, besides Tylenol with Hydrocodeine. Review of Resident #1's EMR, on 12/28/23, reflected no admission paperwork, documents from his previous SNF , history and physical, or nurse practitioner notes. During an interview on 12/29/23 at 2:37 PM, Resident #1 stated he did not ask anyone for fentanyl or any illegal drugs, and no one, not facility staff or family member, gave him anything he did not recognize. He stated he started feeling off before his family arrived for a visit. He stated at lunch, his food was going everywhere but into his mouth. He stated after his family arrived, he felt the highest he had ever felt in his life. He stated when he went to the hospital back at the beginning of December, he did not feel high like he had this most recent incident. He stated no one brings him drugs and staff do not offer him drugs. During a telephone interview on 12/28/23 at 10:11 AM, Resident #1's FM A state he and two other family members came to pick up Resident #1 on 12/25/23 around 5:00 PM. He stated RN C showed them to his room where he immediately noticed something was off with Resident #1. He stated he seemed to be heavily medicated, had a blank stare, and was mumbling. He stated this was unlike him as he was normally very communicative. He stated he asked RN C, You all had not noticed he was like this? He stated RN C said no and left the room. He stated it was very unnerving no one had noticed Resident #1's change in condition as it was obvious something was wrong with him. He stated it looked like someone had given him drugs as he was acting high. He stated Resident #1 was sent to the hospital earlier in the month for similar symptoms and wondered if someone had drugged him then, too. During an interview on 12/28/23 at 10:59 AM, the ADM stated he was notified of Resident #1's Fentanyl overdose on the morning of 12/26/23. He stated he was told by RN C that family members came to visit him on 12/25/23 and spent some time in his room and then stated they were going to take him out for Christmas dinner. RN C told him the family pushed him down the hallway to leave and she (RN C) asked them to sign him out first. RN C told him that an aide noticed Resident #1 did not look right. RN C told him the aide got RN C and she determined he needed to be sent to the hospital. When asked if he believed this should have been self-reported to HHSC he stated he did not because Resident #1 had a history of drug use. He stated he got kicked out of his previous facility for smoking marijuana. He stated he did not believe drugs were pushed on him, rather that he asked for them. When asked if there was any kind of investigation conducted, he stated he was waiting until he could interview Resident #1 once he returned from the hospital because that would be the main source of his investigation. He stated he had seen Resident #1 a few times on 12/25/23 during the day and he was his normal self. He stated he was not sure if he had any other visitors that day but did regularly have friends that visited him in the facility. He stated he had noticed that not all visitors signed in the visitor log when they entered the facility. He stated he planned on [NAME] the three family members that visited him that day. He stated there was nothing in his care plan regarding his history of drug use because they had not had any incidents with Resident #1 and drugs while he had been at the facility. A request was made at this time for any admitting documents or documentation from his previous facility. During an observation and interview on 12/28/23 at 11:41 AM, the Receptionist stated she worked Monday - Friday from 8:00 AM - 5:00 PM. She stated there was not a receptionist that worked on weekends and she did not work on Christmas Day. She stated visitors were to sign-in in their Visitor Logbook, and she pointed across the lobby to a binder. Record Review of the Visitor Logbook in the lobby, from 12/01/23 - 12/28/23, reflected no documented visitors for Resident #1. During an interview on 12/28/23 at 11:49 AM, LVN D stated she did not work on Christmas Day, but is almost always Resident #1's nurse on days she was working at the facility. She stated he often had visitors such as friends and family that would come by. She stated she had never heard of him requesting illegal substances of any kind. During a telephone interview on 12/28/23 at 1:31 PM, Resident #1's FM B stated that the current hospitalization was the second mysterious incident that has happened to Resident #1 at this facility. He stated on 12/08/23 he was sent to the hospital with the same symptoms, but a drug test was not performed. He stated the family members that visited him on 12/25/23 were family members from the other side of the family. He stated an incident like these two had not happened before at any other facility and Resident #1 had been residing in nursing facilities for over [AGE] years. He stated at most nursing facilities, you had to sign in when you entered, and this facility did not do that. He stated there is a book but no one enforced the rule. He stated he had never signed in and no one had ever asked who he was. He stated Resident #1 did have a history of drug abuse which is what led to him needing nursing facility care. He stated he asked Resident #1 at the hospital if he requested drugs and he responded, Why would I request something that could kill me? During a telephone interview on 12/28/23 at 2:11 PM, RN C stated she was working on 12/25/23 when Resident #1 had to be sent to the hospital. She stated during the day he was acting normal and there was nothing out of the usual. She stated in the evening, three family members that she had never seen before came to see him and stated they were going to take him home for Christmas. As they made their way down the hall, she yelled for someone to sign him out first. She stated an aide, who she could not remember who it was, told her that Resident #1 did not look right. She stated she went and assessed him and he was slumped in his wheelchair, was ashy white, eyes were dilated, and he could not talk - which was out of the norm for him. She stated his oxygen level was 81% and she told the family she was calling 911. She stated since the symptoms were very similar to the symptoms he experienced in early December, she requested that a drug test be conducted in the ER. During an interview on 12/28/23 at 2:24 PM, the ADM stated he could not find any admission documents or documents from Resident #1's previous facility. He stated he was an Interim ADM and was not working at the facility when Resident #1 was admitted . He stated the Admissions Coordinator that worked at the facility at that time no longer worked there. Review of the facility's Illegal Drug Use Policy, dated 09/01/23, reflected the following: This facility is an illegal drug-free facility. Illegal drugs are defined for the purpose of this policy as the use, possession, or distribution of any substances which is unlawful under the Controlled Substances Act. The facility reserves the right to inspect staff only areas, conduct staff alcohol and drug testing, and terminate staff employment for violation of this policy. 1. No one is allowed to possess, be under the influence of, or use any of said illegal drugs on the premises of this facility. The ADM was notified on 12/28/23 at 2:47 PM that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 12/29/23 at 11:31 AM: F 689 - The facility failed to ensure resident environment remains as free of accident hazards as possible On 12/28/2023 an abbreviated survey was initiated at (facility). On 12/28/2023 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 to resident health and safety. The notification of Immediate Jeopardy states as follows: Per the ADM, Resident #1 has a history of drug use and was kicked out of his old facility for smoking marijuana. He stated they did not investigate the incident because it was his belief that the family brought in the drugs, due to the resident being fine during the day until the family arrived. During an interview with Resident #1's FM revealed that there is no way of knowing who gave the resident his drugs. However, there is no way for the resident to get the drugs himself, regardless of if he asks for them or not. He stated they have no visitation process, and no one has ever asked him to sign in and anyone could just walk into the facility whenever. Interviews with staff revealed Resident #1 has family and friends visiting him often. Review of the Visitor Log at the entrance of the facility reflected no visitors had signed in for this resident for the month of December. There is nothing in Resident #1's CP regarding a history of drug use/addiction, so no interventions were in place. Immediate Action: 1. Action: Resident returned from the hospital and assessed by licensed nurse and care plan updated by MDS Nurse. Current interventions include scheduling a care conference with resident and responsible party to discuss current interventions put into place to prevent reoccurrence. Resident is receiving (psychiatry care services). Referral for face-to-face visit requested. Start Date: 12/28/2023 Completion Date: 12/28/2023 at 5:35 p.m. Responsible: MDS Nurse and Charge Nurse 2. Action: Incident report completed by Interim DON of alleged incident occurring on 12/25/2023 Start Date: 12/28/2023 Completion Date: 12/28/2023 @ 4:42 p.m. Responsible: Interim DON 3. Action: Ad Hoc QAPI Notified Medical Director of IJ template and action items to lower the immediacy. Start Date: 12/28/2023 Completion Date: 12/28/2023 @ 6:34 p.m. Responsible: Administrator, Medical Director, [NAME] President of Clinical Operations Identification of Resident(s) Affected or Likely to be Affected: 1. Action: Review of all residents ICD-10 codes completed by MDS nurse for identification of other residents with illicit drug history to ensure care plans are in place. No other residents identified. Start Date: 12/28/2023 Completion Date: 12/29/2023 at 5:00 p.m. Responsible: MDS Nurse Actions to Prevent Occurrence/Recurrence: 1. Action: Education provided to Administrator and Interim DON on investigating allegations of residents under the facility's care being on illegal drugs and contacting the proper authorities. Start Date: 12/28/2023 Completion Date: 12/28/2023 at 5:35 p.m. Responsible: [NAME] President of Clinical Operations 2. Action: Signage posted at all facility entrances on no illicit drugs are to be brought in by visitors and/or staff. All facility staff educated on signage posted at all entrances indicating no illicit drugs are to be brought in by visitors and/or staff prior to working their next shift. All new hires will be educated prior to working their first shift. Administrator will designate Department Managers and/or designee to visualize signage remains in place every 8 hours x 7 days a week x 4 weeks. Start Date: 12/28/2023 Completion Date: 12/28/2023 at 6:30 p.m. Responsible: Administrator, Department Managers, [NAME] President of Clinical Operations, and/or designee 3. Action: Visitor log placed at nursing station for facility staff to write name of who is visiting and which resident they are visiting. All facility staff educated on new visitor log and how to complete prior to working their next shift. All new hires will be educated prior to working their first shift. Start Date: 12/28/2023 Completion Date: 12/28/2023 7 p.m. Responsible: Administrator, Interim DON, [NAME] President of Clinical Operations, and/or designee 4. Action: All facility staff educated on Illegal Drug Use Policy and immediately reporting any illegal drugs found in a residents room or on the facility grounds to the Administrator immediately. Start date: 12/29/2023 Completion: 12/29/2023 Responsible: Administrator, Interim DON, [NAME] President of Clinical Operations, and/or designee Action Item: Monitoring for compliance Vice President of Clinical Operations will review all Incident and Accident reports 5 days a week (Monday to encompass Friday-Sunday) x 4 weeks to ensure thorough investigations were completed and interventions care planned. MDS nurse to complete weekly audits of residents ICD-10 codes for current illicit drug use and/or history and such is care planned. Interim DON to audit visitor list at nurses station 5 days a week (Monday to encompass Friday-Sunday) x 4 weeks to ensure visitors are appropriately logged and log indicates which resident they were visiting. Interim DON and/or ADON to validate all staff education completed weekly x 4 weeks. Administrator to validate completion of the above weekly x 4 weeks. Vice President of Clinical Operations to validate completion of the above weekly x 4 weeks. Start Date: 12/28/2023 Completion Date: 2/1/2023 Responsible: [NAME] President of Clinical Operations, MDS nurse, Interim DON, Administrator and/or designee The Surveyor monitored the POR on 12/29/23 as followed: Observation on 12/29/23 at 2:24 PM revealed a sign on the entrance door that read ATTENTION ALL STAFF AND VISITORS: ILLICIT DRUGS ARE NOT PERMITTED TO BE BROUGHT INTO THE FACILITY OR GIVEN TO ANYONE AT THE FACILITY. During interviews on 12/29/23 from 2:58 PM - 5:55 PM with one HSKA, three LVNs, one MA, and two CNAs revealed they were all in-serviced before their shifts on illegal drugs not be allowed in the facility, on the facility's Illegal Drug Use Policy and immediately reporting any illegal drugs found in a residents room or on the facility grounds to the Administrator immediately, the signage posted on all entrance/exit doors regarding no illegal drugs were to be brought in, and the new visitor sign-in process. Observation on 12/29/23 at 3:32 PM revealed a visitor logbook at the nurses' station that was highly visible. There was a large sign that read ALL VISITORS MUST SIGN IN AT THE NURSES STATION. Review of an in-service entitled Illegal Drug Signage conducted by the MDSC, dated 12/28/23, reflected staff were educated on the following: There is a sign posted at the entrance for all staff and visitors that illicit drugs are not permitted to be brought into the facility or given to anyone in the facility. Review of an in-service conducted by the VPCO , dated 12/28/23, reflected staff were educated on the following: Anytime we receive information from outside entities or facility staff and/or visitors regarding illegal drug use the investigation must be started immediately and reported to the Police Department and HHSC if warranted. Review of the facility's Ad Hoc QAPI meeting, dated 12/28/23, reflected the following were in attendance: ADM, VPCO, RDO, and MD. While the IJ was removed on 12/29/23 at 6:15 PM, the facility remained out of compliance at a severity of actual harm at a scope of isolated that is not Immediate Jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to ensure each resident recived adequate supervision to prevent accidents for one (Resident #1) of five residents reviewed for accidents and hazards, in that: The facility failed to supervise or prevent access to illegal drugs for Resident #1, knowing he had a history of drug use. On 12/25/23, Resident #1 went unresponsive and was diagnosed with a Fentanyl overdose in the hospital. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 12/28/23 at 2:47 PM. While the IJ was removed on 12/29/23 at 6:15 PM, the facility remained out of compliance at a severity of actual harm at a scope of isolated that is not Immediate Jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk of a drug overdose, hospitalization , or death. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including inhalant abuse (a broad range of household and industrial chemicals whose volatile vapors or pressurized gases can be concentrated and breathed in via the nose or mouth to produce intoxication), nicotine dependence, personal history of traumatic brain injury, major depressive disorder, and other psychoactive substance dependence. Review of Resident #1's admission MDS assessment, dated 09/15/23, reflected a BIMS of 12, indicating a moderate cognitive impairment. Section G (Functional Status) reflected he was completely dependent with ADLs. Review of Resident #1's quarterly care plan, dated 09/28/23, reflected he presented with primary diagnosis of depression and bipolar with an intervention of ensuring all needs were met. Review of Resident #1's admission summary, dated 09/06/23, reflected the following: Lifestyle: Resident/family member report currently uses or HX of alcohol use. [Resident #1] has a history of smoking in past. Smoked, drank, abused drugs at an early age in life. Review of Resident #1's progress notes in his EMR, dated 12/25/23 at 11:36 PM and documented by RN C, reflected the following: Nurse called ER to get updated, [Resident #1] is being admitted d/t / opioid overdose, [Resident #1] tested positive for opioids and Fentanyl. [Resident #1] has current orders for opioids however does not have an order for Fentanyl. Review of Resident #1's hospital discharge paperwork, dated 12/25/23, reflected the following: Chief Complaint: [Resident #1] presets with Altered Mental Status HPI: .who presented to ED for evaluation of acute encephalopathy (a group of disorders that affect the brain and cause confusion, memory loss, or other mental changes) which began last night. Per chart review this afternoon nursing staff noticed [Resident #1] was not acting like himself and was more lethargic. Reportedly [nursing staff] are worried [Resident #1]'s family was giving him extra medications or narcotics . In ER [Resident #1] was medicated with multiple doses of Narcan (a drug used to treat known or possible opioid overdose), woke up had GCS 15 (The highest possible GCS score is 15, and the lowest is 3. A score of 15 means you were fully awake, responsive and have no problems with thinking ability or memory). Now requiring Narcan drip. Further workup revealing: UA consistent with infection, UDS + opiates and Fentanyl. Mental status: obtunded (dazed, desensitized), withdraws to pain. Principal Diagnosis: Opioid overdose Review of Resident #1's physician orders in his EMR, on 12/28/23, reflected no order for Fentanyl or any other opioids, besides Tylenol with Hydrocodeine. Review of Resident #1's EMR, on 12/28/23, reflected no admission paperwork, documents from his previous SNF , history and physical, or nurse practitioner notes. During an interview on 12/29/23 at 2:37 PM, Resident #1 stated he did not ask anyone for fentanyl or any illegal drugs, and no one, not facility staff or family member, gave him anything he did not recognize. He stated he started feeling off before his family arrived for a visit. He stated at lunch, his food was going everywhere but into his mouth. He stated after his family arrived, he felt the highest he had ever felt in his life. He stated when he went to the hospital back at the beginning of December, he did not feel high like he had this most recent incident. He stated no one brings him drugs and staff do not offer him drugs. During a telephone interview on 12/28/23 at 10:11 AM, Resident #1's FM A state he and two other family members came to pick up Resident #1 on 12/25/23 around 5:00 PM. He stated RN C showed them to his room where he immediately noticed something was off with Resident #1. He stated he seemed to be heavily medicated, had a blank stare, and was mumbling. He stated this was unlike him as he was normally very communicative. He stated he asked RN C, You all had not noticed he was like this? He stated RN C said no and left the room. He stated it was very unnerving no one had noticed Resident #1's change in condition as it was obvious something was wrong with him. He stated it looked like someone had given him drugs as he was acting high. He stated Resident #1 was sent to the hospital earlier in the month for similar symptoms and wondered if someone had drugged him then, too. During an interview on 12/28/23 at 10:59 AM, the ADM stated he was notified of Resident #1's Fentanyl overdose on the morning of 12/26/23. He stated he was told by RN C that family members came to visit him on 12/25/23 and spent some time in his room and then stated they were going to take him out for Christmas dinner. RN C told him the family pushed him down the hallway to leave and she (RN C) asked them to sign him out first. RN C told him that an aide noticed Resident #1 did not look right. RN C told him the aide got RN C and she determined he needed to be sent to the hospital. When asked if he believed this should have been self-reported to HHSC he stated he did not because Resident #1 had a history of drug use. He stated he got kicked out of his previous facility for smoking marijuana. He stated he did not believe drugs were pushed on him, rather that he asked for them. When asked if there was any kind of investigation conducted, he stated he was waiting until he could interview Resident #1 once he returned from the hospital because that would be the main source of his investigation. He stated he had seen Resident #1 a few times on 12/25/23 during the day and he was his normal self. He stated he was not sure if he had any other visitors that day but did regularly have friends that visited him in the facility. He stated he had noticed that not all visitors signed in the visitor log when they entered the facility. He stated he planned on [NAME] the three family members that visited him that day. He stated there was nothing in his care plan regarding his history of drug use because they had not had any incidents with Resident #1 and drugs while he had been at the facility. A request was made at this time for any admitting documents or documentation from his previous facility. During an observation and interview on 12/28/23 at 11:41 AM, the Receptionist stated she worked Monday - Friday from 8:00 AM - 5:00 PM. She stated there was not a receptionist that worked on weekends and she did not work on Christmas Day. She stated visitors were to sign-in in their Visitor Logbook, and she pointed across the lobby to a binder. Record Review of the Visitor Logbook in the lobby, from 12/01/23 - 12/28/23, reflected no documented visitors for Resident #1. During an interview on 12/28/23 at 11:49 AM, LVN D stated she did not work on Christmas Day, but is almost always Resident #1's nurse on days she was working at the facility. She stated he often had visitors such as friends and family that would come by. She stated she had never heard of him requesting illegal substances of any kind. During a telephone interview on 12/28/23 at 1:31 PM, Resident #1's FM B stated that the current hospitalization was the second mysterious incident that has happened to Resident #1 at this facility. He stated on 12/08/23 he was sent to the hospital with the same symptoms, but a drug test was not performed. He stated the family members that visited him on 12/25/23 were family members from the other side of the family. He stated an incident like these two had not happened before at any other facility and Resident #1 had been residing in nursing facilities for over [AGE] years. He stated at most nursing facilities, you had to sign in when you entered, and this facility did not do that. He stated there is a book but no one enforced the rule. He stated he had never signed in and no one had ever asked who he was. He stated Resident #1 did have a history of drug abuse which is what led to him needing nursing facility care. He stated he asked Resident #1 at the hospital if he requested drugs and he responded, Why would I request something that could kill me? During a telephone interview on 12/28/23 at 2:11 PM, RN C stated she was working on 12/25/23 when Resident #1 had to be sent to the hospital. She stated during the day he was acting normal and there was nothing out of the usual. She stated in the evening, three family members that she had never seen before came to see him and stated they were going to take him home for Christmas. As they made their way down the hall, she yelled for someone to sign him out first. She stated an aide, who she could not remember who it was, told her that Resident #1 did not look right. She stated she went and assessed him and he was slumped in his wheelchair, was ashy white, eyes were dilated, and he could not talk - which was out of the norm for him. She stated his oxygen level was 81% and she told the family she was calling 911. She stated since the symptoms were very similar to the symptoms he experienced in early December, she requested that a drug test be conducted in the ER. During an interview on 12/28/23 at 2:24 PM, the ADM stated he could not find any admission documents or documents from Resident #1's previous facility. He stated he was an Interim ADM and was not working at the facility when Resident #1 was admitted . He stated the Admissions Coordinator that worked at the facility at that time no longer worked there. Review of the facility's Illegal Drug Use Policy, dated 09/01/23, reflected the following: This facility is an illegal drug-free facility. Illegal drugs are defined for the purpose of this policy as the use, possession, or distribution of any substances which is unlawful under the Controlled Substances Act. The facility reserves the right to inspect staff only areas, conduct staff alcohol and drug testing, and terminate staff employment for violation of this policy. 1. No one is allowed to possess, be under the influence of, or use any of said illegal drugs on the premises of this facility. The ADM was notified on 12/28/23 at 2:47 PM that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 12/29/23 at 11:31 AM: F 689 - The facility failed to ensure resident environment remains as free of accident hazards as possible On 12/28/2023 an abbreviated survey was initiated at (facility). On 12/28/2023 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 to resident health and safety. The notification of Immediate Jeopardy states as follows: Per the ADM, Resident #1 has a history of drug use and was kicked out of his old facility for smoking marijuana. He stated they did not investigate the incident because it was his belief that the family brought in the drugs, due to the resident being fine during the day until the family arrived. During an interview with Resident #1's FM revealed that there is no way of knowing who gave the resident his drugs. However, there is no way for the resident to get the drugs himself, regardless of if he asks for them or not. He stated they have no visitation process, and no one has ever asked him to sign in and anyone could just walk into the facility whenever. Interviews with staff revealed Resident #1 has family and friends visiting him often. Review of the Visitor Log at the entrance of the facility reflected no visitors had signed in for this resident for the month of December. There is nothing in Resident #1's CP regarding a history of drug use/addiction, so no interventions were in place. Immediate Action: 1. Action: Resident returned from the hospital and assessed by licensed nurse and care plan updated by MDS Nurse. Current interventions include scheduling a care conference with resident and responsible party to discuss current interventions put into place to prevent reoccurrence. Resident is receiving (psychiatry care services). Referral for face-to-face visit requested. Start Date: 12/28/2023 Completion Date: 12/28/2023 at 5:35 p.m. Responsible: MDS Nurse and Charge Nurse 2. Action: Incident report completed by Interim DON of alleged incident occurring on 12/25/2023 Start Date: 12/28/2023 Completion Date: 12/28/2023 @ 4:42 p.m. Responsible: Interim DON 3. Action: Ad Hoc QAPI Notified Medical Director of IJ template and action items to lower the immediacy. Start Date: 12/28/2023 Completion Date: 12/28/2023 @ 6:34 p.m. Responsible: Administrator, Medical Director, [NAME] President of Clinical Operations Identification of Resident(s) Affected or Likely to be Affected: 1. Action: Review of all residents ICD-10 codes completed by MDS nurse for identification of other residents with illicit drug history to ensure care plans are in place. No other residents identified. Start Date: 12/28/2023 Completion Date: 12/29/2023 at 5:00 p.m. Responsible: MDS Nurse Actions to Prevent Occurrence/Recurrence: 1. Action: Education provided to Administrator and Interim DON on investigating allegations of residents under the facility's care being on illegal drugs and contacting the proper authorities. Start Date: 12/28/2023 Completion Date: 12/28/2023 at 5:35 p.m. Responsible: [NAME] President of Clinical Operations 2. Action: Signage posted at all facility entrances on no illicit drugs are to be brought in by visitors and/or staff. All facility staff educated on signage posted at all entrances indicating no illicit drugs are to be brought in by visitors and/or staff prior to working their next shift. All new hires will be educated prior to working their first shift. Administrator will designate Department Managers and/or designee to visualize signage remains in place every 8 hours x 7 days a week x 4 weeks. Start Date: 12/28/2023 Completion Date: 12/28/2023 at 6:30 p.m. Responsible: Administrator, Department Managers, [NAME] President of Clinical Operations, and/or designee 3. Action: Visitor log placed at nursing station for facility staff to write name of who is visiting and which resident they are visiting. All facility staff educated on new visitor log and how to complete prior to working their next shift. All new hires will be educated prior to working their first shift. Start Date: 12/28/2023 Completion Date: 12/28/2023 7 p.m. Responsible: Administrator, Interim DON, [NAME] President of Clinical Operations, and/or designee 4. Action: All facility staff educated on Illegal Drug Use Policy and immediately reporting any illegal drugs found in a residents room or on the facility grounds to the Administrator immediately. Start date: 12/29/2023 Completion: 12/29/2023 Responsible: Administrator, Interim DON, [NAME] President of Clinical Operations, and/or designee Action Item: Monitoring for compliance Vice President of Clinical Operations will review all Incident and Accident reports 5 days a week (Monday to encompass Friday-Sunday) x 4 weeks to ensure thorough investigations were completed and interventions care planned. MDS nurse to complete weekly audits of residents ICD-10 codes for current illicit drug use and/or history and such is care planned. Interim DON to audit visitor list at nurses station 5 days a week (Monday to encompass Friday-Sunday) x 4 weeks to ensure visitors are appropriately logged and log indicates which resident they were visiting. Interim DON and/or ADON to validate all staff education completed weekly x 4 weeks. Administrator to validate completion of the above weekly x 4 weeks. Vice President of Clinical Operations to validate completion of the above weekly x 4 weeks. Start Date: 12/28/2023 Completion Date: 2/1/2023 Responsible: [NAME] President of Clinical Operations, MDS nurse, Interim DON, Administrator and/or designee The Surveyor monitored the POR on 12/29/23 as followed: Observation on 12/29/23 at 2:24 PM revealed a sign on the entrance door that read ATTENTION ALL STAFF AND VISITORS: ILLICIT DRUGS ARE NOT PERMITTED TO BE BROUGHT INTO THE FACILITY OR GIVEN TO ANYONE AT THE FACILITY. During interviews on 12/29/23 from 2:58 PM - 5:55 PM with one HSKA, three LVNs, one MA, and two CNAs revealed they were all in-serviced before their shifts on illegal drugs not be allowed in the facility, on the facility's Illegal Drug Use Policy and immediately reporting any illegal drugs found in a residents room or on the facility grounds to the Administrator immediately, the signage posted on all entrance/exit doors regarding no illegal drugs were to be brought in, and the new visitor sign-in process. Observation on 12/29/23 at 3:32 PM revealed a visitor logbook at the nurses' station that was highly visible. There was a large sign that read ALL VISITORS MUST SIGN IN AT THE NURSES STATION. Review of an in-service entitled Illegal Drug Signage conducted by the MDSC, dated 12/28/23, reflected staff were educated on the following: There is a sign posted at the entrance for all staff and visitors that illicit drugs are not permitted to be brought into the facility or given to anyone in the facility. Review of an in-service conducted by the VPCO , dated 12/28/23, reflected staff were educated on the following: Anytime we receive information from outside entities or facility staff and/or visitors regarding illegal drug use the investigation must be started immediately and reported to the Police Department and HHSC if warranted. Review of the facility's Ad Hoc QAPI meeting, dated 12/28/23, reflected the following were in attendance: ADM, VPCO, RDO, and MD. While the IJ was removed on 12/29/23 at 6:15 PM, the facility remained out of compliance at a severity of actual harm at a scope of isolated that is not Immediate Jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure all Pre-Admission Screening and Resident Review (PASARR) Level I Screening for residents diagnosed with mental illness were accurate and residents were provided with a PASRR Level II Screening for 1 of 2 resident (Resident #3) reviewed for PASARR coordination, by failing to ensure: 1. Resident # 3's PASARR Level I was completed accurately for Resident #3 who had active mental health diagnosis. This failure could place residents at risk for inappropriate placement in the nursing facility for long term care and at risk of not receiving appropriate care and services from the local authority, which could result in a possible decline in mental health The findings were: 1. Record review of Resident # 3's face sheet, dated 05/10/23, revealed a [AGE] year-old female admitted on [DATE] with diagnoses that included schizophrenia (a serious mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation, bipolar disorder (a mental disorder characterized by periods of depression and periods of abnormally elevated mood that each lasts from days to weeks), unspecified psychosis (certain types of schizophrenia, paranoid, and other psychotic disorders), and paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease). Record review of Resident # 3's Quarterly MDS dated [DATE] revealed a BIMS score of 99, suggesting the patient could not complete the interview. Further review revealed in section I, 5900 - Bipolar Disorder, I, 5950 - Psychotic Disorder (other than Schizophrenia), and I, 6000 - Schizophrenia entered as a diagnosis. Record review of Resident # 3's physician orders dated 01/26/22 revealed that Resident # 3 had order for may refer to LPC for Mental Health Counseling Evaluation as needed. Record review of Resident # 3's PASARR Level I screening dated 01/21/19 completed by LVN B revealed Resident # 3 did have a mental illness. Record review of Resident # 3's PASARR Level I screening dated 01/26/22 completed by SS revealed Resident # 3 did not have a mental illness. Record review of Resident # 3's clinical record revealed there was no PASRR Level II Screening found after 01/26/22. Record review of Resident # 3's care plan, last revised on 03/10/23, revealed a care plan for Resident # 3 has a diagnosis of Schizophrenia. She exhibits behaviors of verbal and physical aggression towards staff. She also has episodes of care and medication refusals. Goal: No report of injury to self or other due to behaviors through next review date. Interventions: If resident becomes agitated/combative, provide for safety, back away, seek assistance, reproach when calm, provide medication as ordered and indicated for PRN, Refer to psychological services as indicated. In an interview on 05/10/23 at 2:15 PM with LVN A, she stated in regard to Resident # 3, that she had contacted the LIDDA for residents with MI earlier that day, and they told her there had been an error with Resident # 3's PASARR. LVN A stated the other facility that Resident # 3 had been at was responsible for doing the PASARR. She stated Resident # 3 had never had a diagnosis of Dementia. She stated she did not do Resident # 3's PASARR upon Resident # 3 re-admitting and that it had been done by a previous staff member, but she had seen the first PASARR upon residents initial admission. She stated Resident # 3 had gotten COVID-19 and was transferred to another facility and then returned to this facility. She stated she is responsible for checking the accuracy of PASARR's for new admissions after they admit now. She stated she had worked here before and left for a while and then came back. She stated when she worked here before, her and another staff member split the alphabet to determine who did the PASARR's and MDS's. She stated she always corrected any PASARR that she may have found that was wrong She stated the LIDDA for ID/DD normally informed her when it was close to time to have a meeting for residents with ID/DD, but the previous social worker had tried keeping up with residents with MI. She stated if a resident had a PASARR completed incorrectly it could cause them to not receive the services available to them. In an interview on 05/10/23 at 12:24 PM with ADM, he stated the MDS nurse was usually responsible for ensuring the accuracy and completion of PASARR's for residents and sometimes the Social worker ensured the accuracy as well. He stated he was not aware Resident # 3's PASARR was completed incorrectly until LVN A told him about it and LVN A then submitted a form 1012 (mental illness/dementia resident review) and a new PASARR Level I must be submitted. He stated if a PASARR screening was done incorrectly a resident may be identified incorrectly and the resident may miss care needed or not be taken care of correctly, or the resident could miss services that could be offered to them. In an interview on 05/10/23 at 12:32 PM with DON, she stated LVN A was responsible for ensuring accuracy of PASARR screenings. She stated she was not aware that Resident # 3's PASARR was inaccurately completed, and that resident had already resided in facility when she began working there. She stated if a resident's PASARR was not completed correctly, the resident may not get the extra services that may be needed, and Resident # 3 could have missed some counseling or something else that Resident # 3 may have wanted. Record Review of facility policy Admission Criteria dated 2001 (revised March 2019) revealed under Policy Statement: Policy Interpretation and Implementation: 9. All new admissions and re-admissions are screened for mental disorders (MD), intellectual disabilities (ID), or related disorders (DR) per the Medical Pre-Admission Screening and Resident Review (PASARR) process; a. The facility conducts a level I PASARR screen for all potential admissions, regardless of payor source, to determine if the individual meets the criteria for MD, ID or RD, b. If the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process; (1) The admitting nurse notifies the social services department when a resident is identified as having a possible (or evident) MD, ID, or RD. (2) The social worker is responsible for making referrals to the appropriate state-designated authority. c. Upon completion of the Level II evaluation, the state PASARR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in the facility is appropriate. d. The state PASARR representative provides a copy of the report to the facility. e. The interdisciplinary team determines whether the facility is capable of meeting the needs and services of the potential resident that are outlined in the evaluation. f. Once a decision is made, the State PASARR representative, the potential resident and his or her representative are notified . 12. Our admission policies apply to all resident s admitted to the facility regardless of race, color, creed, national origin, age, sex, religion, handicap, ancestry, marital or veteran status, and/or payment source. 13. The Administrator, through the Admissions Department, ensures that the resident and the facility follow applicable admission policies.

Based on observation, interview, and record review the facility failed to ensure residents were free from abuse for 1 of 8 (Resident # 1 residents reviewed for abuse. The facility failed to ensure Resident # 1 was not assaulted by Resident # 4 on [DATE]. Resident #1 was hospitalized on [DATE] and died from the injuries sustained on [DATE]. Resident # 1 had a history or wandering in residents rooms and Resident # 4 had a history of aggressive behaviors towards other residents and staff. An IJ was identified on [DATE]. The IJ began on [DATE] and removed on [DATE]. The facility took action to remove the IJ before the survey began. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of actual harm that was not immediate Jeopardy and a severity level of isolated because (e.g.) all staff had not been trained on abuse/neglect, supervision, wandering/ elopement signs. This failure placed all residents at risk of being Abused. Findings included: Record review of Resident # 1 and Resident #4 records are closed records. Resident # 1 discahrged from facility to hopsital on [DATE] and died on [DATE]. Resident # 4 transferred to another facility not to return to this facility on [DATE]. Record review of Resident #1's face sheet reflected she was a [AGE] year-old woman admitted to the facility on [DATE]. Resident # 1 was admitted with diagnoses of Dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), Alzheimer's (a type of Dementia that affects memory, thinking and behavior), Cirrhosis of the Liver (severe scaring of the liver). Record review of Quarterly MDS dated [DATE], reflected Resident #1 had a BIMS score of 99 which indicated unable to complete assessment. Resident # 1 had a history of wander ing and exit seeking behaviors. Review of a Care Plan dated [DATE] reflected Resident # 1 had exit seeking behaviors and had the following interventions: Check for proper functioning of the wander guard system every shift Monitor resident for tail gaiting when visitor and staff exiting facility Reassess elopement risk at least quarterly Refer to social services as needed Use diversion activities when exit seeking behavior occurs Use verbal and if necessary physical cues for redirection to persuade exit-Convey acceptance during periods of inappropriate behavior Talk to resident during entire procedure of care seeking behaviors. Use wander guard system to alert staff of exit seeking behavior Record Review of hospital records dated [DATE]for Resident #1 reflected, Resident #1 was admitted to the hospital on [DATE]. The records reflected Resident # 1 was diagnosed with a Subdural Hematoma (a type of bleeding in which a collection of blood usually associated with a traumatic brain injury). The records reflected that Resident # 1 clinically decompensated and a repeat CT showed a worsening (SDH) Subdural Hematoma (a type of bleeding in which a collection of blood usually associated with a traumatic brain injury) and a (SAH) Seperatical Subarachroid Hemorrhage bleeding that is spreading to other parts of the body). The medical records further reflected that on [DATE] Resident # 1 had a decompressive craniotomy (used to treat intercranial pressure that is unresponsive to conventional treatment for SDH/SAH). Review of Resident #4 face sheet reflected he was a [AGE] year-old man admitted to the facility on [DATE]. Resident # 4 was admitted with a diagnosis of Generalized Epilepsy ( a form of epilepsy characterized by general seizures with no apparent cause), Cerebral Palsy (a group of disorders that affect a person's ability to move and maintain balance and posture), Congenital deformity of spine (the vertebrae don't form properly very early in fetal development), Contracture right elbow(an injury that causes pain and limits bending of the elbow), Unspecified Dementia(a Mental disorder in which a person loses the ability to think, remember, learn, and make decisions), Unspecified Psychosis (when there is inadequate information to make the diagnosis of a specific psychotic disorder), Moderate intellectual disabilities (intellectual and adaptive functioning that are approximately three to four standard deviations below the mean), and Schizoaffective Disorder(a combination of symptoms of schizophrenia and mood disorder, such as depression or bipolar disorder). Record review of Resident # 4 MDS dated [DATE] reflected a BIMS score of 00 (which indicated the resident does not have the cognitive ability for the assessment to be completed). The MDS reflected Resident # 4 is ambulatory no assistance walking or with transfers. Resident #4 has a contracted arm, so he only has the use of one arm. Requires assistance dressing, some ADL's. Record review of Resident #4 care plan dated [DATE], reflected a behavior to be physically aggressive. The plan reflected that Resident # 4 is very protective of his belongings and has become aggressive with staff and recently with another resident. Interventions included: Administer medications as ordered, analyze time of day, places, circumstances, triggers, and what de-escalates behavior and document. Monitor Q shift (every shift) and document observed behavior and attempted interventions Monitor/document any signs /symptoms that resident is posing a danger to self or others Staff to provide Q 15minute (every shift) or Q 1-hour (every shift) checks as directed Staff will encourage resident to keep distance from other residents that provoke agitation Record review of facility progress notes dated [DATE] - [DATE] of Resident # 4 aggressive behaviors towards others, the incidents are as follows: Incident [DATE], Resident # 4 assaulted Resident # 1 causing death. Incident [DATE], Resident # 4 assaulted another resident. Incident [DATE], Resident # 4 assaulted another resident Incident [DATE], Resident # 4 assaulted staff member LVN D Observation of facility video dated [DATE], reflected Resident #1 going into Resident # 4's room earlier that day with several staff on the hall never redirected. The video showed there were two staff observed in the hall prior to Resident # 1 entering Resident # 4's room. The video showed LVN B on the hall, and another unknown staff no redirection was provided. Resident #1 sustained were a busted lip that was bleeding, busted nose, one tooth was knocked out, and swelling to the left side on her forehead. Resident # 1 died from the injuries she sustained. Observation on [DATE] at 12:30pm, revealed an unidentified resident wandering on the East end of the hall near the Pharmacy supply room, which was observed to be open at the time. No staff observed in the area to resident this resident. Observation on [DATE] at 4:00, revealed unidentified resident on far East end of the building, near back exit door. Resident came in conference where surveyor was working asking to be changed, no staff observed on hall, resident not redirected. During a phone interview on [DATE] at 5:21pm with LVN A, revealed she was working the day of the incident. She stated she provided one on one care and supervision for another resident. LVN A stated she saw Resident # 4 pushing something aggressively in his door, but could not see what, she stated when she walked down the hall, she saw Resident # 1 in the doorway of the Resident #4's room. LVN A described Resident #1 as laid with her head back and legs stretched out in her wheelchair. LVN A stated she pulled Resident # 1 out the room and called for help. LVNA stated Resident # 1 was conscience but seemed to be confused. In an interview on [DATE] at 2:22pm with LVN D, revealed one time when she tried to assist Resident # 2 with pouring the sugar, he got upset and grabbed her wrist. She stated Resident # 2 grabbed her wrist really hard and started to twist it, she stated it hurt and she yelled out in pain. LVN D stated when she yelled out Resident # 2 let her wrist go, stated her arm was red and it hurt. LVN D stated Resident # 1 was a wanderer and stated she had taken the Resident # 1 out of Resident # 2's room before maybe a week before and stated Resident # 1 was in his room while he was asleep watching him sleep. LVN D stated they would try to keep an eye on Resident # 1 throughout the day and redirect her if she went into someone's room. During a phone interview on [DATE] at 2:47pm with LVN B, revealed Resident # 1 was known to be a wanderer and had been known to wander into other resident's rooms. She stated on the day of the incident [DATE] early that day she pushed Resident # 1 off the 1 [NAME] Hall, back to the common area. She stated later she talked to Resident # 1 on the 1 [NAME] Hall but could not remember what she spoke to her about. She stated she did not remember what happened after she had spoken with Resident # 1. She stated she did not redirect Resident # 1 at that time because she was just sitting in the hall, she stated she was not bothering anyone she was just in her chair. LVN B stated she had been trained on abuse/neglect and stated the administrator is the abuse/neglect coordinator. She stated she had never seen or suspected abuse/neglect. In an interview on [DATE] at 3:10pm the ADM. stated Resident # 1 was a wanderer. He stated staff would redirect Resident # 1 when she would go into resident's rooms. The ADM. stated staff tried to keep Resident # 1 in their sight. He stated staff did not redirect Resident # 1 when she was assaulted because it was during dinner time and all staff assisted with dinner service for the other residents. In an interview on [DATE] at 4:21PM the DON stated Resident # 1 was a wanderer. She stated the resident wore a wander guard, they redirected Resident # 1, and tried to keep her in their sight the best they could. The DON stated the staff would make rounds every two hours to check on all the residents. In an interview on [DATE] at 5:00pm the ADON revealed, Resident #1 was a wanderer. She stated they often removed and redirected Resident # 1 from going into other resident's rooms and messing with their things. The ADON stated Resident # 1 wears a wander guard and stated they tried to keep an eye on her the best they could by redirecting, she stated the door alarm would go off if she got close to any of the doors. In a phone interview on [DATE] at 11:30am LE, revealed the facility contacted EMS at 5:55PM on [DATE] and they were dispatched to the facility. LE reported that Resident # 1 was assaulted by Resident #4 at the facility and was transported to the hospital for further treatment. The LE reported the resident that assaulted Resident # 1 was not arrested at the time of the incident due to his diagnosis. LE stated the case was sent to the District Attorney's office to see if charges would be filed. In a phone interview on [DATE] at 1:30PM MD, revealed that Resident # 1 died from the injuries sustained from being assaulted by another resident. He reported that Resident # 1 continued to hemorrhage (bleed) worsened and spread through other parts of Resident # 1 body, he stated Resident # 1 expired on [DATE]. Review of QAPI - (Quality Assurance and Performance Improvement) dated Nov. 2022- [DATE]. ADM. reported the incident was discussed in the meeting along with the other incidents and accidents. Record review of in-service completed [DATE], reflected staff in-serviced on Abuse/Neglect. Record review of facility Abuse /Neglect policy dated [DATE] which reflected: Our resident has the right to be free from abuse/neglect Protect our residents from neglect by anyone including but not necessarily limited to facility staff other residents, consultants, and volunteer staff from other agencies. An Immediate Jeopardy was identified on [DATE]. The ADM. was informed of the IJ on [DATE] and provided with the IJ template on [DATE] at 4:20pm. Record review on [DATE] reflects staff in-serviced on Dementia / Behavioral issues 73 staff have been in-serviced. Record review on [DATE] reflected the DON/ADON, and DON completed a training on governance and Leadership on [DATE]. Records review on [DATE] reflected staff were in-serviced on Dementia care 73 staff have been trained and 17 more staff still need to be trained. Review of records reflect 19 staff have been trained on the mealtime monitoring services. Review of records on [DATE] reflected residents identified as wander risk had been reassessed on [DATE], which indicated they were no longer a wander risk. Review of care plans on [DATE], reflected the care plans for residents identified as wander risk had been updated to reflect any new interventions. Record review on [DATE] reflected, the MD (Medical Director) was made aware of the IJ, consulted regarding the plan of removal and agreed with the plan presented. Record review on [DATE] reflected, a QAPI meeting was held on [DATE] the IJ was discussed and plan of correction. An IJ was identified on [DATE]. The IJ began on [DATE] and removed on [DATE]. The facility took action to remove the IJ before the survey began. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of actual harm that was not immediate Jeopardy and a severity level of isolated because (e.g.) all staff had not been trained on abuse/neglect, supervision, wandering/ elopement signs.

Based on observation, interview, and record review the facility failed to provide adequate supervision and devices to prevent accidents for 2 of 8 (Resident #1, Resident # 4) residents reviewed for accidents and supervision. The facility failed to supervise and redirect Resident # 1 from entering Resident # 4's room resulting in Resident # 1 being assaulted by Resident # 4 on [DATE]. Resident # 1 died from the injuries sustained on [DATE]. Resident # 1 had a history of wandering behavior and would often wander into other residents rooms. Resident # 4 had a history of aggressive behaviors towards staff and residents. An IJ was identified on [DATE]. The IJ began on [DATE] and removed on [DATE]. The facility took action to remove the IJ before the survey began. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of actual harm that was not immediate Jeopardy and a severity level of isolated because (e.g.) all staff had not been trained on abuse/neglect, supervision, wandering/ elopement signs. This failure placed all residents at risk of accidents, hazards, hospitalization , and /or death. Findings included: Record review of Resident # 1 and Resident # 4 records are closed records review. Resident # 1 discharged to the hospital on [DATE] where she later died on [DATE]. Resident # 4 discharged from the facility on [DATE] return not expected. Record review of Resident #1's face sheet reflected she was a [AGE] year-old woman admitted to the facility on [DATE]. Resident # 1 was admitted with diagnoses of Dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), Alzheimer's (a type of Dementia that affects memory, thinking and behavior), Cirrhosis of the Liver (severe scaring of the liver). Record review of Quarterly MDS dated [DATE], reflected Resident #1 had a BIMS score of 99 which indicated unable to complete assessment. Review of a Care Plan dated [DATE] reflected Resident # 1 had exit seeking behaviors and had the following interventions: Check for proper functioning of the wander guard system every shift Monitor resident for tail gaiting when visitor and staff exiting facility Reassess elopement risk at least quarterly Refer to social services as needed Use diversion activities when exit seeking behavior occurs Use verbal and if necessary physical cues for redirection to persuade exit-Convey acceptance during periods of inappropriate behavior Talk to resident during entire procedure of care seeking behaviors. Use wander guard system to alert staff of exit seeking behavior Review of Resident #4 face sheet reflected he was a [AGE] year-old man admitted to the facility on [DATE]. Resident # 4 was admitted with a diagnosis of Generalized Epilepsy ( a form of epilepsy characterized by general seizures with no apparent cause), Cerebral Palsy (a group of disorders that affect a person's ability to move and maintain balance and posture), Congenital deformity of spine (the vertebrae don't form properly very early in fetal development), Contracture right elbow(an injury that causes pain and limits bending of the elbow), Unspecified Dementia(a Mental disorder in which a person loses the ability to think, remember, learn, and make decisions), Unspecified Psychosis (when there is inadequate information to make the diagnosis of a specific psychotic disorder), Moderate intellectual disabilities (intellectual and adaptive functioning that are approximately three to four standard deviations below the mean), and Schizoaffective Disorder(a combination of symptoms of schizophrenia and mood disorder, such as depression or bipolar disorder). Record review of Resident # 4 MDS dated [DATE] reflected a BIMS score of 00 (which indicated the resident does not have the cognitive ability for the assessment to be completed). Resident # 4 was ambulatory no assistance walking or with transfers. Resident #4 has a contracted arm, so he only has the use of one arm. Requires assistance dressing, some ADL's Record review of Resident #4 care plan dated [DATE], reflected a behavior to be physically aggressive. The plan reflected that Resident # 4 is very protective of his belongings and has become aggressive with staff and recently with another resident. Interventions included: Administer medications as ordered, analyze time of day, places, circumstances, triggers, and what de-escalates behavior and document. Monitor Q shift (every shift) and document observed behavior and attempted interventions Monitor/document any signs /symptoms that resident is posing a danger to self or others Staff to provide Q 15minute (every shift) or Q 1-hour (every shift) checks as directed Staff will encourage resident to keep distance from other residents that provoke agitation Record review of facility progress notes dated [DATE] - [DATE] of Resident # 4 aggressive behaviors towards others, the incidents are as follows: Incident [DATE], Resident # 4 assaulted Resident # 1 causing death. Incident [DATE], Resident # 4 assaulted another resident. Incident [DATE], Resident # 4 assaulted another resident Incident [DATE], Resident # 4 assaulted staff member LVN D In an interview on [DATE] at 4:00pm LVN C, stated Resident # 1, was a wanderer. She statedshe wore a wander guard, so this would alert them if the resident went near the exit doors. She stated they monitored by redirecting the resident and checking on her every two hours. During a phone interview on [DATE] at 5:21pm LVN A, revealed that Resident # 1, was a wanderer and they monitored as best as they could. LVN A stated they monitored by redirecting, tried to keep her close to the nurse's station, and when they completed their two- hour checks on all residents. LVN A described Resident # 4 as being pleasant when around others, stated she had heard that he was aggressive with others but stated she had never seen Resident # 4 be aggressive. During a phone interview on [DATE] at 2:47pm LVN B, revealed Resident # 1, was a wander stated they monitored by redirecting the resident and she wore a wander guard so if she went close to the doors the alarm would sound. LVN B stated Resident # 4 had been aggresive with other residents in the past, and stated also a staff member. LVN B stated Resident # 4 is usually a happy person who likes to speak to everyone when walking down the halls. In an interview on [DATE] at 2:22pm with LVN D, revealed one time when she tried to assist Resident # 4 with pouring the sugar, he got upset and grabbed her wrist. She stated Resident # 2 grabbed her wrist really hard and started to twist it, she stated it hurt and she yelled out in pain. LVN D stated when she yelled out Resident # 4 let her wrist go, stated her arm was red and it hurt. LVN D stated Resident # 1 was a wanderer and stated she had taken the Resident # 1 out of Resident #4's room before maybe a week before and stated Resident # 1 was in his room while he was asleep watching him sleep. LVN D stated they would try to keep an eye on Resident # 1 throughout the day and redirect her if she went into someone's room In an interview on [DATE] at 2:00pm with CNA A, B, and C, revealed Resident # 1, was identified as a wanderer. They reported that they monitored the resident movements by keeping her close to the nurse's station throughout the day. They reported the resident also wore a wander guard and she went close to the doors the alarm would sound and alert them. CNA A, B, and C stated they monitored Resident # 1, the best that they could. CNA A, B, and C stated Resident # 4 was usuaully happy, he liked to interact with others and wave when he walked down the halls. CNA A, B, and C stated Resident # 4 had been aggressive with other residents and with another staff member. They stated Resident # 4 was protective of his things and didn't like people messing with this things such as his hats and sun glasses that he always wore. In an interview on [DATE] at 4:45pm with DON revealed, Resident # 1, was a wanderer and staff must redirect resident. She stated they monitor the resident every two hours and check the wander guard daily to ensure that it is working. The DON described Resident # 4 as pleasant, happy guy and stated this was the first aggressive behavior she had seen by Resident # 4 since she started at the facility. In an interview on [DATE] with ADM. revealed all staff were aware that Resident # 1, was a wanderer. He stated the resident wore a wander guard that would alarm if she went near the doors. He stated Resident # 1was injured by Resident # 4 during dinner time service and the staff were passing trays to the other residents. The administrator stated they had their QAPI meeting on [DATE] and they discussed their incidents and reportable findings and that the facility had been substantiated but not cited. The administrator did not indicate that there was any discussion regarding monitoring of the other residents, how t the incident occurred and what they needed to do to prevent an incident like this from happening again. He stated they did not talk about the incident in detail. The administrator stated that he was not able to put every resident on one-to-one supervision. Records Review of in-service completed [DATE], revealed staff in-serviced on Abuse/Neglect. Review of facility Abuse /Neglect policy dated [DATE] which reflected: Our resident has the right to be free from abuse/neglect Protect our residents from neglect by anyone including but not necessarily limited to facility staff other residents, consultants, and volunteer staff from other agencies. Record Review of Wander guard Policy dated [DATE] reflected the following: 1. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. Record Review of facility Safety and Supervision of Residents policy dated [DATE] reflected the following: 1. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee trainings, employee monitoring, and reporting process. 2. Our individualized, resident- centered approach to safety addresses safety and accident hazards for individual residents 3. The are team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. 4. Monitoring the effectiveness of interventions to include the following: a. Evaluating the effectiveness of interventions b. Modifying and replacing interventions as needed c. Ensuring that interventions are implemented correctly and consistently An Immediate Jeopardy was identified on [DATE]. The ADM. was informed of the IJ on [DATE] and provided with the IJ template on [DATE] at 4:20pm. Observation of facility video dated [DATE], reflected Resident #1 going into Resident # 4's room earlier that day with several staff on the hall never redirected. The video showed there were two staff observed in the hall prior to Resident # 1 entering Resident # 4's room. The video showed LVN B on the hall, and another unknown staff no redirection was provided. Resident #1 sustained were a busted lip that was bleeding, busted nose, one tooth was knocked out, and swelling to the left side on her forehead. Resident # 1 died from the injuries she sustained. Observation of facility video dated [DATE], reflected Resident #1 going into Resident # 4's room that day with several staff on the hall with no redirection provided. Observation on [DATE] at 12:30pm, revealed an unidentified resident wandering on the East end of the hall near the Pharmacy supply room, which was observed to be open at the time. No staff observed in the area to resident this resident. Observation on [DATE] at 4:00, revealed unidentified resident on far East end of the building, near back exit door. Resident came in conference where surveyor was working asking to be changed, no staff observed on hall, resident not redirected. In an interview on [DATE] at 3:30pm with CNA D revealed, he had been trained on abuse/neglect, wandering and supervision, resident rights. Stated the abuse /neglect protocol is to report if they see or suspect abuse /neglect to the administrator who is the abuse/ neglect coordinator. Stated they have been trained on monitoring during mealtimes, stated residents are being required to dine in their room or in the dining room so they can ensure supervision of the residents. Stated she looked at the Kardex to see what a resident's care needs were and the nurse updated them when changes were made to the care plan. Stated rounds are made every two hours or as needed when residents use their call lights. In an interview on [DATE] at 3:40 with CNA E revealed, he had been trained on abuse/neglect, wandering and supervision, resident rights. Stated they have been trained on monitoring during mealtimes, stated residents are being required to dine in their room or in the dining room so they can ensure supervision of the residents. Stated he looked at the Kardex to see what a resident's care needs were and the nurse updated them when changes were made to the care plan. Stated rounds are made every two hours, stated however throughout the day they are walking the halls. Stated the abuse /neglect protocol is to report if they see or suspect abuse /neglect to the administrator who is the abuse/ neglect coordinator. In an interview on [DATE] at 3:50pm with CNA F revealed, she had been trained on abuse/neglect, wandering and supervision, resident rights. Stated she looked at the Kardex to see what a resident's care needs were and the nurse updated them when changes were made to the care plan. Stated rounds are made every two hours, stated however throughout the day they are walking the halls. Stated they have been trained on monitoring during mealtimes, stated residents are being required to dine in their room or in the dining room so they can ensure supervision of the residents. Stated the abuse /neglect protocol is to report if they see or suspect abuse /neglect to the administrator who is the abuse/ neglect coordinator. In an interview on [DATE] with DON, stated all nursing and CNA staff have been trained on how to review the Kardex in the PCC (point click care system) and know what the care needs are for the residents. She stated the nurses would continue to train staff on changes with residents on admission and as they occur with the residents. DON stated they would continue to assess the residents for wandering and elopement risk and make changes to interventions as they go. In an interview on [DATE] with ADM. Stated was his expectation that all staff get the needed training, and they follow the care plans of the residents when providing care and supervision. He stated they would continue to monitor and make changes as needed to their facility policies and systems that are in place. Record review on [DATE] reflects staff in-serviced on Dementia / Behavioral issues 73 staff have been in-serviced. Record review on [DATE] reflected the DON/ADON, and DON completed a training on governance and Leadership on [DATE]. Records review on [DATE] reflected staff were in-serviced on Dementia care 73 staff have been trained and 17 more staff still need to be trained. Review of records reflect 19 staff have been trained on the mealtime monitoring services. Record review on [DATE] of wander assessment dated [DATE] reflected, Resident # 1 and Resident # 2 are no longer identified as risk for wandering or elopement from the facility. Records Review of care plans on [DATE], reflected the care plans for Resident # 2 reflected no changes to the current interventions in place. The care plan for Resident # 3 reflected new interventions in place and that Resident # 3 has a wander guard for wandering and elopement. Record review on [DATE] reflected, the MD was made aware of the IJ, consulted regarding the plan of removal and agreed with the plan presented. Record review on [DATE] reflected, a QAPI meeting was held on [DATE] the IJ was discussed and plan of correction. An IJ was identified on [DATE]. The IJ began on [DATE] and removed on [DATE]. The facility took action to remove the IJ before the survey began. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of actual harm that was not immediate Jeopardy and a severity level of isolated because (e.g.) all staff had not been trained on abuse/neglect, supervision, wandering/ elopement signs.

Intakes: TX 928 Based on observations, interviews and record reviews the facility failed to ensure the facility remained free of accidents and hazards as possible for one of four residents (Resident #1) reviewed for accidents and hazards. CNA A provided Resident #1 with coffee from the employee coffee pot, with unregulated temperature instead of the resident coffee pot with regulated temperature. This resulted in Resident #1 receiving [CONDITION(S)] to the left hip/buttock when the coffee spilled. This failure could place residents at risk of severe injuries and hospitalization . The findings included: Review of Resident #1's Face Sheet reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of: Mild Cognitive Impairment, other unspecified depressive episodes, idiopathic gout, cerebral infarction without residual deficits, age-related nuclear cataract (right eye), presence of intraocular lens, hypermetropia (bilateral), , and gastro-[CONDITION(S)] reflux disease without esophagitis. Review of Resident #1's MDS (Minimum Data Set) assessment dated [DATE] reflected the resident had a Brief Interview for Mental Status of 10 indicating mild cognitive impairment. Resident was wheelchair bound. Resident was also assessed to require supervision, set-up help only, with eating and drinking. Review of Resident #1's Care Plan revised on 02/09/2022 reflected resident was at risk for skin breakdown and pressure ulcers secondary to fragile skin. Notify MD and RP of change in condition. Observe skin weekly per schedule and any reports of open/red area notify MD and WND care nurse as appropriate and implement ordered interventions. Observe skin when providing care for redness/open area and notify Nurse. Review of Resident #1's Incident Report note dated 03/09/2022 reflected RN wound care nurse reported to this charge nurse that upon skin assessment noted pt had blisters/redness to left buttocks. In the resident description box it was noted, Resident stated, I spilled my breakfast coffee. No other injuries were noted upon skin assessment. Resident notes pain 7/10 in pain scale. Administered [MEDICATION(S)] 50mg 1 po as directed prn. Pt was turned on rt. side of body, left buttocks opened to air. Notified DON and Pts [family member]. The level of consciousness noted for resident was alert and the mental status was oriented to person, oriented to place, oriented to time, and oriented to situation. In an interview on 03/10/2022 at 4:48 PM, Resident #1 stated she spilled her coffee, and it was no one's fault. She stated she had coffee every day and she wanted it right out of the pot. In an interview on 03/10/2022 at 4:31 PM CNA A stated she gave Resident #1 coffee on 03/09/2022 for breakfast from the employee coffee pot as it was closer to her than the resident coffee pot in the kitchen. She stated she informed the resident to be careful because it was hot. She stated she continued passing out meal trays for other residents when she was informed Resident #1 spilled the coffee and had some [CONDITION(S)]. She stated she was only supposed to get coffee for residents from the resident coffee pot but was busy. She stated she did not know the temperature of the coffee before she gave it to the resident. She stated she did not give any coffee to any other residents from the employee coffee pot. In an interview on 03/10/2022 at 5:24 PM, Cook E stated if a resident wanted coffee, they had to ask for it and staff would serve it to them. She stated the coffee temperature in the resident pot was around 100 degrees. She stated no residents had complained about the temperature of the coffee. In an interview on 03/10/2022 at 7:41 PM the Administrator stated staff are to get coffee from the resident coffee pot in the kitchen only. He stated regardless of what a resident's family member said, even if they worked at the facility, staff were supposed to get coffee from the resident coffee pot. He stated dietary was responsible for ensuring the resident's coffee was the appropriate temperature. He stated staff were in-serviced on 3/9/2022 to only serve residents coffee from the resident coffee pot , regardless of what the residents family okayed. He stated they made it easier for staff by bringing down the resident coffee pot to the nurse's station. Observation at 5:18 PM revealed a coffee pot labeled Residents located behind the nurse's station on the first floor. Record Review of a undated facility policy titled Quality of Care reflected j. Beverages/temperatures- all hot liquids including coffee, broths, etc . temperatures need to be 130-150 for proper nursing home safety regulations with the elderly; this will be individualized per resident based on their health and medical history diagnosis. Patients/residents with Tremors, Dementia, or Alzheimer's will need assistance handling/drinking and hot beverage cooled below 110 for safety; so, a burn does not occur. It is also reflected i. Coffee of hot liquids are placed at a localized nursing station for proper monitoring. Depending on if resident needs assistance or getting hot temped beverage and returning to their room. These guidelines may change based on resident needs, state guidelines, or policy update. Coffee machine is wired to temp at 140-150. Temp may be adjusted by Folgers Vendors if needed. Record review of facility policy titled Safety and Supervision of Residents (revised July 2017) reflected a policy statement of, Our facility strives to make the environment as free from accident hazards as possible. Residents' safety and supervision and assistance to prevent accidents are facility-wide priorities.

Based on observations, interviews, facility document review, and facility policy review, the facility failed to ensure staff entering the facility, located in a high COVID-19 transmission county, were screened for signs and symptoms of COVID-19; and staff failed to report signs/symptoms of COVID-19. The facility also failed to ensure all staff wore appropriate personal protective equipment in the facility and when providing care to residents. This deficient practice had the potential to spread COVID-19 to the 45 residents in the facility, staff, and visitors, leading to serious illness and/or death; and occurred during the COVID-19 pandemic. Two facility staff members, Licensed Vocational Nurse (LVN) C and Laundry A, failed to properly screen and/or report symptoms of COVID-19 and subsequently tested positive for COVID-19 during their shift. LVN C, who had omitted screening, tested positive on [DATE]. Those residents becoming positive within 14 days assigned to the LVN included Resident #3, Resident #13, Resident #17, and Resident #35. On [DATE] at 8:15 AM, a second entry was made to gather additional information. It was determined the facility's non-compliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.80 (Infection Control) at a scope and severity of L. The facility Administrator was notified of the IJ on [DATE] at 1:55 PM and was provided with the IJ template on [DATE] at 2:03 PM. A Removal Plan was requested. An acceptable Removal Plan was received on [DATE]. The IJ was determined to be removed on [DATE], after the survey team performed onsite verification that the Removal Plan had been implemented. Findings included: A review of the facility's policy, titled, Emergent Infectious Disease Management Program, undated, indicated, POLICY: To protect our residents, families, and staff from any harm resulting from exposure to any emergent infectious disease while they are in our care or are in our facility .Assess staff, visitors and vendors using screening tool. If staff, visitor, or vendor answer yes to any of the screening questions they should be directed to the administrator/director of nursing or designee and requested to refrain from entering the facility. A review of the Centers for Disease Control and Prevention (CDC) publication, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, last updated [DATE], indicated, If SARS-CoV-2 infection is not suspected in a patient presenting for care (based on symptom and exposure history), HCP [healthcare personnel] working in facilities located in counties with substantial or high transmission should also use PPE as described below: . Eye protection (i.e., goggles or a face shield that covers the front and sides of the face) should be worn during all patient care encounters. A review of the Centers for Disease Control and Prevention (CDC) website, COVID Data Tracker, indicated that, as of [DATE], [NAME] County (the county in which the facility was located), Texas had a high community transmission rate of COVID-19. The Texas Health and Human Services COVID-19 Response for Nursing Facilities [DATE] version indicated in Section 12. Interim Guidance for Prevention, Management, and Reporting of COVID-19 Outbreaks in LTC under Active Screening - The CDC and CMS recommend, and the NF COVID-19 Response rules require NFs screen all staff prior to entering the NF at the beginning of their shift for fever and symptoms consistent with COVID-19. Actively take their temperature and document absence of or shortness of breath, new or change in cough, sore throat, and other symptoms of COVID-19. If they are ill, have them put on a facemask per CDC guidance, immediately leave the NF and self-isolate at home. 1. During an observation on [DATE] at 9:17 AM, the facility staff were observed in the hallways of the first-floor unit. The facility staff were noted to be wearing N95 masks with no eye protection, and one unidentified employee (later identified as Licensed Vocational Nurse (LVN) C) was observed to be wearing a surgical mask. During an interview on [DATE] at 1:15 PM, the Infection Preventionist (IP) stated two employees on shift that day ([DATE]) tested positive for COVID-19 (LVN C and Laundry A). The IP stated the two employees had screened when entering the facility and denied having any symptoms. The IP stated the process for screening involved having the body temperature checked to make sure there was no fever and asking if signs and symptoms of COVID-19 were present. The IP stated it was important to answer all the questions truthfully to ensure people with active symptoms did not enter the facility and expose residents and staff to COVID-19 or other respiratory infections. The IP stated that after testing positive, Licensed Vocational Nurse (LVN) C reported having a runny nose when entering the facility but thought it was sinus issues. The IP stated the other employee from the laundry, Laundry A reported having had a cough but thought it was because of being a smoker. The IP stated sinus issues and a cough were COVID-19 symptoms and should have been reported immediately to prevent the spread of COVID-19. The IP stated LVN C had been providing direct care to residents and was only wearing a surgical mask due to a medical exemption. The IP stated LVN C exposed the residents and staff to COVID-19. A review of the facility's COVID-19 Employee/Vendor Screen form for [DATE], indicated LVN C did not screen for signs and symptoms of COVID-19 nor did LVN C perform a temperature check prior to providing care for residents. The form indicated Laundry A screened on [DATE] at 6:05 AM and had a temperature of 97 degrees F. The form indicated Laundry A answered no to having chills, cough, shortness of breath, nausea/vomiting, diarrhea, or new loss of taste or smell. The form did not indicate who screened Laundry A. During a concurrent interview and record review, on [DATE] at 1:40 PM, the IP reviewed the COVID-19 Employee/Vendor Screen form for [DATE] and confirmed LVN C did not screen prior to entering the facility. The IP stated a staff member was normally assigned to screen staff from 7:00 AM to 5:00 PM. The IP stated when employees arrived before 7:00 AM another employee had to let them in the facility and screen them. The IP stated there was no system in place to audit and make sure staff screened prior to entering the facility. The IP would only review screening forms at the end of the day and look for any yes responses. The IP stated if any yes responses were found, the employee would be further questioned. The IP had not considered checking the screening forms during the day and stated it would be a better practice than waiting until the end of the day. The IP stated it was important to make sure all employees screened and only entered the facility if no symptoms were present. During an interview on [DATE] at 2:00 PM, the Director of Nursing (DON) stated they were not aware that LVN C was not wearing an N95 mask and did not screen prior to entering the facility on [DATE]. The DON stated employees were expected to wear an N95 and screen every day. The DON stated if an employee arrived at the facility and had an elevated temperature when screened, the DON would be called, and the employee would be screened by the DON. During an interview on [DATE] at 8:08 AM, the DON stated the facility tested all 45 residents on [DATE] in response to the positive staff members. The DON stated one resident (Resident #45) had a positive result and was placed in isolation. During a telephone interview on [DATE] at 11:28 AM, LVN C stated that on [DATE], upon arrival to the facility, LVN C self-screened for COVID-19 symptoms, went to clock in, and forgot to fill out the screening form. LVN C admitted to having a runny nose and congestion upon arrival to the facility. The LVN did not report it because they felt it was because of allergies and the weather was cold the day before. LVN C stated that they had gone to the facility before with a runny nose and congestion and did not test positive. LVN C stated the facility was not informed of the runny nose until the positive test result. LVN C stated having a runny nose and congestion were symptoms of COVID-19 and they should have reported the symptoms upon screening on [DATE]. LVN C stated that due to a medical exception, LVN C did not wear an N95 mask and wore a surgical mask instead, which allowed for more air flow in and out of the mask. LVN C stated the purpose of screening was to make sure those experiencing COVID-19 symptoms did not enter the facility, to help stop the spread of COVID-19. LVN C stated that by entering the facility and not screening, not reporting the runny nose, and wearing only a surgical mask while being positive for COVID-19, the potential to spread COVID-19 to residents and staff was higher, especially because LVN C provided care to residents from 6:00 AM until around 9:30 AM when the facility sent LVN C home. During an interview on [DATE] at 11:35 AM, Laundry A stated that on [DATE] nobody was available to screen staff, so Laundry A did a self-screen. Laundry A denied having any symptoms upon arrival to the facility and went to smoke after screening. Laundry A stated that after smoking, they developed a cough, and Laundry A did not report the cough because Laundry A assumed it was due to smoking. Laundry A stated the facility was not informed of the cough until after the positive test result. Laundry A denied entering any resident care areas and stated the morning was spent in the laundry department until testing around 9:30 AM. Laundry A stated it was important to screen before entering the facility and report all symptoms to prevent the spread of COVID-19. Laundry A stated that they were not sure if COVID-19 could be spread on clothing, linen, or other inanimate objects. During an observation on [DATE] at 12:10 PM, all staff were observed in the hallways of the nursing unit wearing N95 masks and no eye protection. During an interview on [DATE] at 8:50 AM, LVN B stated that prior to coming into the facility to work, all staff had to screen at the front. LVN B stated staff were required to have their temperatures taken and to report any COVID-19 symptoms to prevent the spread of COVID-19. LVN B stated the only required personal protection equipment (PPE) in the facility at that time was an N95 mask. LVN B stated that eye protection was only needed when entering an isolation room, and LVN B was not informed eye protection was needed when in the hallways or common areas. LVN B stated the IP was responsible for informing staff what PPE was required, and the current requirement was only an N95 mask. During an interview on [DATE] at 12:25 PM, Certified Nursing Assistant (CNA) B stated all employees were required to screen prior to entering the facility to prevent spreading any virus or infection to the residents and staff. CNA B stated the IP had not informed the staff eye protection was required, and only N95 masks were being worn by staff. During an interview on [DATE] at 12:31 PM, CNA C stated all employees had to screen prior to entering the facility, and it was important to answer honestly because you don't want to hurt anyone. CNA C stated that if a staff member was observed with COVID-19 symptoms while working, the unit manager needed to be made aware immediately. CNA C stated the current requirement for eye protection was that eye protection had to be worn when entering an isolation room. CNA C stated the IP had not yet informed the facility staff that eye protection was required anywhere else. During an interview on [DATE] at 12:40 PM, the Unit Manager (UM) stated staff had to screen prior to entering the facility and be truthful with the responses to prevent the spread of COVID-19. The UM was not aware that LVN C did not screen prior to entering the facility, and the UM did not audit screening forms to ensure all staff were screened. The UM stated LVN C worked from 6:00 AM to around 9:30 AM on [DATE]. The UM stated LVN C informed the facility of congestion and a runny nose after the COVID-19 test came back positive. The unit manager stated the PPE requirements for the staff were only an N95 mask. The UM stated that they did not know at what point eye protection would be needed or what the county transmission rate was and relied on the instructions from the Infection Preventionist (IP) as to what PPE the staff needed to wear. The UM stated the IP was responsible for informing the staff when eye protection would be required. During an interview on [DATE] at 1:59 PM, the IP stated the transmission rate in the county the facility was in was still in the red zone, which meant the transmission rate was high. The IP did not know how to check for the current PPE guidance regarding what was recommended for the facility staff. The IP stated the requirements were only an N95 mask and that was based off what the facility had been doing since September of 2021. The IP stated it was important to know what the requirements were to prevent the spread of COVID-19 and because it was the IP's responsibility to make sure facility staff were following guidelines. The IP did not know where to locate the guidance that was provided in September of 2021. The IP did not know if the staff were required to wear eye protection and stated the DON would inform the IP when eye protection was required. During an interview on [DATE] at 3:08 PM, the DON stated the current infection control practices in place for employees at the facility due to the active COVID-19 outbreak included an N95 mask or a surgical mask for employees with medical/religious exemptions, hand hygiene, and goggles while on the units. The DON stated, gloves, and gowns would be worn in isolation or quarantine rooms. The DON stated guidance on what PPE to use was received from the state agency website, and the DON checked the state website daily. The DON stated the facility was following the guidance for PPE that had been in place for months, and the DON had not checked for updates. The DON stated the facility does not go off the CDC guidance and only checked the CDC website for the COVID-19 transmission rates. The DON stated the current transmission rate for the county the facility was in was very high. The DON stated CMS (Centers for Medicaid and Medicare Services) also provided updates and the DON had always been told that CMS trumps everything. The DON then stated that CMS obtained their guidance on what to do to manage the pandemic from the CDC and that the DON and IP should check the CDC website for current guidance on the appropriate PPE. The DON stated during the last COVID-19 outbreak, PPE for the facility staff while in the facility hallways and common areas was an N95 mask and eye protection. The DON stated eye protection should currently be in place and confirmed no staff in the facility were wearing any eye protection. The DON stated, It totally slipped my mind. The DON confirmed all staff should be wearing eye protection since the facility was in a high transmission county with an active COVID-19 outbreak, and that the eyes were another mode of transmission for the virus. The Administrator was not available for interview and was not present during the initial onsite survey. 22445 2. On arrival to the facility a sign was observed posted on the front door that indicated there were active cases of COVID-19 in the building. Prior to entering the facility, Registered Nurse (RN) A providing screening to the surveyor by taking a temperature and asking the questions related to potential close contact with a COVID-positive person, travel, and signs and symptoms (s/s) of COVID-19. A KN95 mask and goggles were required to enter the building. RN A stated there had been one positive resident in the building, adding Resident #22 had expired the previous Friday, [DATE]. She stated there were no other positive residents in the building. On the initial tour of the facility, starting on [DATE] at approximately 8:25 AM, it was observed that residents in the halls and common areas were wearing face masks. All staff had on masks and all but two staff members had on goggles. It was determined by interviewing Licensed Vocational Nurse (LVN) A that she and the other staff member had a medical exemption from wearing the N95 mask and goggles. LVN D was interviewed on [DATE] at 8:30 AM. She stated infection control (IC) in-services were ongoing and there had been a few in-services held since the surveyors had exited on [DATE]. The LVN stated the information provided during the in-services included handwashing, gloving, and donning/doffing PPE. The LVN did not identify screening re-education as part of the IC in-service. On [DATE] at 8:40 AM, the Assistant Director of Nursing (ADON) stated she had been out with COVID-19 during the January survey. On her return to the facility, the Director of Nursing (DON) and Infection Preventionist (IP) had touched on the survey concerns including proper screening of employees upon entering the building. The ADON added the staff felt they needed to tighten up policies already in place such as handwashing and wearing proper personal protective equipment (PPE). A review of screening sheets was completed that spanned from [DATE] to [DATE]. In the review of the screening sheets the following was revealed: -180 examples of the recorded temperature between 90.2 degrees Fahrenheit (F) and 95.9 degrees F. -13 examples of the screening not including a temperature. -39 examples of the questions related to the signs/symptoms (s/s) of COVID-19 not answered. -7 examples of the name of the staff omitted from the screening. During an interview with the Maintenance Assistant (MA) on [DATE] at 10:05 AM, he stated he had received training that included keeping the N95 mask on and to wear goggles. At this time, the MA did not have goggles on and added he had to get a new pair due to his goggles breaking. He added as MA he had to spray high-touch areas at least every two hours. The MA stated the recent training included putting a mask on prior to entering the building and completing the COVID-19 screening prior to clocking in. The MA confirmed the [DATE] signature on the facility screening sheet was his and stated he was unable to say why the signs and symptoms of COVID-19 had not been completed. The Housekeeping Supervisor (HS) was interviewed on [DATE] at 10:14 AM. The HS stated she had received training on how to wear the N95 mask and to make sure it fit properly. The education she had received also included wearing PPE, including putting on the PPE and taking off the PPE. She added screening included taking the person's temperature and answering the questions related to the s/s of COVID-19. The HS stated she had tested positive for COVID-19 on [DATE] and had to immediately leave the building, adding she had been at home for a full 14 days. Dietary Aide (DA) A was interviewed on [DATE] at 10:26 AM. The DA stated she had been trained on handwashing but had not been trained on the screening process. The DA stated self-screening was not allowed and she had to wait for another staff person to screen her before she could enter the building. She stated that when she was screened, she was asked if she had any s/s of COVID-19 including cough, chills, fever, or runny nose. The DA stated different people screened when she arrived for work in the morning, so she was unaware who had screened her and not completed the questions related to s/s of COVID. The DA stated a lot of staff in the dietary department had tested positive. She added when a person tested positive, they were asked to leave the building immediately. The DA stated staff left in the kitchen had to then sanitize all surfaces, including doors and doorknobs. She stated nothing different was done for the staff that remained after a close co-worker tested positive including immediate screening or increased temperatures. The Administrative Assistant (AA) was interviewed on [DATE] at 10:40 AM. The AA stated part of her assigned duties included screening employees upon arrival for work. She added she also had to screen visitors or vendors prior to entry to the building. The AA stated the education she received on screening was when COVID-19 first started, and education was updated as the rules changed. The AA stated she had been out sick and had returned to work on [DATE]. On return, the DON told her to make sure everyone entering the building had either goggles or face shields. She was also to make sure everyone washed their hands, temperatures were taken, and all entering the building were asked if they had s/s of COVID-19. The AA stated no findings from the [DATE] survey had been shared, as those findings related to the screening process. The AA reviewed the sign-in sheets and verified her initials were in several spots where information was missing. She stated at times during the screening process the phone would ring and then she would forget to go back and record the name, temperature, or answers to the screening questions. The Director of Medical Records (MR) was interviewed on [DATE] at 11:17 AM. She explained when she screened employees, she asked employees about s/s of COVID-19, made sure the employee wore a mask and goggles before entering the building, and made sure the temperature was less than 99.0 degrees F. She stated she considered a low temperature in the mid-90's. She stated some temperatures she had written were low because she can't make employees wait because then the line would be too long. She was unable to say if a low temperature was accurate if recorded when the employee was cold from the outside. The MR acknowledged a temperature of 92 degrees F was accurate if that was what she had recorded and stated she was unable to answer if it was beneficial to record a low temperature. The MR stated she had been educated by someone on the screening process and added the former DON told her to let the staff come in the door even if the temperature was low. The MR acknowledged she had not requested clarification from any administrative nurse on what to do about extremely low temperatures. The MR reviewed the screening sheets and acknowledged she had recorded temperatures starting at 90.2 degrees F for employees' screening. The ADON was interviewed on [DATE] at 12:03 PM. She stated it was important to take accurate temperatures and ask COVID-19 screening questions to know who was at risk of transmitting COVID-19. The ADON stated the screeners had been trained by the former IP and DON. The ADON added the range for an acceptable temperature was 96XXX,d+[DATE].3 degrees F and was posted at the desk where the screeners work. The ADON stated she had been unaware of the low temperatures until MR had told her the surveyor questioned the low temperatures. The ADON acknowledged the MR had not asked her what to do about low temperatures. She added the danger of not asking the questions or having accurate temperatures recorded could be someone with COVID-19 could be allowed into the building. The ADON stated she thought the former IP audited the screening sheets weekly but acknowledged a lot could pass through the holes with that process of weekly audits, adding now there was no IP in the building and audits of the screening sheets were not done. The ADON stated the consequences of not writing a name in the employee's name space would be someone with positive symptoms or a temperature may come in and staff would not know who to find. The ADON reviewed the screening sheets and stated she was disappointed to find so many blanks on the screening sheets and added she did not understand why anyone screening would write a temperature of 90 degrees down, not ask the screening questions, or omit an employee's name. The Administrator was interviewed on [DATE] at 12:31 PM. The Administrator reviewed the screening sheets from the time of survey departure until [DATE]. The Administrator stated the low temperatures should have never been recorded and should have been a red flag for the person screening. The consequences of not putting a name of an employee down, not recording the temperature, or not asking the screening questions would be someone with COVID could sneak into the building. The Administrator stated he was not familiar with the former IP's auditing process but added if she had audited weekly that was not enough. The ADON was interviewed on [DATE] at 2:47 PM. The ADON stated the UM had tested positive outside of the facility on [DATE]. She added the UM's last day at work in the building was on [DATE]. On [DATE], the UM had called the ADON and told her she did not feel well. The ADON reviewed the screening sheets for Friday, [DATE], and acknowledged the UM was not listed as having screened prior to entering the building. The ADON stated the UM was on the unit with residents and had the potential to go in residents' rooms. The Social Services Director (SSD) was interviewed on [DATE] at 3:33 PM. The SSD stated she had been confirmed COVID-19 positive on [DATE]. She stated the only symptom she had exhibited was lack of appetite. The SSD stated she could not remember the residents she had seen prior to testing COVID-19 positive. The SSD stated if no one was at the front desk when she arrived to work, usually between 7:15 AM to 7:30 AM, she would self-screen. The SSD stated she had been out of work a few days the week prior to testing positive but confirmed she had worked on [DATE]. The SSD reviewed the screening sheets and acknowledged there was no screening sheet for her on [DATE]. In review of the list of residents and staff testing COVID-19 positive, four residents tested positive within seven days after the SSD tested positive. This included Resident #22, who tested positive on [DATE], who had expired in the building but was receiving hospice services prior to testing COVID-19 positive. At 3:51 PM on [DATE], the Administrator stated the facility did not do contact tracing for positive residents or employees but tested the entire facility when someone tested positive. The ADON was interviewed at 3:53 PM on [DATE]. The ADON reviewed the screening sheets for [DATE] and compared those with the staff assignment sheet for the day and acknowledged there was no screening sheet for Certified Nursing Assistant (CNA) #3 who had worked the 6:00 AM to 2:00 PM shift that day. RN B, who was the weekend supervisor, was interviewed by telephone on [DATE] at 9:15 AM. She stated that on weekends her job was to sit at the front desk and screen employees coming into the building. RN B stated the screening process included sanitizing hands, placing a mask prior to coming into the building, temperature check, and answering questions about s/s of COVID. RN B added any person with positive answers to the screening questions was not allowed into the building. If a person had a low temperature, the staff member waited inside for a few minutes to warm up and then the temperature was taken again. The Transportation Aide (TA) was interviewed on [DATE] at 10:33 AM. The TA also assisted with screening as needed. She stated the former DON gave her a paper with instructions and told her to read over the paper and then sign the paper, adding she had understood the instructions she read. The TA reviewed the screening sheets and acknowledged the initials and handwriting on [DATE] from 1:15 PM to 2:34 PM was hers. The TA stated while she had asked all the COVID-19 screening questions, she had not documented all the answers. The TA stated there was a paper at the desk that listed an acceptable temperature range. The TA stated she acknowledged the screening initials were hers but denied writing the low temperature, adding the person must have self-screened and forged her initials, although she admitted it was her handwriting answering the questions. The UM was interviewed on [DATE] at 10:45 AM. She stated that on [DATE], she had no s/s of COVID-19 and felt fine while at work. The UM stated she remembered being screened that day and did not understand why her screening was not recorded. She added the screener must have gotten side-tracked. LVN C was interviewed at 10:54 AM on [DATE]. The LVN was the one that had been noted not screening during the [DATE] survey. Since then, the LVN stated she had received training on screening from the previous IP in [DATE]. She stated that before entering the building, the employee was given a mask and goggles. When screening, employees were asked questions related to s/s of COVID and their temperature was taken. If the employee's temperature was low, the screener allowed the employee to warm up, and then the temperature was retaken. The LVN stated it was important to ask and document the questions because if someone was positive the staff could go back and refer to the screening. The LVN reviewed the screening sheet and verified she had been the screener on [DATE]. The LVN stated she knew she had taken the temperature but had not left the blank space that was evident, adding she must have written her temperature in a blank space above left by someone else, although all the other spaces had temperatures recorded in the temperature space. The LVN stated someone else had forgotten to write the temperature and she just filled in the empty space. A review of the Education Binder with the ADON, on [DATE] at 11:30 AM, revealed several in-services had been given to staff since the [DATE] survey exit. These in-services with the staff completion rates are as follows: -BinaxNow COVID-19 Ag Card Staff Competency Check offs - included 11 nurses and one CNA -Education pretest on Understanding COVID-19 and Personal Protection - ,d+[DATE] employees for 36% completion rate since [DATE] -Door Screening In-service started on [DATE] with ,d+[DATE] employees trained for 34% completion rate The ADON was interviewed on [DATE] at 11:30 AM and stated the intent was to provide education to all employees, except for how to complete the COVID Binax testing, which was provided to all nurses and one nursing assistant who had been responsible for visitation of residents and family members. She stated the previous DON and IP had been the ones conducting the education and thought those that were in the facility when the education started were the ones that had completed the education. The ADON stated the education, Understanding Covid and Personal Protection, was given 1:1 with the employees as the employee completed the pre-test questionnaire. When the IP reviewed the test with the employee, any issues identified were discussed between the IP and the employee immediately. The ADON added LVN C, who had omitted screening during the previous survey, tested positive on [DATE]. Those residents becoming positive within 14 days assigned to the LVN included Resident #3, Resident #13, Resident #17, and Resident #35. The facility Administrator was notified of the IJ on [DATE] at 1:55 PM and was provided with the IJ template on [DATE] at 2:03 PM. The Administrator presented the following IJ removal plan: This plan is put in place to ensure that all employees, vendors, and visitors, entering the facility, will be screened by a designated staff member. This screening is to include, per facility policy, signs, and symptoms of COVID-19 prior to entering the facility and/or providing care to residents. A new screening system with updated screening sheets has been put in place as of February 8, 2022, by the ADON. To aid in this, new screening sheets have been printed that are to be checked by the Infection Control Person, ADON, Weekend

Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident haszards as is possible for 1 of 3 residents (Resident #1) during transfer resulting in physical injury. Licensed Vocational Nurse (LVN) A and Certified Nurse Aide (CNA) B, CNA C, and CNA D transferred Resident #1 using a gait belt instead of the Hoyer lift as ordered, and used an improper lift sling, resulting in the resident sustaining a fracture of the left humerus (bone in upper arm). This was determined to be past non-compliance at Actual Harm level on 12/24/16 due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the incident investigation. This failure affected one resident and placed 11 residents residing on West Wing, who are transferred using the Hoyer lift, at risk for injury. Findings include: Review of Resident #1's Admission Record revealed he was an [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's care plan, dated 5/24/16 and revised 8/11/16, revealed he has an Activity of Daily Living (ADL) self-care performance deficit related to Spinal Stenosis and [DIAGNOSES REDACTED] and requires extensive assistance of two staff and mechanical lift for transfers. Review of a Provider Investigation Report reflected on 12/24/16 at 9:30 AM, Resident #1 requested to go to the bathroom. CNA B and CNA C were using a gait belt to transfer Resident #1 from his wheelchair to a bedside commode when they heard his left shoulder pop. Resident #1 informed them his shoulder hurt. CNA's B and C lowered lowered Resident #1 onto the bedside commode. LVN A was informed by the CNA's of Resident #1's discomfort. LVN A assessed Resident #1 for injuries and did not find any swelling or discoloration to the shoulder. LVN A, CNA's B and D transferred Resident #1 back to his wheelchair and during this transfer his shoulder made the popping noise. LVN A called the nurse practitioner and reported Resident #1's complaint of discomfort to the shoulder. The Nurse Practioner ordered an x-ray of the left shoulder. At approximately 2:00 PM, mobile x-ray arrived and obtained an x-ray. At 7:00 PM the staff received the results of the x-ray which showed an acute nondisplaced transverse fracture of the left proximal humeral diaphysis. New orders were received to transfer Resident #1 to the hospital for further evaluation and treatment. Resident #1 returned the same day from the hospital with orders for as needed pain medication, a sling, and follow-up visit with an orthopedic provider. LVN A and CNA's B,C and D were suspended with pay until the investigation was completed. An inservice for the nursing staff was provided on 12/27/16 on proper transfer technique using gait belts and lifts. CNA's B and C received written reprimands for defective and improper work. Review of the radiology final report dated 12/24/16, reflected the following: Findings: There is an acute nondisplaced transverse fracture of the left proximal humeral diaphysis. There are multiple small well defined lytic lesions demonstrates throughout the humerus, scapula and clavicle consistent with [DIAGNOSES REDACTED] (cancer of plasma cells). Impression: Left shoulder: findings consistent with [DIAGNOSES REDACTED] with acute pathological transverse fracture of the proximal humeral diaphysis. Orthopedic consultant advised. In an interview on 2/28/17 at 9:00 AM, the Director of Nurses (DON) stated that on the morning of 12/24/16, two CNAs had gotten Resident #1 up using the Hoyer lift. Around 9:30 AM, CNA's B and C were in his room getting him ready to go to dialysis and he asked to use the bedside commode. The sling in the wheelchair did not have a hole in it to enable him to use the bathroom. The two aides (B and C) transferred him from the wheelchair to the commode using a gait belt. Resident #1 said he heard a popping noise and complained of pain. LVN A was notified and assessed Resident #1 and did not find any swelling or bruising. LVN A and CNA's B and D transferred Resident #1 back to his wheelchair and they heard another popping noise. The nurse practioner was notified and ordered an x-ray of Resident #1's left shoulder. The x-ray revealed a fracture and Resident #1 was transferred to the hospital for further assessment and treatment. Resident #1 returned to the facility the same evening with a sling to the left arm. Resident #1 was seen by an orthopedic doctor and an immobilizer was placed on his left arm. He was non-compliant and would not always wear the brace. It has been discontinued by the orthopedic doctor. During an interview on 2/28/17 at 10:15 AM, Resident #1 was sitting in his wheelchair in his room. He stated two CNA's transferred him from the wheelchair to the bedside commode by holding under his arms and they may have used a gait belt, but it was under his arms. He stated he heard a popping noise in his left shoulder/arm area and it hurt. He stated the nurse and two CNA's helped him from the bedside commode back to the wheelchair and he heard another pop. He stated, I had to wait here for the x-ray and report, hurting, before they sent me to the hospital. My arm had a fracture. I don't know how long I will have to put up with this pain. In an interview on 2/28/17 at 3:15 PM, CNA B stated she and CNA C transferred Resident #1 from his wheelchair to the bedside commode using a gait belt. She said Resident #1 requested they use the gait belt and she was always told that the resident has a right to request what they want. She stated he was already in the wheelchair when she entered his room and did not have a lift sling with a hole in it so they transferred using a gait belt. She stated she and CNA D transferred him to the commode chair and heard a pop of the left arm and Resident #1 complained of pain. CNA C stated they reported this to LVN A and she assessed Resident #1 and did not find any bruising or swelling. She stated she and CNA D and LVN A transferred him from the commode chair back to his wheelchair. During the transfer they heard another pop and LVN A notified the nurse practioner. She stated there is a Kardex in the point click care (electronic records) showing the type of transfer used for each resident. Review of LVN A's written statement, dated 12/24/17, reflected LVN A received a report from a CNA that she and two other CNA's transfered Resident #1 to the toilet using a gait belt and Resident #1 complained of discomfort to the left shoulder and arm. LVN A walked into the room and Resident #1was sitting on the toilet. LVN A assessed his arm and there was no bruising or complaint of discomfort when touched and he tried to raise it. LVN A and two other CNA's transfered the resident from the bedside commode into his wheelchair using a gait belt. She called the nurse paractioner and received an order for [REDACTED]. Review of CNA C's written statement, dated 12/24/16, reflected she was assisting CNA B with Resident #1 and that they used a gait belt to transfer Resident #1. CNA C had the right side and CNA B had the left side. In the middle of transferring Resident #1, CNA B heard his left shoulder pop and we proceeded to lower him to the bedside commode and reported this to the nurse. Review of CNA D's written statement, dated 12/24/16/, reflected she assisted CNA B and LVN A transfer Resident #1 from the bedside commode back to his wheelchair. CNA D was on his left side and CNA B was on the right side and LVN A was behind Resident #1. As they transfered Resident #1 from the bedside commode, CNA D heard his shoulder pop. CNA D moved out of the way so CNA B and LVN A could do a quick transfer. In an interview on 2/28/17 at 2:30 PM, the DON stated she would expect the staff to use the Hoyer lift when transfering Resident #1. Review of the Kardex for Resident #1 in the point click care used by CNA's revealed the following: Transfer: The resident requires extensive assistance of two staff and mechanical lift for transfers. Transfers only with mechanical lift and assist of two staff. Keep arms inside the lift sling. Toilet Use: Use mechanical lift and lift pad with elimination opening in it and assist of two for toileting. Review of the current (undated) facility Abuse Prevention Program reflected the following elements: Purpose: Protect the residents in this facility from abuse, neglect, misappropriation of resident property, corporal punishnment and involuntary seclusion. Procedure. 1. The facility is committed to protecting the residents from abuse by anyone including, but not limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. The folowing corrective actions had been taken following the incident on 12/24/16 and prior to surveyor entrance: Nursing staff was inserviced on 12/27/16 regarding proper transfer techniques using gait belts and mechanical lifts. LVN A and CNA's B, C and D were suspended with pay until the facility completed their investigation. CNA's B and D received written reprimands for defective and improper work regarding a non-weight bearing resident. Resident #1's care plan was reviewed and adjusted based on nursing interventions. An inservice on abuse, neglect and exploitation was conducted with staff on 1/9/17. The DON provided a list of 12 residents who are transferred using a mechanical lift on West Wing.

Based on interview and record review, the facility failed to be administered in a manner than enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 2 of 3 residents (Resident #'s 1 and 2) reviewed for accuracy of medication administration. The Administrator and Director of Nurses failed to have a system in place to ensure nurses and medication aides were oriented, trained, and had completed a proficiency skills checklist prior to conducting a medication pass. Licensed Vocational Nurse (LVN) A administered Resident #2's opiate medication ([MEDICATION NAME]) to Resident #1 resulting in emergency treatment and hospitalization . Resident #2 missed one dose of [MEDICATION NAME] 200mg Extended Release, although documented by LVN A as having been given. This failure resulted in identification of an IJ (Immediate Jeopardy) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm at a scope of isolated, that is not an IJ, due to facility administration and staff needing time to train all staff and monitor their plan of removal for effectiveness. This deficient practice placed 23 residents on East Wing who receive medications from facility staff at risk for receiving incorrect medication which has the potential to cause serious harm or death, and/or for missed doses of prescribed medication. Findings include: Surveyor review of facility video dated [DATE] at 5:19 PM, revealed LVN A going into Resident #1's room the first time and when she came out she looked confused as to what she had in her hand (cup of pills). She walked round the med cart several times and went again into Resident #1's room. LVN A did not go near Resident #2's room until 7:20 PM. [MEDICATION NAME] ER 200mg was initialed by LVN A as given at 5:30 PM to Resident #2. An interview with the Director of Nurses (DON) on [DATE] at 2:00 PM, revealed that LVN A was on video as not going to Resident #2's room until 2 hours later than when she documented she gave the medication, but she did go into Resident #1's room at 5:30 PM. The DON stated that LVN A was confused on the video and walking back and forth and looking around like she wasn't sure of her actions and she (DON) thought she placed some medications in the waste container. An interview with LVN A on [DATE] at 3:00 PM revealed she did get confused and she thought she may have given the wrong medication to the wrong resident. She stated she presets her medication, that is punching them out of a blister pack and placing in a cup before getting to the room or before starting the medication pass. She stated she was not trained for medication pass at this facility and it was her first time working on this unit and the second day on this job. When asked by the surveyor if she had ever given medications, she stated that she works part time at another facility, but they let her preset medications. In an interview on [DATE] at 12:30 PM, LVN H, when asked if she could show the training LVN A had received, stated that they had not performed check off for skills, but were in the process of getting together a skills check-off sheet. She also stated, LVN A should have been trained prior to being on a med pass. Review of Resident #1's Face Sheet dated [DATE] revealed a [AGE] year old female admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's physician orders [REDACTED]. There were no ordered opiates for Resident #1. Review of Resident #1's Medication Administration Sheet (MAR) dated [DATE]-[DATE] reflected that the Tylenol pain medication had not been administered during this time period. Review of Nurses Notes dated [DATE] at 1:40 AM revealed Certified Nurse Aide (CNA) A reported to LVN I that Resident #1 was unresponsive and her skin was blue in color to facial area and lips. Resident #1 would not respond to verbal or physical stimuli. Oxygen Saturation was in the 40% range, (Normal ,[DATE]), and oxygen was then applied, Respirations were around 6 breaths per minute, (Normal ,[DATE] per minute), Blood Pressure ,[DATE], Pulse 56. Ambulance was called. Included in the transfer form from the facility is a SBAR (Situation Background And Resident Evaluation) communication form, that reflected Resident #1 was unresponsive, Blue/Gray facial areas/lips, eyes rolled up to the back of head, and body tight. Review of a transfer form dated [DATE] at 2:25AM, reflected Resident #1 was still unresponsive and EMT (Emergency Medical Transport) left the facility with her about 2:35 AM. Review of Nurses Notes dated [DATE] at 5:00 AM, by LVN I reflected the hospital called and inquired if the correct medication list was sent with Resident #1's transfer because the hospital had to administer [MEDICATION NAME] (medication that reverses the effects of opioid). LVN I told her, Yes. Review of Nurses Notes dated [DATE] at 6:30 AM, revealed Registered Nurse (RN) A received a call from the hospital (emergency room ) ER staff that Resident#1 tested positive for opioids, they had her on a [MEDICATION NAME] drip and she would be making a referral to Adult Protective Services (APS). RN A notified the Assistant Director of Nurses (ADON). Record review of emergency room (ER) documents dated [DATE] at 3:13 AM, revealed EMS administered to Resident #1, 0.4 MG [MEDICATION NAME] and respirations improved from 6 breaths a minute to 22 breaths a minute. Dictation by Dr. Jonathan Walker attending physician in the ER reflected Resident #1 came in the ER with altered mental status. Paramedics noted that the resident appeared to be hypoventilating (low breaths per minute) with a low blood pressure and pinpoint pupils. They gave resident [MEDICATION NAME], as mentioned above, with some improvement in her mental status. Examination was very similar on my arrival and I was initially concerned about narcotic overdose, but the resident wasn't on narcotic medications. We gave the resident an additional dose of [MEDICATION NAME] while assessing for other possible etiologies of the resident's altered mental status. Our laboratory examination is essentially unremarkable. The resident continues to respond to [MEDICATION NAME] and Urine Drug Screen (testing the urine for different chemicals) has come back positive for narcotics. I suspect the resident has inadvertently received another resident's narcotic at the nursing home as a source for her significant sedation. I contacted the intensivist in order to arrange for admission for close airway monitoring as the patient runs a risk for need for intubation. Final Impression: Opiate or related narcotic overdose. Reference dailymed.nth.gov/daily: [MEDICATION NAME] extended-release (ER) tablets are an extended-release oral formulation of [MEDICATION NAME] sulfate indicated for the management of moderate to severe pain when a continuous, around-the-clock opioid [MEDICATION NAME] is needed for an extended period of time. Review of Resident #2's medication orders dated [DATE] reflected the following: [MEDICATION NAME] ER 200MG every 8 hours, [MEDICATION NAME] tablet 30mg 2 tablets every 4 hours for pain. Review of a facility Medication Error Report dated [DATE] revealed Resident #1 was given another resident's medication in error as per their investigation of viewing camera video and review of their records. LVN A was doing medication pass the evening of [DATE]. Video camera at 5:30 PM revealed LVN A was in the room of Resident #1. Resident #2 was ordered 200mg ER (Extended Release) [MEDICATION NAME] every 8 hours and on her Medication Administration Record [REDACTED]. The camera showed no activity of LVN A at the room of Resident #2 at 5:30 PM and not until 7:19 PM did LVN A go into Resident #2's room. The facility asked Resident #2 if she got her 4:00 PM [MEDICATION NAME] medication and she couldn't remember. She said she takes so much [MEDICATION NAME] she gets confused. An interview with the Director of Nurses (DON) on [DATE] at 2:00 PM, revealed that LVN A was on video as not going to Resident #2's room until 2 hours later than when she documented she gave the medication, but she did go into Resident #1's room at 5:30 PM. The DON stated that LVN A was confused on the video and walking back and forth and looking around like she wasn't sure of her actions and she (DON) thought she placed some medications in the waste container. Review of facility policy Administering Medications (no date) Policy Statement: Administering Oral Medications General Guidelines and Precautions 1. Medication Aides must understand and follow the Rules at 40 TAC Chapter 95 with attention to 95.103 and 995.105 on administering medications. 2. Work in a clean, organized, well-lighted area and avoid distractions while preparing and administering medications. 3. Give only medicines that you have prepared. 4. Give medicines only from clearly labeled containers. 5. Follow the SIX RIGHTS of medication administration. -Right Patient -Right Drug -Right Dose -Right Route -Right Time -Right Documentation 6. Read the label 3 times as you prepare a medication, carefully checking the drug label against the Medication Administration Sheet (MAR), med card or physicians orders, according to facility policy. Check #1 as you take the medicine from the storage area Check #2 you pour the medication Check #3 For multi-dose drugs as you replace the label container into the storage area. For unit-dose drugs- at bedside, before opening the unit-dose medicine package. Assessments (Activities to be completed prior to preparing medications) 1. Check medication card or MAR indicated [REDACTED]. 2. Check for the SIX RIGHTS 3. Review your knowledge of medications and look up needed information such as drug interactions, therapeutic effects, side effects, usual doses/routes, contraindications and nursing implications **The PRE-PULLING of medications is STRICTLY prohibited and grounds for IMMEDIATE TERMINATION OF EMPLOYMENT Review of the Administrator's written statement dated [DATE] revealed the following: Resident was sent to the hospital immediately due to a change of condition. After the hospital update stating the resident tested positive for opiates, an investigation was started. Video was reviewed, interviews were initiated, staff member admitted to getting confused and the video revealed she did not enter the room that she was supposed to have given the med, but did sign off as having given. The video reflected she never entered the room of the resident due the medication, (Resident #2), but did enter Resident #1's room at that time. Staff member was suspended until further investigation could be conducted. In-services began immediately. The first in-service covers Medication Administration Policy & Procedure, the second covers Medication Error Reporting, Medication Administration Proficiency checks began as soon as possible in two in-services. After record review, staff interviews and observations it appears that this nurse administered an opiate medication to the wrong resident which resulted in a significant change of condition. Investigation shows no willful intent to harm or neglect. Staff member will be terminated based on the investigation outcome. Review of hospital records dated [DATE] at 6:06 PM, reflected documentation from a physician accepting Resident #1 for Hospice care. Resident #1 admitted on [DATE] with altered mental status and poor respiratory effort. She tested positive for opiates onlyper UDS (Urine Drug Screen) on [DATE]. She was presumed given the wrong medication at the NH (Nursing Home). She never fully recovered and I anticipate she will expire in ,[DATE] days in her condition. Resident #1 expired on [DATE]. In an interview on [DATE] at 10:42 AM, with Resident #1's attending physician, he was asked if he thought Resident #1 being given someone else's pain medication by mistake contributed to her death. He stated, Most definitely it contributed to her early demise. She actually did die and we brought her back. He also stated, If she did receive an opioid med in error it would complete the circle of what was wrong and what happened to this lady. The facility Administrator and DON were notified on [DATE] at 2:02 PM that an Immediate Jeopardy (IJ) had been identified due to the above failures. A Plan of Removal was submitted by the Administrator on [DATE] at 5:10 PM. The final Plan of Removal was accepted by the surveyor/investigator on [DATE] at 5:30 PM. The plan of removal included the following: 1. In-service will be performed on Medication Administration Procedure immediately with a focus on the six rights of medication administration (the right resident, medication, route, time, dose, and documentation) to ensure proper patient identification. 2. In-service will be performed on Reporting Medication Errors immediately. 3. To assist with patient identification, we updated all patients records with updated resident pictures and re-printed all Medication Administration records (MAR's), Treatment Administration Records (TAR's), Nurses Medication Administration Records (NMAR's), And Wound treatment MAR's to include pictures. 4. Proficiency check offs will be performed on current nurses, medication aides and PRN's (as needed). All to be completed by [DATE]. The facility also initiated a New Hire Mentorship Training Policy which was covered in staff inservices as part of the facility Plan of Removal. The plan included designated mentors, who will provide new hires no less than 3 days of training, and will not allow new hires to be scheduled on the floor without supervision from the Mentor or supervisor until all proficiency checks are performed. The surveyor monitored the current plan of removal as follows: On [DATE] and [DATE], Medication Administration Skills Checklists for proficiency were completed and checked off for current charge nurses and medication aides except for seven (7) employees. The DON stated these 7 would not have a schedule until they received the in-services and were checked off on the Medication Administration Skills. During interviews on [DATE], RN A ,CMA B, C, D, LVN B, C, D and LVN E stated they had been in-serviced and had completed the Medication Administration Skills Checklist. On [DATE] at 12:05PM, the Administrator and DON were informed the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm, with a scope identified as isolated, due to the facility administration and staff requiring time to train all staff and monitor their plan of removal. The DON identified 23 residents on East Wing who receive medications from facility staff.

Based on interview and record review, the facility staff failed to ensure 2 of 3 residents (Resident #'s 1 and 2) reviewed for accuracy of medication administration were free of significant medication errors. Licensed Vocational Nurse (LVN) A administered Resident #2's opiate medication ([MEDICATION NAME]) to Resident #1 resulting in hospitalization of Resident #1, who had no physician orders for opiate pain medication. Resident #2 missed one dose of the opiate medication ordered by her physician. This failure resulted in an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a level of actual harm at a scope of isolated, that is not an IJ, because the facility administrator and staff needed time to monitor their plan of removal for effectiveness. This deficient practice placed 23 residents on East Wing who receive medications from facility staff at risk for receiving incorrect medication which has the potential to cause serious harm or death, and/or for missed doses of prescribed medication. Findings include: Review of Resident #1's Face Sheet dated [DATE] revealed a [AGE] year old female admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's physician orders dated [DATE] revealed the following medications: [REDACTED]. DO NOT EXCEED 4000mg per 24 hours, [MEDICATION NAME] 500 MG one tablet every 4 hours as needed for pain, [MEDICATION NAME] Nebulization Solution (2.5 mg/3ml) (milliliters) 0.083% 1 vial orally via nebulizer (Inhaled) as needed for shortness of breath TID (three times a day) PRN (as needed), [MEDICATION NAME] CD Capsule Extended Release 24 hour/ 240 MG Tablet (Diltizem HCI ER Coated Beads) 1 capsule by mouth once a day, Carvedilol Tablet 12.5mg 1 tablet twice a day, [MEDICATION NAME] Sodium 100mg 1 capsule as needed for constipation, [MEDICATION NAME] 10mg 1 tablet by mouth twice a day, [MEDICATION NAME] tablet 5mg 1 tablet at bedtime, Multivitamin Capsule once daily, [MEDICATION NAME] (blood thinner) tablet 75mg, one tablet once a day, [MEDICATION NAME] Sodium tablet 40 mg one tablet at bedtime. There were no ordered opiates for Resident #1. Review of Resident #1's Medication Administration Sheet (MAR) dated [DATE]-[DATE] reflected no documentation that pain medications were administered during this time period. Review of Nurses Notes dated [DATE] at 1:40 AM revealed Certified Nurse Aide (CNA) A reported to LVN I that Resident #1 was unresponsive and her skin was blue in color to facial area and lips. Resident #1 would not respond to verbal or physical stimuli. Oxygen Saturation was in the 40% range, (Normal ,[DATE]), and oxygen was then applied, Respirations were around 6 breaths per minute, (Normal ,[DATE] per minute), Blood Pressure ,[DATE], Pulse 56. Ambulance was called. Included in the transfer form from the facility is a SBAR (Situation Background And Resident Evaluation) communication form, that reflected Resident #1 was unresponsive, Blue/Gray facial areas/lips, eyes rolled up to the back of head, and body tight. Review of a transfer form dated [DATE] at 2:25AM, reflected Resident #1 was still unresponsive and EMT (Emergency Medical Transport) left the facility with her about 2:35 AM. Review of Nurses Notes dated [DATE] at 5:00 AM, by LVN I reflected the hospital called and inquired if the correct medication list was sent with Resident #1's transfer because the hospital had to administer [MEDICATION NAME] (medication that reverses the effects of opioid). LVN I told her, Yes. Review of Nurses Notes dated [DATE] at 6:30 AM, revealed Registered Nurse (RN) A received a call from the hospital (emergency room ) ER staff that Resident#1 tested positive for opioids, they had her on a [MEDICATION NAME] drip and she would be making a referral to Adult Protective Services (APS). RN A notified the Assistant Director of Nurses (ADON). Record review of emergency room (ER) documents dated [DATE] at 3:13 AM, revealed EMS administered to Resident #1, 0.4 MG [MEDICATION NAME] and respirations improved from 6 breaths a minute to 22 breaths a minute. Dictation by the attending physician in the ER reflected Resident #1 came in the ER with altered mental status. Paramedics noted that the resident appeared to be hypoventilating (low breaths per minute) with a low blood pressure and pinpoint pupils. They gave resident [MEDICATION NAME], as mentioned above, with some improvement in her mental status. Examination was very similar on my arrival and I was initially concerned about narcotic overdose, but the resident wasn't on narcotic medications. We gave the resident an additional dose of [MEDICATION NAME] while assessing for other possible etiologies of the resident's altered mental status. Our laboratory examiniation is essentially unremarkable. The resident continues to respond to [MEDICATION NAME] and Urine Drug Screen (testing the urine for different chemicals) has come back positive for narcotics. I suspect the resident has inadvertently received another resident's narcotic at the nursing home as a source for her significant sedation. I contacted the intensivist in order to arrange for admission for close airway monitoring as the patient runs a risk for need for intubation. Final Impression: Opiate or related narcotic overdose. Reference dailymed.nth.gov/daily: [MEDICATION NAME] extended-release (ER) tablets are an extended-release oral formulation of [MEDICATION NAME] sulfate indicated for the management of moderate to severe pain when a continuous, around-the-clock opioid [MEDICATION NAME] is needed for an extended period of time. Review of Resident #2's medication orders dated [DATE] reflected the following: [MEDICATION NAME] ER 200MG every 8 hours, [MEDICATION NAME] tablet 30mg 2 tablets every 4 hours for pain. Review of a facility Medication Error Report dated [DATE] revealed Resident #1 was given another resident's medication in error as per their investigation of viewing camera video and review of their records. LVN A was doing medication pass the evening of [DATE]. Video camera at 5:30 PM revealed LVN A was in the room of Resident #1. Resident #2 was ordered 200mg ER (Extended Release) [MEDICATION NAME] every 8 hours and on her Medication Administration Record [REDACTED]. The camera showed no activity of LVN A at the room of Resident #2 at 5:30 PM and not until 7:19 PM did LVN A go into Resident #2's room. The facility asked Resident #2 if she got her 4:00 PM [MEDICATION NAME] medication and she couldn't remember. She said she takes so much [MEDICATION NAME] she gets confused. An interview with the Director of Nurses (DON) on [DATE] at 2:00 PM, revealed that LVN A was on video as not going to Resident #2's room until 2 hours later than when she documented she gave the medication, but she did go into Resident #1's room at 5:30 PM. The DON stated that LVN A was confused on the video and walking back and forth and looking around like she wasn't sure of her actions and she (DON) thought she placed some medications in the waste container. An interview with LVN A on [DATE] at 3:00 PM revealed she did get confused and she thought she may have given the wrong medication to the wrong resident. She stated she presets her medication, that is punching them out of a blister pack and placing in a cup before getting to the room or before starting the medication pass. She stated she was not trained for medication pass at this facility and it was her first time working on this unit and the second day on this job. When asked by the surveyor if she had ever given medications, she stated that she works part time at another facility, but they let her preset medications. Surveyor review of facility video dated [DATE] at 5:19 PM, revealed LVN A going into Resident #1's room the first time and when she came out she looked confused as to what she had in her hand (cup of pills). She walked round the med cart several times and went again into Resident #1's room. LVN A did not go near Resident #2's room until 7:20 PM. [MEDICATION NAME] ER 200mg was initialed by LVN A as given at 5:30 PM to Resident #2. In an interview on [DATE] at 12:30 PM, LVN H, when asked if she could show the training LVN A had received, stated that they had not performed check off for skills, but were in the process of getting together a skills check-off sheet. She also stated, LVN A should have been trained prior to being on a med pass. Review of facility policy Administering Medications (no date) Policy Statement: Administering Oral Medications reflected the following elements: General Guidelines and Precautions 1. Medication Aides must understand and follow the Rules at 40 TAC Chapter 95 with attention to 95.103 and 995.105 on administering medications. 2. Work in a clean, organized, well-lighted area and avoid distractions while preparing and administering medications. 3. Give only medicines that you have prepared. 4. Give medicines only from clearly labeled containers. 5. Follow the SIX RIGHTS of medication administration. -Right Resident -Right Drug -Right Dose -Right Route -Right Time -Right Documentation 6. Read the label 3 times as you prepare a medication, carefully checking the drug label against the Medication Administration Sheet (MAR), med card or physicians orders, according to facility policy. Check #1 as you take the medicine from the storage area Check #2 you pour the medication Check #3 For multi-dose drugs as you replace the label container into the storage area. For unit-dose drugs- at bedside, before opening the unit-dose medicine package. Assessments (Activities to be completed prior to preparing medications) 1. Check medication card or MAR indicated [REDACTED]. 2. Check for the SIX RIGHTS 3. Review your knowledge of medications and look up needed information such as drug interacrtions, therapeutic effects, side effects, usual doses/routes, condaindications and nursing implications **The PRE-PULLING of medications is STRICTLY prohibited and grounds for IMMEDIATE TERMINATION OF EMPLOYMENT Review of the Administrator's statement dated [DATE] revealed the following: Resident was sent to the hospital immediately due to a change of condition. After the hospital update stating the resident tested positive for opiates, an investigation was started. Video was reviewed, interviews were initiated, staff member admitted to getting confused and the video revealed she did not enter the room that she was supposed to have given the med, but did sign off as having given. The video reflected she never entered the room of the resident due the medication, (Resident #2), but did enter Resident #1's room at that time. Staff member was suspended until further investigation could be conducted. In-services began immediately. The first in-service covers Medication Administration Policy & Procedure, the second covers Medication Error Reporting, Medication Administration Proficiency checks began as soon as possible in two in-services. After record review, staff interviews and observations it appears that this nurse administered an opiate medication to the wrong resident which resulted in a significant change of condition. Investigation shows no willful intent to harm or neglect. Staff member will be terminated based on the investigation outcome. Review of hospital records dated [DATE] at 6:06 PM, reflected documentation from a physician accepting Resident #1 for Hospice care. Resident #1 admitted on [DATE] with altered mental status and poor respiratory effort. She tested positive for opiates onlyper UDS (Urine Drug Screen) on [DATE]. She was presumed given the wrong medication at the NH (Nursing Home). She never fully recovered and I anticipate she will expire in ,[DATE] days in her condition. Resident #1 expired on [DATE]. In an interview on [DATE] at 10:42 AM, with Resident #1's attending physician, he was asked if he thought Resident #1 being given someone else's pain medication by mistake contributed to her death. He stated, Most definitely it contributed to her early demise. She actually did die and we brought her back. He also stated, If she did receive an opioid med in error it would complete the circle of what was wrong and what happened to this lady. The facility Administrator and DON were notified on [DATE] at 2:02 PM that an Immediate Jeopardy (IJ) had been identified due to the above failures. A Plan of Removal was submitted by the Administrator on [DATE] at 5:10 PM. The final Plan of Removal was accepted by the surveyor/investigator on [DATE] at 5:30 PM. The plan of removal included the following: 1. In-service will be performed on Medication Administration Procedure immediately with a focus on the six rights of medication administration (the right resident, medication, route, time, dose, and documentation) to ensure proper patient identification. 2. In-service will be performed on Reporting Medication Errors immediately. 3. To assist with patient identification, we updated all patients records with updated resident pictures and re-printed all Medication Administration records (MAR's), Treatment Administration Records (TAR's), Nurses Medication Adminstration Records (NMAR's), And Wound treatment MAR's to include pictures. 4. Proficiency check offs will be performed on current nurses, medication aides and PRN's (as needed). All to be completed by [DATE]. The facility also initiated a New Hire Mentorship Training Policy which was covered in staff inservices as part of the facility Plan of Removal. The plan included designated mentors, who will provide new hires no less than 3 days of training, and will not allow new hires to be scheduled on the floor without supervision from the Mentor or supervisor until all proficency checks are performed. The surveyor monitored the current plan of removal as follows: On [DATE] and [DATE], Medication Administration Skills Checklists for proficiency were completed and checked off for current charge nurses and medication aides except for seven (7) employees. The DON stated these 7 would not have a schedule until they received the in-services and were checked off on the Medication Administration Skills. During interviews on [DATE], RN A ,CMA B, C, D, LVN B, C, D and LVN E stated they had been in-serviced and had completed the Medication Administration Skills Checklist. On [DATE] at 12:05PM, the Administrator and DON were informed the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm with a scope identified as isolated due to the facility administration and staff requiring time to train all staff and monitor their plan of removal. The DON identified 23 residents on East Wing who receive medications from facility staff.

Based on interview and record review, the facility staff failed to ensure services provided or arranged by the facility met professional standards of quality for 2 of 3 residents (Resident #'s 1 and 2) reviewed for accuracy of medication administration. Licensed Vocational Nurse (LVN) A administered Resident #2's opiate medication ([MEDICATION NAME]) to Resident #1 resulting in hospitalization of Resident #1, who had no physician orders for opiate pain medication. Resident #2 missed one dose of the opiate medication ordered by her physician. This failure resulted in an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a level of actual harm at a scope of isolated, that is not an IJ, because the facility administrator and staff needed time to monitor their plan of removal for effectiveness. This deficient practice placed 23 residents on East Wing who receive medications from facility staff at risk for receiving incorrect medication which has the potential to cause serious harm or death, and/or for missed doses of prescribed medication. Findings include: Reference https://www.bon.texas.gov/practice_bon_position_statements_content. asp Texas Board of Nursing -Nursing Practice: LVNs must use clinical reasoning and establishes evidence-based policies, procedures or guidelines as the basis for decision making in nursing practice. LVNs are accountable and responsible for the quality of nursing care provided and must exercise prudent nursing judgement to ensure the standards of nursing practice are met at all times. Review of Resident #1's Face Sheet dated [DATE] revealed a [AGE] year old female admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's physician orders dated [DATE] revealed the following medications: [REDACTED]. DO NOT EXCEED 4000mg per 24 hours, [MEDICATION NAME] 500mg one tablet every 4 hours as needed for pain, [MEDICATION NAME] Nebulization Solution (2.5 mg/3ml) (milliliters) 0.083% 1 vial orally via nebulizer (Inhaled) as needed for shortness of breath TID (three times a day) PRN (as needed), [MEDICATION NAME] CD Capsule Extended Release 24 hour/ 240 MG Tablet (Diltizem HCI ER Coated Beads) 1 capsule by mouth once a day, Carvedilol Tablet 12.5mg 1 tablet twice a day, [MEDICATION NAME] Sodium 100mg 1 capsule as needed for constipation, [MEDICATION NAME] 10mg 1 tablet by mouth twice a day, [MEDICATION NAME] tablet 5mg 1 tablet at bedtime, Multivitamin Capsule once daily, [MEDICATION NAME] (blood thinner) tablet 75mg, one tablet once a day, [MEDICATION NAME] Sodium tablet 40 mg one tablet at bedtime. There were no ordered opiates for Resident #1. Review of Resident #1's Medication Administration Sheet (MAR) dated [DATE]-[DATE] reflected no documentation that pain medications were administered during this time period. Review of Nurses Notes dated [DATE] at 1:40 AM revealed Certified Nurse Aide (CNA) A reported to LVN I that Resident #1 was unresponsive and her skin was blue in color to facial area and lips. Resident #1 would not respond to verbal or physical stimuli. Oxygen Saturation was in the 40% range, (Normal ,[DATE]), Blood Pressure ,[DATE], Pulse 56, and oxygen was then applied, Respirations were around 6 breaths per minute, (Normal ,[DATE] per minute). Ambulance was called. Included in the transfer form from the facility is a SBAR (Situation Background And Resident Evaluation) communication form, that reflected Resident #1 was unresponsive, Blue/Gray facial areas/lips, eyes rolled up to the back of head, and body tight. Review of a transfer form dated [DATE] at 2:25AM, reflected Resident #1 was still unresponsive and EMT (Emergency Medical Transport) left the facility with her about 2:35 AM. Review of Nurses Notes dated [DATE] at 5:00 AM, by LVN I reflected the hospital called and inquired if the correct medication list was sent with Resident #1's transfer because the hospital had to administer [MEDICATION NAME] (medication that reverses the effects of opioid). LVN I told her, Yes. Review of Nurses Notes dated [DATE] at 6:30 AM, revealed Registered Nurse (RN) A received a call from the hospital (emergency room ) ER staff that Resident#1 tested positive for opioids, they had her on a [MEDICATION NAME] drip and she would be making a referral to Adult Protective Services (APS). RN A notified the Assistant Director of Nurses (ADON). Record review of emergency room (ER) documents dated [DATE] at 3:13 AM, revealed EMS administered to Resident #1, 0.4 MG [MEDICATION NAME] and respirations improved from 6 breaths a minute to 22 breaths a minute. Dictation by the attending physician in the ER reflected Resident #1 came in the ER with altered mental status. Paramedics noted that the resident appeared to be hypoventilating (low breaths per minute) with a low blood pressure and pinpoint pupils. They gave resident [MEDICATION NAME], as mentioned above, with some improvement in her mental status. Examination was very similar on my arrival and I was initially concerned about narcotic overdose, but the resident wasn't on narcotic medications. We gave the resident an additional dose of [MEDICATION NAME] while assessing for other possible etiologies of the resident's altered mental status. Our laboratory examination is essentially unremarkable. The resident continues to respond to [MEDICATION NAME] and Urine Drug Screen (testing the urine for different chemicals) has come back positive for narcotics. I suspect the resident has inadvertently received another resident's narcotic at the nursing home as a source for her significant sedation. I contacted the intensivist in order to arrange for admission for close airway monitoring as the patient runs a risk for need for intubation. Final Impression: Opiate or related narcotic overdose. Reference dailymed.nth.gov/daily: [MEDICATION NAME] sulfate extended-release (ER) tablets are an extended-release oral formulation of [MEDICATION NAME] sulfate indicated for the management of moderate to severe pain when a continuous, around-the-clock opioid [MEDICATION NAME] is needed for an extended period of time. Review of Resident #2's medication orders dated [DATE] reflected the following: [MEDICATION NAME] ER 200MG every 8 hours, [MEDICATION NAME] tablet 30mg 2 tablets every 4 hours for pain. Review of a facility Medication Error Report dated [DATE] revealed Resident #1 was given another resident's medication in error as per their investigation of viewing camera video and review of their records. LVN A was doing medication pass the evening of [DATE]. Video camera at 5:30 PM revealed LVN A was in the room of Resident #1. Resident #2 was ordered 200mg ER (Extended Release) [MEDICATION NAME] every 8 hours and on her Medication Administration Record [REDACTED]. The camera showed no activity of LVN A at the room of Resident #2 at 5:30 PM and not until 7:19 PM did LVN A go into Resident #2's room. The facility asked Resident #2 if she got her 4:00 PM [MEDICATION NAME] medication and she couldn't remember. She said she takes so much [MEDICATION NAME] she gets confused. An interview with the Director of Nurses (DON) on [DATE] at 2:00 PM, revealed that LVN A was on video as not going to Resident #2's room until 2 hours later than when she documented she gave the medication, but she did go into Resident #1's room at 5:30 PM. The DON stated that LVN A was confused on the video and walking back and forth and looking around like she wasn't sure of her actions and she (DON) thought she placed some medications in the waste container. An interview with LVN A on [DATE] at 3:00 PM revealed she did get confused and she thought she may have given the wrong medication to the wrong resident. She stated she presets her medication, that is punching them out of a blister pack and placing in a cup before getting to the room or before starting the medication pass. She stated she was not trained for medication pass at this facility and it was her first time working on this unit and the second day on this job. When asked by the surveyor if she had ever given medications, she stated that she works part time at another facility, but they let her preset medications. Surveyor review of facility video dated [DATE] at 5:19 PM, revealed LVN A going into Resident #1's room the first time and when she came out she looked confused as to what she had in her hand (cup of pills). She walked round the med cart several times and went again into Resident #1's room. LVN A did not go near Resident #2's room until 7:20 PM. [MEDICATION NAME] ER 200mg was initialed by LVN A as given at 5:30 PM to Resident #2. In an interview on [DATE] at 12:30 PM, LVN H, when asked if she could show the training LVN A had received, stated that they had not performed check off for skills, but were in the process of getting together a skills check-off sheet. She also stated, LVN A should have been trained prior to being on a med pass. Review of facility policy Administering Medications (no date) Policy Statement: Administering Oral Medications reflected the following elements: General Guidelines and Precautions 1. Medication Aides must understand and follow the Rules at 40 TAC Chapter 95 with attention to 95.103 and 995.105 on administering medications. 2. Work in a clean, organized, well-lighted area and avoid distractions while preparing and administering medications. 3. Give only medicines that you have prepared. 4. Give medicines only from clearly labeled containers. 5. Follow the SIX RIGHTS of medication administration. -Right Resident -Right Drug -Right Dose -Right Route -Right Time -Right Documentation 6. Read the label 3 times as you prepare a medication, carefully checking the drug label against the Medication Administration Sheet (MAR), med card or physicians orders, according to facility policy. Check #1 as you take the medicine from the storage area Check #2 you pour the medication Check #3 For multi-dose drugs as you replace the label container into the storage area. For unit-dose drugs- at bedside, before opening the unit-dose medicine package. Assessments (Activities to be completed prior to preparing medications) 1. Check medication card or MAR indicated [REDACTED]. 2. Check for the SIX RIGHTS 3. Review your knowledge of medications and look up needed information such as drug interactions, therapeutic effects, side effects, usual doses/routes, contraindications and nursing implications **The PRE-PULLING of medications is STRICTLY prohibited and grounds for IMMEDIATE TERMINATION OF EMPLOYMENT Review of the Administrator's statement dated [DATE] revealed the following: Resident was sent to the hospital immediately due to a change of condition. After the hospital update stating the resident tested positive for opiates, an investigation was started. Video was reviewed, interviews were initiated, staff member admitted to getting confused and the video revealed she did not enter the room that she was supposed to have given the med, but did sign off as having given. The video reflected she never entered the room of the resident due the medication, (Resident #2), but did enter Resident #1's room at that time. Staff member was suspended until further investigation could be conducted. In-services began immediately. The first in-service covers Medication Administration Policy & Procedure, the second covers Medication Error Reporting, Medication Administration Proficiency checks began as soon as possible in two in-services. After record review, staff interviews and observations it appears that this nurse administered an opiate medication to the wrong resident which resulted in a significant change of condition. Investigation shows no willful intent to harm or neglect. Staff member will be terminated based on the investigation outcome. Review of hospital records dated [DATE] at 6:06 PM, reflected documentation from a physician accepting Resident #1 for Hospice care. Resident #1 admitted on [DATE] with altered mental status and poor respiratory effort. She tested positive for opiates onlyper UDS (Urine Drug Screen) on [DATE]. She was presumed given the wrong medication at the NH (Nursing Home). She never fully recovered and I anticipate she will expire in ,[DATE] days in her condition. Resident #1 expired on [DATE]. In an interview on [DATE] at 10:42 AM, with Resident #1's attending physician, he was asked if he thought Resident #1 being given someone else's pain medication by mistake contributed to her death. He stated, Most definitely it contributed to her early demise. She actually did die and we brought her back. He also stated, If she did receive an opioid med in error it would complete the circle of what was wrong and what happened to this lady. Reference dailymed.nth.gov/daily: [MEDICATION NAME] extended-release (ER) tablets are an extended-release oral formulation of [MEDICATION NAME] sulfate indicated for the management of moderate to severe pain when a continuous, around-the-clock opioid [MEDICATION NAME] is needed for an extended period of time. The facility Administrator and DON were notified on [DATE] at 2:02 PM that an Immediate Jeopardy (IJ) had been identified due to the above failures. A Plan of Removal was submitted by the Administrator on [DATE] at 5:10 PM. The final Plan of Removal was accepted by the surveyor/investigator on [DATE] at 5:30 PM. The plan of removal included the following: 1. In-service will be performed on Medication Administration Procedure immediately with a focus on the six rights of medication administration (the right resident, medication, route, time, dose, and documentation) to ensure proper patient identification. 2. In-service will be performed on Reporting Medication Errors immediately. 3. To assist with patient identification, we updated all patients records with updated resident pictures and re-printed all Medication Administration records (MAR's), Treatment Administration Records (TAR's), Nurses Medication Administration Records (NMAR's), And Wound treatment MAR's to include pictures. 4. Proficiency check offs will be performed on current nurses, medication aides and PRN's (as needed). All to be completed by [DATE]. The facility also initiated a New Hire Mentorship Training Policy which was covered in staff inservices as part of the facility Plan of Removal. The plan included designated mentors, who will provide new hires no less than 3 days of training, and will not allow new hires to be scheduled on the floor without supervision from the Mentor or supervisor until all proficiency checks are performed. The surveyor monitored the current plan of removal as follows: On [DATE] and [DATE], Medication Administration Skills Checklists for proficiency were completed and checked off for current charge nurses and medication aides except for seven (7) employees. The DON stated these 7 would not have a schedule until they received the in-services and were checked off on the Medication Administration Skills. During interviews on [DATE], RN A ,CMA B, C, D, LVN B, C, D and LVN E stated they had been in-serviced and had completed the Medication Administration Skills Checklist. On [DATE] at 12:05PM, the Administrator and DON were informed the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm with a scope identified as isolated, due to the facility administration and staff requiring time to train all staff and monitor their plan of removal. The DON identified 23 residents on East Wing who receive medications from facility staff.

Based on observation, interview and record review, the facility failed to ensure that one (1) of 4 sampled residents reviewed for falls received adequate supervision and assistance devices during a staff transfer to prevent accidents. (Resident #1) On 3/22/11 Certified Nurse Aide (CNA A) transferred Resident #1 without assistance of another staff member and without using the Hoyer (mechanical) lift resulting in a fall for Resident #1. Resident #1 was hospitalized for [REDACTED]. This deficient practice resulted in hospitalization and surgical repair of a fractured hip for Resident #1 and placed the additional 45 residents identified as totally dependent on staff for transfers at risk of injury when staff fails to provide care and services specific to resident care plans. Findings include: Review of Resident #1's Face Sheet dated 3/28/11 reflected admission to the facility on [DATE]. Resident #1 is a [AGE] year old female with [DIAGNOSES REDACTED]. Review of Resident #1's current (undated) Kardex information revealed the following instructions for care: Mobility: Fall Risk. Transfer with assist of 2 staff members. Use Hoyer Lift to transfer. Review of Resident #1's Nurse Aide ADL (Activities of Daily Living - bathing, transfers, dressing, hygiene, etc.) Tracking Form prior to the fracture, dated February, 2011 revealed she required extensive assistance for weight bearing during transfers, and the support of two + person physical assist with transfers. During observation of incontinent care to Resident #1 on 4/11/11 at 10:20 AM, she was rolled to the left and right side while CNA staff cleaned her buttocks. Each time she was rolled, Resident #1 would call out, "Don't drop me." She had a surgical incision with staples to her left leg at the lower thigh bone. Resident #1 has short term memory problems, and could not remember having a fall, or the fractured leg, but was afraid of being dropped during direct care. During an interview on 4/11/11 at 10:40 AM, Resident #2 stated, "A new CNA (no name given) came in to get my roommate up (Resident #1). I saw her get the wheelchair, and pull the privacy curtain half way. I know the aide did not use a lift or get help. I heard a loud 'blam', and I saw the wheelchair scoot forward. She must not have locked the wheels. I saw Resident #1 and the CNA fall on the wheelchair. It took them both down. Resident #1 said, 'You dropped me.' The CNA said, 'No, I didn't drop you' and she blamed the fall on the wheelchair. Another CNA (no name given) came in to help her get Resident #1 up to the wheelchair. Then, a few days later, a nurse (no name given) noticed some bruising on Resident #1. I told the nurse what I saw, and she said the fall had never been reported. Resident #2 stated that Resident #1 did not complain of pain, except for when they moved her, but she always complained when she was moved." Review of a facility Investigation Report dated 4/2 /11 revealed the following: On 3/22/11 just before lunch, CNA A transferred Resident #1 by herself to the wheelchair. Resident #1 is a 2 person transfer with a lift according to her Kardex. CNA A stated that she turned away to get something and when she turned back Resident #1 was sliding to the floor, however in the interview with CNA A this part of her story changed several times. CNA A said she stepped into the hallway get help, and CNA B came in and assisted her in getting Resident #1 back into the wheelchair. Resident #1 was then taken to the beauty shop, and was also up in the dining room for lunch. While in the dining room, Resident #1 told CNA C that she was "mad because that new girl dropped me". CNA C told Registered Nurse RN D. RN D said she was told about the incident and she assessed Resident #1 for visible injuries, but failed to report the incident or to document. Resident #1 complained of pain and swelling in the left thigh on Saturday morning (3/26/11) and was assessed to have bruising and swelling. On Sunday (3/27/11) the evening shift skin assessment revealed bruising and edema (swelling). An X-ray was ordered Monday morning, and upon finding the fracture, she was immediately transferred to the hospital. Review of the Final X-Ray Report dated 3/28/11 revealed the following findings: An acute angulated and displaced fracture of the mid-femoral shaft (newly acquired broken thigh bone). During interview on 4/11/11 at 8:40 AM the Director of Nurses (DON) stated, "The CNA's have a Kardex Notebook at the nurse's station with a flow sheet that explains the care needs of the residents. The Kardex tells how and how many staff to use for transfers. Resident #1 requires a Hoyer Lift transfer. When using a Hoyer Lift, our policy is always to have 2 staff members for the transfer. CNA A transferred Resident #1 without using the Hoyer lift, and without assistance. She was terminated, and CNA B was counseled." Interviews on 4/11/11 through 4/12/11 with multiple CNA staff at random from both day and evening shifts revealed they were all familiar with and used the Kardex notebook for resident care information. During interview on 4/11/11 at 11:30 AM, RN D stated, "The morning of 3/22/11, I told CNA A to get Resident #1 up to her wheelchair because she had a hair appointment. I specifically told CNA A to get someone to help her, because it takes 2 people to get Resident #1 up. Later that day, CNA D came up to me and said Resident #1 had had a fall. I went to CNA B and asked about it. CNA B stated, 'CNA A called me into Resident #1's room where I saw her lying on the floor in front of her wheelchair. CNA B told me when she was getting the resident up, she pushed her wheelchair back and slid to the floor. I thought CNA A would report the incident, as she witnessed it.' Resident #1 was still in her wheelchair, I went over to assess her. I checked her head and back and didn't see anything. I didn't see any bumps or scrapes, so I did not make out an incident report. I did not assess her lower extremities and I did not document the fall. Then on 3/26/11 the evening nurse noticed some swelling and a quarter size bruise to the back of her left leg. The next day the swelling increased and the bruising spread to the upper thigh. The unit manager was notified." Review of CNA A's personnel file on 4/11/11 revealed she received training and demonstrated proficiency in patient transfers, with and without mechanical lifts. Review of a staff in-service dated 3/29/11 (following Resident #1's incident) revealed the following: Lifting Machine, Using a Portable Purpose: to help lift residents using a manual lifting device. Preparation: Review the resident's care plan to assess for any special needs bf the resident. General Guidelines: Two (2) nursing assistants will be required to perform the procedure. Review of a current facility policy dated 2007 titled Safety and Supervision of Residents reflected the following elements: Employees shall be trained and in-serviced on potential accident hazards and how to identify and report accident hazards, and try to prevent avoidable accidents. Our resident oriented approach to safety addresses safety and accident hazards for individual residents. The care team shall target interventions to reduce the potential for accidents. Implementing interventions to reduce accident risks and hazards shall include the following: Communicating specific interventions to all relevant staff. Ensuring that interventions are implemented, and documenting interventions. During a telephone interview on 4/11/11 at 11:00 AM, Resident #1's primary care physician stated, "Resident #1 was non weight bearing and basically bedfast prior to the accident, and her level of functioning has not changed significantly. She is very stoic and does not complain much. She always says 'no' when asks if she has pain. I did not know about an incident, but I got a fax (facsimile) from the nursing home on 3/26/11 stating her left leg had swelling, and seemed more contracted. I faxed back an order for [REDACTED]. Early on 3/28/11, we received a call that she had increased swelling, bruising and complained of pain to left leg, I ordered an x-ray. She was sent to the hospital for treatment with the finding of the fracture. I think that she may have sustained a stress fracture at first. She is very osteoporosis (weak bones) and then on the 27th maybe someone just rolled her and the fracture went through the bone causing the start of the swelling and bruising symptoms." The facility completed CMS 672 identified 46 residents who are totally dependent on staff for transfers.

Based on observation, interview and record review the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being, in accordance with the comprehensive assessment and plan of care, for one (1) of 4 sampled residents reviewed for falls, when licensed nursing staff failed to thoroughly assess, document the findings and consult with the physician following an incident/accident that occurred during a staff transfer. (Resident #1) RN D was notified that Certified Nurse Aide (CNA A) transferred Resident #1 without assistance 3/22/11 that resulted in a fall. RN D failed to perform a thorough body assessment was after the reported fall on 3/22/11. Resident #1 Resident #1 complained of pain on 3/26/11 and the evening staff noticed some swelling and a quarter size bruise to the back of her left leg. Resident #1 did not received medical intervention and treatment until 3/28/11 when she was hospitalized for [REDACTED]. Resident #1 returned to the facility on [DATE]. This deficient practice contributed to a delay in medical intervention and treatment for [REDACTED]. Findings include: Review of Resident #1's Face Sheet dated 3/28/11 reflected admission to the facility on [DATE]. Resident #1 is a [AGE] year old female with [DIAGNOSES REDACTED]. During observation of incontinent care to Resident #1 on 4/11/11 at 10:20 AM, she was rolled to the left and right side while CNA staff cleaned her buttocks. Each time she was rolled, Resident #1 would call out, "Don't drop me." She had a surgical incision with staples to her left leg at the lower thigh bone. Resident #1 has short term memory problems, and could not remember having a fall, or the fractured leg, but was afraid of being dropped during direct care. During an interview on 4/11/11 at 10:40 AM, Resident #2 stated, "A new CNA (name unknown) came in to get my roommate up (Resident #1). I saw her get the wheelchair, and pull the privacy curtain half way. I know the aide did not use a lift or get help. I heard a loud ' blam ', and I saw the wheelchair scoot forward; she must not have locked the wheels. I saw Resident #1 and the CNA fall on the wheelchair. It took them both down. Resident #1 said, 'You dropped me.' The CNA said, 'No, I didn't drop you' and she blamed the fall on the wheelchair. Another CNA (name unknown) came in to help her get Resident #1 up to the wheelchair. Then, a few days later, the nurse (name unknown) noticed some bruising on Resident #1. I told the nurse what I saw, and the nurse said the fall had never been reported. Resident #1 did not complain of pain, except for when they moved her, but she always complained when she was moved." Review of a facility Investigation Report dated 4/2 /11 revealed the following: On 3/22/11 just before lunch, CNA A transferred Resident #1 by herself to the wheelchair. Resident #1 is a 2 person transfer with a lift according to her Kardex. CNA A stated that she turned away to get something and when she turned back Resident #1 was sliding to the floor, however in the interview with CNA A this part of her story changed several times. CNA A said she stepped into the hallway get help, and CNA B came in and assisted her in getting Resident #1 back into the wheelchair. Resident #1 was then taken to the beauty shop, and was also up in the dining room for lunch. While in the dining room, Resident #1 told CNA C that she was "mad because that the new girl dropped me". CNA C told Registered Nurse (RN) D. RN D said she was told about the incident and she assessed Resident #1 for visible injuries, but failed to report the incident or to document. Resident #1 complained of pain and swelling in the left thigh on Saturday morning (3/26/11) and was assessed to have bruising and swelling. On Sunday (3/27/11) the evening shift skin assessment revealed bruising and [MEDICAL CONDITION] (swelling). An X-ray was ordered Monday morning, and upon finding the fracture, she was immediately transferred to the hospital. Review of the Final X-Ray Report dated 3/28/11 revealed the following findings: An acute angulated and displaced [MEDICAL CONDITION]-femoral shaft (newly acquired broken thigh bone). During interview on 4/11/11 at 11:30 AM, RN D stated, "The morning of 3/22/11, I told CNA A to get Resident #1 up to her wheelchair because she had a hair appointment. Later that day, CNA C came up to me and said Resident #1 had a fall. I went to CNA B and asked her about it. She said CNA A called her into Resident #1's room and she saw the resident lying on the floor in front of her wheelchair, so she helped CNA A pick her up and get her into her wheelchair. Resident #1 was in her wheelchair, and I went over to assess her. I checked her head and back and didn't see anything. I didn't see any bumps or scrapes, so I did not make out an incident report. I did not assess her lower extremities, and I did not document the fall. Then on 3/26/11, the evening nurse noticed some swelling and a quarter size bruise to the back of her left leg. The next day the swelling increased and the bruising spread to the upper thigh. The unit manager was notified that night. I know now I should have assessed her better and made out an incident report." During an interview on 4/12/11 at 12:00 PM, the DON stated, "RN D should have done a thorough head to toe assessment, and documented the accident and findings in the nurses notes. She did not report the accident to oncoming staff in the 24 hour report. She did not notify the physician or administrative staff of the incident, resulting in no follow-up to observe the resident for changes in condition." Review of RN D's personnel file revealed she received training on 12/10/10 on Abuse/Neglect Prevention and Reporting same. Review of a current facility policy dated 2007 titled Abuse and Neglect - Clinical Protocol reflected the following elements: The nurse will assess the individual and document related findings. Assessment data will include: Injury assessment (bleeding, bruising, swelling, etc.) All current medications; especially anticoagulants. Vital Signs. Behavior over last 24 hours. All active diagnoses. Any recent labs. The nurse will report findings to the physician. As needed, the physician will assess the resident to verify or clarify such findings. Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. During a telephone interview on 4/11/11 at 11:00 AM, Resident #1's primary care physician stated, "Resident #1 was non weight bearing and basically bedfast prior to the accident, and her level of functioning has not changed significantly. She is very stoic and does not complain much. She always says 'no' when asks if she has pain. I did not know about an incident, but I got a fax (facsimile) from the nursing home on 3/26/11 stating her left leg had swelling, and seemed more contracted. I faxed back an order for [REDACTED]. I think that she may have sustained a stress fracture at first. She is very [MEDICAL CONDITION] (weak bones) and then on the 27th maybe someone just rolled her and the fracture went through the bone causing the start of the swelling and bruising symptoms." The facility completed CMS 672 identified a current census of 149 residents. ******************************************************************************************************** 323 Based on observation, interview and record review the facility failed to immediately consult with the physician following an incident/accident involving staff assisted transfer that resulted in a fall and fractured femur for one (1) of 4 sampled residents reviewed for falls. (Resident #1) RN D failed to document and consult with the physician or oncoming staff concerning an accident and a fall that occurred on 3/22/11, when Certified Nurse Aide (CNA A) transferred Resident #1 without assistance of another staff member and without using the Hoyer (mechanical) lift. Resident #1 sustained a fall as a result of the transfer and was hospitalized for [REDACTED]. Resident #1 returned to the facility on [DATE]. Resident #1 was not assessed for injury, or treated from 3/22/11 until 3/27/11 when staff noticed bruising and swelling of the Resident's left thigh. This deficient practice contributed to a delay in medical intervention and treatment of [REDACTED]. Findings include: Review of Resident #1's Face Sheet dated 3/28/11 reflected admission to the facility on [DATE]. Resident #1 is a [AGE] year old female with [DIAGNOSES REDACTED]. During observation of incontinent care to Resident #1 on 4/11/11 at 10:20 AM, she was rolled to the left and right side while CNA staff cleaned her buttocks. Each time she was rolled, Resident #1 would call out, "Don't drop me." She had a surgical incision with staples to her left leg at the lower thigh bone. Resident #1 has short term memory problems, and could not remember having a fall, or the fractured leg, but was afraid of being dropped during direct care. During an interview on 4/11/11 at 10:40 AM, Resident #2 stated, "A new CNA (name unknown) came in to get my roommate up (Resident #1). I saw her get the wheelchair, and pull the privacy curtain half way. I know the aide did not use a lift or get help. I heard a loud ' blam ', and I saw the wheelchair scoot forward. She must not have locked the wheels. I saw Resident #1 and the CNA fall on the wheelchair. It took them both down. Resident #1 said, 'You dropped me.' The CNA said, 'No, I didn't drop you' and she blamed the fall on the wheelchair. Another CNA (name unknown) came in to help her get Resident #1 up to the wheelchair. Then, a few days later, the nurse (name not mentioned) noticed some bruising on Resident #1. I told them the nurse I saw, and she said the fall had never been reported. Resident #1 did not complain of pain, except for when they moved her, but she always complained when she was moved." Review of a facility Investigation Report dated 4/2 /11 revealed the following: On 3/22/11 just before lunch, CNA A transferred Resident #1 by herself to the wheelchair. Resident #1 is a 2 person transfer with a lift according to her Kardex. CNA A stated that she turned away to get something and when she turned back Resident #1 was sliding to the floor, however in the interview with CNA A this part of her story changed several times. CNA A said she stepped into the hallway get help, and CNA B came in and assisted her in getting Resident #1 back into the wheelchair. Resident #1 was then taken to the beauty shop, and was also up in the dining room for lunch. While in the dining room, Resident #1 told CNA C that she was "mad because that the new girl dropped me". CNA C told Registered Nurse (RN) D. RN D said she was told about the incident and she assessed Resident #1 for visible injuries, but failed to report the incident or to document. Resident #1 complained of pain and swelling in the left thigh on Saturday morning (3/26/11) and was assessed to have bruising and swelling. On Sunday (3/27/11) the evening shift skin assessment revealed bruising and [MEDICAL CONDITION] (swelling). An X-ray was ordered Monday morning, and upon finding the fracture, she was immediately transferred to the hospital. Review of the Final X-Ray Report dated 3/28/11 revealed the following findings: An acute angulated and displaced [MEDICAL CONDITION]-femoral shaft (newly acquired broken thigh bone). During interview on 4/11/11 at 8:40 AM the Director of Nurses (DON) stated, "Staff got Resident #1 up to a wheelchair on 3/22/11 for a hair appointment. Later CNA C told RN D that CNA A dropped Resident #1 when getting her up. RN D did a brief assessment, asking the resident if she had hit her head. RN D did not document or report the incident." During interview on 4/11/11 at 11:30 AM, RN D stated, "The morning of 3/22/11, I told CNA A to get Resident #1 up to her wheelchair because she had a hair appointment. Later that day, CNA D came up to me and asked if I knew Resident #1 had a fall. I went to CNA B and asked her about it. She stated, "CNA A called me into Resident #1's room where I saw her lying on the floor in front of her wheelchair.' Resident #1 was still in her wheelchair, and I went over to assess her. I checked her head and back and didn't see anything. I didn't see any bumps or scrapes, so I did not make out an incident report. I did not assess her lower extremities, and I did not document the fall call her doctor. Then on 3/26/11, the evening nurse noticed some swelling and a quarter size bruise to the back of her left leg. The next day the swelling increased and the bruising spread to the upper thigh. The unit manager was notified that night, and the doctor was called and ordered an x-ray the next morning." Review of nurses notes for Resident #1 revealed no documentation of the incident/fall reported to RN D on 3/22/11 by CNA C. there was no documentation of physician notification on 3/22/11, 3/23/11, 3/24/11 or 3/25/11. 3/26/11: Resident #1's physician was notified that her left leg had swelling and was starting to get contracted. Signed: RN D. 3/27/11 at 10:00 PM: [MEDICAL CONDITION] of left upper thigh is larger than yesterday, also is hard when touched. Bruising on back of leg spread. Roommate says she fell on the day her hair was done, in AM. Nothing reported of this fall. Signed: LVN Licensed Vocational Nurse (LVN E). Review of the facility's 24 hour reports (shift to shift nurse report) dated 3/22/11 through 3/28/11 revealed no documentation of Resident #1's incident/fall. During an interview on 4/12/11 at 12:00 PM, the DON stated, "RN D should have done a thorough head to toe assessment. She should have documented the accident and findings in the nurses notes. She did not report the accident to oncoming staff in the 24 hour report. She did not notify or consult with the physician or administrative staff of the incident resulting in no follow-up to observe the resident for changes in condition. Review of a current facility policy dated April, 2007 reflected the following elements: Abuse and Neglect-Clinical Protocol Assessment and recognition: The nurse will assess the individual and document related findings. Assessment data will include injury assessment. The nurse will report findings to the physician. Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Monitoring and Follow-Up: The staff and physician will monitor individuals who have been abused at least until their medical condition, mood and function have stabilized, and periodically thereafter. During a telephone interview on 4/11/11 at 11:00 AM, Resident #1's primary care physician stated, "Resident #1 was non weight bearing and basically bedfast prior to the accident, and her level of functioning has not changed significantly. I did not know about an incident, but I got a fax (facsimile) from the nursing home on 3/26/11 stating her left leg had swelling, and seemed more contracted. I faxed back an order for [REDACTED]. I think that she may have sustained a stress fracture at first. She is very [MEDICAL CONDITION] (weak bones) and then on the 27th maybe someone just rolled her and the fracture went through the bone causing the start of the swelling and bruising symptoms." The facility completed CMS 672 identified 46 residents who are totally dependent on staff for transfers.

Based on observation, interview and record review the facility failed to immediately consult with the physician following an incident/accident involving staff assisted transfer that resulted in a fall and fractured femur for one (1) of 4 sampled residents reviewed for falls. (Resident #1) RN D failed to document and consult with the physician or oncoming staff concerning an accident and a fall that occurred on 3/22/11, when Certified Nurse Aide (CNA A) transferred Resident #1 without assistance of another staff member and without using the Hoyer (mechanical) lift. Resident #1 sustained a fall as a result of the transfer and was hospitalized for [REDACTED]. Resident #1 returned to the facility on [DATE]. Resident #1 was not assessed for injury, or treated from 3/22/11 until 3/27/11 when staff noticed bruising and swelling of the Resident's left thigh. This deficient practice contributed to a delay in medical intervention and treatment of [REDACTED]. Findings include: Review of Resident #1's Face Sheet dated 3/28/11 reflected admission to the facility on [DATE]. Resident #1 is a [AGE] year old female with [DIAGNOSES REDACTED]. During observation of incontinent care to Resident #1 on 4/11/11 at 10:20 AM, she was rolled to the left and right side while CNA staff cleaned her buttocks. Each time she was rolled, Resident #1 would call out, "Don't drop me." She had a surgical incision with staples to her left leg at the lower thigh bone. Resident #1 has short term memory problems, and could not remember having a fall, or the fractured leg, but was afraid of being dropped during direct care. During an interview on 4/11/11 at 10:40 AM, Resident #2 stated, "A new CNA (name unknown) came in to get my roommate up (Resident #1). I saw her get the wheelchair, and pull the privacy curtain half way. I know the aide did not use a lift or get help. I heard a loud ' blam ', and I saw the wheelchair scoot forward. She must not have locked the wheels. I saw Resident #1 and the CNA fall on the wheelchair. It took them both down. Resident #1 said, 'You dropped me.' The CNA said, 'No, I didn't drop you' and she blamed the fall on the wheelchair. Another CNA (name unknown) came in to help her get Resident #1 up to the wheelchair. Then, a few days later, the nurse (name not mentioned) noticed some bruising on Resident #1. I told them the nurse I saw, and she said the fall had never been reported. Resident #1 did not complain of pain, except for when they moved her, but she always complained when she was moved." Review of a facility Investigation Report dated 4/2 /11 revealed the following: On 3/22/11 just before lunch, CNA A transferred Resident #1 by herself to the wheelchair. Resident #1 is a 2 person transfer with a lift according to her Kardex. CNA A stated that she turned away to get something and when she turned back Resident #1 was sliding to the floor, however in the interview with CNA A this part of her story changed several times. CNA A said she stepped into the hallway get help, and CNA B came in and assisted her in getting Resident #1 back into the wheelchair. Resident #1 was then taken to the beauty shop, and was also up in the dining room for lunch. While in the dining room, Resident #1 told CNA C that she was "mad because that the new girl dropped me". CNA C told Registered Nurse (RN) D. RN D said she was told about the incident and she assessed Resident #1 for visible injuries, but failed to report the incident or to document. Resident #1 complained of pain and swelling in the left thigh on Saturday morning (3/26/11) and was assessed to have bruising and swelling. On Sunday (3/27/11) the evening shift skin assessment revealed bruising and [MEDICAL CONDITION] (swelling). An X-ray was ordered Monday morning, and upon finding the fracture, she was immediately transferred to the hospital. Review of the Final X-Ray Report dated 3/28/11 revealed the following findings: An acute angulated and displaced [MEDICAL CONDITION]-femoral shaft (newly acquired broken thigh bone). During interview on 4/11/11 at 8:40 AM the Director of Nurses (DON) stated, "Staff got Resident #1 up to a wheelchair on 3/22/11 for a hair appointment. Later CNA C told RN D that CNA A dropped Resident #1 when getting her up. RN D did a brief assessment, asking the resident if she had hit her head. RN D did not document or report the incident." During interview on 4/11/11 at 11:30 AM, RN D stated, "The morning of 3/22/11, I told CNA A to get Resident #1 up to her wheelchair because she had a hair appointment. Later that day, CNA D came up to me and asked if I knew Resident #1 had a fall. I went to CNA B and asked her about it. She stated, "CNA A called me into Resident #1's room where I saw her lying on the floor in front of her wheelchair.' Resident #1 was still in her wheelchair, and I went over to assess her. I checked her head and back and didn't see anything. I didn't see any bumps or scrapes, so I did not make out an incident report. I did not assess her lower extremities, and I did not document the fall call her doctor. Then on 3/26/11, the evening nurse noticed some swelling and a quarter size bruise to the back of her left leg. The next day the swelling increased and the bruising spread to the upper thigh. The unit manager was notified that night, and the doctor was called and ordered an x-ray the next morning." Review of nurses notes for Resident #1 revealed no documentation of the incident/fall reported to RN D on 3/22/11 by CNA C. there was no documentation of physician notification on 3/22/11, 3/23/11, 3/24/11 or 3/25/11. 3/26/11: Resident #1's physician was notified that her left leg had swelling and was starting to get contracted. Signed: RN D. 3/27/11 at 10:00 PM: [MEDICAL CONDITION] of left upper thigh is larger than yesterday, also is hard when touched. Bruising on back of leg spread. Roommate says she fell on the day her hair was done, in AM. Nothing reported of this fall. Signed: LVN Licensed Vocational Nurse (LVN E). Review of the facility's 24 hour reports (shift to shift nurse report) dated 3/22/11 through 3/28/11 revealed no documentation of Resident #1's incident/fall. During an interview on 4/12/11 at 12:00 PM, the DON stated, "RN D should have done a thorough head to toe assessment. She should have documented the accident and findings in the nurses notes. She did not report the accident to oncoming staff in the 24 hour report. She did not notify or consult with the physician or administrative staff of the incident resulting in no follow-up to observe the resident for changes in condition. Review of a current facility policy dated April, 2007 reflected the following elements: Abuse and Neglect-Clinical Protocol Assessment and recognition: The nurse will assess the individual and document related findings. Assessment data will include injury assessment. The nurse will report findings to the physician. Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Monitoring and Follow-Up: The staff and physician will monitor individuals who have been abused at least until their medical condition, mood and function have stabilized, and periodically thereafter. During a telephone interview on 4/11/11 at 11:00 AM, Resident #1's primary care physician stated, "Resident #1 was non weight bearing and basically bedfast prior to the accident, and her level of functioning has not changed significantly. I did not know about an incident, but I got a fax (facsimile) from the nursing home on 3/26/11 stating her left leg had swelling, and seemed more contracted. I faxed back an order for [REDACTED]. I think that she may have sustained a stress fracture at first. She is very [MEDICAL CONDITION] (weak bones) and then on the 27th maybe someone just rolled her and the fracture went through the bone causing the start of the swelling and bruising symptoms." The facility completed CMS 672 identified 46 residents who are totally dependent on staff for transfers.