Every finding on record at Knopp Nursing & Rehab Center Inc

Based on interviews and record review, the facility failed to ensure that the assessment accurately reflected the residents' status for 2 of 7 (Resident #10 and Resident #20) whose MDS assessments were reviewed in that: Resident #10 had a diagnosis of anxiety and depression that was not coded on the MDS assessment.Resident #10 had orders for psychotropic medications that were not coded on the MDS assessment.Resident #20 had a diagnosis of Alzheimer's disease and depression that was not coded on the MDS assessment. This deficient practice could place residents at risk for inadequate care and services to meet their needs based on inaccurate MDS assessments.Findings included: Resident #10Review of Resident #10's admission Record dated 1/20/2026 reflected an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included other specified viral disease (encompass a range of viral infections that do not fit neatly into established categories), weakness, and repeated falls. Review of Resident #10's Care Plan (undated, printed 1/20/2026) reflected the following: The resident uses phychotropic [psychotropic] med (date initiated 1/06/2026) . Intervention: Administer PSYCHOTROPIC medications as ordered by physician. Monitor for side effects and effectiveness (date initiated 1/06/2026) .The resident uses antidepressant medication (date initiated 1/09/2026) . Intervention: Administer ANTIDEPRESSANT medications as ordered by physician (date initiated 1/9/2026) .The resident uses anti-anxiety medications (date initiated 1/9/2026: revision 1/12/2026) . Intervention: Administer ANTI-ANXIETY medications as ordered by physician (date initiated 1/9/2026).The resident has depression (date initiated 1/9/2026: revision 1/12/2026) . Interventions: Administer medications as ordered (date initiated 1/9/2026). Review of Resident #10's Order Summary Report dated 1/12/2026 reflected the following physician's orders: FLUoxetine HCl Oral Tablet 20 MG Give 80 mg by mouth one time a day for DEPRESSION (order date 12/29/2025) ALPRAZolam Oral Tablet 0.25 MG Give 0.25 mg by mouth two times a day for ANXIETY (order date 12/29/2025) Review of Resident #10's Consent for Antipsychotic or Neuroleptic Medication Treatment consent form dated 12/31/2025 reflected Medication prescribed: Alprazolam and Diagnosis/Reason for Treatment was left incomplete. Record review of Resident #10's initial comprehensive assessment dated [DATE] did not reveal an active diagnosis for psychiatric/mood disorders of depression and anxiety. Further review of Resident #10's initial MDS reflected that Resident #10was taking antidepressant and antianxiety medications and there was an indication notified for these medications in the drug class. Resident #20 Review of Resident #20's admission Record dated 1/20/2026 reflected a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included encounter for other orthopedic aftercare (denote instances where a patient has an encounter with healthcare providers for aftercare following other orthopedic procedures), cognitive communication deficit (refers to difficulties in communication that arise from underlying cognitive impairments rather than primary language or speech issues), and weakness. Record review of Resident #20's initial comprehensive assessment dated [DATE] did not reveal an active diagnosis for Alzheimer's Disease. Further review of Resident #20's initial comprehensive assessment reflected that Resident #20 was not taking antidepressant nor antianxiety medications. Review of Resident #20's Care Plan (undated, printed 1/20/2026) reflected the following: The resident has depression r/t (date initiated 1/14/2026).Goal: the resident will remain free of s/sx [signs and symptoms] of distress, symptoms of depression, anxiety or sad mood by/through review date (dated initiated 1/14/2026: revision on 1/18/2026).Interventions: Administer medications as ordered.Arrange for psych [psychiatric] consult, follow up as indicated (initiated 1/15/2026). Review of Resident #20's admission Referral from hospital to Skilled Nursing Facility (SNF) dated 1/2/2026 reflected the following: Medications [ordered list]Donepezil 10 mg Tablet 10 MG PO BEDTIME 1/2/2026 Donepezil (Aricept) 10 mg ODT/10 mg tab Donepezil 10mg tabDonepezil (Aricept) 23 mg tab Two Donepezil 10 mg tabsALZHEIMERS DZ [disease] (start date 1/2/2026)]. Review of Resident #20's Medication Administration Record 1/1/2026 - 1/31/2026 (printed 1/20/2026) reflected the following physician's orders: Donepezil HCl Oral Tablet 10 MG (Donepezil Hydrochloride) Give 10 mg by mouth at bedtime for memory deficit (start date 1/5/2026). In an interview on 1/20/2026 at 6:30 PM the DON said the MDS Coordinator was responsible for obtaining information for incoming residents from providers for diagnosis and medications to enter accurately on the initial comprehensive assessment [MDS Assessment] for new admissions. In an interview and record review on 1/20/2026 at 6:45 PM the MDS Coordinator said she was responsible for completing all resident assessments. She said she has been employed for roughly 18 months at this facility and has received training in MDS assessments. She said RN A signs off on the completed MDS assessments. She said the MDS assessment was completed with resident's electronic medical records, which include history and physical notes, progress notes, any physician documentation, psychiatric, and hospital records. MDS Coordinator said if the MDS assessment is not completed accurately it can impact reimbursement and would not capture the whole picture of what was going on with the residents and their care. She said she does not have a staff member providing oversight of her completed assessments other than RN A who signs and certifies that the assessment was completed. MDS Coordinator went over Resident #10's and Resident #20's electronic medical record with surveyor and said she cannot recall why the diagnoses, nor the medications taken were not coded correctly on the MDS assessment and she would look into this further. In an interview and record review with the DON on 1/20/2026 at 7:15 PM she said RN A was responsible for signing and certifying that the assessment was completed. She said she believes RN A reviews the MDS assessments for accuracy. DON said she does not have staff who provide oversight or audits to ensure MDS assessment accuracy. DON went over Resident #10's and Resident #20's electronic medical record with surveyor and said she was not sure why the MDS Coordinator would not have used the supporting documentation in their electronic medical record when completing the admission MDS assessment. She said Resident #10 and Resident #20's diagnoses and medication summary were present in their electronic medical record. She said she does not generate a diagnosis; however, the medication summary was used to identify the residents' diagnoses, which she also uses when developing the initial care plan for each resident. In an interview on 1/20/2026 at 8:15 PM the RN A said she has been employed with the facility for 2 1/2 years and was a charge nurse. She said when the DON left the facility early in 2025, she was asked if she would take on the task of signing and certifying that resident assessments are completed. She said she completed an 8-hour training course online and became responsible with this task as she was an RN. She said the assessment can outline if someone who requires more care to be billed or reimbursed at a higher rate. She added that she believes the MDS assessment was for billing purposes and was not sure of anything else. She said if MDS assessments were not completed accurately then this could affect billing reimbursement for the facility. RN A said she sometimes reviews the MDS assessments against the resident's electronic medical record, but not always. She said she was not reviewing the assessments for accuracy, she was not tasked with auditing them for accuracy, and she was not sure who ensures assessment accuracy. RN A said she believed the assessments were accurate and she signed off with this idea. She said she trusts the MDS Coordinator and never had a reason to think she was being left astray or completing assessments inaccurately. RN A said she was not sure why Resident #10 or Resident #20's MDS Assessments were inaccurate as she signed off on them as the RN Assessment Coordinator verifying assessment completion. In a subsequent interview with the MDS Coordinator on 1/21/2026 at 12:10 PM she said the facility does not have specific policy related to initial comprehensive assessments and she follows State regulations and Resident Assessment Manual.No pages of policies related to comprehensive assessments were provided by the facility. Review of Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.20.1 dated October 2025 reflected the following: In addition, an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian and/or other legally authorized representative, or significant other as appropriate or acceptable. It was important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment.

Based on interview and record review, the facility failed to use any individual working in the facility as a nurse aide for more than 4 months, on a full-time basis, unless that individual is competent to provide nursing and nursing related services; and that individual has completed a training and competency evaluation program, for 2 of 6 NAs (NA C and NA F) reviewed for competent staffing. The facility failed to ensure NA C and NA F completed the required training and competency evaluation program for nursing assistants within four months of full-time employment. This failure could result in incompetent care provided for residents and decreased quality of life. Findings included: Record review of the facility document titled Employee List 01.08.2026 revealed 6 total NAs employed by the facility. The job titles of NA C and NA F were documented as N.A. (nursing assistant), and the job titles for the remaining 4 NAs were documented as C.N.A. (certified nursing assistant). NA C's hire date was listed as 3/24/2024, and NA F's hire date was listed as 9/20/2025. In an interview with the BOM on 1/20/2025 at 9:15 AM, she said NA C has completed all of the requirements required for the nursing assistant program, but she has not yet taken the test. She was unsure why NA C had not taken the test. She was unsure if NA F was enrolled in a competency program but said she did not have a certificate of completion. She said the facility will begin the training requirements with any newly hired NA within the first week of hire, if the staff member has not completed a competency program prior to hire. She was not aware of a timeline imposed by the facility for completion of the program. Record review of the Nurse Aide Public Registry accessed on 1/20/2026 (https://tulip.hhs.texas.gov/TULIP/s/public-search) did not reveal records for NA C or NA F. In an interview with the DON on 1/20/2026 at 10:34 AM, she said she was aware NA C and NA F had both been employed by the facility for greater than four months without completion of the required competency program. She said NA C had not yet taken the test for program completion due to personal issues. She said NA F had just reached four months of employment, and she had not taken her test yet due to issues with the required FBI fingerprinting, a name change after marriage, and credentialing from a nursing program she had completed outside of the country. She said she had no concerns with the competency of NA C or NA F and did not consider there to be potential harm to residents by this deficiency. She said there was no facility policy related to competency program completion by nursing assistants.

Based on interview and record review, the facility failed to complete a performance review of every nurse aide at least once every 12 months and to provide regular in-service education based on the outcome of these reviews for 3 of 6 NAs (NA C, NA D, and NAD E) reviewed for competent staffing. The facility failed to complete a performance review and outcome based in-service education for NA C since hire on 3/24/2024, NA E since hire on 5/20/2024, and NA D since hire on 10/16/2024. These failures could lead to incompetent care provided for residents and decreased quality of life. Findings included: Record review of the facility document titled Employee List 01.08.2026 revealed 5 total NAs employed by the facility. Three of these NAs had been employed by the facility for longer a period greater than 12 months as of 1/19/2026:NA C's hire date was 3/04/2024NA D's hire date was 5/20/2024NA E's hire date was 10/16/2024 In an interview on 1/20/2025 at 9:15 AM with the BOM, she said NA D was incorrectly listed as LVN on the employee roster, and she was actually NA. The BOM said she was unsure where the facility stored the annual performance reviews for NAs as they were typically performed by the DON or ADON. She said the facility should be performing annual reviews of all staff, including NAs but she was unsure if they had been completed for NA C/D/E. In an interview with the DON on 1/20/2026 at 10:34 AM, she said she did not complete annual performance reviews of any staff member, including NA C/D/E. She said the facility did not have a policy or procedure regarding that requirement, and she was unaware it was required for licensure. She said she counseled her staff individually when there was a performance issue, and the annual skills competency from the facility for all NAs was the same every year based on the template provided by the facility. She said she did not think the lack of performance review and subsequent education based on the reviews had potential for harm. In an interview with NA E on 1/21/2026 at 10:00 AM, she said she spoke with the DON whenever she has questions, but she had not ever had a scheduled review of her overall performance in her job. In an interview with the ADM on 1/21/2026 at 11:57 AM, she said they did not complete annual performance reviews and they just talk to them [staff] whenever we need it. She said the facility did not have a policy or procedure regarding performance reviews.

Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments for 1 of 1 medication storage rooms reviewed for medication storage. The facility failed to ensure the prescription medication MediHoney gel (a topical medication used for wound care) was not stored in a resident's room. This failure could result in residents having unintended access to medications or accidental administration of medications. Findings included: Record review of Resident #45's admission Record dated 1/18/2026 reflected a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included weakness. Record review of Resident #45's MDS submissions did not reveal an admission MDS submission. Record review of Resident #45's Order Summary Report dated 1/18/2026 revealed the following physician's orders: May apply barrier cream topically with incontinence care as needed (order date 1/16/2026)Further record review of Resident #45's Order Summary Report did not reveal an order for MediHoney gel (a topical medication used for wound care) application. In an observation and interview on 1/21/2026 at 10:30 AM, NA F and NA E were observed performing routine catheter care for Resident #45. NA F was observed removing a partially used tube of MediHoney gel from the resident's bedside table. NA F was observed applying a layer of MediHoney gel to Resident #45's genitals, thigh creases, and buttocks. NA F said MediHoney gel was the same as barrier cream and used for wounds. She was unsure if Resident #45 had an order from the physician for MediHoney gel. NA E said the barrier cream she typically used for residents did not have the same packaging or appearance as the MediHoney gel. She said she knew which cream to apply during incontinence care by asking the nurse but she had not asked the nurse prior to providing care for Resident #45. In an interview with LVN H on 1/21/2026 at 11:55 AM, she said Resident #45 did not have a physician's order for MediHoney gel application as barrier cream. She said NA F should have told her about the mistake. She was unsure why the MediHoney gel was in Resident #45's drawer and said it should have been stored securely in the medication cart or medication storage room. In an interview with the DON on 1/21/2026 at 12:20 PM she said NA F should not have used any creams on Resident #45 without asking the nurse, and the MediHoney gel should not have been stored in Resident #45's room. She said since Resident #45 did not have an order for MediHoney gel application during wound care, the medication probably belonged to the previous occupant of the room. A policy regarding medication storage was requested from the facility during the interview with the DON but not provided prior to exit.

Based on interviews and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required for 1 of 1 dietician and 1 of 1 director of food and nutrition services reviewed. The facility failed to employ a qualified dietician or other clinically qualified nutrition professional from October 2025 to January 2026.The facility failed to employ a full-time director of food and nutrition services. FSS works less than 25 hours per week at the facility. These failures could place residents at risk of not having their nutritional needs met.Findings included: In an interview on 1/21/2026 at 11:00 AM, the FSS said she has been employed with the facility for nearly 21 years. She said a new dietician was hired on to the facility that week on a consultation basis. She said she had yet to be introduced to the dietician and was not familiar with the new contract developed between her and the facility management staff. The FSS said the last dietician, or other clinically qualified nutrition professional, was employed with the facility in October 2025. She said the last dietician resigned abruptly. She said the facility management had challenges with finding a dietician on a consultant basis due to being in a rural area. She said that she worked 40 hours between two different facilities owned by the company at that time. She said she was a salaried staff, and she usually does exceed 40 hours per week. She said she feels she possesses the competencies to carry out the food and nutrition services for the facility. She said that she was tasked with completing resident assessments, collaborating with the physician, DON, speech therapist, resident, and at times, families to develop individual plans of care. She said that all the tasks required of a dietician or other clinically qualified nutritional professional are being met by her. She said there was no effect on residents' nutritional needs by not having a dietician on staff. In an interview on 1/21/2026 at 11:39 AM, the DON said she and the FSS worked together for resident diet changes. She said she works with the speech therapist, and together, they can identify any change in a resident and recommend a diet change. The DON said the facility has been without a qualified dietician or other clinically qualified nutrition professional for a period, and she could not recall the dates. She said she did not see any concerns with the lapse of dietician at the facility as there were other interventions in place to ensure resident nutritional needs were being met. She said the facility was actively seeking a dietician. In an interview on 1/21/2026 at 12:02 PM the ADM said the FSS was not a full-time dietary manager, and she recently hired a dietician on a consultation basis of 16 hours per month. She said the dietician position was vacant for less than six weeks, and during this vacancy, the FSS was tasked with nutrition changes for residents. She said the diets were followed by a physician, and if residents were experiencing weight loss, the DON would take the lead and coordinate with physicians and start interventions for residents. She said she did not see a problem and there was no impact on the residents' nutritional needs by not having a qualified dietician or other clinically qualified nutrition professionals. Record review of document titled, Agreement to Provide Dietary Consultant Services dated 1/14/2026 reflected the following: AGREEMENT made this 14th day of January, 2026 by and between [facility] hereinafter referred to as the Facility and . RD, LD hereinafter referred to as Provider.1. PURPOSEThe purpose of this Agreement is to arrange for dietetic consultation. for the Facility, and when indicated for any resident served by the Facility.3. RESPONSIBILITIES OF THE [NAME]:Consultant shall provide the services of a qualified registered dietitian acceptable to and subject to the approval of the Facility. Said registered dietitian shall assume the exclusive duties of providing consultation to the Facility and personnel located on the premises of the Facility. As such consultant, the registered dietitian shall give guidance and counsel to the nutrition services program as follows:a. Correlate and integrate the nutritional aspects of resident care with other resident care services to include directing the following:Reviewing the resident's medical history and assessing the resident's nutritional status.Interviewing and counseling the residents.Recording pertinent resident information in the medical record.Assessing, planning, and implementing nutrition care for all residents.Developing nutrition care goals.Conferring with other members of the resident care team.Sharing specialized knowledge with other members of the resident's care team.Developing and providing all nutrition assessment forms. Record review of undated document titled, POLICY AND PROCEDURAL GUIDE FOR THE FOOD SERVICES OF [FACILITY]reflected the following: ORGANIZATION OF THE DEPARTMENTA qualified Dietitian will serve as consultant to the Administrator and to the Food Service Supervisor.The Dietary Consultant works with the Administrator and Food Service SupervisorThe consultant will make regular scheduled visits of (16) sixteen hours each month or (20) twenty hours depending on monthly census. Record review of document titled, Dietary Consultant dated March 1, 2012, reflected the following: Purpose: To maintain a dietary department in compliance with roles and regulations of Federal, State and local authorities. To provide therapeutic diets and meals, as prescribed by the physician, in a well-balanced, attractive and appetizing manner under safe, sanitary conditions for a reasonable cost. Qualifications: Must be a professional dietitian who is a member of the American Dietetic Association and meets the registration requirements, or is a graduate of a baccalaureate degree program with major studies in food service management, or foods and nutrition. The Chief Nutritionist, Bureau of Long Term Care and Texas Department of Health shall evaluate and determine suitability of this person. A minimum of 15 clock hours of appropriate continuing education per year shall be completed, reported and approved according to instructions issued by the Texas Department of Health, Long [NAME] Care Division.

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 development and transmission of communicable diseases and infections for 1 of 1 laundry area and 1 of 5 residents (Resident #45) reviewed for infection control. The facility failed to ensure clean laundry was stored to prevent contamination in the laundry room. The facility failed to ensure laundry staff utilized PPE during handling of linen identified as potentially infectious. The facility failed to ensure appropriate level of TBP was initiated for Resident #45. The facility failed to ensure soiled linens from Resident #45 were properly secured and identified for cleaning. These failures could result in the spread of infection and illness, or the unnecessary seclusion and isolation of a resident. Findings included: 1. In an observation and interview on 1/21/2026 at 11:36 AM, a moveable rack of clothing on hangers and a fixed rack of clothing on hangers were observed in the room of the laundry area that contained the washing machine. LA I identified the area as the location in which soiled linens and clothing were sorted. She said the clothing on the two racks was clean, and she knew they should not be stored in their current location, but she was instructed by the DON to put the clothing there. She said the clothing could get contaminated by being stored in that area. In an interview with the ADM on 1/21/2026 at 2:30 PM, she said the clean clothing should not be stored in the area where laundry was sorted due to potential contamination. 2. In an observation and interview on 1/21/2026 at 11:36 AM, no PPE was observed in the sorting area of the laundry area. LA I said if linen is received in a red bag, it means that it is infectious and should be washed separately. She said they use disposable gloves but do not have gowns. She said no one had ever told her to use a gown, and she said she had not received training related to infection prevention or control. In an interview with the DON on 01/21/2026 at 12:14 PM, she said she was the Infection Preventionist for the facility. She said she did not oversee the laundry process because she did not think it related to infection prevention. She said she did not know if laundry aides should be utilizing PPE when handling potentially infectious laundry. She said she had not provided PPE or guidance to the laundry aides regarding infection prevention and control because she did not see the laundry area as a threat of infection spread. 3. Record review of Resident #45's admission Record dated 1/18/2026 reflected a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included weakness. Record review of Resident #45's MDS submissions did not reveal an admission MDS submission. Record review of Resident #45's Care Plan Report undated/printed 1/29/2026, did not reveal care planning related to TBP. Record review of Resident #45's Order Summary Report dated 1/18/2026 did not reveal an order for TBP. In an observation and interview on 1/19/2026 at 2:21 PM Resident #45 was observed to have a urinary catheter. No signage indicating TBP or PPE cart was observed outside of Resident #45's room. NA J said she had just come on shift and was unsure why Resident #45 did not have TBP initiated. She said Resident #45 was a new admission, but she was agency staff and unsure of the protocol for initiating TBP at the facility. Resident #45 was unable to participate in attempted interview due to cognitive decline. In a subsequent observation on 1/21/2026 at 10:30 AM PM, two signs were observed on Resident #45's door. One indicated Resident #45 required Contact Precautions, and the second indicated Resident #45 required EBP. In an interview with the DON 1/21/2026 at 12:14 PM, she said she required staff to initiate Contact Precautions as well as EBP for any resident with an indwelling catheter, including Resident #45. She said Resident #45 did not have any infection that was spreadable but was on Contact Precautions to ensure staff used when providing care. She said she was aware that Resident #45 met criteria for EBP level of preucations, but she said she felt like staff were not properly initiating EBP in the past, so she decided to enforce a higher level of TBP to increase compliance. She said the difference between Contact Precautions and EBP was wearing gloves so she felt it was an appropriate measure for the prevention of infection. She said Resident #45 did not have TBP in place on 1/19/2026 because the resident was the last admission on [DATE] and she had not yet initiated TBP at the time of the observation. Record review of the facility policy titled Infection Prevention & Control undated/ reviewed 1/19/2026 revealed the following:6) . If the disease or infections requires isolation or precautions the resident will be isolated only to the delineated in these policies and procedures. If the disease or infections requires isolation of precautions, the resident will be isolated only to the degree necessary to isolate the infecting organism. Contact precautions are indicated (unless other orders are received from physician) for residents with MDROs who are ill and totally dependent upon HCWs for ADL assistance or whose secretions of drainage cannot be contained. Further review of the policy did not reveal findings related to EBP. 4. In an observation and interview on 1/21/2026 at 10:30 AM, NA E and NA F were observed providing catheter care to Resident #45. Resident #45 had signage on her door indicating she required Contact Precautions and EBP. At the completion of the procedure, NA E removed her PPE and pushed a large, lidded bin on wheels to the doorway of Resident #45's room. NA F then deposited soiled linen from Resident #45 directly into the bin, on top of other, soiled, unbagged linen. NA F was asked why Resident #45's soiled linen was not put into a red, biohazard bag, as she was on Contact Isolation. NA F said the red bags indicating contamination are only used if an item is heavily soiled with bodily fluids, like vomit or blood. She also said facility staff will usually bag soiled linen into garbage bags before putting it into the larger bin, but she did not bag the linen this time because she did not have a bag available and the bin was brought to the room. In an interview with the DON on 1/21/2026 at 12:14 PM, she said soiled linen leaving a resident's room on Contact Isolation, such as Resident #45, did not need to be bagged prior to being put into the soiled linen bin. She said the red, contaminated bags are only indicated when a resident had a spreadable infection, and Resident #45 was not infectious and only on Contact Isolation due to the urinary catheter. The DON was asked how staff could differentiate which resident on Contact Precautions had a contagious infection and required bagging of soiled linen if the precaution procedures were not uniform for all residents on Contact Precautions. The DON said she would tell the staff which resident required their linen to be bagged, and they would pass the information to each other verbally. Record review of the facility policy titled Infection Prevention & Control undated/ reviewed 1/19/2026 revealed the following:Key principles for handling soiled laundry are as follows: (1) not shaking the items or handling them in any way that may aerosolize infectious agents; (2) avoiding contact of one's body and personal clothing with the soiled items being handled; and (3) containing soiled items in a laundry or designated bin.

Based on interview and record review, the facility failed to consider the views of the resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility or to demonstrate their response and rationale for such response for 1 of 1 Resident Council group reviewed. The facility failed to follow up on concerns and requests expressed in Resident Council meetings from July 2025 through December 2025.The facility failed to provide the Resident Council group with a response, actions, and rationale taken regarding their concerns. This failure placed residents at risk of not having their grievances followed up and addressed.Findings included: Review of the Resident Council Meeting minutes from July 2025 through December 2025 reflected there was no documentation of the facility's responses to Resident Council grievances identified during Resident Council group meetings:* Resident Council Meeting dated December 27, 2025, reflected: Resident Council group members communicated concerns with dietary items, housekeeping, laundry, maintenance and activities.* Resident Council Meeting dated November 28, 2025, reflected: Resident Council group members communicated concerns with dietary items, housekeeping, laundry, maintenance and activities.* Resident Council Meeting dated October 24, 2025, reflected: Resident Council group members communicated concerns with dietary items, housekeeping, laundry, maintenance and activities.* Resident Council Meeting dated September 26, 2025, reflected: Resident Council group members communicated concerns with housekeeping, maintenance and activities. *Resident Council Meeting dated August 29, 2025, reflected: Resident Council group members communicated concerns with dietary items, housekeeping, laundry and maintenance.*Resident Council Meeting dated July 25, 2025, reflected: Resident Council group members communicated concerns with dietary items and housekeeping. In an interview on 1/19/2026 at 1:30 PM the Resident Council group said the AD takes the monthly minutes and hears all their concerns with the facility and notifies the management staff. The group said they did not get information on the outcome of the grievances and would like this to change. In an interview on 1/19/2026 at 2:13 PM AD said the residents will go to her directly with grievances and they are addressed. She said the grievances are addressed verbally, they do not fill out the grievance form that was available and located near the ADM's office. She said most grievances are issues that can be addressed quickly, so she will go directly to the department head that the grievance was regarding and notify them of the grievance so they may provide a resolution. She said this process was done verbally or via text message. She said she was the staff that will go back and notify the resident verbally that the grievance has been resolved. She said there was not a need to document the grievance as it was handled quickly. AD said the grievances that she was unable to handle quickly she will write them down and turn them into the ADM to resolve. She said ADM should have these grievances documented. She said that she believed the grievance was handled by the ADM and ADM would be responsible for notifying the Resident Council group of the resolution. She said the ADM does not address the Resident Council group to notify them of the status of their grievances and she was not sure if it was documented, but she was confident the ADM addresses. AD said if grievances are not responded to and actions are not taken to address resident concerns can make them feel unimportant. In an interview on 1/21/2026 at 11:39 AM, the DON said the ADM was the grievance coordinator. She said ADM normally gets complaints and she works on them. She said most grievances are received verbally. She said if a grievance addresses an incident, it will be logged in the facility's system for reporting purposes. DON said AD will provide her with the monthly Resident Council meeting minutes that outline the grievances the group has communicated. She said the AD was responsible for documenting these grievances and she was not sure if this was occurring. She said the grievances identified during Resident Council meetings are handled and she does not document the actions taken to resolve them, but she does provide a response to the group. She said if grievances whether individuals or groups are not provided with a response or actions are not taken to address the grievance, she believes it would make the residents feel as if their concerns were not important. In an interview with the AD and DON on 1/21/2026 at 11:50 AM, the AD informed the DON directly that she only obtains Resident Council group concerns and handles them verbally with department heads or by text; but does not document the actions taken or if resident or group received a response to their grievances. She said since her employment two years back she was tasked with the Resident Council group, and she has not had to document grievances or concerns identified during the Resident Council monthly meetings. Both the DON and AD agreed that moving forward they would document all Resident Council group grievances on a standard grievance form and provide a response verbally and in writing. AD said the impact of not knowing if grievance was being addressed can make the residents and the group feel unimportant and not wanting to discuss further. In an interview on 1/21/2026 at 12:02 PM ADM said the facility handles grievances. She said the facility follows the grievance policy when addressing grievances. She said this task was handled by the AD. Review of the facility policy dated 2005, titled Complaint/Grievance reflected the following: 2. Prompt efforts by the facility to resolve grievances the resident may have.3. Complaints will be acknowledged by the staff of the agency that receives the complaint. All complaints will be investigated, whether oral or written.PURPOSE: To ensure that all complaints are investigated thoroughly and that appropriate corrective action is taken.PROCEDURE:2. The administrator &/ or the DON review the complaint at weekly care plan meeting or immediately depending on the severity of the complaint.3. The administrator and / or the DON does a follow up with the resident / family.4. Resident council or other resident meeting minutes are given to the administration and department heads. The administrator meets with resident council officers as requested. Review of facility document undated titled Concern/Grievance Investigation and Response reflected the following: PURPOSE:To assist in identifying concerns of staff, residents and/or families.To assure appropriate investigation is made and concern has been addressed.To provide an on-going record of concerns which will assist in program and procedure modification.

Based on observation, interview, and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 of 8 residents (Resident #45) reviewed for care planning. The facility failed to ensure Resident #45's baseline care plan included TBP and planning for urinary catheter care. This failure could result in residents not receiving necessary care and decreased quality of life. Findings included: Record review of Resident #45's admission Record dated 1/18/2026 reflected a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included weakness. Record review of Resident #45's MDS submissions did not reveal an admission MDS submission. Record review of Resident #45's Order Summary Report dated 1/18/2026 revealed the following physician's orders:[Urinary [sic] Catheter 14f 10 cc balloon every night shift starting on the 1st and ending on the 1st every month [sic] (order date 1/16/2026) Record review of Resident #45's Care Plan Report (undated, printed 1/19/2026) reflected the following: The resident has (SPECIFY: Condom/Intermittent/Indwelling/Suprapubic) [sic] catheter (date initiated 1/18/2026) . CATHETER: The resident has (SPECIFY Size [sic]) (SPECIFY Type of Catheter [sic]). Position catheter bag and tubing below the level of the bladder and away from the entrance room door (date initiated 1/18/2026). Further record review of Resident #45's Care Plan Report did not reveal care planning for TBP. In an observation on 1/18/2026 at 2:09 PM, Resident #45 was observed to have a urinary catheter in place. The resident's room did not have signage to indicate the resident required TBP. In a subsequent observation on 1/19/2026 at 1:50 PM, two signs were observed on Resident #45's door. One indicated Resident #45 required Contact Precautions, and the second indicated Resident #45 required EBP. In an interview with the DON on 1/21/2026 at 12:14 PM, she said she was primarily responsible for resident's care planning. She said she did not have a formal process for creating and revising the care plans but reviewed them on a daily basis. She said the care planning in Resident #45's care plan report was sufficient to provide care for Resident #45 because staff would know the care needed for the urinary catheter based on the physician's orders. She said staff would know the resident required isolation precautions because she had a urinary catheter. She did not feel the exclusion of this information from Resident #45's baseline care plan had potential for harm. Record review of the facility titled Care Plan/Comprehensive Interdisiplinary dated 2005 revealed the following:The care plan must include measurable objectives and timetables to meet a resident's medical, nursing, and psychosocial needs as identified in the comprehensive assessment. Also [sic] a temporary care plan will be completed by the admitting nurse for every new patient to the facility (see form on next page). No additional pages or policies related to care planning, including aforementioned form for temporary care planning, were provided by the facility.

Based on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for 1 of 3 residents (Resident #45) reviewed for urinary catheters. The facility failed to ensure NA E performed proper catheter care for Resident #45 when she did not protect the catheter tubing from unnecessary tension while cleansing. This failure could result in the unintentional dislodgement of the urinary catheter or pain and injury to a resident's urinary tract. Findings included: Record review of Resident #45's admission Record dated 1/18/2026 reflected a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included weakness. Record review of Resident #45's MDS submissions did not reveal an admission MDS submission. Record review of Resident #45's Order Summary Report dated 1/18/2026 revealed the following physician's orders:[Urinary [sic] Catheter 14f 10 cc balloon every night shift starting on the 1st and ending on the 1st every month [sic] (order date 1/16/2026)May apply barrier cream topically with incontinence care as needed (order date 1/16/2026) Further record review of Resident #45's Order Summary Report did not reveal an order for MediHoney gel (a topical medication used for wound care) application. Record review of Resident #45's Care Plan Report (undated, printed 1/19/2026) reflected the following: The resident has (SPECIFY: Condom/Intermittent/Indwelling/Suprapubic) [sic] catheter (date initiated 1/18/2026) . CATHETER: The resident has (SPECIFY Size [sic]) (SPECIFY Type of Catheter [sic]). Position catheter bag and tubing below the level of the bladder and away from the entrance room door (date initiated 1/18/2026). Resident #45 was unable to participate in an interview attempted on 1/18/2026 at 2:30 PM due to cognitive decline. In an observation and interview on 1/21/2026 at 10:30 AM, Resident #45 was observed to have a urinary catheter in place. NA F was performing catheter care for Resident #45, and she was observed grasping the tube near Resident #45's knees with one hand. She then used a disposable cleaning cloth in the other hand to wipe the tube away from the resident, away from the entrance point of the catheter. While wiping, the area of tubing between the resident's genitals and the point at which NA F's hand was grasping tube became taut, and Resident #45 was observed verbalizing a sound of discomfort when the tubing was pulled, approximately three times.NA F asked Resident #45 if she was okay, and Resident #45 said she was fine. After cleansing, NA E asked NA F to obtain barrier cream for application before the disposable brief was applied. NA F was observed to remove a partially used tube of MediHoney gel from the drawer near Resident #45's bed. NA F was observed applying a layer of MediHoney gel to Resident #45's genitals, thigh creases, and buttocks. NA F said MediHoney gel was the same as barrier cream and used for wounds. She was unsure if Resident #45 had an order from the physician for MediHoney gel. NA E said the barrier cream she typically used for residents did not have the same packaging or appearance as the MediHoney gel. She said she knew which cream to apply during incontinence care by asking the nurse but she had not asked the nurse prior to providing care for Resident #45. NA E also said the purpose of grasping the catheter tube during cleaning was to prevent accidentally pulling the catheter out. In an interview with LVN H on 1/21/2026 at 11:55 AM, she said Resident #45 did not have a physician's order for MediHoney gel application as barrier cream. She said NA F should have told her about the mistake. She was unsure why the MediHoney gel was in Resident #45's drawer and said it should have been stored securely in the medication cart or medication storage room. In an interview with the DON on 1/21/2026 at 12:20 PM, she said NAs at the facility are trained to grasp catheter tubing near the patient's body and cleanse away from the area being grasped, in order to prevent the catheter from being dislodged. She said NA F should not have used any creams on Resident #45 without asking the nurse, and the MediHoney gel should not have been stored in Resident #45's room. Record review of the facility policy titled Catheter Care, Indwelling Catheter dated 2005, reflected the following: 6. Hold catheter tubing to one side and support it so as to avoid traction or unnecessary movement of the catheter while performing care.

Based on observation, interview, and record review, the facility failed to use the services of a registered professional nurse at least 8 consecutive hours a day, 7 days a week for 2 of 141 days reviewed for sufficient staffing. Additionally, the facility failed to designate a registered nurse to serve as the director of nursing on a full-time basis for 1 of 1 DON reviewed for staffing. The facility failed to use the services of a registered nurse for 8 consecutive hours on 9/24/2025 and 10/19/2025.The facility designated an LVN to serve as the director of nursing effective 3/1/2024. These failures could lead to residents not receiving necessary care or oversight of their care and decreased quality of life. Findings included: 1. Record review of the facility document titled Employee Timesheet [RN A] dated 9/16/2025- 9/30/2025 reflected RN A utilized 8 hours of paid time off on Wednesday, 9/24/2025. Record review of the facility document titled Employee Timesheet [RN A] dated 10/1/2025 - 10/15/2025 reflected RN A utilized 8 hours of paid time off on Thursday, 10/9/2025. In an interview with the DON on 1/20/2026 at 8:43 AM, she said the facility did not have RN coverage on 9/24/2025 or 10/9/2025 as indicated by RN A's timesheets. She said she spoke with RN A regarding the two shifts, and RN A said she did not work those shifts due to personal commitments. The DON said she did not feel this impacted care provided to resident because an LVN was staffed during those times to provide any necessary nursing care. 2. Record review of the facility document titled Job Description for Charge Nurse dated 10/23/2023 reflected a signature and date from staff member RN A. Record review of the facility document titled Director of Nursing dated 3/01/2024 reflected a signature and date from the DON and the Admin. Qualifications were listed as currently licensed as a Registered Nurse in the State [sic] of Texas and graduate of an accredited university with a 4 year [sic] degree. In an observation and interview on 1/19/2026 at 2:47 PM, RN A was observed at the nurse's station working on the facility computer. She said her job title is Charge Nurse. She said she is not the DON and has no oversight or management responsibilities of the facility other than signing MDS assessments performed by the MDS nurse. She said that she does not review any work performed by the DON and was asked previously by the facility to serve as the DON, but she declined the position. In an interview with the DON on 1/20/2026 at 10:17 AM, she stated her job title was ADON, but she was serving as the acting DON until she completed the RN program. She said RN A was the actual DON and responsible for overseeing her work. She said she felt the needs of the residents were met by her qualifications and there was no potential harm.

Based on observation, interview, and record review, the facility failed to ensure medication error rates are not 5 percent or greater for 2 of 4 Residents (Residents #36 and #37), and 2 of 25 medication administration observations, resulting in an error rate of 8%. The facility failed to ensure Resident #36 received medication Donepezil at 7:00 AM on 1/19/2026, as ordered by the physician.The facility failed to ensure Resident #37 received medication Pantoprazole at 8:00 AM on 1/19/2026, as ordered by the physician. This failure could result in residents not receiving correct and timely medications.Findings included: Record review of Resident #36's medication administration record for January 2026, dated 1/19/2026, reflected the following order:Donepezil HCl Oral Tablet 5mg (Donepezil Hydrochloride) Give 1 tablet my mouth one time a day related to Alzheimer's disease [a progressive neurological condition causing deterioration of memory, thinking, and daily function] with late onset . start date 11/08/2025 07:00 [AM]A check mark symbol and initials of LVN G were documented on 1/19/2026, which indicated Resident #36 had received the medication. Record review of Resident #37's medication administration record for January 2026, dated 1/19/2026, reflected the following order:Pantoprazole Sodium Oral Tablet Delayed Release 40MG (Pantoprazole Sodium) Give 40mg by mouth one time a day for gerd [sic] [chronic heartburn] . start date 01/10/2026 08:00 [AM]A check mark symbol and initials of LVN G were documented on 1/19/2026, which indicated Resident #37 had received the medication. In an observation and interview on 1/19/2026 beginning at 8:22 AM, LVN G was observed preparing and administering morning medications. At 8:33 AM, LVN G administered the Donepezil 5mg tablet to Resident #36. At 8:46 AM, LVN G was observed preparing medications for administration to Resident #37. She said Resident #37 did not have an available dose of the Pantoprazole 40mg tablet, and she was unsure where to obtain the medication because she was not full-time staff and unfamiliar with the medication reordering processes of the facility. She said she was told by another nurse that the facility did not maintain an emergency supply of medications, so she would skip the Pantoprazole for Resident #37 and ask the DON. In an interview with the DON on 1/19/2026 at 10:20 AM, she said the facility policy was to administer medications within one hour before or after the ordered time, so Resident #36's Donepezil administration would be considered late. She also said LVN G had not informed her of the missing Pantoprazole for Resident #37, and LVN G should not have documented a medication she did not administer. She said LVN G made the errors because she is agency and she does not have a process to train agency staff about the facility's expectations for medication administration or reordering. Record review of the facility policy titled Medication Administration, Oral undated, received 1/19/2026, reflected the following:Document on MAR that medication was either given or refused by patient.May give med 1 hr before scheduled time and 1 hr after

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 8 residents (Resident #140) reviewed for neglect with serious injuries and lack of supervision, in that: On 09/01/2024 CNA A assisted Resident #140 with a mechanical lift transfer by herself. Resident #140 fell during the transfer, suffered a broken right leg, and was hospitalized with a need for surgical repair. Prior to the fall Resident #140 was assessed with a need for more than 1 staff for assistance with transfers . An Immediate Jeopardy (IJ) was identified on 10/17/2024. The IJ Template was provided to the facility on [DATE] at 04:30 PM. While the IJ was removed on 10/18/2024, the facility remained out of compliance at a scope of isolated with risk for harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of their corrective actions. This deficient practice could place residents who needed more than 1 staff assistance with mechanical transfers at risk for harm by neglect to include serious injury, or death. The findings included: A record review of Resident #140's admission and discharge record dated 10/17/2024 revealed an admitted [DATE] and a discharge date of [DATE] with diagnoses which included dementia (a group of symptoms affecting memory, thinking and social abilities. In people who have dementia, the symptoms interfere with their daily lives), psychotic disturbance (a condition of the mind or psyche that results in difficulties determining what is real and what is not real), mood disturbance and anxiety. A record review of Resident #140's MDS assessment dated [DATE] revealed Resident #140 was an [AGE] year-old female admitted for long term care and assessed with a BIMS score of 01 out of a possible of 15 which indicated severe cognition impairment. Further review revealed Resident #140 was assessed as 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 all of Resident #140's needs for transfers, sit to stand, chair / bed to chair transfer, and toilet transfers. A record review of Resident #140's care plan dated 10/17/2024 revealed, (Resident #140) is dependent on staff for meeting . physical . needs . related to dementia . the Resident needs assistance / escort to activity functions A record review of the facility's fall incident report dated 09/01/2024 revealed Resident #140 suffered a fall during a 1-person mechanical lift transfer performed by CNA A, (agency aid CNA A) notified skill nursing that resident is on the floor. When entering residence room Resident (#140) was laying on left side hidden between the legs of the sit to stand. During an interview on 10/16/2024 at 03:00 PM, the ADON stated Resident #140 was discharged to the hospital on 09/02/2024 for evaluation and treatment for pain to her right leg and was diagnosed with a broken right leg which was surgically repaired. The ADON stated Resident #140's family did not return Resident #140 to the facility and moved Resident #140 to their home where they continued to care for her. The ADON stated on 09/01/2024 CNA A attempted to transfer Resident #140 by herself from the bed to a wheelchair. CNA A alerted LVN B that she needed assistance with Resident #140 because CNA A lost control of Resident #140 and lowered her to the floor. The ADON stated Resident #140 was assessed by LVN B without serious injury and or pain and was placed in bed. During an interview on 10/16/2024 at 02:17 p.m., Resident #140's representative stated she received a report from LVN B on the evening of 09/01/2024. Resident #140's representative stated LVN B reported that CNA A alerted LVN B for assistance with Resident #140, when LVN B entered the room, she observed Resident #140 sitting on the floor on her bottom with her legs to the right and the mechanical lift nearby. LVN B assessed Resident #140 to be without pain and with one small skin tear to her arm. Resident #140's representative stated LVN B reported Resident #140 was placed in bed, her physician was called, and an order for an x-ray was obtained. Record review of Resident #140's nursing progress notes revealed the DON documented on 09/02/2024 at 09:00 AM, Resident #140 was in pain when CNAs attempted incontinent care. The DON communicated with the physician and transferred Resident #140 to the hospital for evaluation. A record review of Resident #140's admission Hospital reco rds dated 09/02/2024 revealed Resident #140 was diagnosed with a right femur (leg) fracture which was surgically repaired. During an interview on 10/16/2024 at 02:25 p.m., the ADON stated she learned from the Administrator that CNA A had transferred Resident #140 from her bed to her wheelchair with a sit to stand mechanical lift by herself. The ADON stated the Administrator possessed written statements and audio recordings from CNA A and LVN B that confirmed CNA A transferred Resident #140 alone. The ADON stated Resident #140 was assessed by the RAI and documented on Resident #140's MDS as needing more than 2 persons assistance with all transfers. The ADON stated her expectation, and the facility policy was residents who were assessed as needing 2 persons assistance with transfers would receive 2 persons assistance with transfers. The ADON stated LVN B and CNA A were no longer employed by the facility, specifically CNA A was a temporary agency employee and was no longer invited back, and LVN B was terminated for other infractions. The ADON stated Resident #140 had a history of not following commands, not cooperating with transfers, biting, and scratching staff when staff attempted assist Resident #140 with a transfer. The ADON stated she and the Administrator reviewed the details of the fall with injury and concluded the event was not a reportable event since the injury, a broken leg, was not from an unknown source. During an interview on 10/16/2024 at 03:00 PM, CNA U stated she was an agency CNA and had worked here since the end of September - beginning of October. CNA U stated she had not received any in-services during her 2 weeks employment. CNA U stated she would refer to the shower book binder for instructions for which residents required assistance with transfers. During an interview on 10/16/2024 at 03:03 PM, RN G stated she was the Monday through Friday 02:00 PM to 10:00 PM nurse and had been a nurse for the facility during the past year. RN G stated she received regular in-services every payday (2 weeks) to include hand washing, infection control, etc. RN G could not recall any in-services for transferring residents with mechanical lifts. During an interview on 10/16/2024 at 03:05 PM, LVN H stated she was the 06:00 AM to 10:00 PM nurse and stated she received regular in-services every payday (2 weeks) to include hand washing, infection control, etc. LVN H could not recall any in-services for transferring residents with mechanical lifts. During an interview on 10/16/2024 at 03:10 PM, the DON stated the facility routinely provides in-services every 2 weeks and as needed. The DON provided copies of the most recent in-services since August 2024. A record review of the facility's in-services from the time period August 01, 2024, through October 16, 2024, revealed no in-services regarding transferring residents with mechanical lifts or any transfers. During an interview on 10/17/2024 at 11:58 AM, Nurse Practitioner T (NP T) stated Resident #140 was under his care when Resident #140 resided at the facility. NP T stated his expectations for residents who were assessed for the need for transfers as dependent on staff should receive transfer care with 2 or more staff to include the use of mechanical lifts. NP T stated he had not received a report to include Resident #140 had been transferred with only 1 staff during the incident which led to her broken leg. NP T stated Resident #140 should have received a 2-person assisted mechanical lift care. During a joint interview and record review on 10/17/2024 at 12:58 PM, with DON and ADON confirmed that the shower book binder was the resource provided to staff for care details to include 1 person or 2 person assists with ADL's and transfers. The DON and ADON reviewed the shower book binder and stated Resident #140 was not included in the details for care. The ADON stated she could not recall if at the time of Resident #140's transfer incident, Resident #140 was or was not included in the shower book binder. During a joint interview on 10/17/2024 at 02:50 PM with the Administrator and the ADON, ADON stated CNA A transferred Resident #140 by herself after LVN B warned her not to due to Resident #140's lack of following commands and combativeness. Administrator and ADON stated CNA A and LVN B have been dismissed due to their poor performance and have not worked at the facility since September 2024 after the incident. Administrator stated she possessed audio recordings of her interviews with CNA A and LVN B and learned LVN B had warned CNA A not to transfer Resident #140 alone but CNA A transferred Resident #140 by herself with a sit to stand mechanical lift. Administrator stated she understood Resident #140 was assessed as needing more than 1 person to assist with all transfers due to residents' inability to follow commands and history of combativeness. During a joint interview on 10/17/2024 at 02:50 PM, with the Administrator and the ADON a policy regarding a safe environment related to accidents and hazards was requested and not received. The Administrator was notified on 10/17/24 at 04:30 PM, an IJ situation had been identified due to the above failures. The IJ template was given to the administrator on 10/17/24 at 02:45 PM, and a POR was requested. The POR was accepted on 10/18/24 at 04:36 PM and indicated the following : Plan of Removal and Verification Please accept this POR for citation F689 on 10/17/2024 The following in-services were done on 10/17/2024 per DON (DON) and ADON (ADON). On the following topics: Hoyer and stand assist. Suspicious injuries Proper and timely documentation Reporting abuse or neglect and abuse coordinator Nurse aide information binder (Radiology Contractor) Xray Communication with Physicians Nursing Judgement Pain assessment Incident report and documentation Who to call for injuries. The following nurses attended: (DON) (ADON) (LVN H) (LVN I) (LVN G) (LVN J) (LVN K) (LVN L) Attached is the sign in log. In-services held for CNAs per (ADON) ADON, on the following topics at 10/17/2024 5:30pm: Hoyer lift Stand assist. CNA information binder and its location Abuse coordinator Abuse and neglect Suspicious scenarios and how to identify injuries. CNAs that attended: (CNA M) (CNA N) (CNA O) (CNA P) (CNA R) (CNA Q) (CNA E) (agency) The ADON will make sure that the Kardex for residents is updated on Mondays and PRN to include new admissions. This will be ongoing to make sure of resident's safety. Updates to include changes in status, transfers, and ADL'S. This will be included in the Kardex and in the same information binder for CNA'S to access. Frequency of monitoring for incoming shifts and outgoing shifts for exchange in report the agency CNA will check in with charge nurse. Charge nurse will make sure the agency CNA knows where the information binder will be located and will ensure they will access it for any question and guidance. This will be monitored by the charge nurse every shift. Agency staff has all their credentials on their profile on the agency app. Agency restricts agency CNA'S from picking up shifts if out of compliance for CNA certification requirements. Effective 10/17/2024 ongoing process monitored per ADON/ DON. Any suspicious injuries should not wait for (Radiology Contractor) Xray company to communicate to MD that our STAT orders are greater than 4 hours per mobile Xray, advocate for your residents. Effective immediately. This ongoing process is to be monitored by ADON and DON - effective 10/17/2024 all STAT or suspicion of injury and or STAT X rays will be sent to the ER per physician orders. The CNA binder holds the following information: Kardex from POC on each resident reflecting information and current transfer status. The binder will be located at the nurse's station for quick reference and guidance. Effective 10/17/2024Agency CNA will be educated on binder location and for reference upon the beginning of all shifts. CNA will receive report from DON, ADON, floor nurses, and or previous CNA to make sure the oncoming CNA is educated on resident care. Effective 10/17/2024. Shift change report exchange per CNAs will be mandatory for all incoming and leaving shifts. This will be monitored per ADON/ DON and an ongoing process and monitoring. All agency CNA's will sign a log in sheet located in the front of the binder acknowledging they have reviewed the residents. Effective 10/17/2024 The Kardex info binder reflects transfer status, dentures, diets, special instructions, If NPO person etc . this information reflects from the MDS on PCC per CNA documentation. Effective 10/18/2024 this will be monitored per ADON (ADON) daily to ensure compliance and safety to our residents. POR Validation: Training: Record review of facility's sign in sheet dated 10/17/24 reflected that 100% of nursing staff received training on Hoyer transfer, standing assist transfer, ADLs, NA information Binder, Abuse/Neglect, (radiology contractor) X-ray, Pain Assessment, Suspicious Injuries, Documentation, Send to ER and Binder Documentation (Total Working Nursing staff was 17 (94 % completion rate). During interviews on 10/18/24 from 1:45 PM to 2:47 PM of 4 day shift staff (6 A-2 P) (1 RN, 2 LVN, 1 CNA) and 3 evening shift (2 P to 10 P) (1 RN, 2 LVN) , 2 night shift staff (10 P-6A) (1 LVN, 1 CNA) and 2 weekend staff (2 CNA) reflected the training highlights were: machinal lift required 2 staff members; standing transfer could be done if the resident was non-combative; ADLs required to check on the level of assistance; and the NA binder contained information on assistance for showers, transfer, and mobility. Further the training highlights were report abuse/neglect to the Administrator and any suspicion of abuse/neglect; do not wait on the (radiology contractor)-Xray if there is harm to a resident; notify physician and send to the ER; pain assessments are routinely done; and signs and symptoms are documented. Also, the Binder containing information about a resident was found at the nurse station . Kardex During an interview on 10/18/24 at 2:49 PM, ADON stated: the Kardex was in the Nurse Station and contained transfers, dentures, feeding assistance, and shower list. ADON stated the Kardex is updated every Monday and at new admissions. ADON stated that the Kardex was put into effect on 10/17/24 and there were no new entries into the Kardex. Observation on 10/18/24 at 2:54 PM, reflected that the Kardex was at the Nurse Station. Record review of the facility's Kardex dated 10/27/24 reflected items contained the Kardex included transfers, dentures, feeding assistance, and shower list. Suspicious injuries/(radiology contractor) X-ray: During a joint interview on 10/18/24 at 3:00 PM, the DON and ADON stated that: any suspicious injury requiring an X-ray would not wait for an X-ray and the resident will be sent to the ER; and notify the physician and RP. The ADON stated she monitored incidents by telephone calls from staff, reviewing (electronic record), and reviewing Change of Condition report. The DON stated in addition to what the ADON relayed, she would confirm and review the incident report. The ADON that she was called on a witness fall with no injury on 10/17/24. Her actions included after the call: she checked that nursing staff did vitals, skin breakdown and inquired on nursing assessment for further action requiring calling the MD; and verified that the incident was documented on (electronic record). The DON added that she reviewed the nurse's notes for accuracy and timely. CNA Knowledge of Kardex During a joint interview on 10/18/24 at 3:15 PM, CNA R and CNA S stated: Kardex contained shower list, dining list, Hoyer residents, and standing to assist list. They stated the Kardex was checked before doing an ADL for the resident. They stated that no attempt would be made to transfer a 2 person lift by one person. Agency CNA S was educated on 10/17/24 before she came on duty and the education involved the Kardex and the lists in the binder. She added that at shift change she would share information about ADLs and incidents with the on-coming shift. CNA R stated that at shift change she would communicate ADLs performed and any change of condition or incident. An Immediate Jeopardy (IJ) was identified on 10/17/2024. The IJ Template was provided to the facility on [DATE] at 04:30 PM. While the IJ was removed on 10/18/2024, the facility remained out of compliance at a scope of isolated with risk for harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of their corrective actions.

Based on interviews and record reviews 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 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not 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 se rvices where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures, for 3 of 8 residents (Residents #5, #17, and #140) reviewed for reporting allegations of abuse, neglect, and exploitation. 1. The administrator failed to report an allegation of neglect, with serious injury, when Resident #140 was assisted with a mechanical lift transfer by 1 staff member, CNA A. Resident #140 fell during the transfer, suffered a broken right leg, and was hospitalized with a need for surgical repair. Prior to the fall Resident #140 was assessed with a need for more than 1 staff for assistance with transfers. 2. The administrator and the Social Worker failed to report an allegation of abuse on behalf of Resident #17. Resident #17 reported to CNA M, when she (Resident #17) was out on pass with a family member, she was nude and scared by a drunken, bloodied , family member and had to crawl to safety. 3. The administrator and the Social Worker failed to report an allegation of neglect on behalf of Resident #5 when CNA M alleged Resident #17 removed Resident #5's oxygen nasal cannula and oxygen concentrator because Resident #17 stated it was too loud and she (Resident #17) could not fall asleep. This deficient practice could place residents at risk for harm by not reporting allegations of abuse, neglect, and exploitation to the state agency. The findings included: 1. A record review of Resident #140's admission and discharge record dated [DATE] revealed an admitted [DATE] and a discharge date of [DATE] with diagnoses which included dementia (a group of symptoms affecting memory, thinking and social abilities. In people who have dementia, the symptoms interfere with their daily lives), psychotic disturbance (a condition of the mind or psyche that results in difficulties determining what is real and what is not real), mood disturbance and anxiety. A record review of Resident #140's quarterly MDS assessment dated [DATE] revealed Resident #140 was an [AGE] year-old female admitted for long term care and assessed with a BIMS score of 01 out of a possible of 15 which indicated severe cognition impairment. Further review revealed Resident #140 was assessed as 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 all of Resident #140's needs for transfers, sit to stand, chair / bed to chair transfer, and toilet transfers. A record review of Resident #140's care plan dated [DATE] revealed, (Resident #140) is dependent on staff for meeting . physical . needs . related to dementia . the Resident needs assistance / escort to activity functions A record review of the facility's fall incident report dated [DATE] revealed Resident #140 suffered a fall during a 1-person mechanical lift transfer . During an interview on [DATE] at 03:00 PM, the ADON stated Resident #140 was discharged to the hospital on [DATE] for evaluation and treatment for pain to her right leg and was diagnosed with a broken right leg which was surgically repaired. The ADON stated Resident #140's family did not return Resident #140 to the facility and moved Resident #140 to their home where they continued to care for her. The ADON stated on [DATE] CNA A alerted LVN B that she needed assistance with Resident #140 because CNA A lost control of Resident #140 during a transfer from the bed to a wheelchair. During an interview on [DATE] at 02:17 p.m., Resident #140's representative stated she received a report from LVN B on the evening of [DATE]. Resident #140's representative stated LVN B reported that CNA A alerted LVN B for assistance with Resident #140 and, when LVN B entered the room, she observed Resident #140 sitting on the floor on her bottom with her legs to the right and the mechanical lift nearby. LVN B assessed Resident #140 to be without pain and with one small skin tear to her arm. Resident #140's representative stated LVN B reported Resident #140 was placed in bed, her physician was called, and an order for an x-ray was obtained. Record review of Resident #140's nursing progress notes, revealed the DON documented on [DATE] at 09:00 AM, Resident #140 was in pain when CNAs attempted incontinent care. The DON communicated with the physician and transferred Resident #140 to the hospital for evaluation. A record review of Resident #140's admission Hospital records dated [DATE], revealed that Resident #140 was diagnosed with a right femur (leg) fracture. During an interview on [DATE] at 02:25 p.m., the ADON stated she learned CNA A had transferred Resident #140 from her bed to a wheelchair with a mechanical lift, a sit to stand lift, by herself. The ADON stated she learned this from the Administrator. The ADON stated the Administrator possessed written statements and audio recordings from CNA A and LVN B that confirmed CNA A transferred Resident #140 alone. ADON stated Resident #140 was assessed on the MDS as needing more than 2 persons assistance with all transfers. ADON stated her expectation, and the facility policy was residents who were assessed as needing 2 persons assistance with transfers would receive 2 persons assistance with transfers. ADON stated LVN B and CNA A were no longer employed by the facility, specifically CNA A was a temporary agency employee and was no longer invited back, and LVN B was terminated for other infractions. ADON stated Resident #140 had a history of not following commands, not cooperating with transfers, biting, and scratching staff when staff attempted assist Resident #140 with a transfer. ADON stated she and the Administrator reviewed the details of the fall with injury and concluded the event was not a reportable event since the injury, a broken leg, was not from an unknown source. During an interview on [DATE] at 02:50 PM, the Administrator and the ADON, ADON stated CNA A transferred Resident #140 by herself after LVN B warned her not to, due to Resident #140's lack of following commands and combativeness. Administrator and ADON stated CNA A and LVN B have been dismissed due to their poor performance and have not worked at the facility since [DATE] after the incident. Administrator stated she had audio recordings of her interviews with CNA A and LVN B and learned LVN B had warned CNA A not to transfer Resident #140 alone, but CNA A had transferred Resident #140 by herself with a sit to stand mechanical lift. Administrator stated she understood Resident #140 was assessed as needing more than 1 person to assist with all transfers due to residents' inability to follow commands and history of combativeness. Administrator stated she and the ADON reviewed the details of the incident and believed the incident with a broken leg would not be a reportable incident to the state agency because the injury was witnessed. Administrator stated she had not considered the 1-person mechanical lift was neglect. 2. A record review of the Resident #17's quarterly MDS assessment dated [DATE] revealed an admitted [DATE] with diagnoses which included cerebral palsy (damage to brain areas that control muscle movement, or when those areas don't develop as they should), anxiety disorder, and psychotic disorder (a condition of the mind or psyche that results in difficulties determining what is real and what is not real). Further review revealed Resident #17 was a [AGE] year-old female admitted for long term care and assessed with a BIMS score of 13, out of a possible 15, which indicated intact cognition. A record review of Resident #17's nursing progress notes revealed Resident #17 went out on pass with her family member on [DATE] and returned on [DATE]: Effective Date: [DATE] 09:26:00 Department: Nursing Position: Registered Nurse Created By: RN (C) Created Date: [DATE] 10:31:17; Note Text: LEFT FOR 2 DAY PASS AT HOME WITH (family). LEFT VIA PRIVATE AUTO WITH WHEELCHAIR. MEDICATION FOR 2 DAYS SENT WITH PATIENT. INSTRUCTIONS FOR ADMINISTRATION GIVEN TO PATIENT AND (family). LEFT IN STABLE CONDITION. Activity Participation Note, Effective Date: [DATE] 15:28:00 Department: Activities Position: Activities Director Created By: (Activity Director) Created Date: [DATE] 15:28:21 Note Text: OOP (out on pass) for the day. Administration Note Effective Date: [DATE] 15:05:00 Department: Nursing, Position: Registered Nurse Created By: (RN G) Created Date: [DATE] 15:05:52, Note Text: Patient may have 6 ounces of wine QD. in the afternoon for Per patient's request, I just don't want the wine today. A record review of the facility's grievance logbook which covered January to [DATE] revealed a grievance form for Resident #17 signed by the Social Worker, dated [DATE]. Further review revealed a written statement, dated [DATE], authored by CNA M which revealed Resident #17 while out on pass with family felt vulnerable while nude and threatened by a bloodied , drunken family member, I (CNA M) who works weekends was walking by Resident #17 and she stopped me to ask me how my New Year's was and I told her I was good. She then laughed and shook her head and told me she needed to talk to me later I said OK. I then after breakfast went in to get her bed made-up for the day and she told me her New Year's wasn't good. I ask why not and I'm sorry to hear that she then said her (family member) was drunk with a bloody nose and she was on the bed naked, and she was so scared she threw herself off the bed and pulled herself across the room to the restroom to get dressed and she just was so scared and wanted to (call for) help but couldn't call for any help. Further review revealed the social worker documented on the written statement, Resident is being seen by (psychiatric consultant) who has addressed this issue with the Resident. Social Worker spoke with resident about this on [DATE]. Resident stated she does not plan to go home out on pass with family member in the future. Signed Social Worker. During an interview on [DATE] at 08:50 a.m., Resident #17 did not want to participate in an interview regarding her New Year's Eve pass. During an interview on [DATE] at 3:30 PM, CNA M stated she recalled writing the statement on behalf of Resident #17's bad new year's pass and recalled the Social Worker was aware of the incident. CNA M stated the Social Worker (SW) had asked her to write the statement. During a joint interview on [DATE] at 03:05 PM, with the Administrator (ADM), the DON, and the ADON; DON and ADON stated they were not the DON and ADON during February 2024. The ADM stated she and the previous DON reviewed the grievances daily and had not recognized the second page of the grievance which was the written statement of by CNA M. The ADM stated her expectation was for the SW to have reported the allegation of abuse to her. The ADM stated the allegation of abuse could have been reported and investigated. The ADON stated Resident #17 had a diagnosis of psychotic disorder and had voluntarily gone out on pass with family since February 2024. 3. A record review of Resident #5's admission record dated [DATE] revealed an admitted [DATE] with diagnoses which included heart failure, presence of cardiac pacemaker (a small implanted electrical device to periodically shock the heart to keep a regular heartbeat), and atrial fibrillation (an irregular heart beat out of sequence contributing to the formation of harmful blood clots.) A record review of Resident #5's annual MDS assessment dated [DATE] revealed Resident #5 was a [AGE] year-old female admitted for long term care, assessed with a debility with breathing and circulation, and assessed with a BIMS score of 06 out of a possible 15 which indicated severe cognitive impairment. Further review revealed Resident #5 was assessed with shortness of breath or trouble breathing with exertion (e.g., walking, bathing, transferring); shortness of breath or trouble breathing when sitting at rest; and shortness of breath or trouble breathing when lying flat. Resident #5 was assessed as having a life expectancy of less than 6 months. A record review of Resident #5's care plan dated [DATE] revealed Resident #5 was received oxygen therapy and had interventions which included, . for residents who should be ambulatory, provide extension tubing or portable oxygen apparatus A record review of the facility's grievance logbook which covered January to [DATE] revealed a grievance form dated [DATE], for Resident #17 which involved Resident #5, and was signed by the Social Worker. Further review revealed CNA M documented (Resident #17) has turned off (Resident #5's) O2 (oxygen) concentrator during the night shift because it is to (too) loud and she has an go up and took off her nasal cannula and put it in her drawer beside her bed when (Resident #5) does not get up out of bed as she does have a bed alarm. Further review revealed the SW documented, Findings: 3 concerns on this issue - SW spoke with Resident on [DATE] when concerns were submitted. Resident admitted to removing O2 cannula because Resident wasn't using it and turning the O2 concentrator off because it was too noisy and she couldn't sleep. Resolution: SW advised Resident (#17) that she is endangering her roommate (Resident #5). Resident (#17) became tearful and stated she would no longer turn the O2 concentrator off. Resident (#17) to be moved to another room ASAP. Resident (#17) advised she would be moving and agreed to do so. (signed by the SW). During an interview on [DATE] at 09:10 AM, Resident #5 could not recall any incidents regarding her use of oxygen. During an interview on [DATE] at 08:50 AM, Resident #17 did not want to participate in an interview regarding her previous roommate. During an interview on [DATE] at 08:50 AM, Resident #5 could not participate in an interview due to confusion. An attempt to interview Resident #5's representative was unsuccessful. During a joint interview on [DATE] at 03:05 PM, with the Administrator, the DON, and the ADON; DON and ADON stated they were not the DON and ADON during February 2024. The ADM stated she and the previous DON reviewed the grievances daily and had not recognized the allegation of neglect and or abuse on behalf of Resident #5. The ADM stated the SW had not brought the allegation to her attention. The ADM stated the allegations of abuse and or neglect could have been reported to the state. A record review of the facility's undated Residents Abuse, Neglect or Mistreatment policy revealed, Policy: Each Resident shall be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. Abuse shall include physical harm, pain, mental anguish, verbal abuse (derogatory terms), sexual abuse or involuntary seclusion. All facility staff shall be in-serviced upon employment and annually regarding residents right and freedom form abuse, neglect, mistreatment, and misappropriation of property. suspected or substantiated cases of Resident abuse, neglect, misappropriation of property or mistreatment shall thoroughly be investigated and documented by the administrator and reported to the appropriate state agencies.

Based on interviews and record reviews the facility failed to ensure allegations of abuse, neglect, exploitation, or mistreatment have evidence that all alleged violations were thoroughly investigated and prevented further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress and reported the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action were taken, for 3 of 8 residents (rResidents #5, #17, and #140) reviewed for allegations of abuse, neglect, and exploitation. 1. The administrator failed to investigate and report an allegation of neglect, with serious injury, when Resident #140 was assisted with a mechanical lift transfer by 1 staff member, CNA A. Resident #140 fell during the transfer, suffered a broken right leg, and was hospitalized with a need for surgical repair. Prior to the fall Resident #140 was assessed with a need for more than 1 staff for assistance with transfers. 2. The administrator and the Social Worker failed to investigate and report an allegation of abuse on behalf of Resident #17. Resident #17 reported to CNA M, when she (Resident #17) was out on pass with a family member, she was nude and scared by a drunken, bloodied , family member and had to crawl to safety. 3. The administrator and the Social Worker failed to investigate and report an allegation of neglect on behalf of Resident #5 when CNA M alleged Resident #17 removed Resident #5's oxygen nasal cannula and oxygen concentrator because Resident #17 stated it was too loud and she (Resident #17) could not fall asleep. This deficient practice could place residents at risk for harm by not investigating and reporting allegations of abuse, neglect, and exploitation to the state agency. The findings included: 1. A record review of Resident #140's admission and discharge record dated [DATE] revealed an admitted [DATE] and a discharge date of [DATE] with diagnoses which included dementia (a group of symptoms affecting memory, thinking and social abilities. In people who have dementia, the symptoms interfere with their daily lives), psychotic disturbance (a condition of the mind or psyche that results in difficulties determining what is real and what is not real), mood disturbance and anxiety. A record review of Resident #140's MDS assessment dated [DATE] revealed Resident #140 was an [AGE] year-old female admitted for long term care and assessed with a BIMS score of 01 out of a possible of 15 which indicated severe cognition impairment. Further review revealed Resident #140 was assessed as 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 all of Resident #140's needs for transfers, sit to stand, chair / bed to chair transfer, and toilet transfers. A record review of Resident #140's care plan dated [DATE] revealed, (Resident #140) is dependent on staff for meeting . physical . needs . related to dementia . the Resident needs assistance / escort to activity functions A record review of the facility's fall incident report dated [DATE] revealed Resident #140 suffered a fall during a 1-person mechanical lift transfer. During an interview on [DATE] at 03:00 PM, the ADON stated Resident #140 was discharged to the hospital on [DATE] for evaluation and treatment for pain to her right leg and was diagnosed with a broken right leg which was surgically repaired. ADON stated Resident #140's family did not return Resident #140 to the facility and moved Resident #140 to their home where they continued to care for her. ADON stated on [DATE] CNA A alerted LVN B that she needed assistance with Resident #140 because CNA A lost control of Resident #140 during a transfer from the bed to a wheelchair. During an interview on [DATE] at 02:17 pm, Resident #140's representative stated she received a report from LVN B on the evening of [DATE]. Resident #140's representative stated LVN B reported that CNA A alerted LVN B for assistance with Resident #140 and, when LVN B entered the room, she observed Resident #140 sitting on the floor on her bottom with her legs to the right and the mechanical lift nearby. LVN B assessed Resident #140 to be without pain and with one small skin tear to her arm. Resident #140's representative stated LVN B reported Resident #140 was placed in bed, her physician was called, and an order for an x-ray was obtained. Record review of Resident #140's nursing progress notes revealed the DON documented on [DATE] at 09:00 AM Resident #140 was in pain when CNAs attempted incontinent care. The DON communicated with the physician and transferred Resident #140 to the hospital for evaluation. A record review of Resident #140's admission Hospital records dated [DATE], revealed that Resident #140 was diagnosed with a right femur (leg) fracture and was surgically repaired. During an interview on [DATE] at 02:25 pm ADON stated she learned CNA A had transferred Resident #140 from her bed to a wheelchair with a mechanical lift, a sit to stand lift, by herself. ADON stated she learned this from the Administrator. ADON stated the Administrator possessed written statements and audio recordings from CNA A and LVN B that confirmed CNA A transferred Resident #140 alone. ADON stated Resident #140 was assessed on the MDS as needing more than 2 persons assistance with all transfers. ADON stated her expectation, and the facility policy was residents who were assessed as needing 2 persons assistance with transfers would receive 2 persons assistance with transfers. ADON stated LVN B and CNA A were no longer employed by the facility, specifically CNA A was a temporary agency employee and was no longer invited back, and LVN B was terminated for other infractions. ADON stated Resident #140 had a history of not following commands, not cooperating with transfers, biting, and scratching staff when staff attempted assist Resident #140 with a transfer. The ADON stated she and the Administrator reviewed the details of the fall with injury and concluded the event was not a reportable event since the injury, a broken leg, was not from an unknown source. During a joint interview on [DATE] at 02:50 PM with the Administrator and the ADON, ADON and ADM stated CNA A transferred Resident #140 by herself after LVN B warned her not to due to Resident #140's lack of following commands and combativeness. Administrator and the ADON stated CNA A and LVN B have been dismissed due to their poor performance and have not worked at the facility since [DATE] after the incident. Administrator stated she had audio recordings of her interviews with CNA A and LVN B and learned LVN B had warned CNA A not to transfer Resident #140 alone but CNA A transferred Resident #140 by herself with a sit to stand mechanical lift. Administrator stated she understood Resident #140 was assessed as needing more than 1 person to assist with all transfers due to residents' inability to follow commands and history of combativeness. Administrator stated she and her ADON reviewed the details of the incident and believed the incident with a broken leg would not be a reportable incident to the state agency because the injury was witnessed. Administrator stated she had not considered the 1-person mechanical lift was neglect and thus there was no investigation and report to the state agency. 2. A record review of the Resident #17's quarterly MDS assessment dated [DATE] revealed an admitted [DATE] with diagnoses which included cerebral palsy (damage to brain areas that control muscle movement, or when those areas don't develop as they should), anxiety disorder, and psychotic disorder (a condition of the mind or psyche that results in difficulties determining what is real and what is not real). Further review revealed Resident #17 was a [AGE] year-old female admitted for long term care and assessed with a BIMS score of 13 out of a possible 15 which indicated intact cognition. A record review of Resident #17's nursing progress notes revealed Resident #17 went out on pass with her family member on [DATE] and returned on [DATE]: Effective Date: [DATE] 09:26:00 Department: Nursing Position: Registered Nurse Created By: RN (C) Created Date: [DATE] 10:31:17; Note Text: LEFT FOR 2 DAY PASS AT HOME WITH (family). LEFT VIA PRIVATE AUTO WITH WHEELCHAIR. MEDICATION FOR 2 DAYS SENT WITH PATIENT. INSTRUCTIONS FOR ADMINISTRATION GIVEN TO PATIENT AND (family). LEFT IN STABLE CONDITION. Activity Participation Note, Effective Date: [DATE] 15:28:00 Department: Activities Position: Activities Director Created By: (Activity Director) Created Date: [DATE] 15:28:21 Note Text: OOP (out on pass) for the day. Administration Note Effective Date: [DATE] 15:05:00 Department: Nursing, Position: Registered Nurse Created By: (RN G) Created Date: [DATE] 15:05:52, Note Text: Patient may have 6 ounces of wine QD. in the afternoon for Per patient's request, I just don't want the wine today. A record review of the facility's grievance logbook which covered January to [DATE] revealed a grievance form for Resident #17 signed by the Social Worker, dated [DATE]. Further review revealed a written statement, dated [DATE], authored by CNA M which revealed Resident #17 while out on pass with family felt vulnerable while nude and threatened by a bloodied , drunken family member, I (CNA M) who works weekends was walking by Resident #17 and she stopped me to ask me how my New Year's was and I told her I was good. She then laughed and shook her head and told me she needed to talk to me later I said OK. I then after breakfast went in to get her bed made-up for the day and she told me her New Year's wasn't good. I ask why not and I'm sorry to hear that she then said her (family member) was drunk with a bloody nose and she was on the bed naked, and she was so scared she threw herself off the bed and pulled herself across the room to the restroom to get dressed and she just was so scared and wanted to (call for) help but couldn't call for any help. Further review revealed the social worker documented on the written statement, Resident is being seen by (psychiatric consultant) who has addressed this issue with the Resident. Social Worker spoke with resident about this on [DATE]. Resident states she does not plan to go home out on pass with family member in the future. Signed Social Worker. During an interview on [DATE] at 08:50 Resident #17 did not want to participate in an interview regarding her New Year's Eve pass. During an interview on [DATE] at 3:30 PM CNA M stated she recalled writing the statement on behalf of Resident #17's bad new year's pass and recalled the Social Worker was aware of the incident. CNA M stated the Social Worker had asked her to write the statement. During a joint interview on [DATE] at 03:05 PM with the Administrator, the DON, and the ADON; DON and ADON stated they were not the DON and ADON during February 2024. The ADM stated she and the previous DON reviewed the grievances daily and had not recognized the second page of the grievance which was the written statement of by CNA M. ADM stated her expectation was for the SW to have reported the allegation of abuse to her. ADM stated the allegation of abuse could have been reported and investigated. ADON stated Resident #17 had a diagnosis of psychotic disorder and had voluntarily gone out on pass with family since February 2024. 3. A record review of Resident #5's admission record dated [DATE] revealed an admitted [DATE] with diagnoses which included heart failure, presence of cardiac pacemaker (a small implanted electrical device to periodically shock the heart to keep a regular heartbeat), and atrial fibrillation (an irregular heart beat out of sequence contributing to the formation of harmful blood clots.) A record review of Resident #5's annual MDS assessment dated [DATE] revealed Resident #5 was a [AGE] year-old female admitted for long term care, assessed with a debility with breathing and circulation, and assessed with a BIMS score of 06 out of a possible 15 which indicated severe cognitive impairment. Further review revealed Resident #5 was assessed with shortness of breath or trouble breathing with exertion (e.g., walking, bathing, transferring); shortness of breath or trouble breathing when sitting at rest; and shortness of breath or trouble breathing when lying flat. Resident #5 was assessed as having a life expectancy of less than 6 months. A record review of Resident #5's care plan dated [DATE] revealed Resident #5 was received oxygen therapy and had interventions which included, . for residents who should be ambulatory, provide extension tubing or portable oxygen apparatus A record review of the facility's grievance logbook which covered January to [DATE] revealed a grievance form dated [DATE], for Resident #17 which involved Resident #5, and was signed by the Social Worker. Further review revealed CNA M documented (Resident #17) has turned off (Resident #5's) O2 (oxygen) concentrator during the night shift because it is to (too) loud and she has an go up and took off her nasal cannula and put it in her drawer beside her bed when (Resident #5) does not get up out of bed as she does have a bed alarm. Further review revealed the SW documented, Findings: 3 concerns on this issue - SW spoke with Resident on [DATE] when concerns were submitted. Resident admitted to removing O2 cannula because Resident wasn't using it and turning the O2 concentrator off because it was too noisy and she couldn't sleep. Resolution: SW advised Resident (#17) that she is endangering her roommate (Resident #5). Resident (#17) became tearful and stated she would no longer turn the O2 concentrator off. Resident (#17) to be moved to another room ASAP. Resident (#17) advised she would be moving and agreed to do so. (signed by the SW). During an interview on [DATE] at 09:10 AM Resident #5 could not recall any incidents regarding her use of oxygen. During an interview on [DATE] at 08:50 Resident #17 did not want to participate in an interview regarding her previous roommate. During an interview on [DATE] at 08:50 Resident #5 could not participate in an interview due to confusion. An attempt to interview Resident #5's representative was unsuccessful. During a joint interview on [DATE] at 03:05 PM with the Administrator, the DON, and the ADON; DON and ADON stated they were not the DON and ADON during February 2024. The ADM stated she and the previous DON reviewed the grievances daily and had not recognized the allegation of neglect and or abuse on behalf of Resident #5. ADM stated the SW had not brought the allegation to her attention. ADM stated the allegations of abuse and or neglect could have been investigated and reported to the state. A record review of the facility's undated Residents Abuse, Neglect or Mistreatment policy revealed, Policy: Each Resident shall be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. Abuse shall include physical harm, pain, mental anguish, verbal abuse (derogatory terms), sexual abuse or involuntary seclusion. All facility staff shall be in-serviced upon employment and annually regarding residents right and freedom form abuse, neglect, mistreatment, and misappropriation of property. suspected or substantiated cases of Resident abuse, neglect, misappropriation of property or mistreatment shall thoroughly be investigated and documented by the administrator and reported to the appropriate state agencies.

Based on observation, interviews, and record reviews the facility failed to ensure its medication error rates were not 5% or greater. The facility had a medication error rate of 7.69%, based on 2 errors out of 26 opportunities which involved 2 of 6 residents (Resident #8 and #24) reviewed for crushed medication administration and medication errors. 1. RN G administered Resident #8's medications: a. ranolazine 500mg extended-release tablet by crushing the tablet. Ranolazine is used to treat heart related chest pain. 2. RN G administered Resident #24's medications: a. duloxetine 30mg delayed-release capsule by opening the capsule. Duloxetine is used to treat depression and anxiety. These deficient practices could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. The findings included: 1. A record review of Resident #8's admission record dated 10/17/2024 revealed an admitted [DATE] with diagnoses which included dysphagia oropharyngeal and pharyngoesophageal phases (difficulty swallowing, oropharyngeal airway refers to the pharynx, the hollow tube inside the neck that starts behind the nose and stops at the top of the windpipe and esophagus) as a result from a stroke. A record review of Resident #8's admission MDS assessment dated [DATE] revealed Resident #8 was an [AGE] year-old female admitted under hospice care and assessed with a BIMS score of 07 out of a possible 15 which indicated severe cognitive impairment. Further review revealed resident #8 was assessed as medically complex and had a surgery for her gastrointestinal tract . including creation . percutaneous feeding tubes (a peg-tube) and was assessed with a feeding tube. Further review revealed Resident #8 used high risk drugs which included anti-depressants. A record review of Resident #8's physicians' orders dated 10/18/2024 revealed Resident #8 was to receive crushed medications as follows, may alter meditation by crushing, opening caps, or administering in food or fluids. (Only open or crash if manufacturer allows) Further review revealed Resident #8 was prescribed ranolazine extended release 12-hour 500mg give 500mg via peg tube two times daily for antianginal (heart pain) A record review of Resident #8's October 2024 Medication Administration record revealed RN G documented she administered ranolazine extended release 12-hour 500mg give 500mg via peg tube two times daily for antianginal at 07:00 PM. A record review of The United States of America's Food and Drug Administrations website https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/021526s012lbl.pdf accessed 10/18/2024 revealed, . (ranolazine) extended-release tablets - Initial U.S. Approval: 2006 ------------------------INDICATIONS AND USAGE------------------------- (Brand name ranolazine) is indicated for the treatment of chronic angina. DOSAGE AND ADMINISTRATION 2.1 Dosing Information Initiate (Brand name ranolazine) dosing at 500 mg twice daily . Take (Brand name ranolazine) with or without meals. Swallow (Brand name ranolazine) tablets whole; do not crush, break, or chew. During an observation on 10/18/2024 at 07:00 PM revealed RN G prepared and administered to Resident #8 ranolazine 500mg one tablet extended release by crushing the tablet and administering the medication via Resident #8's indwelling a Peg tube. 2. A record review of Resident #24's admission record dated 10/17/2024 revealed an admitted [DATE] with diagnoses which included Parkinson's disease with dyskinesia (involuntary, erratic, writhing movements of the face, arms, legs or trunk). A record review of Resident #24's annual MDS assessment dated [DATE] revealed Resident #24 was an [AGE] year-old female admitted for long term care under hospice services and assessed with a BIMS score of 04 out of a possible 15 which indicated severe cognitive impairment. Resident #24 was assessed with a life expectancy of less than 6 months. Further review revealed Resident #24 received antidepressant medications. A record review of Resident #24's physicians' orders dated 10/18/2024 revealed Resident #24 was to receive crushed medications as follows, may alter meditation by crushing, opening caps, or administering in food or fluids. (Only open or crash if manufacturer allows) Resident #24 was prescribed to receive a regular diet with a pureed diet and an antidepressant medication duloxetine oral capsule delayed-release sprinkle 30mg give 1 capsule two times a day for depression A record review of The United States of America's Food and Drug Administrations website https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/021427s049lbl.pdf accessed 10/18/2024 revealed, . (Brand Name) (duloxetine hydrochloride) Delayed-Release Capsules for Oral Use. Initial U.S. Approval: 2004 . DOSAGE AND ADMINISTRATION----------------------- o (Brand name duloxetine) should generally be administered once daily without regard to meals. (Brand name duloxetine) should be swallowed whole and should not be chewed or crushed, nor should the capsule be opened and its contents be sprinkled on food or mixed with liquids (2.1). 2 DOSAGE AND ADMINISTRATION (Brand name duloxetine) should be swallowed whole and should not be chewed or crushed, nor should the capsule be opened and its contents sprinkled on food or mixed with liquids. All of these might affect the enteric coating. A record review of Resident #24's October 2024 Medication Administration record revealed RN G documented she administered duloxetine oral capsule delayed release sprinkle 30mg give 1 capsule by mouth two times a day for depression on 10/18/2024 at 07:00 PM. During an observation on 10/18/2024 at 06:50 PM revealed RN G prepared and administered to Resident #24 duloxetine 30mg 1 oral capsule by opening the capsule and mixing it with apple sauce. During an interview on 10/18/2024 at 07:05 PM RN G stated she did not recognize Resident #8's and nor Resident #24's extended-release medications and should have not crushed the medications. RN G stated extended release, delayed release medications should not be opened and or crushed. RN G stated she would report the medication errors to the DON and the medical director. During a joint interview on 10/18/2024 at 5:30 PM with the DON and ADON, the DON stated delayed release medications should not be crushed and or opened. A record review of the facility's undated Medication Error policy revealed, it is the policy of (the facility) to be free of significant medication errors and error rates. A medication error will be filled out for each medication or treatment error. medication error: federal regulations state a medication error is a discrepancy between what the physician ordered and what is actually administered. Significant medication error causes the resident discomfort or jeopardizes his or her health . examples are listed below : . wrong dosage form

Based on interview and record review, the facility failed to ensure residents and/or the residents' representatives the right to participate in the development and implementation of his or her person-centered plan of care for 1 of 6 residents (Resident #28) reviewed for care plans. The facility failed to invite and include the input of Resident #28 and/or residents' representative as members of the interdisciplinary team in Care Plan Conference meetings. This failure could place residents at risk of not receiving the interventions, treatments, and care necessary for the resident to reach their highest practicable physical, mental, and psychosocial well-being by not involving the resident and/or the residents' representative in Care Plan Conference meetings. The findings included: Record review of Resident #28's face sheet, dated 10/18/2024, reflected a [AGE] year-old male resident initially admitted on [DATE] with diagnosis including diabetes mellitus, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (a condition that affects one side of the body after a stroke causing paralysis), and dysphagia (difficulty swallowing). No diagnosis of dementia was present on Resident #28's face sheet. Record review of Resident #28's MDS Assessment, dated 10/8/2024, reflected Resident #28 had a BIMS score of 8, suggesting moderate impairment. No diagnosis of dementia was present on Resident #28's MDS assessment. During an interview on 10/14/2024 at 12:39 PM, Resident #28 and FM stated that they had not been invited to any care plan conference meeting prior to the one they were invited to which was being held that day, 10/14/2024. Resident #28's wife stated she was confident she had not been invited to any care plan conference meetings around the time Resident #28 arrived at the facility because she visits almost daily and would not have missed any care plan conference meeting or any meeting that related to Resident #28. During an interview on 10/18/2024 at 4:42 PM, the ADON, DON, and ADM, the ADON stated that she had a folder with care plan conference invitations in them. No invitation for Resident #28 and/or Resident #28's family member was found in the folder. The ADON stated that she was confident the facility invited Resident #28 and/or Resident #28's family member to their care plan conference meeting, but that Resident #28 and Resident #28's FM likely had dementia. The ADM stated that her expectation is for residents and their family members be involved in their care plan conference meetings. Record review of Resident #28's Electronic and Paper Health Record did not reflect any care plan conference invitations for any care plan conferences prior to 10/14/2024. Record review of facility policy, dated copyrighted 2005, titled, Care Plan/Comprehensive Interdisciplinary, reflected, The interdisciplinary team shall develop quantifiable objectives for the highest level of functioning the resident may be expected to attain, based on the comprehensive assessment. The interdisciplinary team shall include: Resident (if possible), Residents family or POA, Social Worker, Dietary supervisor, Activities staff member, Director of Nurses, Any other staff member pertinent to residents care at the time.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 6 residents (Resident #18) reviewed for care plans. The facility failed to develop a person-centered care plan with interventions that addressed Resident #18's diagnoses of mental illness including depression. This failure could place residents at risk for not having their needs and preferences met. The findings included: Record review of Resident #18's face sheet, dated 10/18/2024, reflected a [AGE] year-old resident, initially admitted on [DATE], with diagnoses including pneumonia (a lung infection that causes the air sacs in the lungs to fill with fluid or pus, making it difficult to breathe), depression, and dysphagia (difficulty swallowing). Record review of Resident #18's MDS Assessment, dated 9/22/2024, reflected Resident #18's takes antidepressants. Resident #18's MDS Assessment also reflected a BIMS of 14, indicating cognitively intact. Record review of Resident #18's Care Plan, undated, reflected a 5-page document without any interventions or mention of Resident #18's diagnosis of depression or antidepressant therapy. Interview on 10/18/2024 at 5:20 PM, the ADON stated she is responsible for care plans and ensuring they are done correctly and address all areas of care. The ADON stated she was not certain why Resident #18 did not have her diagnosis of depression on her care plan . The ADON stated she looks at assessments to complete care plans, and any input from other staff. Interview on 10/18/2024 at 5:25 PM, the ADM stated her expectation was for care plans to be done correctly. Record review of facility policy, dated copyrighted 2005, titled, Care Plan/Comprehensive Interdisciplinary, reflected, The care plan must include measurable objectives and timetables to meet a resident's medical, nursing, and psychosocial needs as identified in the comprehensive assessment.

Based on interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 6 residents (Resident #28) reviewed for personal hygiene. The facility failed to provide Resident #28, 18 of 30 scheduled showers between 7/2/2024 and 10/15/2024. This failure could place residents who require assistance from staff for personal hygiene at risk of not receiving care and services contributing to overall poor hygiene, risk of experiencing a diminished quality of life, and possible skin infections. The findings included: Record review of Resident #28's face sheet, dated 10/18/2024, reflected a [AGE] year-old male resident initially admitted on [DATE] with diagnoses including diabetes mellitus, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (a condition that affects one side of the body after a stroke causing paralysis), and dysphagia (difficulty swallowing). Record review of Resident #28's MDS Assessment, dated 10/8/2024, reflected Resident #28 had a BIMS score of 8, suggesting moderate impairment. No diagnosis of dementia was present on Resident #28's MDS assessment . Resident #28's MDS assessment indicated that Resident #28 needed Partial/moderate assistance for bathing. Record review of Resident #28's Care Plan, undated, reflected interventions stating the resident had an ADL self-care performance deficit related to diagnosis of hemiplegia and hemiparesis. Interview on 10/14/2024 at 12:39 PM, Resident #28 and FM stated that Resident #28 only got showered once a week and would prefer to be showered at least twice a week, ideally on Tuesday and Saturday. Resident #28 stated he was not aware he should have been getting showered more than once weekly and was thankful to hear he could be showered more than once weekly. Record review of Resident #28's shower log reflected that the resident's shower days were Tuesday, Thursday, and Saturday. Further review revealed Resident #28 did not receive 18 of 30 instances of scheduled showers, with 1 instance of refusing a shower. Interview on 10/18/2024 at 5:22 PM, with the ADON, DON, and ADM, the ADON stated that Resident #28 and Resident #28's FM likely did not remember his showers correctly, as they likely had dementia. The ADON requested to interview Resident #28 in front of the surveyor and stated that she was confident Resident #28 would not say he only received showers once a week if the ADON asked Resident #28 in front of the surveyor. The ADM stated that her expectation was for residents to receive showers on their scheduled shower dates . Record review of facility policy, undated, titled, Bath, Shower reflected Residents are showered a minimum of three times weekly on one of two shower schedules either a Monday, Wednesday, & Friday or a Tuesday, Thursday, Saturday schedule which is determined by that patients charge nurse.

Based on interview and record review the facility failed to ensure that residents who had not used psychotropic drugs were not given psychotropic drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 3 residents (Resident #13) reviewed for unnecessary medications. The facility failed to ensure Resident #13 was taking a psychotropic medication (Mirtazapine (an antidepressant)), to treat a specific diagnosed condition. This deficient practice could place residents at risk for receiving medications that were not necessary for their care. The findings include: Record review of the Admission Record reflected Resident #13 was a [AGE] year-old resident who was initially admitted to the facility on [DATE]. Resident #13 had diagnoses which included essential hypertension (abnormally high blood pressure), and a pressure ulcer of the sacral region, stage 4. A diagnosis of depression was not documented. Record review of the comprehensive MDS assessment, dated 9/23/2024, reflected Resident #13's Section I - Active Diagnosis section of her MDS did not reflect a diagnosis of Depression. Resident #13' s BIMS score reflected a BIMS of 13, which indicated moderate cognitive impairment. Record review of Resident #13' s Order Summary Report, dated 10/18/2024, reflected an order for Mirtazapine Oral Tablet 15 MG with the instruction, Give 15 mg by mouth one time a day for depression. Record review of Resident #13' s MAR for October 2024, dated 10/18/2024, reflected Resident #13 was receiving Mirtazapine Oral Tablet 15 MG for depression. Interview on 10/18/2024 at 5:32 PM, the ADON stated she was not sure why Resident #13 did not have a diagnosis of depression . The ADON stated she was not certain who was responsible for ensuring residents have the correct diagnosis for psych medications. Record review of the facility's policy titled, Medications, Drug Regimen Reviews undated, reflected, Unnecessary Drugs: Drugs that are given in excessive doses, for excessive periods of time, without adequate monitoring, or in the absence of a diagnosis or reason for the drug.

Based on interview and record review the facility personnel failed to provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 of 6 residents (Resident #1) whose records were reviewed for code status. Facility staff failed to follow emergency protocol and did not obtain an AED or call emergency services for 25 minutes after Resident #1, who had a Full Code in place, was found unresponsive with no pulse or respirations, according to professional standards of practice. The facility failed to ensure nursing staff had current CPR certification. On 09/05/2024 at 5:01 p.m., and Immediate Jeopardy (IJ) was identified. While the IJ was removed on 09/9/2024 at 6:49 p.m., the facility remained out of compliance a severity level of potential for more than minimal harm that was not an Immediate Jeopardy and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure could place residents at risk of not receiving life-saving measures, decline in health resulting in serious injury and or death. The findings included: Record review of Resident #1's face sheet, dated 09/04/2024, reflected she was an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses to include acute osteomyelitis of right ankle and foot (infection of the bone), type 2 diabetes mellitus, hypercholesterolemia (a disorder known for an excess of low-density lipoprotein (LDL) in your blood), ischemic cardiomyopathy (is a condition of the heart resulting from weakened heart muscles), acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity (is clotting of blood in a deep vein of an extremity), chronic combined systolic (congestive) and diastolic (congestive) heart failure (syndrome caused by an impairment in the heart's ability to fill with and pump blood.). Resident #1's face sheet did not list his code status. Record review of Resident #1's nursing notes revealed he was admitted to the facility after dinner service on 9/22/23 and passed on 9/23/23 around midnight. Record review of Resident #1's admission assessment dated [DATE] reflected he had intact cognition. Record review of Resident #1's clinical record revealed a care plan was not available. Record review of Resident #1's physician orders, dated 09/04/2024, reflected he had an order for full code with original date 09/22/2023. Record review of Resident #1's nursing notes late entry dated 9/23/23 at 9:51 a.m. for 9/22/23 at 4:50 p.m. authored by the DON indicated the resident was admitted after a below the knee amputation on 9/20/23 and was a full code status. Record review of Resident #1's nursing progress note dated 09/23/2023 at 1:22 a.m., authored by LVN A read as follows was called to resident room. No breathes assess. No pulse. Call out to [hospice company name]. Awaiting call back. DON informed. Record review of Resident #1's progress note dated 09/23/2023 at 1:39 a.m., authored by LVN A read as follows This nurse went to check on resident upon entering noted skin color ashen no respiration no pulse. the time was 12:30 am 9/23/23. CPR initiated with crash cart. At 12:45 am 911 was called and arrived at 0109 am (1:09 a.m.) . DON notified and left message to call back tried multiple times to reach. Also called [Doctor] no answer and unable to leave message voicemail full. Also next of kin .multiple times to return call asap unable to reach. DON was called and left message to call N.H. (nursing home) Also [Administrator] notified. able to reach and report resident condition. EMS called [funeral home] awaiting his arrival. Record review of Resident #1's certificate of death, dated 9/23/23, revealed the cause of death was heart infraction (heart attack), an autopsy was not performed, and the manner of death was natural. During an interview on 09/05/2024 at 11:39 a.m., the LVN A stated she worked night shift 11:00 PM to 7:00 AM. LVN A stated when she showed up for work it was busy with call lights going off form residents. LVA A stated she was working with two other CNA's that night. LVN A stated she found the resident unresponsive at 12:40 a.m. on 09/23/23. She stated she started chest compression by herself. LVN A stated she did compression by herself until she stopped to go to the doorway and yell for an aide. She stated CNA C helped obtain the crash cart and placed the back board under the resident. LVN A stated she did not think to get the AED because she panicked. LVN A stated she then stopped giving compressions around 1:05 a.m., 25 minutes after she found him, to call emergency services. LVN A stated EMS arrived around 1:05 a.m. connected him to machines and stated he was deceased . LVN A stated she thought she had a current CPR certification at the time. LVN A stated night shift was responsible for checking the crash cart nighty and the AED machine monthly. During an observation on 9/04/24 at 11:32 a.m. the crash cart contained 1 ambu bag (a medical tool which forces air into the lungs of patients who have either ceased breathing completely or who are struggling to breathe properly and need additional assistance) that expired on 05/29/2023 and 1 flange tip yankauer with vent (is an oral suctioning tool used in medical procedures. It is typically a firm plastic suction tip with a large opening surrounded by a bulbous head and is designed to allow effective suction without damaging surrounding tissue. The vent allows for control of suctioning) that expired on 07/28/2024. The log for daily checks of the cart was blank for September of 2024. The log to daily checks was last completed on 08/20/24. During an interview on 09/04/2024 at 12:21 p.m., The acting DON, LVN, stated staff was expected to complete the crash cart log every night, the AED log was checked monthly and night shift does the logs. The DON stated staff took a course here with the previous DON but they never got their certificates. The DON stated she had been keeping up with the AED checklist but had not kept up with the crash cart check list. The DON stated when she started at the facility in May of 2024 the AED pads were expired and she replaced them. Record review of LVN A's CPR certification reflected LVN A had completed an online only course. The certification was completed 10/25/2023 and had no expiration date listed. Record review of staff CPR certification revealed 8 (RN G, LVN A, LVN H, RN K, LVN B, LVN M, LVN I, and LVN J) did not have current BLS CPR certification as of 09/04/2024. Record review of the AED checklist log for 2024 revealed the AED was not check of for the months of 02/2024 and 04/2024. Record review of the crash cart logs, on 9/4/24, revealed to check offs for 09/2023 and 10/2023 were missing. Further review revealed the logs for 11/2023 and 12/2023 were not completed out daily. Record review of an in-service training attendance roster, dated 09/26/2023, titled Emergency Preparedness & Response, reflected the following topics of discussion: *Make sure you are aware of the code status on residents and that they're up to date and easy to locate. *Ensure crash cart is checked daily that it is in working order and all items in stock. *Check the AED battery daily for proper functioning. *If you enter an emergency situation, call for help by yelling, pull the emergency call light in the room, call on phone, etc. *When finding someone unresponsive, begin assessment for breathing and pulse, and call for help then CPR if indicated. *Keep your CPR up to date so you can practice the skills. *Respond to an emergency regarding a patient/resident by treating them first, then call and notify the physician, DON, Administrator, family, etc. *Make sure to do walking rounds at the beginning of the shift and lay eyes on all of your patients/ residents. *Be sure to report any changes in conditions promptly to MD for prevention and early catch of an emergency situation. *Thoroughly review chart and medication orders on new admissions to ensure no concerns, interactions, and/or discrepancies are in place. *Call pharmacy to review any medication questions and/or transferring facility for questions or concerns. *For diabetic patients, ensure blood sugar checks are in place and utilized as well as insulin if indicated. *Ensure oxygen is readily available and in good working order. *Contact Administrator and/or DON for any questions or concerns. The in-service was signed by LVN A. Record review of facility document titled Cardiopulmonary Resuscitation (CPR), dated 2005, indicated the following equipment was needed: cardiac arrest board or hard surface, sphygmomanometer (is a device that measures blood pressure ) and stethoscope (a medical instrument for listening to the action of someone's heart or breathing), airway, oxygen, suction machine, disposable CPR mask (medical device used to assist in performing CPR while providing a barrier between the rescuer and the person in need) if available per manufacturer's instructions, face mask with handheld portable positive pressure device if available use per manufacturer's instructions. It listed steps for licensed nurses that included 1. Determine unresponsiveness by tapping urgently shaking the basement and shouting are you OK? .2. If the resident does not respond, call out for help. 3. Delegate a specific individual to check resident care plan for CPR or no CPR order, have individual call paramedics, attending physician and administrative personnel per facility procedure and report back to you as soon as possible. 4 .Start .6. If resident is breathless, perform rescue breathing by gently pinching residents nose shut, using your thumb and index finger. 7. Take a deep breath, put your lips around the residence mouth to create an airtight seal. 8. Delivered 2 full breaths, each lasting 1 to 1 1/2 seconds. 9. Pause the inhale between breaths. 10. Observe the chest rise .11. Allow deflation between breaths .14. If there are no signs of breathing or circulation begin chest compressions . Circulation .6. Place heel of one hand on lower part of resident sternum. With your hands directly on top of the first hand, depressed sternum 1 inch or 1 1/2 inches. 7. With arms straight, elbows lock and shoulders over your hands (over resident sternum closed parentheses, performed 15 compressions at a rate of 80 to 100 per minute. 8. Compress any straight downward motion (do not rock or roll close ( 1 1/2 to two inches for an adult resident. Maintain contact between resident's chest and your hand at all times to assure correct position. Use equal compressions and relaxation, compress 1 1/2 to two inches straight down keep hands on sternum during upstroke. 9. Repeat cycle of 15 compressions to two breaths, performing 4 cycles before you elevate 10. continue uninterrupted until you are relieved by another person knowledgeable about CPR, emergency life support arrives, a physician pronounces the resident expired or you are able to continue . Record review of facility's policy titled Policy for Use of AED in Facility, no date, stated location: the AED is located in the hall next to the communication station and across from the director of nurses office . on site coordinator: the onsite coordinator is the director of nursing . responsibilities of the onsite coordinator include assuring that the AED is maintained in a state of readiness, that it is documented, that there is a mechanism to assure continued competency of the authorized individuals trained to use the AED. Maintaining readiness: the AED will be checked for readiness after each use and at least once every 30 days if it has not been used in the preceding 30 days. Checks will include the following: 1. Assure that the OK light is visible in the readiness display. 2. Check the expiration date on the electrode packet. If the date has passed, replace. Authorized users: all licensed nurses will successfully complete training within 30 days of hire and will be retrained every two years. Record review of the facility's policy titled Policy for Emergency Cart, dated 7/2021, stated purpose: to organize and maintain the emergency cart (e-cart) to ensure adequate needed equipment for CPR procedures. Adhered to: Nursing departments and other CPR certified staff. Policy: The DON will ensure the equipment are stocked in the e-cart. The DON contacts the contracted pharmacy for the equipment supplies. The E cart will be located on each floor, hall, unit in the medication prep room where it is accessible and known to all staff. The E cart will be inventoried and restocked after each use and checked at least monthly and documented by nursing staff for pharmacist consultant. Back up emergency supplies should be kept in the Med room. Additional supplies and/ or equipment may not be added to the e-cart. All emergency equipment in the E-cart will be checked monthly by the DON. The E-cart should be locked. Once a month the E-cart should be opened and checked for outdated supplies. Internal and external equipment should be checked by ensuring proper functions of equipment. E-cart checks should be documented on the list maintained on the e-cart. E-carts will be maintained and supplied in accordance with the crash cart minimum requirements list which include respiratory equipment. All nurses should be familiar with the E-cart contents and content locations. The nursing staff will ensure that all appropriate documentation has been completed during emergency procedures. Emergency medication stocks separately in an E-kit by the pharmacist. This kit must be checked monthly for expired drugs. New employees will be oriented to all emergency bags/ kits and procedures, and the training programs would be provided to maintain competence in emergency response. E-cart location, supplies, and emergency procedures shall be reinforced each time during the mandatory in service. All nurses should maintain updated CPR certification. At least two staff who are CPR certified are scheduled at each shift. Procedures: during the emergency situations such as: resident is found unresponsive, no response in neurologic checks, severely injured, excessive bleeding, initiate the nursing assessment along with assigned duty to call 911 or EMS. The charge nurse on that shift is in charge of the emergency procedure, including ensuring the reports are properly given to other agencies and the documentation reflects the actual procedures. During the emergency situation, the charge nurse immediately assigns duties to staff include who calls 911, who brings the emergency supplies to the scene, who initiates CPR, who assists, who calls the family and the attending physician, who writes the notes, where are the notes written and saved, who takes the vital signs, what information will you give EMS and who will prepare this information, who will administer medications, who does the documentation (residents response and nursing procedures), who contacts the administrator and/ or DON (if not present) . This was determined to be an Immediate Jeopardy (IJ) on 09/05/2024 at 5:01 p.m. The Administrator was notified and provided with the IJ template. The following Plan of Removal (POR) was accepted on 09/07/2024 at 6:49 p.m. and indicated the following: The facility needs to take immediate action to ensure nursing staff are trained for emergencies to include CPR and AED and emergency response items are in place. Plan of removal 9/6/2023 DON ADON will have every licensed staff in facility CPR certified by end of 9/6/2024. DON and ADON started training (9/6/2024) 2pm in AED/CPR training what we did after we collected every one's current certifications for CPR, we set up a mandatory in-service for all nursing staff. All nurses and CNAs were in serviced in person and were allowed to demonstrate skills to ADON on how to correctly perform CPR. We also in serviced all nursing staff on the use of AED we had them demonstrate to ADON how to fully use the AED machine as well as to where it is always located. Nursing staff were able to properly demonstrate to ADON DON proper use of both AED and crash cart location use of and items were identified in crash cart and demonstrated to nursing staff. As of 9/6/2024 crash cart will be revised nightly per night shift nurse, there is a current log that we implemented (9/6/2024) in a binder in nurses station night shift nurses were shown where to keep binder for nightly check off crash cart. ADON will check log once a week and sign off on log once checked that week. Administrator to review these logs at the end of month every month to ensure compliance. Safety checks were performed in person per [Administrator] to ensure the safety of our residents on the following resident: [Residents # 2-9]all residents voiced no complaints while interview performed per Admin all residents voiced feeling safe in facility. On 9/6/2024 We implemented all nursing staff be current with CPR status I was able to obtain all nurses current CPR cards as attached deadline for them per facility was end of day 9/6/2024 all nurses were able to obtain certs. A few nurses already had certs in place those who did not obtained as per new guidelines. On 9/6/2024 at 2pm we held an in-house in-service training for all licensed personnel. We had this meeting in the activity room where ADON was able to have nurses demonstrate hands on CPR skills as well as full understanding as to when to initiate CPR. We also touched on the topic of AED location as well as the importance of the devices and crash carts not being occluded or in their assigned place. The AED is in the nurses' station in AED box and the crash cart is by the nurse station all staff in serviced not to move crash cart from assigned place on 9/6/2024 As of 9/6/2024, new implemented mandatory for all licensed personnel to have current status of CPR training and current card demonstrating so. As of 9/6/2024 all PRN staff follow guidelines as mentioned. If card is not in place or expired assigned to keep up with status of current cards has been the business office manager to check licensed personnel file to ensure compliance this duty was delegated to BOM effective 9/6/2024 We did include [CAN D] and [CNA E] in in service to implement importance of CNA role during code to call for help how to call who and when CNAs fully understood their roles by end of in service. All other CNA staff was in serviced per ADON in person setting. This took place the 9/6/2024 ADON stayed in building to receive night CNAs and in service them on CPR and AED. Our policy states 2 CPR certified staff for each shift we are complying currently we have 2 nurses per shift as well as 1 nurse and 1 CNA current on CPR status for night shift [CNA F]certs are attached CNA As of 9/6/2024 ADON will ensure there is always 2 CPR certified personnel per shift as she is staffing coordinator A mock code was presented per ADON to the following nurses; RN [G], LVN [H], [DON] LVN, LVN [J], [K] RN, CNA [D],CNA [E], LVN [L] on 9/6/2024 at 3:30pm All other nurses that are not mentioned above are PRN nurses and the plan in place is to in service them before any scheduled shift. I have set up a follow up in service for 9/13/2024 at 2pm On 9/06/24 to 9/9/2024 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ after verifying their POR had been initiated and/or completed by: All 11 of 12 nursing staff CPR were verified or completed a hands-on CPR course on 9/9/24. LVN M was unable to attend to CPR training and was removed from the schedule until she completed a hands-on CPR course. Interviews conducted between 9/6/24 to 9/9/24 with 9 full time licensed nurse employees from all shifts. 4 PRN employees were unable to be reached by phone and were not on the schedule. The employees interviewed revealed they had received training from the DON regarding how to perform CPR, how to use the AED, where to obtain the crash cart and use items on the crash cart. A sperate CPR course was given on 9/9/24 to some licensed staff. The licenses nurses were all able to answer the questions correctly, validating understanding of the in-service topic. Record review of a binder title Crash Cart Daily Checklist, dated 9/2024, revealed the following: *Cash cart was checked off on 9/6/24 and initialed by LVN A. *Crash cart was checked off on 9/7/24 and initialed by LVN I. * The AED monthly September maintenance for 2024 was and initialed,. Further review revealed the binder included AED training curricula. How to use the AED safely and appropriately with pictures. AED post incident report. DON weekly check signed by ADON for 9/1/24 - 9/7/24. During an observation on 9/9/24 at 8:00 p.m. all items on the crash cart were replaced and not expired. Record review of a statement dated 9/6/24 indicated Safety checks for the following residents were done in person by the Administrator of [facility name and address] 9/6/2024 at 1:06pm for the following residents [#2-9] spoke to [representative] from [insurance company] [company number] who was calling to check on residents due to knowledge of IJ citation. On 9/6/2024 DON/ADON was observed giving a course to several staff. In-service - Hands on Demonstration of CPR skills & AED equipment (crash cart demonstration, calling for help/CNAs), conducted by ADON and DON. In-service handouts included: Policy for emergency cart (E-Cart) Facility has a total of 12 FT nurses (including the ADON and DON) Signed by 10 nurses. 2 RNS 8 LVNS (including the ADON) 2 RNs attended via Skype (including the DON and a PRN nurse) 1 LVN attended via Skype. Signed by 4 out of 6 CNAs. Record review of the facility's policy stated Personnel have completed training on the initiation cardiopulmonary resuscitation (CPR) and basic life support (BLS), including defibrillation, victims of sudden cardiac arrest. RN's and LVNs will be required to be CPR certified upon hire date. There will be at least 1 CPR certified RN/LVN on duty per shift per day. During an interview on 9/9/24 at 5:22 pm the BOM said she was responsible for ensuring the LVN and RNs CPR are current on hire, annually, or when the CPR certificate expires. She stated she had a binder to keep track. Record review of E-Cart policy - said the facility will have 2 CPR certified staff per shift. Interview on 9/9/24 the Administrator said they had updated their CPR policy as of 9/9/24 to say 1 staff per a shift was CPR certified. The Administrator was informed the Immediate Jeopardy was removed on 09/09/2024 at 6:49 p.m. While the IJ was removed the facility remained out of compliance at a severity level of potential harm that was not an Immediate Jeopardy and a scope of pattern, due to the facility was still monitoring the effectiveness of their Plan of Removal.