Every finding on record at Lake Lodge Nursing & Rehabilitation

Based on observation, interview and record review, the facility failed to ensure that each resident has a right to secure, confidential personal medical records; in that:The facility failed to secure residents' personal health care information using an instant messaging phone application for 7 of 9 staff (LVN A, LVN B, CNA C, CNA D, ADON, DON, and Administrator) who used the unsecured phone application to communicate about the facility's residents. This failure could place the residents at risk of unauthorized individuals knowing their personal and private health information. Findings included:During an interview with LVN A on 07/21/26 at 10:38 AM, LVN A stated that she had been employed at the facility for approximately a year. LVN A said that the nurses and administration communicated about the residents using a phone application. LVN A stated that she had seen residents' first names and last initials. LVN A stated that they communicated about residents, who went out on pass for doctor appointments, and with family. LVN A stated that she recalled the DON discussing a medication and a residents' last name only. LVN A stated that she did not believe that was a HIPAA violation because only nurses used the application so there was no harm to the residents. During an observation and interview on 07/21/26 at 10:53 AM, LVN B revealed that she communicated rarely on the phone application because she was new to the facility. LVN B stated that she was afraid that it violated HIPAA, so she tried not to document on the phone application. LVN B stated she only observed on the application because she was afraid that she would violate HIPAA. LVN B opened her phone and scrolled through her phone application to demonstrate how the application worked. LVN B stopped on a screen and pointed at a resident's full name and then turned the screen back to her. LVN B stated that the HIPAA regulation stated that healthcare providers were directed not to give out residents' or patients' information to people not providing healthcare for them. LVN B stated that it was everyone's responsibility to protect residents' information. LVN B stated that the application was not a secure application. LVN B stated that if someone opened her phone, they could also open the application and see residents' information. During an interview on 07/21/26 at 1:03 PM with CNA C, she that CNAs at the facility utilized the phone application in one of the groups specifically for CNAs. CNA C stated that the staff used the application to inform other staff of things such as which residents were out on pass or if a staff was needed in a resident's room. CNA C stated that staff used residents' full names in the application. CNA C stated that she was following the facility policy by using the phone application and was not aware of any violation or if it could cause harm to a resident. During an interview on 07/21/26 at 1:27 PM with CNA D, she revealed that she used the phone application to communicate with other staff about residents. She stated that she had witnessed other staff use residents' full names and details such as admit date s, discharges from the hospital, and other resident details on the application that all the CNAs and nurses had access to view. CNA D said that she thought that staff should not be documenting residents' full names on the application because it could be violating HIPAA. CNA D stated that the importance of HIPAA was to keep the residents' information private. CNA D revealed that the staff were not supposed to share residents' information on social media and other types of platforms. CNA D stated she was unaware if the phone application that the staff at the facility used was a safe application to share the residents' information. CNA D stated that the importance of HIPAA was to keep residents' information private. CNA D said that if fraud occurred with the information on a staff member's phone, it could affect residents in many ways like financial misappropriation. CNA D stated that it was all staff's responsibility to keep residents' information secure to prevent any type of HIPAA violation. During an interview on 07/21/26 at 1:52 PM with the ADON, she revealed that she had been employed at the facility for five years. The ADON stated that the staff at the facility used a phone application to communicate about the residents and their needs. The ADON said that there were three different groups so that each group could communicate regarding their duties and the residents' needs. The ADON stated that the facility had used the group application for several years. The ADON said there were three different groups based on job duties. The ADON said that HIPAA was based on what they needed to know to do perform job duties. The ADON stated that the staff at the facility use residents' full names when discussing residents and their needs. The ADON revealed that she believed that the phone application was a secure platform. However, the ADON revealed there was no additional security login on the phone application. The ADON stated if the phone was opened, the application could be opened as well with no additional security login. The ADON said that it would be a HIPAA violation if residents' information was accessed on the staff's phones. The ADON said that the purpose of HIPAA was to protect residents' private health information. And that it was everyone's responsibility to ensure that the HIPAA regulation was followed. The ADON stated that the risk of violating HIPPA was that the residents' privacy was violated and if that occurred, it should be reported to the Administrator.During an interview with the Administrator on 07/21/26 at 2:10 PM, he revealed that residents' medical information such as medications were documented in the application. The Administrator revealed that he did not know that residents' names were used in the application. The Administrator said that he thought his staff used the application for things like residents' call lights. The Administrator stated that the HIPAA policy stated that residents' information should be safe and secure no matter the location. The Administrator said that he had not had a conversation with the DON about the information the staff were using on their phones on the application. The Administrator stated that it was everyone's responsibility to be HIPAA compliant. The Administrator said that it was not a secure site for the facility and residents' personal information. The Administrator stated that if staff saw a HIPAA violation, they should report it to their manager because there was a risk of fraud if individuals had access to residents' information. The Administrator stated that HIPAA was important to ensure residents have a safe environment and that they could trust the staff and the facility. The Administrator also stated that the application does not have a Business Associate Agreement (BAA), which was a legally binding contract required under the Health Insurance Portability and Accountability Act (HIPAA) between a covered entity (such as a healthcare provider, health plan, or health insurance company) and a business associate (a third party that performs functions or activities involving access to or disclosure of Protected Health Information, or PHI).During an interview with the DON on 07/21/26 at 3:08 PM, she revealed that the staff at the facility use the phone application to communicate about residents. The DON said that some staff use the residents' whole names when communicating about residents. The DON said that the facility policy stated that staff should not use residents' names when communicating outside the facility or not taking care of the resident. The DON stated that if someone logged into a staff member's phone and they had the application, they could see the residents' names and information on the application. The DON stated that she recalled posting a resident's orders, but she marked the name of the resident out on the document. The DON said that it was everyone's responsibility to ensure residents' information was not accessible. The DON also said that people could take a resident's information and cause stress to the resident if they used it in the wrong way. The DON said that the HIPAA policy stated that when staff leave a workstation, they should turn off the monitor or log off. The DON stated if a staff member suspected that someone violated HIPAA, they should report it to the Administrator. Record review of the facility's current, undated Resident Rights policy reflected the following: .Privacy and confidentiality - The resident has a right to personal privacy and confidentiality of his or her personal and medical records. 1. Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, meetings of family and resident groups.Record review of the electronic Code of Federal Regulations accessed at https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164 reflected the following: S 164.306 Security standards: General rules.(a) General requirements. Covered entities and business associates must do the following:(1) Ensure the confidentiality, integrity, and availability of all electronic protected health information the covered entity or business associate creates, receives, maintains, or transmits.(2) Protect against any reasonably anticipated threats or hazards to the security or integrity of such information.(3) Protect against any reasonably anticipated uses or disclosures of such information that are not permitted or required under subpart E of this part.(4) Ensure compliance with this subpart by its workforce. Record review of The HIPAA Journal accessed at https://www.hipaajournal.com/whatsapp-hipaa-compliant/ reflected the following: Is [Phone Application] HIPAA Compliant?[Phone Application] is not HIPAA compliant and should not be used for receiving, storing, or sending Protected Health Information unless a patient initiates a contact via [Phone Application] or exercises their right to request confidential communication via a specific channel or platform. In such cases, the healthcare providers must document the initial contact or request and implement reasonable safeguards to protect the privacy of health information.There are many ways in which [Phone Application] can be used in healthcare settings to accelerate workflows and improve patient outcomes. However, the platform should not be used to communicate PHI because it lacks the capabilities to support compliance with the HIPAA Security Rule.

Based on interview and record review, the facility staff failed to ensure staff reported potential use of medication not provided by the facility to the ADM and DON for 1 of 5 (Resident #1) reviewed for quality of care.CNA B failed to report Resident #1 told her he had been taking medication for weight loss provided by family.This failure could place residents at risk of adverse effects to medications or medication interactions, that can lead to residents not meeting their highest practicable physical, mental, and psychosocial needs.Findings included:Record review of Resident #1's face sheet revealed an [AGE] year-old male admitted with a primary diagnosis of acute respiratory failure (lungs cannot get enough oxygen in blood). Other pertinent diagnoses included anxiety disorder (excessive fear or worry), acute on chronic systolic congestive heart failure (body cannot pump enough blood to heart), acute pulmonary edema (fluid buildup in lungs), type 2 diabetes mellitus (body cannot produce enough insulin to maintain blood sugar levels), and obesity (excessive fat accumulation, can lead to serious health conditions). Record review of Resident #1's progress notes, dated 03/07/2026, reflected: Entered resident's room for routine check. Witnessed resident's [family member], handing a syringe to the resident. Observed resident self-inject into lower abdomen. [family member] stated he takes this for anxietyResident remained conscious, alert and oriented.Immediately asked to see the syringe but she refused stating everybody in this facility knows about this Notified DON and Physician- left message. No immediate adverse reactions noted. Will continue to monitor.Record review of Resident #1's orders, dated 03/09/2026, revealed Resident #1 did not have an order for weight loss medication. Record review of Resident #1's care plan, dated 03/13/2026, revealed Resident #1 did not have a care plan for weight loss mediation or self-administering medications. Care plan interventions included for medications to be given as ordered by physician. During an interview on 03/30/2026 on 11:27 a.m. with Resident #1's family member, she said she had not provided Resident #1 with any anti-anxiety medications from outside the facility. The family member said she did provide Resident #1 with the over-the-counter medication, Mucinex (loosens chest congestion, treats cold, flu, and coughs), from outside the facility. There was no mention of weight loss medication at this time. During an interview on 03/31/2026 at 9:30 a.m. with the DON, she said LVN A reported to her that she had seen Resident #1 self-administering medication on 03/07/2026 and that the family member was the one who provided the medication. LVN A reported to the DON that the family member said it was for anxiety and all the nurses knew about it. The DON said she told LVN A she did not know about it and requested LVN A to get the medications from the family member. The DON said LVN A told her the family member then said it was water used as a placebo and she would not give her the medication. The DON said she contacted the family member to educate her she could not provide medications to Resident #1 and requested to meet on 03/09/2026 and to bring the medication to her. The DON said Resident #1 was monitored for changes after the alleged incident of the self-administered medications and did not show adverse side effects on 03/07/2026 and 03/08/2026. She said on 03/09/2026 she went to educate Resident #1 that he could not take medications not provided by the facility. The DON said at that time, he had just eaten breakfast and did not look normal. She said a nurse had taken his vitals and his oxygen saturation level was low, and they discharged him to the hospital. The DON said Resident #1 had a history of respiratory issues before that day. The DON said she had called the family member about the discharge, and the family member did not ever bring the medication to the DON. She indicated the family member was not seen again in the facility after the alleged incident on 03/07/2026 through when Resident #1 was discharged to the hospital on [DATE], due to complications related to his diagnosis of acute respiratory failure. The DON said the over-the-counter medication, Mucinex, was in Resident #1's room. The DON said the facility felt it was not safe for Resident #1 to reside at the facility due to the family member not following the facility's policy of not providing medications from outside of the facility. She indicated it was a risk to Resident #1 due to possible negative side effects. During an interview on 03/31/2026 at 11:41 a.m. with LVN A, she said she saw Resident #1 injecting himself with a medication and the family member standing by Resident #1. She said the family member said it was for anxiety and everyone (nursing staff) knew about it. LVN A said she asked the family member to look at it and the family member told her she had a prescription for it. LVN A said the family member then said it was just water used as a placebo to make him calm down and she walked away. LVN A said she called the DON and documented the alleged incident. LVN A said she monitored Resident #1 every 30 minutes to check for change of conditions, and she did not see any change during the remainder of her shift. She indicated the next shift monitored Resident #1 too. LVN A said it was important to report the alleged incident because the facility administers medications to the resident and anything coming from outside could end his life and the facility would not know what the medication was. During an interview on 03/31/2026 at 1:47 p.m. with CNA B, she said she provided care for Resident # when he was a resident at the facility. She said she had not heard about the incident regarding a family member giving Resident #1 medication that was not provided by the facility. CNA B said Resident #1 did say something to her about the family member giving him medication for weight loss. She said she never saw the family member give him medication; she said she had not heard from other staff members that Resident #1 said he took weight loss medication. CNA B said she did not report to her supervisor what Resident #1 had told her because she did not think it needed to be but maybe should have because if he received medication that was not provided by the facility, it could have been a risk to Resident #1. During an interview on 03/31/2026 at 2:47 p.m., RN C said they provided care for Resident #1. RN C said they had not heard from Resident #1 about him taking medication that was not provided by the facility. RN C said they would report it to the DON if they had heard that because the facility and doctor needed to know what medication Resident #1 was taking due to medication interactions, and for the best interest of the resident. During an interview on 03/31/2026 at 3:10 p.m. with LVN D, she said she provided care for Resident #1, and he had never told her about taking medications provided by family members. LVN D said she worked on 03/07/2026 during the alleged incident. She said the family member came to the nurse's station and told LVN A the medication was for weight loss. She said she never heard the family member say it was for anxiety. LVN D said if she had heard about or seen Resident #1 receiving medication from outside of the facility, she would report it to the DON, ADM, and MD. She said it was a risk for residents to take medications not given by the facility because residents may not administer them the right way and something could happen. During an interview on 03/31/2026 at 3:40 p.m., the DON said she had asked other nurses about Resident #1 receiving medication provided by family members and they indicated they did not know about the medication. The DON said nurses were expected to report if they had heard a resident was receiving medications not provided by the facility. The DON said she had not heard from the CNAs if they had heard about residents receiving medications not provided by the facility, but CNAs were educated to report to her and the ADM if they heard something. The DON said they know to report to her but would do further education. She said the risk of not reporting could be harmful to the resident due to medication interactions or if a resident was allergic to the medication. During an interview on 03/31/2026 at 4:25 p.m. with the ADM, he said he expected staff to communicate because he and the DON were supposed to be aware of everything, so they can care plan and document. The ADM said if Resident #1 was receiving medication without the facility knowing there was a risk of medication interactions.Record review of the facility's Abuse/Neglect policy, undated, reflected: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals.The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility.Definitions1. Abuse: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals.2. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility.7. Neglect: is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.E. Reporting1. Any person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse, neglect or exploitation must report this to the DON, administrator, state and/or adult protective services. State law mandates that citizens report all suspected cases of abuse, neglect or financial exploitation of the elderly and incapacitated persons.

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 infection for 08 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, and Resident #8,) of 12 residents reviewed for infection control. The facility failed on 03/11/26 to ensure infection control procedures were followed when the MA failed to sanitize the wrist blood pressure cuff between each resident when she obtained blood pressure readings.This failure could place residents at risk of infection. Findings included: Record review of Resident #1's face sheet, dated 03/11/26 reflected he was a [AGE] year-old male who was admitted on [DATE] and diagnosed with Parkinson (progressive neurological disorder causing movement problems), unspecified, tremor (an involuntary, rhythmic shaking movement of body parts) unspecified, personal history of traumatic brain injury and essential primary Hypertension (high blood pressure).Record review of Resident #1's MDS, dated [DATE] reflected, his BIMS score was 14 which indicated no cognition impairment. Record review of Resident #2's face sheet, dated 03/11/26 reflected she was a [AGE] year-old female who was initially admitted on [DATE] and readmitted on [DATE] and diagnosed with Type 2 Diabetes Mellitus without complications and essential primary hypertension (high blood pressure).Record review of Resident #2's MDS, dated [DATE] reflected, his BIMS score was 14 which indicated no cognition impairment. Record review of Resident #3's face sheet, dated 03/11/26 reflected he was a [AGE] year-old male who was admitted on [DATE] and diagnosed with chronic kidney disease stage 4 (severe) and essential (primary) hypertension (high blood pressure).Record review of Resident #3's MDS, dated [DATE] reflected, his BIMS score was 09 which indicated moderate cognition impairment. Record review of Resident #4's face sheet, dated 03/11/26 reflected she was a [AGE] year-old female who was initially admitted on [DATE] and readmitted on [DATE] and diagnosed with essential (primary) hypertension (high blood pressure).Record review of Resident #4's MDS, dated [DATE] reflected, her BIMS score was 15 which indicated no cognition impairment. Record review of Resident #5's face sheet, dated 03/11/26 reflected she was a [AGE] year-old female who was admitted on [DATE] and diagnosed with essential (primary) hypertension (high blood pressure).Record review of Resident #5's MDS, dated [DATE] reflected, her BIMS score was 01 which indicated severe cognition impairment. Record review of Resident #6's face sheet, dated 03/11/26 reflected she was an [AGE] year-old female who was initially admitted on [DATE] and readmitted on [DATE] and diagnosed with essential (primary) hypertension (high blood pressure).Record review of Resident #6's MDS, dated [DATE] reflected, her BIMS score was 99 which indicated resident was unable to complete interview. Record review of Resident #7's face sheet, dated 03/11/26 reflected he was a [AGE] year-old male who was initially admitted on [DATE] and readmitted on [DATE] and diagnosed with essential (primary) hypertension (high blood pressure).Record review of Resident #7's MDS, dated [DATE] reflected, his BIMS was not documented. Record review of Resident #8's face sheet, dated 03/11/26 reflected she was a [AGE] year-old female who was admitted on [DATE] and diagnosed with essential (primary) hypertension (high blood pressure).Record review of Resident #8's MDS, dated [DATE] reflected, his BIMS score was 15 which indicated no cognition impairment. During an observation on 03/11/26 at 7:53 AM, the MA attempted to obtain Resident #1's BP with BPM #1. The MA was not able to obtain a read from Resident #1's wrist. The MA used BPM #1 on Resident #2's wrist without sanitizing between each resident. The MA washed and dried her hands before she exited out of the room. During an observation on 03/11/26 at 8:05 AM, the MA used BPM #1 and used BPM #2 on Resident #3's wrist. The MA did not sanitize the wrist cuff to both machines after she obtained the BP measurements. The MA washed and dried her hands before she exited Resident #3's room. During an observation on 03/11/26 at 8:20 AM, the MA used BPM #2 on Resident #4's wrist. The MA did not sanitize the wrist cuff after she obtained Resident # 4's BP measurement. The MA washed and dried her hands before she exited Resident #4's room. During an observation on 03/11/26 at 8:34 AM, the MA used BPM #2 on Resident #5's wrist. The MA did not sanitize the wrist cuff after she obtained Resident #5's BP measurement. The MA washed and dried her hands before she exited Resident #5's room. During an observation on 03/11/26 at 8:40 AM, the MA used BPM #2 on Resident #6's wrist. The MA did not sanitize the wrist cuff after she obtained Resident #6's BP measurement. The MA washed and dried her hands before she exited Resident #6's room. During an observation on 03/11/26 at 8:48 AM, the MA used BPM #2 on Resident #7's wrist. The MA did not sanitize the wrist cuff after she obtained Resident #7's BP measurement. The MA washed and dried her hands before she exited Resident #7's room. During an observation on 03/11/26 at 8:56 AM, the MA used BPM #2 on Resident #8's wrist. The MA did not sanitize the wrist cuff after she obtained Resident #8 BP measurement. The MA washed and dried her hands before she exited Resident #8's room. During an interview and observation on 03/11/26 at 9:02 AM, The MA stated the cuff was sanitized between each resident when the residents had covid to prevent cross contamination. The MA showed the surveyor the sanitizer wipes on the medication cart and stated those were the wipes that are used to clean the cuff and cart. During an interview on 03/11/26 at 9:40 AM, LVN B stated BP cuffs must be sanitized between residents because residents could have something contagious on their skin and could pass it to other residents. During an interview on 03/11/26 at 10:12 AM, LVN C stated BP cuffs are sanitized between each resident to avoid cross contamination. During an interview on 03/11/26 at 2:30 PM, the DON stated BP cuffs are sanitized between each resident to prevent cross contamination. The DON stated she started an in-service with nursing staff. Record review of facility policy titled Infection Control Plan Overview, revised 03/2024 reflected, Process surveillance reviews practices directly related to resident care in order to identify whether the practices comply with established prevention and control procedures and policies based on recognized guidelines. Examples of this type of surveillance include monitoring of compliance with transmission based precautions, proper hand hygiene, and the use and disposal of gloves. Process surveillance determines, for example, whether the facility: Minimizes exposure to a potential source of infection Uses appropriate hand hygiene prior to and after all procedures Ensures that appropriate sterile techniques are followed, for example, that staff: Use sterile gloves, fluids, and materials, when indicated, depending on the site and the procedure, Avoid contaminating sterile procedures; and Ensure that contaminated/non-sterile items are not placed in a sterile field. Uses Personal Protective Equipment (PPE) when indicated. Ensures that reusable equipment is appropriately cleaned, disinfected, or reprocessed.

Based on interview and record review, the facility failed to ensure a Registered Nurse was on duty in the facility for a minimum of eight consecutive hours a day, seven days a week, for 6 of 26 weekend days (11/01/2025, 11/02/2025, 11/15/2025, 11/16/2025, 11/29/2025, 11/30/2025) reviewed for RN coverage. The facility failed to have RN coverage on the following dates in 2025:- 11/01/2025, 11/02/2025, 11/15/2025, 11/16/2025, 11/29/2025, 11/30/2025 This failure could place residents at risk of not having their nursing and medical needs met, and other direct care staff not receiving sufficient oversight.Findings included: Review of an undated excel file, covering the RN time stamp hours for weekend dates of the first fiscal quarter of 2026 reflected insufficient RN coverage on the following dates of 2025. - 11/01/2025, 11/02/2025, 11/15/2025, 11/16/2025, 11/29/2025, 11/30/2025During an interview on 1/08/2026 at 2:56 PM, the DON revealed she was responsible for RN weekend schedules. She said RNs were scheduled to work 6:00 PM - 6:00 AM during the weekends and the RNs would take a break from 6:00 AM to 6:00 PM and return for the next 6:00 PM - 6:00 AM shift (providing 6 hours of coverage in the morning and 6 hours of coverage in the evening). The DON had thought the facility just needed at least 8 hours of coverage during weekend days, not 8 consecutive hours. During an interview on 1/08/2026 at 3:20 PM with the ADM revealed he understood the RN weekend day scheduled as RNs were scheduled from 6:00 AM - 6:00 PM, because that was the schedule for weekdays. He stated the risk of not having an RN in the facility for 8 consecutive hours was not having staff present with the clinical expertise of an RNs and knowledge to make decisions for (a resident's) life. The facility did not have a policy regarding nurse staffing.

Based on observation, interview and record review, the facility failed to provide safe and secured storage of drugs and biologicals by not keeping medication in locked compartments, for 1 of 5 carts reviewed for medication storage in that:LVN A failed to lock treatment cart while not in use. This failure could result in physical injuries to residents; drug diversions, ingestion of medications causing adverse effects and violation of HIPAA (Health Insurance Portability and Accountability Act). Findings includedIn an observation on 1/6/2026 at 9:10am, treatment cart in hall 400 was unlocked when not in use. Inside treatment cart was Resident #1's silver sulfa cream, wound supplies, 2 pairs of scissors, and 2 bottles of wound cleaning liquid. Treatment cart was unlocked and not in use for 5 minutes.In an interview on 1/6/2026 at 9:15am with treatment nurse. She stated medication cart and treatment cart should be locked at all times due to risk of injuries to residents and HIPAA violation. She stated a resident could have gotten ahold of would cleaning liquid and caused chemical injuries. She also stated a resident could have sustained physical injuries using the scissors in an unlocked cart. She stated she forgot to lock the wound cart when she walked back to medication room to get wound supplies to refill the cart. In an interview on 1/8/2026 at 2:30pm, the DON stated that all carts should be locked at all times when not in use. She stated residents could have access to medications or biologicals or medical tools in the carts that could cause harm. The DON also stated that nurses were to lock all carts even if they were going to step away for a brief moment. She stated all nurses were trained to lock all carts when carts are not in use. Review of facility's policy, Medication Administration Procedures, dated 10/25/2027, stated .the medication cart must be completely locked, or otherwise secured.

Based on interviews and record reviews, the facility failed to protect residents' right to personal privacy and confidentiality of his or her personal and medical records for 10 of 74 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10) reviewed for confidentiality of records. CNA A provided a list containing residents' names and medical appointment details to Resident #1. This failure could place residents at risk for psychosocial damage, emotional damage and potential fraudulent. Findings included:Record review of facility's incident investigation, dated 8/4/2025, revealed CNA A, who was the facility's transport person, gave a list of residents' names and their appointments to Resident #1. The list included the following information_Resident #2's Magnetic Resonance Imaging (MRI) appointment._Resident #3's orthopedic (bone & joint specialist) appointment._Resident #4's podiatry (foot specialist) appointment._Resident #5's orthopedic appointment._Resident #6's podiatry appointment._Resident #7's pain management appointment._Resident#8's pulmonary (lung specialist) appointment._Resident #9's urology (urinary specialist) appointment._Resident #10's nephrology (kidney specialist) appointment._Resident #1's dermatology (skin specialist) appointment. In an interview on 9/4/2025 at 9:35am, Resident #1 stated that CNA A gave him a list of resident's appointments that were missed because she was suspended by the facility pending investigation involving damage to facility's transport van. He stated that CNA A wanted him to give the list to the volunteer Ombudsman. Record review of Resident #1's MDS assessment, dated 8/2/2025, revealed his BIMS score was 15, indicating intact cognitive state. In an interview on 9/4/2025 at 11:15am, CNA A stated she gave the list to Resident #1 to give it to the volunteer Ombudsman. She stated that she understood that she breached residents' confidentiality by doing that. She stated that she felt Resident #1 was trustworthy and would not discuss other residents' information, so she gave him the list. In an interview on 9/5/2025 at 10:30am, the volunteer Ombudsman stated that he did not receive any list from CNA A. He stated that due to the suspension of CNA A, he went to the facility on 8/5/2025 to discuss alternative options with residents to ensure there was an alternative form of transportation to take them to their appointments. In an interview on 9/4/2025 at 12:50pm, the DON stated that on 8/4/2025, Resident #1 came to her to express his frustration that CNA A was suspended and presented the list to her. The DON advised Resident #1 that the information on the list was confidential and asked to take the list from him. He agreed. The DON stated that she expected her staff to follow the facility's protocol to protect residents' confidential information at all times and everywhere. She expected that staff keeps medication carts locked, computers locked and any discussion regarding residents' health information be done in private. CNA A was terminated as a result of her violation. The facility had a third party transportation service to transport residents to appointments in the meantime. In an interview on 9/4/2025 at 1:15pm, the Administrator stated that he expected his staff to respect resident right to their confidential information because violating their rights may result in frauds, emotional and psychological damage. Record review of CNA A's General Employee Orientation Training Inventory, dated 12/1/2020, revealed confidentiality of resident information (HIPAA) was included in the orientation checklist. Record review of CNA A's Privacy acknowledgement and non-disclosure agreement, employee scope of access to Resident Personal Health Information, signed and dated by CNA A on 12/2/2020, revealed that the employee agreed that he or she will not verbally or in any written form disclose confidential resident information to any unauthorized party. Record review of facility's Resident Rights policy, date unknown, revealed The resident has a right to personal privacy and confidentiality of his or her personal and medical records.1. Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups.

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 4 Residents (Resident #1) reviewed for infection control. 1. The facility failed to ensure CNA B used the required PPE for Resident #1, who was on enhanced barrier precautions due to her wound, and indwelling foley catheter, while assisting LVN A with Resident #1's wound care and getting Resident#1 dressed on 04/07/25. 2. The facility failed to ensure LVN A used the required PPE for Resident #1, who was on enhanced barrier precautions due to her wound, and indwelling foley catheter, while performing wound care for Resident #1on 04/07/25. 3. The facility failed to ensure LVN A performed hand hygiene between glove changes when she went from dirty to clean during incontinence care for Resident #1. 4. The facility failed to ensure LVN C used the required PPE for Resident #1, who was on enhanced barrier precautions due to her wound, and indwelling foley catheter, while assisting the resident with getting dressed and ready for the mechanical lift on 04/07/25. These failures could place residents at risk of cross-contamination and development of infection. Finding Include: Record review of Resident #1's quarterly MDS assessment, dated 03/14/25, reflected a [AGE] year-old female who was initially admitted to facility on 08/23/24 and readmitted on [DATE]. Resident #1 had a BIMS score of 08, which indicated she was moderately cognitively impaired. Resident #1 had diagnoses which included hypertension (elevated blood pressure), end stage renal disease (kidney failure) and cerebral vascular accident (type of ischemic stroke resulting from a blockage in the blood vessels supplying blood to the brain). Record review of Resident #1's comprehensive care plan, dated 01/13/25, reflected Focus. [Resident #1] is on Enhanced Barrier Precautions. Goal. There will not be any transmission of infection from or to the resident. Intervention. Gloves and gown should be donned if any of the following activities are to occur .transfer, dressing .incontinent care, bed mobility, wound care . other high contact activity. Record review of Resident#1's Physician Orders Report, dated 11/05/24, reflected Enhanced Barrier Precaution related to foley Catheter and wounds. Wear gloves and gown for all catheter care and wound care. In an observation on 04/07/25 at 9:05 AM, Resident #1's room was noted with a sign on her door which indicated she was on Enhanced Barrier Precautions, no PPE cart in front of the room. LVN A entered Resident #1's room to do wound care. Resident #1's wound was in the sacral area. LVN A washed her hands and put on gloves, but no gown. CNA B entered Resident #1's room to help LVN A with wound care. CNA B washed her hands and put on gloves, but no gown. LVN A uncovered Resident #1 and unfastened Resident #1's brief. Both staff helped Resident #1 turn to her left side. LVN A opened Resident #1's brief, the resident had a bowel movement. LVN A removed the old dressing, and cleaned Resident #1's buttocks area, folded the brief, and pushed it under the resident. LVN A changed gloves without performing any kind of hand hygiene. LVN A cleaned Resident #1's wound, applied Santyl ointment, alginate calcium and border dressing on the wound. CNA B got a clean brief from the drawer and put it under the resident. Both staff turned Resident #1 on to her back, CNA B cleaned Resident #1's front area. Both staff turned Resident #1 to her right side. CNA B removed the dirty brief and finished putting the clean brief on the resident. LVN A washed hands and exited the room. LVN C entered Resident #1's room to help CNA B dress Resident #1 and get her ready for the mechanical lift, in anticipation of a dialysis appointment. LVN C washed hands, put on gloves, and no gown. Both staff got Resident #1 dressed in a T-Shirt and pants and put a sling under her. Both staff covered Resident #1, removed gloves, and washed hands before exiting the room . Interview with LVN A on 04/07/25 at 09:26 AM revealed she knew she was supposed to wear a gown for the resident's wound care, but she forgot. She stated she was nervous. LVN A stated she was trained to wear a gown for high contact with residents in Enhanced Barrier precautions. LVN A stated she was required to change gloves and perform hand hygiene whenever she was going from dirty to clean task. She stated she realized she had not done hands hygiene She stated the risk of not following the proper infection control policy, like not wearing proper PPE in EBP room, and performing hand hygiene was the spread of germs and infections. In an interview with CNA B on 04/07/25 at 09:28 AM, she stated she did not put on a gown, because there was no PPE supplies cart in front of the room, as the other rooms for EBP in the Hall. She stated she would put a PPE supply cart in front of the room. She stated the risk to residents was cross contamination. Interview with LVN C on 04/07/25 at 09:32 AM revealed she knew she supposed to wear a gown for any high contact with the residents on EBP, but she forgot. She stated she was in serviced on EBP, but she could not recall how long ago. She stated the risk to residents was cross contamination and development of infections. In an interview with the DON on 04/07/25 at 11:59 AM, she stated staff were taught any resident who was on Enhanced Barrier Precautions required gloves and a gown when providing any contact with the resident. The DON stated the staff were trained on when to change their gloves and sanitize their hands. She stated staff needed to change their gloves when they went from dirty to clean. She stated the risk was an increased risk of infections. Record review of the facility's policy, dated 04/01/2024 and titled Enhanced Barrier Precaution, revealed Enhanced Barrier Precaution (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistance organisms that employ targeted gown and glove use during high contact resident care activities. Record review of the facility's policy, updated 03/2024 and titled Infection Control Policy & Procedure Manual 2019, , reflected 1. Hands hygiene. Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene . After removing gloves . Gloves. Wearing gloves does not replace the need for hand washing.

Based on interview and record review the facility failed to report an alleged violation involving neglect, misappropriation of resident property, exploitation, or mistreatment, and does not result in serious bodily injury not later than 24 hours to the administrator of the facility and to other officials, including to the State survey and certification agency and adult protective services in accordance with State law for one (Resident #1) of four residents reviewed for misappropriation of resident's property and exploitation. The Housekeeper failed to report to the facility administrator who was the abuse coordinator that Resident #1 was missing money totaling $90 when Resident #1 first reported the missing money weeks prior to 03/11/25. This failure could place residents at risk of not receiving timely investigations and reporting of misappropriation of resident's property and exploitation. Findings included: Review of Resident #1's admission record dated 03/11/25 revealed a [AGE] year-old female with an initial admitted [DATE]. Her diagnosis included vascular dementia (this is brain damage that is caused by multiple strokes causes memory loss and or cognitive decline), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (this is paralysis after having a stroke affecting the right side of the body), Cerebral infraction (Stroke), acquired absence of other specified parts of digestive tract (missing part of digestive tract), and type 2 diabetes (uncontrolled blood sugar disorder). Resident #1 was her own responsible party. Review of Resident #1's quarterly MDS (this is a set of standardized assessments done on admission, quarterly, and with a significant change of condition, on each resident), dated 02/19/25 revealed a BIMS (this is a standardized assessment to measure long and short-term memory) score of 13 out of 15 indicating intact cognition. Further review of the MDS revealed Resident #1 was dependent for bed mobility, transfers, toileting, and personal hygiene. Review of Resident #1/s care plan initiated 12/31/24, revealed Resident #1 had impaired cognitive function/impaired thought process related to dementia. The interventions were to break down large or complex tasks into smaller, more manageable parts or segments to improve focus and short-term memory issues. In an interview with Resident #1 on 03/11/25 at 11:09 AM who stated, I have had money stolen here at the facility. She said the money was in her bedside table drawer [pointed to the side table by her bed]. She said it happened a month ago. She stated she had $60 first stolen then a few days later $30 was also stolen. She stated a total of $90 was stolen from her. Resident #1 said she could not remember the exact dates. Resident #1 said she did not have a lock box and that she did not ask for one. Resident #1 stated that she did not report the incident but everyone in the facility knew that there was someone going around robbing residents. Resident #1 said a CNA told her that information about the robberies, but she declined to name the staff members name, stating I don't want her to get in trouble. In an interview with the Housekeeper on 03/11/25 at 11:35 AM, revealed she was aware of Resident #1's missing money. She stated Resident #1 informed her a few weeks ago about the stolen money. The Housekeeper stated she had found some money ($30) laying around in Resident #1's room and Resident #1 asked her to help her secure it, so the Housekeeper went to the business office, got an envelope and placed the money inside the envelope then placed the sealed envelope inside a [book name] in Resident #1's drawer. She stated she could not remember the exact dates, a few weeks ago. The Housekeeper stated Resident #1 told her that she had reported the missing money and so she did not report it herself because it was already reported. The Housekeeper stated she did not even think of helping Resident #1 get a lock box for her money. She said Resident #1 was a holder and liked to carry her belongings with her, therefore she would not have agreed to a lock box. The Housekeeper stated she knew what misappropriation and exploitation meant in regard to Abuse and Neglect. She stated misappropriation and exploitation was not just money but any residents' personal belongings being taken or befriending the residents so that they can trust you with personal information and you misuse it. She stated misappropriation and exploitation should be reported to the administrator immediately. Interview with CNA A and CNA B on 03/11/25 at 11:40 AM revealed they did not know nor had heard of any robberies in the facility, and they did not know anything about any resident's money being stolen. Both CNA A and CNA B stated they had done in-services on ANE in the past month. They stated they would report missing money or any resident's property to the DON and Administrator immediately. In an interview with the Business Office on 03/11/25 at 1:46 PM she stated Resident #1 withdraw $30 on 1/14/25, $30 on 1/22/25, $30 on 02/10/25 and $30 on 02/25/25. The Business office said that no one had reported to her that Resident #1 was missing money. She stated Resident #1 wanted two small fridges for her drinks and butter and it was likely that Resident #1 had spent the money on the items. She stated if she had known about the money missing, she would have reported to the abuse coordinator right away. She stated misappropriation and exploitation are to be reported to the abuse coordinator, the administrator. Interview with ADM on 03/11/25 at 2:33 PM, revealed she was not aware of Resident #1 missing money. She stated she reported the incident after finding out today 3/11/25. She stated the expectation was that the housekeeper should have reported the incident to her. She said the risk was misappropriation and exploitation. In an interview with DON on 03/11/25 at 2:52 PM, revealed she was not aware of Resident #1's missing money until the ADM told her today. She stated the expectation was that the incident was reported immediately. DON stated the facility had lock boxes and the residents were aware and one could be provided if they wanted one. She stated she would rather have 11 people report the same incident than for them to say, someone already reported the incident. The DON stated she had in-served on ANE, and the expectation was that all staff follow the ANE policy and report incidents immediately. Review of Resident #1's statement titled Resident Statement Landscape reflected Resident #1 withdraw a cash on the following dates: $30 cash on 01/14/25, $30 cash on 01/22/25, $30 cash on 02/10/25, $30 cash on 02/25/25. Review of facility In-Service training attendance roster titled Abuse and Neglect lead by DON dated 02/28/25 was signed by Housekeeper, CNA A, CNA B, and 36 other staff members from nursing and other departments. Record review intake [number] reported on 03/11/25 by ADM allegation Exploitation/Misappropriation. Review of facility policy titled Abuse and Neglect, dated 09/09/24, reflected: The facility Reportable Incident Protocol, Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 2024-14 dated 8/29/24. a. If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation. b. If the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation.

Based on observation, interview and record review the facility failed to ensure the resident had a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living for three of 13 residents (Residents #1, #2 and #3) reviewed for environmental concerns. 1. The facility failed to ensure Resident #1's restroom was cleaned daily. 2. The facility failed to ensure Residents #1, #2 and #3's restroom had hot water. These failures could place residents at risk for a decreased quality of life. Findings include: 1. Record review of Resident #1's, undated, Admission Record revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had a primary diagnosis of Chronic obstructive Pulmonary Disease with (Acute) Exacerbation (is a sudden worsening of COPD symptoms, including shortness of breath, cough, and/or an increase in the volume and/or purulence of the sputum [A mixture of saliva and mucus produced by the lungs as a result of viral or bacterial Infections] produced). Record review of Resident #1's Care Plan, dated 12/20/2024, revealed Focus: the resident uses bedside commode related to Impaired Mobility and residence. Goal: the resident will be continent at all times through the review. Interventions: The resident prefers a bedside commode at the bedside, on the left side during the day and night while in bed, at night. Record review of Resident #1's most recent MDS State Assessment Quarterly report, dated 02/21/2025, revealed a BIMS score of 12, which indicated moderate cognitive impairment. Section G- Functional Status: I. Toilet use Limited assistance-resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance. 2. Record review of Resident #2's, undated Admission Record revealed a [AGE] year-old-female who was readmitted to the facility on [DATE]. Resident #2 had a primary diagnosis which included Transient Cerebral Ischemic Attack (also known as a mini-stroke, is a temporary interruption of blood flow to the brain that causes stroke-like symptoms that resolve within 24 hours.) Record review of Resident #2's Care Plan, dated 01/27/2025, revealed Focus: ADL Self Care. Goal: Improve current level of function in Toilet Use and Personal Hygiene. Interventions: Toilet use: requires staff x1 for assistance. Record review of Resident #2's MDS Nursing Home Quarterly, dated 02/18/2025, revealed a BIMS score of 13, which indicated cognition was intact. Section G- Functional Status: I. Toilet use Limited assistance-resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance. 3. Record review of Resident #3's, undated, Admission Record revealed a [AGE] year-old-female who was admitted to the facility on [DATE]. Resident #3 had a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD is an on-going lung condition caused by damage to the lungs.) Record review of Resident #3's Care Plan, dated 01/27/2025, revealed Focus: ADL Self-care performance deficit. Goal: will maintain or improve current level of function in through the review date. Interventions: Assist with personal hygiene as required; hair, shaving, oral care as needed. Record review of Resident #3's MDS Nursing Home Quarterly, dated 02/03/2025, revealed a BIMS score of 13, which indicated cognition was intact. Section G- Functional Status I. Toilet use- Supervision - oversight, encouragement or cueing. Observation on 02/25/2025 at 9:40 AM revealed, upon attempting to access hot water in Resident #1's bathroom by turning on the faucet, it was observed the water supply was non-operational as no water flowed through the fixture. There was standing feces in the resident's toilet , the bathroom had a strong foul odor that could be smelled outside the restroom into the resident's room with the restroom door closed . Interview on 02/25/2025 at 9:42 AM with Resident #1 revealed she did not use the restroom, she used the bedside commode. She stated direct care staff emptied the commode into the resident's toilet and then they rinsed out the basin in the restroom sink. She stated she did not use the restroom because there was no hot water. She was unable to give a timeframe for how long the hot water water was not working. She stated she did not like it because everything smells like poop. Interview on 02/25/2025 at 10:19 AM with LVN A revealed there was no hot water on the 300 hall. She stated residents had not had hot water for a few days. The specific days or weeks were unknown. Interview on 02/25/2025 at 10:25 AM with the Maintenance Director revealed, he was informed on this date (02/25/2025) the hot water was not working on halls 100, 200 and 300. He stated there was a slab leak and the hot water pump for the listed halls were not functioning properly. He stated the facility experienced two slab leaks, they were repaired and another leak happen. He stated, it's an old building . Interview on 02/25/2025 at 10:21 AM with LVN B revealed, the resident's on hall 300 did not have hot water in their rooms and she couldn't remember how long the hot water was off but stated it was longer than a week . Interview on 02/25/2025 at 12:01 PM with CNA C revealed, he was caring for the residents on hall 400 and they did not have hot water. He stated the residents scheduled for showers were taken to the shower room on hall 500. Residents who were unable to ambulate to the shower, warm water was collected in a basin and transported to the resident's room for their use. He stated he could not recall how long residents were without hot water, but it was longer than one day . Interview on 02/25/2025 at 12:10 PM with Resident #1 revealed housekeeping came and cleaned her room but did not clean the restroom. Observation on 02/25/2025 at 12:10 PM revealed standing feces in the toilet and a foul odor coming from the restroom. Observation and interview on 02/25/2025 at 12:12 PM with LVN B revealed she was alerted to the restroom by the State Surveyor. She stated this was not her resident but would assist with needs. She stated the toilet appeared to be clogged. She flushed the toilet and the water rose up in the toilet basin but the feces did not go down the drain. She stated she would alert the CNA assigned to the resident . She stated the risk of the toilet not working properly was infection control. Interview on 02/25/2025 at 12:16 PM with Housekeeper D revealed she cleaned Resident's #1's room today and the room was cleaned and mopped daily. She stated she did not go into the restroom because the resident did not use the restroom and she was unaware of the feces in the toilet. Interview on 02/25/2025 at 12:18 PM with CNA E revealed she verbally informed housekeeping of the toilet in Resident #1's room . She stated she did not empty the bedside commode in the toilet but noticed the feces in the toilet when she rinsed out the bedside commode in the sink. She stated she always cleaned the bedside commode in the sink even though there was no hot water. She stated she used cold water and soap to clean the commode and returned it to the resident's bedside. She stated she deposed the contents of the commode in a liner and immediately took it outside to the dumpster . She stated there was no risk to the resident for not having hot water. Interview on 02/25/2025 at 2:50 PM with LVN A revealed she was not aware of the clogged toilet in Resident #1's restroom. She stated there was no risk to the residents for not having hot water in their rooms because there was hot water in the building that they had access to. Observation and interview on 02/25/2025 at 3:47 PM with Resident #2 revealed, she did not have access to hot water in her restroom. She stated she had to go to another hallway to wash her hands and she did not like it. She would rather wash her hands in her restroom . Observation and interview on 02/25/2025 at 3:48 PM with Resident #3 revealed, she did not have access to hot water in her restroom for a couple of days. Observation of her restroom revealed antibacterial wipes by the sink. She stated she used the wipes to clean her hands because there is no hot water. She stated she felt dirty and disgusting . Interview on 02/25/2025 at 4:40 PM with DON revealed the water was shut off today for maintenance. She stated the residents could receive hot showers on hall 500 and CNA's provided hot water to residents who were unable to ambulate to the 500 hall. She stated the risk to the residents for not having hot water in their restrooms could be cross contamination. Interview on 02/25/2025 at 5:00 PM with the Administrator revealed she was aware the hot water was turned off for multiple days because of maintenance issues. She stated maintenance was currently working to repair the issue and restore the hot water to all residents. She stated staff should report maintenance issues such as the clogged toilet on the maintenance log. There was a QR code on each hallway where staff could report the issue. She stated she reviewed the log and it did not reveal an order for Resident #1's toilet. Record review of the Water Temperature check log, dated 05/08/24-02/20/25, revealed, weekly temperature checks of the hot water should be at least 100 to 110 degrees Celsius . The Waterlog was a spreadsheet with Halls represented by columns 1-6 and a column labeled kitchen followed by a comment section. The rows represented dates the water temperature was checked. Log revealed the water temperature log was not consistently maintained on a weekly basis, as there was a deviation in the dates recorded. On 06/04/2024and the next entry was not until 09/02/2024, the next entry was not until 12/19/2024. The following notes were made in the comment section: -12/19/2024- no hot water 1,2,3 . No temperature recorded for halls 1, 2, or 3. -12/25/2024- No hot water 1,2,3. No temperature was recorded for halls 1, 2, or 3. -01/01/2025- No hot water 1,2,3. No temperature was recorded for halls 1, 2, or 3. -01/08/2025- No hot water 1,2,3. No temperature was recorded for halls 1, 2, or 3. -01/14/2025- No hot water 1,2,3. No temperature was recorded for halls 1, 2, or 3. 01/28/2025- No hot water 1, 2, 3. No temperature was recorded for halls 1, 2, or 3. 02/06/2025- Hall 1 (81.0), Hall 2 (82.0), Hall 3 (81.1) 02/13/2025- Shut 300 water heater off . No temperature recorded for halls 1, 2, or 3. 02/20/2025- No hot water 1, 2, 3. No temperature recorded for halls 1, 2, or 3 . Record review of the plumbing repair invoice, dated 12/16/2024, revealed repaired 2 leaks on 2' water main. Record review of the plumbing invoice, dated 02/05/2025, revealed access hole concrete access 5'x5' and tunnel & backfill 6 ft tunnel initially-could be more (open estimate on tunnel length) to investigate and repair hot water leak. Record review of the facility's, undated, policy titled Resident Rights revealed, Safe Environment- the resident has a right to a safe, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide- 1. A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. 2. Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Record review of the facility's policy titled Hot Water Systems Environment of Care Policy & Procedure Manual 2003 revealed, 1. The hot water system will be checked daily for temperature variations. 2. The temperatures will be recorded on the water temperature log weekly and maintained by the Maintenance Supervisor. The facility will be responsible for maintaining at least twelve months of water temperature logs for review. 4. Water temperatures should be maintained at 100 degrees F at a minimum, and 110 degrees F at maximum. 14. The facility will make provisions to repair the hot water problem as soon as possible. Use to the areas affected by the malfunctioning unit will be restricted until repairs are complete.

FACILITY Resident Council 10/16/24 09:57 AM Omb TC: [NAME] Omb: [NAME](volunteer) Residents in attendance: [NAME]- RC President [NAME] [NAME] [NAME] [NAME] [NAME] [NAME] [NAME] [NAME] [NAME] (late arrival) Res says staff have not responded to requests/recommendations from residents or council meetings/ same req each month; per Adm res have rights unless it conflicts with her; res state no reasons being given for not responding to , when res go back they are told someone has dropped the ball and start over from sq one Grievance Rep is ADM and she is not responding per residents (per Omb grievance process is supposed to be started with SW) wait times for care 30-45 mins on average; still issues with staff spending /focusing on personal conversations and on personal cell phones during time providing res care; staff still on phones/using ear buds when providing care to res res state not always getting snacks when asked for; feel staff pick and choose what res get snacks (mostly 6p-6a shift that are choosy who they will give a snack, mostly the off crew for tonight not all staff) res state staff will be dismissive when stating their res rights are being violated, some act as though they dont have to respect the res choices and rights-- mailny 6p-6a (today's on crew is very good, respectful, the others are not!) (Day shifts generally ok) key for mail not available on saturdays? states gets from admin and she is not here on weekends to provide key to box to retrieve? nurses getting loud on night shift at nurses station with the rowdy group; no response if addressed with DON/ADM as was interrupted [NAME] states the off shift for tonight is the less professional group of staff, different culture natively and they are bring it to the building and it doesnt fit well with them (the res) concerns with SW not following through in timely manner or at all (one called SW two faced) *Omb confirmed this is something that is being worked on* (third month in a row have expressed that issues ongoing concerns are about all mgmt staff of getting back at res for filing grievances- mgrs have daily mtg on weekdays, everyone in that meeting will decide how/what they will be responding to on the day **aide came in to shower room to talk to other aide while resident in middle of shower, undressed, and they stood with door open while they had personal conversation [NAME] states overall care is good, some individuals are lesser trained and less able to deal with the elderly than some. Feels state should be holding to higher standards and have more control over things like kitchen menu/staffing (kitchen mgr/chef)/state should not be coming in and disrupting their daily routines, stated surveyors are just roaches invading their space complaints about same food different name, tired of routine, too many carbs, no variety just new names to items **grievance started with SW and where problem lies 10:45am [NAME] and [NAME] [NAME]- ADm not enough time to eval effectively, gives appearance to be willing to work with ombs, seen has gotten to know residents and individuals [NAME]- adm good attitude, willing to listen; some items resolved some not as quickly as liked, ombs need to have res consent to bring issues to facility attention and they not always give, tries to make res council when can, bringing in mgmt staff to speak to res/answers ques, hear reviews; 1 dept mgr each month going forward [NAME]- SW has been inconsistent; i.e. one case started in march and still ongoing; ombs expressed issue with getting resident consent; saw same grievances being listed on res council notes, [NAME] explained in res council mtg grievance process but there seems to be a break in follow up/follow through rec recaps of last mtg to track and remind and look at trends and what he was told; recommend checking on/follow up empl entering and exiting when res council in session

Based on interviews and record reviews the facility failed to review the risks and benefits of bed rails and enabler/grab bars (smaller bars used by the person in bed to reposition themselves), with the resident or resident representative, conduct a safety assessment, and obtain informed consent prior to installation for two (Residents #3 and #63) of six residents observed for bed rails/enabler bars. The facility failed to have an informed consent, assessment of the resident for risk of entrapment, or care planning for the safe use of bed rails/enabler bars for Residents #3 and #63. This failure could affect residents who used bed rails/enabler bars at risk of the resident/responsible party not being aware of the risks, informed consent not being obtained from the resident or responsible party, and care plan not being properly documented. Findings included: Resident #3: Observation of Resident #3 on 10/15/2024 at 9:20 AM revealed the resident asleep in a bed that was pushed against the wall of the room along the left-hand side, both half bedrails were raised. Resident did not arouse to a knock on the door, or her name being announced. Resident was observed a second time in bed asleep with both half bedrails raised on 10/16/2024 at 2:48 PM. Resident was observed a third time in bed with half bedrails raised on /17/2024 at 2:35 PM awake and briefly interviewable. Record review of Resident #3's face sheet, dated 09/24/24, reflected a [AGE] year-old, female resident with an original admitted [DATE] and most recent admitted [DATE]. Resident #3's diagnoses including: Unspecified Dementia, Moderate, with Mood Disturbance (a group of symptoms caused by disorders that affect the brain by personality changes and emotional disorders, impaired concentration, and loss of the ability to think, remember, learn, make decisions, and solve problems), Spinal Stenosis, Site Unspecified (narrowing of the spinal canal in an unspecified level of the spine), Muscle Wasting and Atrophy, Muscle Weakness (Generalized), Unspecified Lack of Coordination, History of Falling, and Cognitive Communication Deficit (difficulty with communication caused by a disruption in cognitive processes). Resident #3 was noted to receive care from a hospice agency. Resident #3 was listed to have a medical and financial power of attorney and was not her own responsible party. Record review of Resident #3's MDS, dated [DATE], reflected a Brief Interview for Mental Status assessment was not able to be completed. Resident #3's cognitive skills for daily decision making was moderately impaired and indicated to have memory problems. Resident #3's functional status reflected the resident utilized a manual wheelchair for mobility. Section P- Restraints and Alarms, reflected that no bed rail or other items were used in bed for Resident #3. Record review on 10/17/2024 of Resident #3's Care Plan updated 07/14/2024 reflected resident was a risk for falls related to dementia, muscle wasting and weakness, was at risk for wandering and at risk for alteration in comfort or pain. The Care Plan indicated a limited physical mobility related to spinal stenosis with a goal of the resident to demonstrate appropriate use of adaptive device(s) to increase mobility . Device: wheelchair. The Care Plan did not included use of bed rails/grab bars. Review of medical records from Resident #3's admitted [DATE] to 10/17/24 for Resident #3 reflected no assessment for safe use of bilateral half bed rails nor Bed Rail Consent form for the bilateral half bed rails signed by the resident or resident's responsible party or noted to have verbal permission for the bilateral half bed rails was in documented in the clinical record. Interview with Resident #3 on 10/17/2024 at 2:35 PM revealed that the resident was glad the bedrails were there as she uses them for repositioning. Resident stated she did not mind that they were half rails and not grab bars, she did not remember if there had been an assessment for safety or if she gave consent for the bed rails. Resident #63: Observation on 10/15/2024 at 9:25AM revealed the resident asleep in a bed that was pushed into the corner of the room with the left-hand side pushed against the wall of the room, head of the bed against another wall, and right side with one half bed rail raised. There was a fall matt along the right-hand side of the bed. The call light was observed looped around the bed rail in reach of the resident. Resident was also observed on 10/16/2024 at 2:08 PM lying in bed that was pushed into the corner of the room with half bed rail along the right-hand side raised. Resident was conversing with a friend who was visiting in Spanish. Resident was dressed casually. Record review on 10/17/2024 of Resident #63's face sheet reflected a [AGE] year-old, female resident who originally admitted on [DATE] and most recently on 09/02/2024. Resident #63 was noted to have diagnoses including: Unspecified Dementia, Severe, with Agitation (a group of symptoms caused by disorders that affect the brain by personality changes and emotional disorders, impaired concentration, agitation, and loss of the ability to think, remember, learn, make decisions, and solve problems; agitation can be a symptom of physical changes in the brain caused by dementia), Muscle Weakness (Generalized), Unsteadiness on Feet, Repeated Falls,. Resident #63 was noted to receive care from a hospice agency. Record review on 10/17/2024 of Resident #63's Quarterly MDS, dated [DATE], reflected Resident #63 needed an interpreter to communicate with a doctor or healthcare staff. A Brief Interview for Mental Status assessment was not able to be completed for Resident #63. Resident #63's cognitive skills for daily living was indicated as moderately impaired and indicated to have memory problems. Section P- Restraints and Alarms, reflected that no bed rail or other items were used in bed for Resident #3. Record review on of Resident #63's Care Plan updated 08/06/2024 reflected resident was a risk for falls and a risk for wandering and elopement. The Care Plan had not included use of bed rails as an intervention for any risk. Review of medical records from Resident #63's admitted [DATE] to 10/17/24 for Resident #63 reflected no assessment for safe use of bed rails completed not was there a Bed Rail Consent form for the half bed rail signed by the resident or resident's responsible party or noted to have verbal permission for the half bed rail. Interview with Visitor 1 (V1) for Resident #63 revealed that she and the resident had been close friends for over [AGE] years. V1 stated she comes to see the resident daily to make sure she was doing ok. V1 stated that the resident had had several falls since admitting to the facility. V1 stated Resident #63 was concerned about continuing to fall and that the resident felt more secure with the bedrails on the bed. V1 did not recall any assessment or the resident signing any consent for bed rails, and when V1 asked Resident #63 about an assessment or consent form the resident did not recall either having been completed with her since her admission. In an interview on 10/17/24 at 1:10 PM, the Maintenance Manager (MM) stated if a resident asked directly for bed rails the request would be forwarded to nursing and therapy for review and authorization, nursing and therapy also informed prior to a new resident being admitted if bed rails were requested. In an interview on 10/17/2024 at 1:50 PM CNA A stated bed rails/grab bars could pose a risk to a resident if the resident was not able to be safe with the bed rail/grab bar. In an interview on 10/17/2024 at 2:03 PM the ADON who stated that bed rails/grab bars were included in information in the residents' EHR for all direct care staff to see. The ADON shared that the Kardex (a quick reference system that displays information such as Care Plans, Orders, and medications by resident) was checked by direct care staff for resident information such as orders and care plans and would reflect if bed rails/grab bars were needed and why. The ADON also stated that nurses could review assessments for a resident, which should be done quarterly for bed rails/grab bars, as well as for a signed consent form. The ADON stated that when filling in on the floor and a bed was seen with bed rails/grab bars that a brief audit of the resident's care plan and assessments was done to confirm all documents were in place. When asked if information for bed rails/grab bars should be in a care plan, the ADON responded when a prompt yes. The ADON did not address why Residents #3 and #63 did not have an assessment, consent, or care plan for bed rails. In an interview on 10/17/2024 at 2:18 PM with the DON revealed that bed rails/grab bars were only used for residents to reposition while in bed and assist with ADL or other care by direct care staff. The DON stated that a resident should have an assessment and signed consent form in the EHR for the bed rails/grab bars. The bed rails/grab bars should also be care planned and have orders. The DON stated that consent forms may need verbal consent if a responsible party was not able to come to the facility to sign, if a resident was their own responsible party, they will be asked to sign the consent form and if not able to sign will obtain verbal consent and notate on the form. The DON stated if the physician orders the bed rails/grab bars as part of the admission orders, the physician will sign orders as consent. The DON stated if a resident has had bed rails/grab bars on their bed and has been using them that was considered verbal consent. The DON stated that weekly audits are completed to endure all assessments and consents have been done and are in the system, i.e., for room changes and bed rails/grab bars. The DON stated that if a resident were on hospice care and can be assessed at admission to the facility then the assessment and consent was completed as for any other resident; if the assessment is not able to be completed then bed rails/grab bars are not placed on the bed. The ADON did not address why Residents #3 and #63 did not have an assessment, consent, or care plan for bed rails. In an interview on 10/17/2024 at 2:45 PM the ADM, stated clinical staff were responsible for assessments the resident for appropriateness for bed rails/grab bars. The ADM stated if a resident was appropriate, the clinical staff were to obtain a signed consent from the resident or responsible party and ensure the bed rails/grab bars were properly care planned. The ADM indicated residents could be at risk for injury if bed rails/grab bars were on beds of inappropriate residents. Record review of the facility's provided Bed Rail policy from Restraint Mini Manual, MM RE 4-00, November 8, 2016, reflected a Policy Statement of This facility will utilize bed rails for those residents that use them for bed mobility. Further review of the Policy reflected applicable information of: The facility will attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements: o Assess the resident for risk of entrapment from bed rails prior to installation. o Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. o Ensure that the bed's dimensions are appropriate for the resident's size and weight. Assessment: o Prior to use of a bed rail the resident will be assessed to ensure the proper rail is utilized for the resident's need. o The facility will re-evaluate the use of the rail on a periodic basis o Based on the resident assessment, the interdisciplinary team (IDT) will make the determination for the plan of care as it relates to bed rails. Consent - The resident and/or resident representative will provide consent for the use of rails prior to installation.

Based on observation and interview, and record review, the facility failed to ensure a medication error rate less than 5 percent. There were 2 errors out of 26 opportunities which resulted in a 7 percent medication error rate for two (Resident #25, #30, and #37) of nine residents reviewed for medication errors. 1. CMA B administered medication Methocarbamol 500 MG belonging to Resident #30 to Resident #25. 2. LVN C did not follow manufacturer's recommendation for Lantus Insulin when she administered it to Resident #37. This failure could place residents at risk of not receiving the maximum benefit of the medication, decreases controlling conditions and overall well-being. Findings included: Error #1 During an observation of the medication pass on [DATE] at 8:12 AM revealed LVN C administered 5 units of Lantus insulin that was expired to Resident #37. Review of physician order dated [DATE] reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of diabetes with high blood sugars. The physician order reflected Insulin Glargine Solution 100 UNIT/ML Inject 5 unit subcutaneously one time a day for diabetes, which was ordered on [DATE] Observation of Medication pass and interview with LVN C on [DATE] at 8:12 AM revealed three insulin pens. Two of the insulin pens were named Humalog KwikPen with a resident's name written in black ink but no date when they were opened was written on them. The other insulin pen was Lantus with a pharmacy label dated [DATE]. LVN C stated all the insulins pens belonged to Resident #37. She took the Lantus and administered 5 units of the expired insulin pen to Resident #37. LVN C stated Resident #37 was a newly admitted resident, and she was the only one who received insulin in the secure unit. LVN C stated all 3 insulin pens were opened but she did not know when they were opened. She stated they were most likely opened on [DATE] when resident admitted During an interview on [DATE] at 08:22 AM, LVN C stated the insulins were still good because the resident had just admitted recently. She stated the long-acting insulin was good to be used for 42 days after opening and the short acting insulin was good for 28 days after opening. She stated she did not see any risk to the resident because the insulin was within the time frame since Resident #37 was newly admitted . Review of facility policy, Insulin Glargine (Lantus) revised ,d+[DATE], revealed, .Expires 28 days after initial use regardless of product storage refrigerated or room temperature . Review of facility policy tilted Pharmacy Policy & Procedure Manual revision date ,d+[DATE] read in part . Medications that require an open date as directed by the manufacturer should be dated when opened in a manner that it is clear when the medication was opened. Below is a list of medications that require a date when opening and the recommended time frame the medication should be used. This is not an all-inclusive list and the manufacturer. recommendations will supersede this list INSULINS (Vials, Cartridge, Pens) Insulin Glargine (Lantus) Insulin Glargine (Apidra) o Refrigerate until initial use o Expires 28 days after initial use regardless of product storage (refrigerated or room temperature). Review of manufacturers of Lantus SOLOSTAR Lantus.pdf revealed, read in part Lantus is a long-acting man-made insulin used to control blood sugars in adults and children with diabetes mellitus. 10 ml multiple dose vial in use (opened) 28 days refrigerated or room temperature. 3 ml single patient use Solostar prefilled pens, in use (opened) 28 days. Room temperature only . Error #2 During an observation of medication pass on [DATE] at 1:30 PM, CMA B took out and administered 2 tablet of Methocarbamol Oral Tablet 500 MG to Resident #25. Record review of Resident #25's Physician orders dated [DATE] indicated Resident #25 admitted [DATE], was [AGE] year-old female with diagnoses for chronic pain. The physician order revealed Robaxin-750 tablet (methocarbamol) give 2 tablets by mouth three times a day for pain related to other chronic pain. Record review of Resident #30's Physician order dated [DATE] indicated Resident #30 was a [AGE] year-old female admitted on [DATE], with diagnoses of falls and multiple fractures. The physician order revealed Methocarbamol Oral Tablet 500 MG Give 1 tablet by mouth every 8 hours for Spasms; give at least 1 hour apart from Oxycodone Hold for sleep/sedation. During an interview on [DATE] at 1:32 PM, CMA B stated she was nervous and did not realize that she took medication that belonged to Resident #25's roommate Resident #30. Interview on [DATE] at 2:36 PM with the DON revealed during medication pass, nurses were supposed to check the medication administration record, follow the 7 rights of medication administration , [right individual, right medication, right dose, right time, right route, right documentation and right response], and follow the medication administration record to make sure medication was not expired and it was the right dose and right person. She stated all insulins should be stored separate from stationery items due to contaminations and the risk to resident having expired insulin was insulin potency/strength. In an interview with the administrator on [DATE] at 3:42 PM, she stated she expected nursing staff to follow medication rights to administration (right patient, right name, right route, right time, right dose). She stated all nurses were responsible for making sure medications were dated and labeled with resident's names. She stated the DON and ADON were responsible for monitoring medication policies were being adhered to by nursing staff. Review of facility undated policy titled Liberalized Medication Policy, did not reflect medication errors.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one (Resident #37) of nine residents reviewed for pharmacy services. The facility failed to ensure LVN C did not administer expired insulin to Resident #37 on [DATE] that had expired on [DATE]. These failures could place residents at risk for altered medications due to being expired and could result in residents not receiving the intended therapeutic effects of their medications causing a health decline. Findings included: Review of Resident #37's factsheet dated [DATE] revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her secondary diagnoses included type 2 diabetes mellitus with hyperglycemia (uncontrolled high blood sugars), and high blood pressure. Review of Resident #37's orders dated [DATE] reflected current orders for the following: *Insulin Glargine Solution 100 UNIT/ML Inject 5 unit subcutaneously one time a day for diabetes. Active order dated [DATE]. Started [DATE]. [long-acting insulin] *Humalog Kwik Pen Subcutaneous Solution Pen injector 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 151 - 200 = 3 units; 201 - 250 = 6 units; 251 - 300 = 9 units; 301 - 350 = 12 units; 351 - 450 = 16 units, subcutaneously before meals and at bedtime for dm. Active order dated [DATE]. Started [DATE]. [short-acting/ fast-acting insulin] Review of Resident #37's admission MDS dated [DATE], revealed a BIMS score of 99 indicating resident was unable to complete due to severe cognitive impairment. MDS indicated Resident #37 had long term and short-term memory problems and she had severe impaired cognitive skills for daily decision making. Observation of Medication pass and interview with LVN C on [DATE] at 8:12 AM revealed three insulin pens. Two of the insulin pens were named Humalog KwikPen with a resident's name written in black ink but no date when they were opened was written on them. The other insulin pen was Lantus with a pharmacy label dated [DATE]. LVN C stated all the insulins pens belonged to Resident #37. She took the Lantus and administered 5 units of the expired insulin pen to Resident #37. LVN C stated Resident #37 was a newly admitted resident, and she was the only one who received insulin in the secure unit. LVN C stated all 3 insulin pens were opened but she did not know when they were opened. She stated they were most likely opened on [DATE] when resident admitted . In an interview with LVN C on [DATE] at 8:22 AM, she sated she did not know who placed the office stationery items in the same basket as the insulins. She stated she did not know who had opened the three insulins, two of which were the same insulin with no date and all insulins should have residents' names on them. LVN C stated the insulins were still good because the resident had just admitted recently. She stated the long-acting insulin was good to be used for 42 days after opening and the short acting insulin was good for 28 days after opening. She stated she did not see any risk to the resident because the insulin was within the time frame since Resident #37 was newly admitted . LVN C stated the insulin was obtained from the facility's pharmacy when Resident#37 was admitted . LVN C stated insulin should be separated from office supplies because of cross contamination to the insulins. In an interview with the ADON on [DATE] at 12:20 PM, she stated all insulins should be dated with opening date and they should have the residents' names on them. She stated insulins should be kept in a clean container/basket free of pens, markers, rubber bands, paper clips and other stationary items. She stated the nurses were responsible for making sure that the insulin was dated when it was opened and not expired. The ADON stated herself and DON did random medication carts audits, however each nurse was ultimately responsible for their med carts. She stated not having the opening date on the insulin can cause confusion not knowing if the insulin was good. She stated the risk to the resident was insulin potency which could cause not achieving the desired medication outcome. In an interview with the DON on [DATE] at 2:36 PM, she stated she had already started to in-servicing on medication and the ADON had removed all the expired insulins out of the nurse med cart. She stated, she expected nursing staff to date the insulin at the time of opening them. She stated the ADON was responsible for weekly med cart audits, and she (DON) did monthly med cart audits, and the pharmacist did monthly medication cart audits upon request, so she was not sure how it was missed. She stated all insulins should be stored separate from stationery items due to contaminations and the risk to resident having expired insulin was insulin potency/strength. In an interview with the Administrator on [DATE] at 3:42 PM, she stated she expected nursing staff to follow medication storage policies. She stated all nurses were responsible for making sure medications were dated and labeled with resident's names. She stated the DON and ADON were responsible for monitoring medication policies were being adhered to by nursing staff. Review of facility policy tilted Pharmacy Policy & Procedure Manual revision date ,d+[DATE] read in part . Medications that require an open date as directed by the manufacturer should be dated when opened in a manner that it is clear when the medication was opened. Below is a list of medications that require a date when opening and the recommended time frame the medication should be used. This is not an all-inclusive list and the manufacturer. recommendations will supersede this list. INSULINS (Vials, Cartridge, Pens) Humulin R, N, ,d+[DATE] and Mix Humalog and Humalog Mix Humalog FlexPen ,d+[DATE] and ,d+[DATE] pens expire 10 days after opening. Novolog and Novolog Mix Insulin Glargine (Lantus)

Based on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 4 medication carts (nurse med cart) reviewed for labeling and storage. 1.The facility failed to date and remove expired insulin from the nurse medication cart in the secure unit. 2. The facility failed to ensure that 3 insulin pens were stored separate from office stationery materials pens, markers, paper clips and rubber bands. These failures could place residents at risk for altered medications due to being expired, exposure to unsanitary storage conditions and could result in residents not receiving the intended therapeutic effects of their medications causing a health decline. Findings included: Review of Resident #37's factsheet dated [DATE] revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her secondary diagnoses included type 2 diabetes mellitus with hyperglycemia (uncontrolled high blood sugars), and high blood pressure. Review of Resident #37's orders dated [DATE] reflected current orders for the following: *Insulin Glargine Solution 100 UNIT/ML Inject 5 unit subcutaneously one time a day for diabetes. Active order dated [DATE]. Started [DATE]. [long-acting insulin] *Humalog Kwik Pen Subcutaneous Solution Pen injector 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 151 - 200 = 3 units; 201 - 250 = 6 units; 251 - 300 = 9 units; 301 - 350 = 12 units; 351 - 450 = 16 units, subcutaneously before meals and at bedtime for dm. Active order dated [DATE]. Started [DATE]. [short-acting/ fast-acting insulin] Review of Resident #37's admission MDS dated [DATE], revealed a BIMS score of 99 indicating resident was unable to complete due to severe cognitive impairment. MDS indicated Resident #37 had long term and short-term memory problems and she had severe impaired cognitive skills for daily decision making. Observation of Medication pass and interview on [DATE] at 8:12 AM revealed LVN C was passing medications and checking blood sugars using the nurse med cart. Blood sugar reading for Resident #37 was 127. LVN C stated she would administer 5 units of insulin to Resident #37. She opened the top drawer, and it revealed a 2X6 small white basket. Inside the small white basket were three insulin pens, 3 black permanent markers, 2 ink pens, 3 tan colored rubber bands and 2 paper clips all inside the same basket. LVN C started to remove the markers, pens, rubber bands, and paper clips from the basket with the insulins stating, these should not be in here. The 2 of the 3 insulin pens were undated. Two of the insulins' pens were named Humalog KwikPen with a resident's name written on them with no date when they were opened. The other insulin pen was Lantus with a pharmacy label dated [DATE]. LVN C stated all the pen insulins belonged to Resident #37. She took the Lantus and administered 5 units of the expired and contaminated insulin pen to Resident #37. LVN C stated Resident #37 was a newly admitted resident, and she was the only one who received insulin in the secure unit. LVN C stated all 3 insulin pens were opened but she did not know when they were opened. She stated they were most likely opened on [DATE] when resident admitted . In an interview with LVN C on [DATE] at 8:22 AM, she sated she did not know who placed the office stationery items in the same basket as the insulins. She stated she did not know who had opened the three insulins, two of which were the same insulin with no date and all insulins should have residents' names on them. LVN C stated the insulins were still good because the resident had just admitted recently. She stated the long-acting insulin was good to be used for 42 days after opening and the short acting insulin was good for 28 days after opening. She stated she did not see any risk to the resident because the insulin was within the time frame since Resident #37 was newly admitted . LVN C stated the insulin was obtained from the facility's pharmacy when Resident#37 was admitted . LVN C stated insulin should be separated from office supplies because of cross contamination to the insulins. In an interview with the ADON on [DATE] at 12:20 PM, she stated all insulins should be dated with opening date and they should have the residents' names on them. She stated insulins should be kept in a clean container/basket free of pens, markers, rubber bands, paper clips and other stationary items. She stated the nurses were responsibly for making sure that the insulin was dated when it was opened and not expired. The ADON stated herself and DON did random medication carts audits, however each nurse was ultimately responsible for their med carts. She stated not having the opening date on the insulin can cause confusion not knowing if the insulin was good. She stated the risk to the resident was insulin potency which could cause not achieving the desired medication outcome. In an interview with the DON on [DATE] at 2:36 PM, she stated she had already started to in-servicing on medication and the ADON had removed all the expired insulins out of the nurse med cart. She stated, she expected nursing staff to date the insulin at the time of opening them. She stated the ADON was responsible for weekly med cart audits, and she (DON) did monthly med cart audits, and the pharmacist did monthly medication cart audits upon request, so she was not sure how it was missed. She stated all insulins should be stored separate from stationery items due to contaminations and the risk to resident having expired insulin was insulin potency/strength. In an interview with the administrator on [DATE] at 3:42 PM, she stated she expected nursing staff to follow medication storage policies. She stated all nurses were responsible for making sure medications were dated and labeled with resident's names. She stated the DON and ADON were responsible for monitoring medication policies were being adhered to by nursing staff. Review of facility policy tilted Pharmacy Policy & Procedure Manual revision date ,d+[DATE] read in part . Medications that require an open date as directed by the manufacturer should be dated when opened in a manner that it is clear when the medication was opened. Below is a list of medications that require a date when opening and the recommended time frame the medication should be used. This is not an all-inclusive list and the manufacturer. recommendations will supersede this list. INSULINS (Vials, Cartridge, Pens) Humulin R, N, ,d+[DATE] and Mix Humalog and Humalog Mix Humalog FlexPen ,d+[DATE] and ,d+[DATE] pens expire 10 days after opening. Novolog and Novolog Mix Insulin Glargine (Lantus) Insulin Glargine (Apidra) o Refrigerate until initial use o Expires 28 days after initial use regardless of product storage (refrigerated or room temperature).

Based on observations, interviews, and record review the facility failed to provide radiology or other diagnostic services to meet the needs of its residents in a timely manner for 1 (Resident #1) of 3 residents reviewed for radiology services. The facility failed to follow up on Resident #1's x-ray results in a timely manner. The facility failed to follow up on x-ray results that revealed a fracture of the right tibial plateau. Resident #1 was sent to hospital on 05/13/2024 at 10:10 am. The noncompliance was identified at PNC. The Immediate Jeopardy (IJ) began on 05/12/2024 and ended on 05/15/2024. The facility had corrected the noncompliance before the survey began. These failures resulted in delayed diagnosis, medical treatment, and hospitalization . Findings included: Review of Resident #1's admission record, dated 06/05/2024, revealed a [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis of Alzheimer's Disease. Review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS score of 3, indicating severe cognitive impairment. Review of Resident #1's care plan, dated 05/13/2024, revealed the resident was at risk for falls - aimlessly wandering. Interventions included anticipate and meet the resident's needs, ensure the resident was wearing appropriate footwear when ambulating or mobilizing in w/c, and keep needed items, water, etc. within reach. Review of Resident #1's nurse note dated 05/12/2024 at 1:15 pm, written by LVN A, reflected Resident c/o pain on right knee, upon assessment noted right knee slightly swollen and tender to touch, Clinician on call notified via phone call, assessment done via video call, new order received for right knee xray and ultrasound and both ordered. Awaiting on the xray and ultrasound. Review of Resident #1's nurse noted, dated 05/12/2024 at 4:55 pm, written by LVN A, reflected Xray of right knee done, RP notified via phone call. Review of Resident #1's nurse note dated 05/13/2024 at 10:42 am, written by the DON, reflected In the course of reviewing nursing documentation, the DON saw that the resident complained of right knee pain which was assessed and seen to be slightly swollen, MD notified, x-ray and ultrasound ordered. The xray results came in 5/13/24 indicating resident has a suspicious metadisphyseal longitudinal fracture of the medial tibial condyle extending into the intercondylar notch. This nurse notified the MD with the result and order received to sent the resident out to the hospital. Nurse administered Tylenol 650, notified RP, and Administrator of the fracture. Resident sent to the ER for evaluation and treatment related to suspicious fracture. Review of Resident #1's nurse note dated 05/13/2024 at 2:55 pm, written by LVN B, reflected Resident returned from Hospital with the Dx: of a closed fracture of the right tibial plateau. The Resident was transferred back into bed. The resident has a brace noted on the right leg. New Order to follow-up with an orthopedic MD given. The PCP aware of the resident's return. No medication changes at this time. Will continue with the plan of care. Review of facility's Provider Investigation report for Resident #1, dated 05/13/2024, revealed the following: Resident complained of pain to her right knee. Right knee swollen and slightly inflamed, no bruising. Physician notified, order for x-ray obtained. Nurse gave resident 2 tablets of Tylenol 325 mg for pain. No bruising around knee, slightly inflamed with some redness. X-ray showed fracture of the medial tibial condyle with extension into the intercondylar notch. When x-ray report was received resident sent to hospital. Hospital sent resident back with an immobilizer on her knee and an order to see orthopedic doctor. Nursing staff obtained orders from physician for pain medication, no weight bearing to right leg, pain assessment every shift, right leg to be in immobilizer at all times, and to keep leg elevated when in wheelchair. Physician, family, DON and Administrator notified of injury. Quality of Life Rounds done by Social Worker in the secure unit. [Resident #1] could not say how she received her fracture. Interviews with staff and residents on the secure unit did not reveal how resident obtained injury. Camera footage of the unit was reviewed for the unit and did not show how resident obtained her injury. Resident does not have a history of falls. In an interview on 06/05/2024 at 9:19 am, the DON stated Resident #1 complained of leg pain. They did an x-ray, the results were delayed, and when the results came in, she realized Resident #1 had a fracture. The DON stated the results were delayed probably 8 hours and she saw the results the next day around 9 am. When asked why the results were delayed, the DON stated communication with the x-ray company. She said they always fax results but did not this time. She said staff have access to the results (through a portal) but if they were critical, the x-ray company was supposed to fax, call, and if no answer from the facility they were supposed to call the DON's cell phone. In an interview on 06/05/2024 at 10:30 am, the DON stated she was in the process of getting a new imaging company after the incident with Resident #1. She stated in-services with the staff were completed on stat x-rays. She stated if the x-ray was not completed within 4-5 hours, the nurse was to notify the doctor who may send the resident out to the hospital. The DON stated the night nurse, RN F, did not call the x-ray company to follow up and communicated to follow up in the morning to the nurse. The DON stated she in-serviced RN F that she was supposed to call the x-ray company about the result or call the doctor to say she did not get any report. Observation on 06/05/2024 at 11:31 am in the secure unit revealed Resident #1 well groomed and dressed sitting up in her wheelchair in the hallway outside of her room. Resident #1's right leg had an immobilizer and was elevated. Resident #1 stated she was not in any pain and did not know how her knee was injured. In an interview on 06/05/2024 at 2:16 pm, the DON stated they did not have a written policy on x-ray services. She stated they follow the change of condition policy, and depending on what it was, if x-rays were needed, they followed the procedures based on the change of condition. Attempted interview on 06/05/2024 at 2:24 pm with RN F was unsuccessful, a voicemail was left. In an interview on 06/05/2024 at 2:53 pm, LVN B stated she was in-serviced on change of condition. She stated if a stat lab/x-ray was ordered, the time frame to check, and call them to follow up. She stated if a stat x-ray was ordered the company would usually come out in 1-4 hours and the results would be available within 1-2 hours. LVN B stated she was in-serviced because a resident on the secure unit had a fractured leg, and they did not know why the injury occurred. LVN B stated if x-rays were ordered on her shift and the x-ray company had not come out, or the x-ray was completed but no results were faxed or called in to the facility, she stated she would call the x-ray company to follow up and notify the MD and the DON. She stated especially if a resident continued to have a change of condition, they would be sent out. LVN B stated she had come in on Monday (05/13/2024) and was told that Resident #1's x-rays were done but results were not posted. She said the ADON had come back to the unit with the results around 9 am. LVN B said when she came in on Monday, Resident #1 just was not moving as much. She stated Resident #1 was normally very mobile, walked, bends over, and tried to clean things everywhere so it was weird for her to not move. She said Resident #1 was not able to verbalize her needs and was pretty depressed the first week or two [after the injury] but was perking back up now. In a telephone interview on 06/05/2024 at 3:34 pm, LVN C stated she was in-serviced on stat x-rays. She stated if they were not completed timely, she would call the x-ray company, let the next nurse know, and inform the doctor. LVN C stated if a resident's x-ray was completed on her shift she would check the fax, or the portal. She stated if results were not received timely, she would call the x-ray company to see what was going on, inform the DON, and let the doctor be aware. She stated the nurse on shift was responsible and the DON or anyone could follow up for the results. She stated the risk was the patient could have an injury. In an interview on 06/05/2024 at 3:49 pm, RN E stated if x-rays or labs were ordered on her shift and they were not done or no results were received she would contact her supervisor, and handover to the next shift. She stated if stat x-ray was done on a resident during her shift and no result was received, she would contact the doctor. RN E stated they could be in pain, or injury if not treated. In an interview on 06/05/2024 at 3:59 pm, LVN D stated she had been in-serviced on x-rays because someone that fell on the [secure] unit. LVN D stated she was in serviced on stat orders and said if it was an emergency like a suspected fracture, she would put in the order stat, and contact the x-ray company if they were not there timely. She stated she was supposed to contact the doctor if the stat x-ray was not done within 4 hours. LVN D stated the nurse checked the fax for results and notify the doctor if the x-ray was done on their shift. LVN D stated if the results were not received timely the resident could be in pain and it could delay treatment. In a telephone interview on 06/05/2024 at 4:49 pm, the Regional Director of Operations for the x-ray company stated the order came in for Resident #1 on 05/12/2024 at 1:08 pm as a routine study. She stated images were uploaded at 4:39 pm and results were read [by the radiologist] at 6:46 pm. She stated they did not get an answer when they called the facility that evening on 05/12/2024. She stated there was a timestamp on 05/13/2024 at 9:54 am where an agent spoke with a nurse (the ADON). She stated the results were faxed usually right when it was read by the radiologist. She stated the facility also had access to their database (where results can be retrieved). In an interview on 06/06/2024 at 9:43 am, LVN A stated she was in-serviced on stat x-rays and the timeframe to follow up. She stated if a stat x-ray was ordered, and the x-ray had not been done then contact the doctor and the DON. She said if the x-ray had been done and results were not received, she would call the x-ray company, and check the portal. LVN A stated if the resident had a broken bone, they would need to go to the hospital. She stated the nurse was responsible to check the results and all nurses have access to the portal. LVN A stated it there was an abnormal lab or x-ray, the company was supposed to call with a critical lab or critical anything. In an interview on 06/06/2024 at 10:08 am, when asked what the risk to the resident was, the DON stated Resident #1 was monitored and pain medicine was given. The DON stated pain was not severe like crying. When Resident #1 went to the hospital, she was not prescribed pain medicine, so they contacted the doctor after she returned, and Resident #1 was prescribed Tylenol 3 to manage pain for the injury. The DON stated nurses and herself were responsible but not one person it was the team. She said they had conversations of changing the x-ray company, and they already had a new lab company as of 06/03/2024. In an interview on 06/06/2024 at 10:08 am, the Regional Compliance Nurse stated they had put a plan in place and an issue could arise if not addressed. She stated they could have continued to have a timeliness issue and pain was not an issue since Resident #1's pain was addressed. She said they had to give a 30-day notice for the new x-ray company. Attempted interview on 06/06/2024 at 10:48 am with RN F was unsuccessful, a voicemail and text message were left. In a telephone interview on 06/06/2024 at 1:07 pm, RN F stated on her shift Resident #1's x-ray was already done, the result was pending, and she handed off to the oncoming nurse. She stated the x-ray company did not call her, and she was not informed of any results. She said the x-ray company was supposed to call if any problem. RN F stated LVN A already documented in [EHR name] and there was nothing new, so she did not document about the pending result, she just informed the oncoming nurse (LVN B). RN F stated she was in-serviced on 05/15/2024 on following up on x-ray and lab results. She stated if any abnormality the x-ray company was supposed to call her. She stated if she got the report that indicated a fracture, she was supposed to notify the MD, the DON, the RP and if any orders, to send to the hospital. RN F stated she knows to check the portal for any results and document the status in [EHR name]. Record review of in-services dated 05/13/2024, on the topic of Injuries of unknown origin imaging request reflected the following: All falls and injury related imaging request must be entered as STAT orders. Notify the MD if the stat orders have not been performed after 4 hrs and request if there can be a change of plan for example sending the resident to the hospital. Record review of in-services dated 05/13/2024, on the topic of Reviewing imaging and laboratory results reflected the following: Review imaging and laboratory results obtained during your shift and notify the MD, the DON, and the RP with the results. Follow up on labs and imaging ordered prior to your shift and during your shift for results and communicate with the next shift on all new orders received. Record review of in-services dated 05/13/2024, on the topic of Injuries of unknown origin and change of condition reflected the following: Notify the Administrator immediately if a resident is found with an injury of unknown origin. Notify the MD, the DON and the RPs of all injuries to a patient and any change of condition. Record review of in-service dated 05/13/2024, signed by RN F, on the topic of Following up and checking on imaging and labs results ordered reflected the following: Following up on imaging and labs results ordered during your shift and on the prior shift and notified the MD, the RP, and the DON of all abnormal results and document in [EHR Name]. Follow up on all new and prior laboratory imaging and medication orders and document in [EHR Name] the result status. Check the laboratory and imaging portal results that were performed prior to your shift and within your shift and notify the MD, the RP and the DON of the results and status documented in [EHR Name]. Notify the MD immediately and document recommendations in [EHR Name] of all abnormal results, during shift change always give report on the results or pending results, pending collection and those performed of all imaging laboratory orders to the oncoming nurse. Check the result tab in [EHR Name] for all residents within your shift and report abnormal results to the MD. Check the imaging portal for all outstanding results. Record review of policy titled Notifying the Physician of Change in Status revised March 11, 2023, reflected in part: The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgment deem it necessary for immediate medical attention. This facility utilizes the INTERACT tool, Change in Condition - When to Notify the MD/NP/PA to review resident conditions and guide the nurse when to notify the physician. This tool informs the nurse if the resident condition requires immediate notification of the physician or non-immediate/Report on Next Workday notification of the physician. 1. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record .9. Faxes should be following up by the end of the business day .11. Abnormal lab, x-ray and other diagnostic reports require physician notification.

Based on observation, interview, and record review, the facility failed to ensure the resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for one (Resident #1) of seven residents reviewed for call lights. The facility failed to ensure Resident #1's call button was placed within reach. This failure could place dependent residents at risk of injuries and unmet needs. The findings included: Record review of Resident #1's face sheet, dated 05/23/2024, reflected a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included, anoxic brain damage (lack of blood flow to brain tissue, results from poisoning such as drug overdose), disruption of traumatic injury wound repair, subsequent encounter (injury, poisoning and certain other consequences of external cause), hyperlipidemia (elevated level of lipids, like cholesterol in the blood), Tracheostomy status (the presence of a tracheostomy), and Type 2 diabetes (a problem in the way the body regulates and uses sugar as fuel). Record review of resident #1's quarterly MDS Assessment, dated 04/12/2024 reflected no record of Resident #1's BIMS. Cognitive patterns included memory problems and severely impaired cognitive skills for daily decision making. He was always incontinent of bowel and bladder and dependent for toileting, showers, and transfers. He had a feeding tube. Record review of Resident #1's care plan, dated 02/05/2021, reflected the following: Focus: [Resident #1] has a Tracheostomy and is at for altered respiratory status/Difficulty Breathing/Shortness of Breath. Intervention: Monitor/document level of consciousness, mental status, and lethargy PRN. Provide means of communication and procedural information. Reassure that help is available immediately. Focus: [Resident #1] requires supplemental oxygen via Tracheostomy r/t Ineffective gas exchange. Intervention: Provide reassurance and allay anxiety: Have an agreed-on method for the resident to call for assistance (e.g., call light, bell). Stay with the resident during episodes of respiratory distress. Focus: [Resident #1] is risk for falls. Intervention: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs a safe environment with: (Specify: even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; handrails on walls, personal items within reach) Focus: [Resident #1] has a communication problem r/t anoxic brain damage. Intervention: Ensure/provide a safe environment: Call light in reach . An observation and attempted interview on 05/23/2024 at 9:30 AM revealed Resident #1 in bed. Resident #1 had a tracheostomy, feeding tube, and oxygen. Resident #1's call button (pad) was on the dresser beside the bed and not accessible to him. Resident #1 did not answer questions this surveyor asked about the call button. In an interview on 05/23/2024 at 9:56 AM, LVN A stated Resident #1 did not speak but could move his hands. She said he did not use the call button, but it should be placed on the bed beside him, so he had access to it. She said he did not have access to the call button when it was on the dresser beside his bed. She said it was all staff's responsibility to ensure call lights were within reach for all residents. She said it was resident's right to be able to call for assistance when they required it. An interview on 05/23/2024 at 10:00 AM, with the DON and Administrator, the DON stated all residents should have access to their call light. She said although Resident #1 never used his call light, it should be placed where he had access to it. She said all staff were responsible to ensure resident's call lights were placed in their reach to ensure they could call for assistance if they needed to. The Administrator stated he expected staff to check for call light placement throughout the day to ensure residents could call for assistance. In an interview on 05/23/2024 at 10:57 AM, CNA B said she placed Resident #1's call pad on the dresser when she was providing care to him earlier in the morning. She said she forgot to place it beside him in bed when she left the room. She stated Resident #1 had a call pad and it should be placed beside him in bed because he could roll onto it to call for assistance as needed. She stated he rarely used the call pad but it was his right to have it accessible to him. She said all staff were responsible to ensure call lights were placed for all residents. In an interview on 05/23/2024 at 12:05 PM, the Corporate Compliance Nurse stated she expected call light to be accessible to all residents no matter their ability to use them. She said residents had a right to call for assistance if they felt they need it. She said all staff were responsible to ensure call lights were placed and accessible to residents. Record review of the facility's undated policy, titled, Resident Rights, reflected, The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy. Respect and Dignity: 3. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.

Based on observations, interviews, and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 6 residents (Residents #1) reviewed for abuse. The facility failed to protect Residents #1 from neglect when they failed to provide the necessary care devices to prevent injury from a fall. Resident #1 had a history of subdural hemorrhage with brain injury and a previous order for a fall mat. The CNA was aware the fall mat was missing and Resident #1 experienced convulsions/seizures resulting in a fall. Resident #1 sustained a skin tear from the fall. These failures could place residents at risk of abuse and neglect, serious injury, serious harm, serious impairment, pain, mental anguish, or death. On 02/28/24 at 3:38 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 02/29/24 at 3:52 PM, the facility remained in compliance at a severity level of no harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. Findings included: Record review of Resident #1's face sheet dated 02/27/24 reflected he was a [AGE] year-old male admitted initially on 06/23/23 and again on 02/23/24 DX included: Traumatic Subdural Hemorrhage with loss of consciousness (brain injury) of unspecified duration, HX of Subsequent Encounter Conversion Disorder with seizures or convulsions (conversion disorder is a condition in which you have physical symptoms but no injury or illness to explain seizures). Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS score of 0 indicating severely impaired cognition- nonverbal, Section K feeding Tube, Section M stage 4 wound documented and being treated with ointments and medication, including diet, Section N Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin), Section O no treatments. Pain unable to answer. Record Review of Resident #1's Care plan dated 12/01/23 reflected he has a resident is at risk for falls r/t traumatic subdural hemorrhage neuromuscular dysfunction and chronic respiratory failure. Record Review of PN dated 2/25/2024 at 7:07 AM by LVN A reflected '[company name]'was notified '[Resident #1's fall and injuries]' and will send a nurse down to assess pt . Record review of Resident #1's PN dated 02/26/24 at 08:47 AM by the DON reflected X ray to the forehead and facial bones shows no obvious fracture. Nursing will continue to treat skin per standing orders. Record review of Resident #1's PN/MD BY MD O note dated 02/26/24 12:55 AM, reflected Date of Service: 02/26/2024 Visit Type: Follow Up Transition of Care: No transition occurred. Details: This is a copy of a signed encounter note documented in Chief Complaint / Nature of Presenting Problem: Review x-ray result .Neurology discussed MRI and EEG results with FM that since patient has not shown improvement clinically from a neurological standpoint. Patient will have to continue with current supportive care treatment .Reviewed. Nursing Staff: Reviewed x-ray result Patient: Limited by cognition. Patient had a fall over the weekend. X-ray reviewed and no fracture. Patient had a small skin tear. Wound care is already following. Observation of Resident #1 on 02/27/24 at 11:00 AM and 02/28/24 at 8:15 AM revealed resident to be lying in bed, head of bed raised, feeding tube operating, both bags were dated, eyes closed, and a fall mat on the floor. Resident was observed to have two healing stage skin injuries to the forehead. Resident was not interviewable. In an interview on 02/27/24 at 3:09 PM, with CNA J revealed on 02/25/24 at 6 PM she arrived to work and conducted rounds every 2 hours or less. CNA J stated that she sat adjacent to Resident #1's room due to his history of falls and seizures. CNA J stated she was familiar with Resident #1's care and knew he required bed in low position, call light near, and fall mat next to bed. CNA J stated she did not notify the head nurse that the fall mat was missing. CNA J had conducted rounds on resident 15 minutes prior him falling at 4:40 AM on 02/25/24. CNA J said at 5:00 AM she heard him hit the floor and entered immediately, called for nurse, and remained until nurse arrived. CNA J stated Resident #1 was bleeding from skin tears located on his bed. CNA J said Neglect of a Resident was failing to provide the Resident with care and identified and scheduled by MD. CNA J said the fall mat would have prevented the injuries that Resident #1 sustained from the fall. In an interview with the DON on 02/27/24 3:38 PM she stated that she was contacted by LVN A on 02/25/24 at 6:40 AM via video call to assess the resident. Reporting that Resident#1 fell out of the bed on the floor and had skin tears with blood on his forehead. The DON stated Resident #1 has fall prevention precautions in place to prevent falls, related to convulsing like seizures. The DON stated the cause of the fall was possibly due to him coughing and convulsing, like a seizure, resulting in falling on the floor and gaining injuries. She said the fall mat was not in place on the day of the incident. The DON said on 02/23/24 the day of re-entry, LVN I was working the 6 PM-6 AM shift and was not familiar with the resident's care and orders, and failed to ensure the fall mat was in place. The DON stated the rounding nurses and aides did not ensure the resident's fall mat was in place during shifts on 02/23/24, 02/24/24, and 02/25/24. The DON stated that the mat should have been in place, and she expects nursing to review MD orders, care plans, and assessments to ensure the residents are receiving care consistent with their needs and orders . DON said failing to provide Resident #1' fall mat per MD orders was neglect, and the staff working on that day confirmed observation of the missing fall mat, however, it was not implemented for his safety. In an interview on 02/28/24 at 9:33 AM RN J stated upon arriving and completing shift change reports on 02/25/24 at 6 AM she was notified by LVN E that Resident #1 had fallen and had injuries to the forehead. RN J said there were no other details provided. RN J proceeded to Resident #1's room and she observed injuries to his forehead. She then cleaned the blood off of his forehead, applied Tiple Antibiotic Ointment to his forehead, and took Resident #1's vital signs. RN J said the fall mat was not on the floor next to the bed. RN J called the MD, the DON, and his family to report the incident. RN J does not know the details of the fall, as it was not provided, and she did not ask additional questions. RN J said the DON arrived at the facility on 02/25/24 at 4:30 PM and the '[company name]'nurse arrived at 5:00 PM. Both assessed the resident and the DON ordered X-rays . RN J stated that she did not review Resident #1's orders the day of the incident. The DON and '[company name]' nurse placed a fall mat on the floor upon arrival. RN J said X-rays were negative for fractures. In an interview on 02/28/24 at 10:28 AM with LVN W revealed the readmission process included taking patient vital signs, skin assessment, review medications and orders to see if orders changed. Nurses should notify the MD and confirm resident orders upon readmission to assure notification of orders and to determine if there was a need to change or follow up on returned orders. In an interview with RN HN nurse on 02/28/24 at 10:55 AM revealed Resident #1 was admitted to '[company name]' at the hospital prior to discharge on 02/24/24. RN HN stated that the facility nurse called '[company name]' on call line to report the incident, and the on-call nurse reported she would be out to assess. RN HN said the on-call report stated Resident #1's fall on 02/25/234 at 6:26 AM. LVN A called and stated he had fallen on the floor from his bed, sustaining injuries to his forehead, no discomfort or distress. RN HN said Resident # 1's first care encounter at the facility was on Monday (02/27/24). She ordered Bolster's (a long thick pillow that is placed under the pillow for support.) for his bed (when sitting up he aspirates/coughs during tube feeding and he moves forward.) She placed the fall mat on 02/25/24 after the fall. She was not aware of the fall mat orders prior to intake to '[company name]'. In an interview on 02/28/24 at 1:04 PM with LVN S, she stated that she arrived on 02/23/24 at 7:00 PM and Resident #1 had been readmitted . She conducted vital signs and completed a skin assessment. She was not familiar with his care. She reviewed his orders. However, she did not recall an order for a fall mat. LVN S stated the mat was present when she arrived, and Resident #1 had no injuries. LVN S said it was important to review orders and ensure the mat was down to prevent injuries from falls or lessen the injuries. LVN S was trained after the incident by the DON on admission assessment, orders, fall precautions, and reviewing of the MD orders. Record review of policy titled Abuse/Neglect dated 03/29/18 reflected The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation This includes but is not limited situations that may constitute abuse or neglect to any resident in the facility. Neglect: is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility will train through orientation and on-going in-services on issues related to abuse/neglect prohibition practices regularly . Investigations will be reviewed by the facility administrator and/or Abuse Preventions within 24 hours of complaint. Appropriate notification to state and home office will be the responsibility of the administrator and per policy. The facility will designate an Abuse Preventions to monitor tracking and trending data and completion of investigations as needed. The facility will be responsible to identify, correct, and intervene in situations of possible abuse/neglect. The facility has in place a method to identify events such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse. All occurrences of potential abuse will be investigated by the Abuse Preventions and/or designee and a comprehensive investigations will be the responsibility of the administrator and/or Abuse Preventions All allegations of abuse, will be investigated. This was determined to be an Immediate Jeopardy (IJ) on 02/28/24 at 3:38 PM The ADM, DON, and CRN were notified. The ADM was provided with the IJ template on 02/28/24 at 3:43 PM. The following Plan of Removal submitted by the facility was accepted on 02/29/24 at 9:10 AM . Plan of Removal was accepted on 02/29/24 at 11:23 AM. Free from Neglect Statement: The facility failed to ensure Resident #1 was free from abuse and neglect in that: Resident #1 was found on the floor in his room on 2/25/24 at 6:47 am by CNA J. Interventions: 1. Resident # 1 was transferred to the hospital as of 2/28/24 for evaluation. 2. The Charge Nurse and CNA that cared for resident #1 on the shift he sustained the fall was in-serviced 1:1 by the DON and Regional Compliance Nurse on: a. Fall Prevention Strategies (ensuring fall mats are in use) b. Abuse and Neglect Policy to include ensuring safety devices are in place. c. Kardex: how to use to determine if a fall mat is required for a resident. 3. An audit was performed by the Regional Compliance Nurse and the DON for all residents who require a fall mat on 2/28/24 to ensure that they are in place. 4. The medical director was notified of the immediate jeopardy citation on 2/28/24 by the Director of Nursing. 5. An ADHOC QAPI meeting was held on 2/28/24 with the IDT Team to include the medical director to discuss the immediate jeopardy and plan of removal. In-services: The following in-services were initiated by the Administrator, the DON, and Regional Compliance Nurse on 2/28/24 for all Charge Nurses. All Charge Nurses, not present on 2/28/24, will be in-serviced prior to the start of next shift. All new hires will be in-serviced during orientation. All agency staff will be in-serviced prior to the start of their shift. o Fall Prevention Strategies (ensuring fall mats are in use) o Abuse and Neglect Policy to include ensuring safety devices are in place. o Kardex: how to use to determine if a fall mat is required for a resident. o Following MD orders (including the use of fall mats and ensuring bed in low in position). o Inservice provided on a list of residents that require a fall mat. Monitoring: The DON/ADON/Designee will review 3 residents per day x 5 days a week to ensure fall mats are in place x 4 weeks. Monitoring of the POR included the following: Record review of in-service titled Abuse and Neglect, by DON, CRN, and ADM dated 02/26/24, 02/27/24, 02/28/24, 02/29/24 reflected curriculum covered the facility's policy on abuse and neglect, fall precautions, interventions, Kardex referencing, MD orders, and reporting abuse and neglect immediately to the Abuse Coordinator (the Administrator). Interviews were conducted on 02/29/24 starting at 1:01 PM and continued through 4:03 PM with the following staff from various shifts: CNA G (6 AM-6 PM), CNA J (6 PM-6 AM), CNA S (6 AM-6 PM), CNA D (6 AM-6 PM), CNA T (6 AM-6 PM), CNA P (6 AM-6 PM), CNA L (6 AM-6 AM), RN J (6 AM-6 PM) ), the CRN , the DM, the MD, the SW, the HKS, the DOR, the ADM, the DON, and the ADON were all able to communicate education attendance and knowledge of the in-service curriculum responding timely, reporting immediately, fall mats, Kardex for care list, types of abuse, abuse coordinator, timing of reporting abuse and neglect, and identifying abuse and neglect. Observations and interviews on 02/29/24 from 1:00 PM to 3:30 PM with Residents#1, #3, #5, #21, #26, and #30 reflected all fall mats were in place, and their current care plans and assessments reflected that interventions were in place for effective and person-centered care. The Administrator and the DON were notified the IJ was removed on 02/29/24 at 4:30 PM. The facility remained out of compliance at a scope of isolated and at the severity level of no harm, due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place. In an interview with the Administrator on 02/29/24 at 3:47 PM revealed his expectations of staff were to comply with facility policies and procedures, follow up with patients requiring specialized care, monitor and report to leadership (ADON, DON, and CRN) any inconsistencies, and compliance nursing services. He stated the DON will assign an overnight staff to follow through on the process in place such as following physician orders, accessing and reviewing Kardex overnight system with aides to ensure familiarity with resident care. The ADM, the DON, and the ADON will monitor documentation of task off site electronically to ensure compliance. All staff will ensure the residents receive the best care possible. Expectation for nursing and aides to complete end of shift reports best practice expectations.

Based on interview and record review the facility failed to ensure the resident environment remained free of accidents hazards and each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 8 residents reviewed for accidents hazards. The facility failed to protect Residents #1 from accidents when they failed to provide the necessary care devices to prevent injury from a fall. Resident #1 had a history of subdural hemorrhage with brain injury and a previous order for a fall mat. The CNA was aware the fall mat was missing and Resident #1 experienced convulsions/seizures resulting in a fall. Resident #1 sustained a skin tear from the fall. This failure could affect 8 Residents at the facility that received fall precautions and interventions resulting in serious harm and injuries. On 02/28/24 at 3:38 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 02/29/24 at 3:52 PM, the facility remained in compliance at a severity level of no harm and a scope of' 'isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. Findings included: Record review of Resident #1's face sheet dated 02/27/24 reflected he was a [AGE] year-old male admitted initially on 06/23/23 and again on 02/23/24 DX included: Traumatic Subdural Hemorrhage with loss of consciousness (brain injury) of unspecified duration, HX of Subsequent Encounter Conversion Disorder with seizures or convulsions (conversion disorder is a condition in which you have physical symptoms but no injury or illness to explain seizures). Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS score of 0 indicating severely impaired cognition- nonverbal, Section K feeding Tube, Section M stage 4 wound documented and being treated with ointments and medication, including diet, Section N Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin), Section O no treatments. Pain unable to answer. Record Review of Resident #1's Care plan dated 12/01/23 reflected he has a resident is at risk for falls r/t traumatic subdural hemorrhage neuromuscular dysfunction and chronic respiratory failure. Record review of PN dated 2/25/24 at 06:47 AM reflected Progress Note: Resident was found on the floor face down. Has a skin tear on the forehead. No neurological deficits noted at this time. wife called no response, unable to leave a voicemail because the mailbox was full. neuro check in progress. DON and Dr. Notified.To continue with the plan of care. BP 120/71 P 78 T 98.7 02 96. Record review of Resident #1's incident report dated 02/25/24 at 6:55 AM by LVN A reflected resident was found on the floor face down. Has a skin tear on the forehead. No neurological deficits noted at this time. Unable to speak. MD notified. Record review of Resident #1's fall nurse note dated 02/25/24 at 7:05 AM by RN J reflected no injury, no decline, no appearance of pain, and fall interventions; fall mat, low bed, bed assist handle, 1/4 rail. Record Review of PN dated 2/25/2024 at 7:07 AM by LVN A reflected '[company name]' was notified '[Resident #1s fall and injuries]' and will send a nurse down to assess pt . Record review of PN dated 02/25/24 at 7:10 AM by RN-EC reflected, Resident admitted to [company name] '[company name]' with the diagnosis of Traumatic Subdural Hemorrhage (a type of bleeding in the brain from a blow to the head) with loss of consciousness (awareness). No directions specified for order. Record review of Resident #1's X-ray dated 02/25/24 (time unknown) reflected order given by MD NK, conducted by technician LO .reviewed by MD PS . procedures (facial bones, less than 3 views .findings no obvious fractures or other significant abnormality seen in visualized facial bones .Impression: normal study electronically signed by MD S 02/26/24 at 5:10 PM Record review of Resident #1's PN dated 02/26/24 at 08:47 AM by the DON reflected X ray to the forehead and facial bones shows no obvious fracture. Nursing will continue to treat skin per standing orders. Record review of Resident #1's PN dated 02/26/24 08:47 AM by the DON reflected X ray to the forehead and facial bones shows no obvious fracture. Nursing will continue to treat skin per standing orders. Record review of Resident #1's PN/MD BY MD O note dated 02/26/24 12:55 PM, reflected Date of Service: 02/26/2024 Visit Type: Follow Up Transition of Care: No transition occurred. Details: This is a copy of a signed encounter note documented in Chief Complaint / Nature of Presenting Problem: Review x-ray result .Neurology discussed MRI and EEG results with FM that since patient has not shown improvement clinically from a neurological standpoint. Patient will have to continue with current supportive care treatment .Reviewed. Nursing Staff: Reviewed x-ray result Patient: Limited by cognition. Patient had a fall over the weekend. X-ray reviewed and no fracture. Patient had a small skin tear. Wound care is already following. Record review of Resident #1's PN dated 02/26/24 at 2:47 PM by the DON reflected Resident admitted to '[company name]' with diagnosis of Traumatic Subdural Hemorrhage with loss of Consciousness .'[company name]' nurse in house to assess resident and new orders received for pain, anxiety, increased secretions and nausea and vomiting, scoop mattress, morphine sulfate Q 3 h for pain or SOB, Lorazepam for anxiety Q 6 h. Record review of Resident #1's PN dated 02/26/24 3:55 AM BY RN AR reflected bump noted on forehead. neuro checks continue to be done; no S/S of infection noted. nurses will continue with ordered wound treatment and monitor for any S/S of infection. LVN I. Record review of Resident #1's fall nursing note dated 02/27/24 at 12:24 AM by LVN DO reflect injury: skin tear forehead .size 8.8 cm X 0.1, 1.2 cm X 0.1, no S/S of infection, no decline since fall no appearance of pain, no changes that required MD notification, all interventions fall mat, low bed. Record review of Resident #1's fall nurse note dated 02/27/24 at 7:04 AM by LVN DO indicate no injury, fall mat and low bed. Fall note assessment dated [DATE] indicated skin tear or laceration on forehead 0.8cm x o.1, 1.2cm x o.1. Record review of neuro assessment dated [DATE] at 07:04 AM and 02/28/24 at 10:10 AM by RN J reflected Eyes were spontaneously opening, sounds only-moans/groans .abnormal flexion-stimulus causes abnormal flection of limbs (adduction of arm, internal rotation of shoulder, pronation of forearm, with flexion-decorticate posture no new observations. Observation of Resident #1 on 02/27/24 at 11:00 AM and 02/28/24 at 8:15 AM revealed resident to be lying in bed, head of bed raised, feeding tube operating, both bags were dated, eyes closed, and a fall mat on the floor. Resident was observed to have two healing stage skin injuries to the forehead. Resident was not interviewable. In an interview on 02/27/24 at 3:09 PM, with CNA J revealed on 02/25/24 at 6PM she arrived at her shift, and conducted rounds every 2 hours or less. CNA J stated she was familiar with Resident #1's care. CNA J stated Resident #1 was a fall risk and required his bed in low position and fall mat next to bed. CNA J heard Resident #1 fall on the floor, and she immediately responded and observed Resident #1 lying fac down on the floor, and bleeding skin tears to his forehead. CNA J, called for the nurse, and remained with Resident #1. CNA J said it was important to ensure fall prevention devices were applied for residents to prevent injurie. CNA J said Resident #1's fall mat was not applied next his bed, and he sustained injures. CNA J said the fall mat could have decreased impact and prevented Resident #1's injures from occurring. In an interview with the DON on 02/27/24 3:38 PM she stated that she was contacted by LVN A on 02/25/24 at 6:40 AM via video call to assess the resident. Reporting that Resident#1 fell out of the bed on the floor and had skin tears with blood on his forehead. The DON stated Resident #1 has fall prevention precautions were ordered to prevent resident injuries from accidents and falls. DON said she was notified immediately. DON stated resident was immediately assessed by nurses per facility protocol and notification to '[company name]', MD, and FM. DON stated the rounding nurses and aides did not ensure the resident's fall mat was in place during shifts on the day of the fall, 02/25/24. DON stated that she expects all nursing staff to ensure resident orders, preventions, and care needs are followed. She further expects the nursing staff to review residents' orders, implement as written, and monitor during rounds to prevent accidents from occurring. DON said she initiated in service with her nursing staff on MD orders, resident monitoring, and care needs, including but limited to fall mats, low beds, new and re-admission orders and precautions to prevent accidents. In an interview on 02/28/24 at 9:33 AM RN J stated upon arriving and completing shift change reports on 02/25/24 at 6AM she was notified by LVN E that Resident #1 had fallen and had injuries to the forehead. RN J notified the MD, the DON, and his family to report Resident #1's fall. RN J was not provided the details of the fall, nor did she did not ask additional questions. RN J said the DON and '[company name]' on call nursed arrived to assess Resident #1's incident, applied fall mat, and additional prevention devices for safety. RN J said failing to follow MD orders could result in resident's receiving injuries when falling. or prevention could prevent accidents from occurring. In an interview on 02/28/24 at 10:28 AM with LVN W revealed nurses are expected to review and follow MD orders, ensure fall prevention devices are implemented and monitored every shift to prevent injuries. Additional tasks include, monitoring devices, following up on orders, and reporting immediately any changes with the orders. LVN W stated that fall mats are a prevention device that can prevent accident injuries if a resident fall. In an interview with RN HN nurse on 02/28/24 at 10:55 AM revealed Resident #1 was admitted to '[company name]' at the hospital prior to discharge on 02/24/24. RN HN stated that the facility nurse called '[company name]' on call line to report the incident, and the on-call nurse reported she would be out to assess. RN HN said the on-call report stated Resident #1's fall on 02/25/234 at 6:26 AM. LVN A called and stated he had fallen on the floor from his bed, sustaining injuries to his forehead, no discomfort or distress. RN HN said Resident # 1's first care encounter at the facility was on Monday (02/27/24). She ordered Bolster's (a long thick pillow that is placed under the pillow for support.) for his bed (when sitting up he aspirates/coughs during tube feeding and he moves forward.) She placed the fall mat on 02/25/24 after the fall. She was not aware of the fall mat orders prior to intake to '[company name]'. In an interview on 02/28/24 at 1:04 PM with LVN S, Resident #1 had been readmitted on [DATE], and she observed his fall mat positioned next to his bed during rounds. LVNS stated Resident #1 had no falls during her shift on 02/23/24 from 7P-6A. LVN S said it was important to review MD orders and ensure they are being followed so the resident does sustain injuries. Record review of the facility policy dated October 5, 2016, titled Preventive Strategies to Reduce Fall Risk reflected Policy: The goal of fall prevention strategies is to design interventions that minimize fall risk by eliminating or managing contributing factors while maintaining or improving the resident's mobility. Procedure: After risk is assessed, individualized nursing care plans will be implemented to prevent falls. Incident Reporting: Reported falls will be thoroughly investigated to assess fall risk factors and contributing factors in order to provide a safe environment for the resident(s). Environment: Keep bed in low position. This was determined to be an Immediate Jeopardy (IJ) on 02/28/24 at 3:38 PM]. The ADM, CRN and DON were notified. The ADM was provided with the IJ template on 02/28/24 at 3:52 AM The following Plan of Removal submitted by the facility was accepted on 02/29/24 at 11:23 AM Plan of Removal Free of Accidents Hazards/Supervision/Devices Statement: The facility failed to supervise Resident #1 and abuse and neglect in that: Resident #1 was found on the floor in his room on 2/25/24 at 6:47a by CNA. Interventions: 1. Resident # 1 was transferred to the hospital as of 2/28/24 for evaluation. 2. The Charge Nurse and CNA that cared for resident #1 on the shift he sustained the fall was in-serviced 1:1 by the DON and Regional Compliance Nurse on: a. Fall Prevention Strategies (ensuring fall mats are in use) b. Abuse and Neglect Policy to include ensuring safety devices are in place. c. Kardex: how to use to determine if a fall mat is required for a resident. 3. An audit was performed by the Regional Compliance Nurse and DON for all residents who require a fall mat on 2/28/24 to ensure that they are in place. 4. The medical director was notified of the immediate jeopardy citation on 2/28/24 by the Director of Nursing. 5 An ADHOC QAPI meeting was held on 2/28/24 with the IDT Team to include the medical director to discuss the immediate eopardy and plan of removal. In-services: The following in-services were initiated by the Administrator, DON, and Regional Compliance Nurse on 2/28/24 for all direct care staff. All direct care staff not present on 2/28/24 will be in-serviced prior to the start of next shift. All new hires will in-serviced during orientation. All agency staff will in-serviced prior to the start of their shift.Fall Prevention Strategies (ensuring fall mats are in use); Abuse and Neglect Policy to include ensuring safety devices are in place; Kardex: how to use to determine if a fall mat is required for a resident .Inservice provided on a list of residents that require Monitoring: The DON/ADON/Designee will review 3 residents per day x 5 days a week to ensure fall mats are in place x 4 weeks. Monitoring of the POR included the following: Record review of in-service titled Abuse and Neglect, by DON, CRN, and ADM dated 02/26/24, 02/27/24, 02/28/24, 02/29/24 reflected curriculum covered the facility's policy on abuse and neglect, fall precautions, interventions, Kardex referencing, MD orders, intervention and reporting abuse neglect immediately to the Abuse Coordinator (Administrator). Interviews were conducted on 02/29/24 starting at 1:30 PM and continued through 4:30 PM with the following staff from various shifts: CNA A, CNA D, CNA L, CNA J, CNA S, CNA T, CNA P, LVN A, LVN C, LVN D, LVN P, LVN S, RN E, RN J, RN R, AD, DM, MAD, SW, HKS, DOR were interviewed and confirmed in-service trainings: Fall Prevention Strategies (ensuring fall mats are in use), Abuse and Neglect Policy to include ensuring safety devices are in place. Kardex: how to use to determine if a fall mat is required for a resident. Following MD orders (including the use of fall mats and ensuring bed in low in position. Inservice provided on a list of residents that require a fall mat. Interviews with the following licensed nurses on 02/29/24 at 2:30 PM LVN A, LVN C, LVN D, LVN P, LVN S, RN E, RN J, RN R, were interviewed and confirmed attendance at in-services training on the types of abuse, Fall Prevention Strategies (ensuring fall mats are in use), Abuse and Neglect Policy to include ensuring safety devices are in place. Kardex: how to use to determine if a fall mat is required for a resident. Following MD orders (including the use of fall mats and ensuring bed in low in position). Interviews with completed on 02/29/24 at 3:20 PM with ADON, DON, and CRN confirming additional in-service training and information for nurse managers to audit and monitor The Don/ADON/Designee will review 3 residents per day x 5 days a week to ensure fall mats are in place x 4 weeks. In an interview with the Administrator on 02/29/24 at 3:47 PM revealed his expectations of staff were to comply with facility policies and procedures, follow up with patients requiring specialized care, monitor and report to leadership (ADON, DON, and CRN) any inconsistencies, and compliance nursing services. He stated the DON will assign an overnight staff to follow through on the process in place such as following physician orders, accessing and reviewing Kardex overnight system with aides to ensure familiarity with resident care. The ADM, the DON, and the ADON will monitor documentation of task off site electronically to ensure compliance. All staff will ensure the residents receive the best care possible. Expectation for nursing and aides to complete end of shift reports best practice expectations. The Administrator and the DON were notified the IJ was removed on 02/29/24 at 4:30 PM. The facility remained out of compliance at a scope of isolated and at the severity level of no harm, due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place.

Based on observations, interview, and record review the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 4 residents (Resident #1) reviewed for neglect. The facility failed to implement their policy on reporting neglect when Resident #1 fell out of bed and sustained 2 injuries to his forehead on 02/25/24. These deficient practices could place residents at risk for abuse, neglect, and not having their needs met. Findings included: Resident #1 Record review of Resident #1's face sheet dated 02/27/24 reflected he was [AGE] year-old male admitted initially on 06/23/23 and again on 02/23/24 DX included: Traumatic Subdural Hemorrhage With Loss Of Consciousness (brain injury) Of Unspecified Duration, Subsequent Encounter Conversion Disorder With Seizures Or Convulsions, Conversion disorder is a condition in which you have physical symptoms but no injury or illness to explain Seizures, Chronic Respiratory Failure With Hypoxia (ineffective exchange of oxygen and gases by the respiratory system), Dysphagia (difficulty swallowing), Unspecified. Record review of Resident #1's quarterly MDS dated [DATE] reflected 0 BIMS severely impaired cognitively nonverbal, Section K feeding Tube, Section M stage 4 wound documented and being treated with ointments and medication, including diet, Section N Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin), Section O no treatments. Pain unable to answer. Record Review of Resident #1's Care plan dated 12/01/23 reflected has an ADL Self Care Performance Deficit . is at risk for nutritional problems r/t G-Tube (tube used for feeding that's inserted directly in the stomach) Status he has a skin tear, laceration, or abrasion. Assess reason for skin injury occurrence. Notify staff of cause; determine measures to prevent further skin injuries . requires tube feeding r/t Dysphagia .is risk for falls r/t traumatic subdural hemorrhage, neuromuscular dysfunction and chronic respiratory failure .subdural hemorrhage, neuromuscular dysfunction and chronic respiratory failure .has Seizure Disorder. Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes. Record review of Resident #1's MD orders dated 02/26/24 at 2:45 PM reflected Morphine Sulfate (Concentrate) Solution 20 MG/ML. Give 0.25 milliliter via NG-Tube (Nasogastric intubation NG Tube Management. A nasogastric (NG) tube is a thin, soft tube made of plastic or rubber that is passed through the nose) every 3 hours as needed for Pain or shortness of breath MD orders dated 10/06/23 at 6:00 PM by DON reflected Apply floor mat when resident is in bed every shift for Fall precaution .MD orders dated 02/27/24 at 6:00 PM by DON reflected Apply floor mat when resident is in bed every shift for Fall precaution In an interview on 02/27/24 at 9:20 AM, the Administrator stated the DON reported the incident to him on 02/25/24 immediately. However, the resident did not sustain any life-threatening injuries, so the Adm did not initially complete a report to the state. The Administrator stated he did investigate the situation by talking to all the staff who worked on shift and everyone she spoke to stated they did not witness anything physical. She stated she did not have any documentation of the investigation. On 02/27/24, the Adm reported the incident to HHS around 6:00 PM. In an interview on 02/27/24 at 9:25 AM with the DON revealed RN EC and LVN A reported the fall to her after all assessments were completed. The DON assessed Resident #1 with both nurses present a second time at 6:50 AM via video call. The DON notified ADM and CRN of the incident on 02/25/24 immediately. The DON stated that she nor the Administrator investigated the fall and injuries. In a phone interview on 02/27/24 at 1:54 PM, CNA J upon hearing the resident fall, she remained with the resident and reported the fall immediately to charge nurse RN EC. CNA J said she observed 2 bleeding injuries to Resident #1's forehead. RN EC was accompanied by LVN A, who reported to Resident #1's room, called for further assistance from LVN A, and assessed the resident and completed vital signs. RN EC and LVN A then transferred him back to the bed. She remained and communicated the fall at shift change with on coming CNA A. In an interview on 02/27/24 at 2:00 PM with RN J she stated upon arrival and completion of shift change reports on 02/25/24 at 6 AM, she was notified by RN EC that Resident #1 had fallen and had injuries to his forehead. RN J proceeded to Resident #1's room and she observed injuries to his forehead. RN J does not know the details of the fall, as it was not provided, and she did not ask additional questions. RN J notified the DON after completing his vital signs and assessment. In a phone interview with RN EC on 02/27/24 at 2:15 PM she reported that she was notified by the aide of the fall on 02/25/24. She notified the charge nurse on duty, LVN A. They both assessed the residents' vital signs and communicated to the oncoming shift about the fall. Resident #1 was observed to have two injuries to his forehead. LVN A notified the DON. Interviews were attempted on 02/27/24, 02/29/24, and 03/06 24 with LVN A, and she did not return the call. In an interview on 02/28/24 at 8:45 AM with the ADM he stated he reported the incident on 02/27/24 to HHS around 6:00 PM. The ADM said he was the abuse coordinator and expected staff to report incidents of abuse and neglect to him, so he could report it to the state. A record review of the facility's policy titled Abuse/Neglect dated 03/29/18 reflected, After receipt of the allegation the Abuse Preventions and administrator in conjunction with Risk Management will immediately evaluate the resident's situation using the criteria as stated in this policy. Determination will be made for required reporting to HHSC per reporting guidelines found in Provider letter 19-17. A report to the appropriate agency will include the following: The name and address of the suspected victim. The name and address of the suspected victim's care giver, if known. The nature and extent of any injuries resulting from the suspected abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property and injury of unknown source The nursing facility will make an addendum to any reportable incident in its report to HHSC if the resident subsequently experiences a negative outcome. g. Other pertinent information as available. The written report must be sent to HHSC no later than the fifth working day after the initial report. The facility will use the designated state reporting form. 4. With an allegation of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property, the employee(s) will immediately be suspended pending an investigation.

Based on interviews and record review, the facility failed to implement their written policies and procedures regarding allegations of neglect for 1 of 4 resident reviewed for abuse. (Resident #1) The facility failed to implement their policy on reporting neglect when Resident #1 fell out of bed and sustained 2 injuries to his forehead on 02/25/24. These deficient practices could place residents at risk for abuse, neglect, and not having their needs met. Findings included: Resident #1 Record review of Resident #1's face sheet dated 02/27/24 reflected he was a [AGE] year-old male admitted initially on 06/23/23 and again on 02/23/24. DX included: Traumatic Subdural Hemorrhage with loss of consciousness (brain injury) of unspecified duration, and Subsequent Encounter Conversion Disorder with seizures or convulsions (conversion disorder is a condition in which you have physical symptoms but no injury or illness to explain Seizures). Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected 0 BIMS score indicating severely impaired cognition-nonverbal, Section K feeding Tube, Section M stage 4 wound documented and being treated with ointments and medication, including diet, Section N Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin), and Section O no treatments. Pain unable to answer. Record Review of Resident #1's Care plan dated 12/01/23 reflected resident is at risk for falls r/t traumatic subdural hemorrhage neuromuscular dysfunction and chronic respiratory failure and date initiated 09/05/23. No additional information listed. Record review of Resident #1's PN/MD BY MD O note dated 02/26/24 12:55 PM, reflected Date of Service: 02/26/2024 Visit Type: Follow Up Transition of Care: No transition occurred. Details: This is a copy of a signed encounter note documented in Chief Complaint / Nature of Presenting Problem: Review x-ray result .Neurology discussed MRI and EEG results with FM that since patient has not shown improvement clinically from a neurological standpoint. Patient will have to continue with current supportive care treatment .Reviewed. Nursing Staff: Reviewed x-ray result Patient: Limited by cognition. Patient had a fall over the weekend. X-ray reviewed and no fracture. Patient had a small skin tear. Wound care is already following. Record review of Resident #1's MD orders dated 02/26/24 at 2:45 PM reflected Morphine Sulfate (Concentrate) Solution 20 MG/ML. Give 0.25 milliliter via NG-Tube (Nasogastric intubation NG Tube Management. A nasogastric (NG) tube is a thin, soft tube made of plastic or rubber that is passed through the nose) every 3 hours as needed for Pain or shortness of breath MD orders dated 10/06/23 at 6:00 PM by DON reflected Apply floor mat when resident is in bed every shift for Fall precaution .MD orders dated 02/27/24 at 6:00 PM by DON reflected Apply floor mat when resident is in bed every shift for Fall precaution Record review of Resident #1's fall nursing note dated 02/27/24 at 12:24 AM by LVN DO reflect injury: skin tear forehead .size 8.8 cm X 0.1, 1.2 cm X 0.1, no S/S of infection, no decline since fall no appearance of pain, no changes that required MD notification, all interventions fall mat, low bed. Record review of TMAR reflected May have floor mat when in bed on time a day for safety precautions may be off the floor during ADL's. Documentation revealed nurse initials for 02/24/24 and 02/25/24 by RN J, 6 AM to 6 PM, indicating this was check. In an interview on 02/27/24 at 9:20 AM, the Administrator reviewed the policy for the facility nursing staff failed to implement the protocol of following MD orders, fall precautions, and reporting reports of abuse and neglect. Administrator sated that nursing staff should have assured that MD orders and fall precautions were followed for Resident #1. The DON and ADON were responsible for monitoring TAR, treatment task, and MD orders to assure nursing practices for followed. DON and ADM reported that the incident was reported on 02/27/24 at 6:00 PM after entrance. Administrator stated that the resident did not sustains severe injuries, however failing to follow procedures led to Resident injuries and pain. Observation of Resident #1 on 02/27/24 at 11:00 AM and 02/28/24 at 8:15 AM revealed resident to be lying in bed, head of bed raised, feeding tube operating, both bags were dated, eyes closed, and a fall mat on the floor. Resident was observed to have two healing stage skin injuries to the forehead. Resident was not interviewable. In an interview on 02/27/24 at 3:09 PM, with CNA J revealed on 02/25/24 at 6 PM she arrived to work and conducted rounds every 2 hours or less. CNA J stated that she sat adjacent to Resident #1s room as h has a history of falls and seizures. CNA J stated she was familiar with Resident #1's care and knew he required bed in low position, call light near, and fall mat next to bed. CNA J stated she did not notify the head nurse that the fall mat was missing. CNA J had conducted rounds on resident 15 minutes prior him falling at 4:40 AM on 02/25/24. CNA J said at 5:00 AM she heard him hit the floor and entered immediately, called for nurse, and remained until nurse arrived. CNA J stated Resident #1 was bleeding from skin tears located on his bed. CNA J said Neglect of a Resident was failing to provide the Resident with care and identified and scheduled by MD. CNA J said the fall mat would have prevented the injuries that Resident #1 sustained from the fall. In an interview with the DON on 02/27/24 3:38 PM she stated that she was contacted by LVN A on 02/25/24 at 6:40 AM via video call to assess the resident. Reporting that Resident#1fell out of the bed on the floor and had skin tears with blood on his forehead. The DON stated Resident #1 has fall prevention precautions in place to prevent falls, related to convulsing like seizures. The DON stated the cause of the fall was possibly due to him coughing and convulsing, like a seizure, resulting in falling on the floor and gaining injuries. She said the fall mat was not in place on the day of the incident no when she arrived on 02/25/24 at 4:30 PM. The DON stated the rounding nurses and aides did not ensure the resident's fall mat was in place during shifts on 02/23/24, 02/24/24, and 02/25/24. The DON stated that the mat should have been in place, and she expects nursing to review MD orders, care plans, and assessments to ensure the residents are receiving care consistent with their needs and care. DON said failing to provide Resident #1' fall mat per MD orders was neglect, and the staff working on that day confirmed observation of the missing fall mat, however, it was not implemented for his safety. In an interview on 02/28/24 at 9:33 AM RN J stated LVN E reported that Resident #1 had fallen and had injuries to the forehead. RN J said there were no other details provided. RN J proceeded to Resident #1's room and she observed injuries to his forehead. She then cleaned the blood off of his forehead, applied Tiple Antibiotic Ointment to his forehead, and took Resident #1's vital signs. RN J said the fall mat was not on the floor next to the bed. RN J does not know the details of the fall, as it was not provided, and she did not ask additional questions. RN J said the DON and hospice nurse were contacted at prior shift and arrived at the facility on 02/25/24 at 4:30 PM and the hospice nurse arrived at 5:00 PM. Resident was further assessed by both RN J stated that she did not review Resident #1's orders the day of the incident, nor place the fall mat down after the injury. She stated that the DON and hospice nurse put the mat in placed upon their arrival that evening. RN J said the facility policy was to review orders and other care documents for implementing and monitoring resident care. RN J said Resident #1 she conducted rounds every two hours from 6 AM to 6 PM. RN J said failing to placed fall mat on the floor and following other procedures and precautions could lead to resident sustaining injuries. A record review of the facility's policy titled Abuse/Neglect dated 03/29/18 reflected, After receipt of the allegation the Abuse Preventions and administrator in conjunction with Risk Management will immediately evaluate the resident's situation using the criteria as stated in this policy. Determination will be made for required reporting to HHSC per reporting guidelines found in Provider letter 19-17. A report to the appropriate agency will include the following: The name and address of the suspected victim. The name and address of the suspected victim's care giver, if known. The nature and extent of any injuries resulting from the suspected abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property and injury of unknown source The nursing facility will make an addendum to any reportable incident in its report to HHSC if the resident subsequently experiences a negative outcome. g. Other pertinent information as available. The written report must be sent to HHSC no later than the fifth working day after the initial report. The facility will use the designated state reporting form. 4. With an allegation of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property, the employee(s) will immediately be suspended pending an investigation.

Based on observation, interview and record review the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for one (Resident #1) of five residents reviewed for respiratory care. The facility failed to place an oxygen cannula for Resident #1 while she waited for EMS to arrive, after she ingested an unknown combination of prescription pills. This deficient practice resulted in actual harm, when Resident #1's oxygen levels dropped, resulting in her carbon dioxide levels being very high when she arrived at the hospital. In addition, oxygen orders for Resident #1 were incomplete, missing parameters for when oxygen was to be administered. An Immediate Jeopardy (IJ) situation was identified, regarding Resident #1 not having oxygen applied, on 07/20/23 at 1:06 PM. While the IJ was removed on 07/21/23, the facility remained out of compliance at a scope of isolated with a severity of actual harm, due to the facility's need to evaluate effectiveness of their corrective systems. This failure could place residents at risk for respiratory distress, which could potentially lead to cardiac arrest. Findings included: Review of Resident #1's face sheet, dated 07/21/23, reflected she was a [AGE] year-old female who was admitted to the facility on [DATE] with a primary diagnosis of acute respiratory failure with hypoxia (a lack of sufficient oxygen in body tissues), and diagnoses of COPD (chronic obstructive pulmonary disease- a disease which causes breathing problems, leading to low oxygen levels in the blood), heart failure, and traumatic brain injury. Review of Resident #1's admission MDS, dated [DATE], reflected Resident #1 had impaired vision, was able to be understood, and understood others. Resident #1 had a BIMS score of 11, which indicated moderate cognitive impairment. She had no psychosis or behaviors. Resident #1 required limited assistance from one person to transfer and bathe, but was able to walk, locomote using her wheelchair, eat, and perform hygiene on her own. She required extensive assistance from one person to get dressed. She was noted to have debility and/or cardiorespiratory (affecting heart function and breathing) conditions, which included heart disease, high blood pressure, history of pneumonia, respiratory failure, and COPD. Resident #1 used oxygen therapy and bi-pap or c-pap (a machine to help with breathing while sleeping.) Review of Resident #1's oxygen orders on 07/19/23 reflected an order with a start date of 06/04/23, May use oxygen @ 3 l/m via nasal canula during the day one time a day related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED. Review of Resident #1's care plans reflected a care plan for oxygen use, revised 06/20/23. [Resident #1] has Oxygen Therapy. Goal: [Resident #1] will have no s/sx of poor oxygen absorption through the review date. Date Initiated: 06/12/2023 Revision on: 06/20/2023 Target Date: 06/19/2023- For residents who should be ambulatory, provide extension tubing or portable oxygen apparatus. Date Initiated: 06/15/2023 Created by: [ADON] - Monitor for s/sx of respiratory distress and report to MD PRN : Respirations, Pulse oximetry, Increased heart rate (Tachycardia), restlessness, Diaphoresis [excessive sweating], Headaches, Lethargy, Confusion, Atelectasis [partial or complete collapse of a lung], Hemoptysis [coughing blood from lungs], Cough, Pleuritic pain, Accessory muscle usage, Skin color. Date Initiated: 06/15/2023 Created by: (ADON)- Oxygen per nasal canula as ordered Date Initiated: 06/05/2023 Created by: (ADON) Revision on: 06/12/2023 oxygen as ordered Date Initiated: 06/15/2023 Created by: (ADON) Revision on: 06/19/2023 - Promote lung expansion and improve air exchange by positioning with proper body alignment (if tolerated, head of bed at 45 degrees). Date Initiated: 06/15/2023 Created by: (ADON) Also reflected were careplans for asthma (revised 06/20/23), congestive heart failure (revised 06/20/23), shortness of breath (Revised 06/20/23), hypertension (revised 06/20/23), altered respiratory status/ difficulty breathing/ shortness of breath re: Bi-pap (revised 06/20/23). Review of the facility transfer progress note, effective 07/18/23 at 8:02 AM reflected Resident #1 was transferred to the hospital for a change in condition. Review of Resident #1's progress note dated 07/18/23 at 7:43 AM, written by LVN A reflected Note Text: Resident observed in lying in bed unable to get to get self up. noted something was wrong, resident speech unclear, stating ' I dont know what is wrong with me, but I'm sorry' Resident was noted to have pills in a bag with no prescription bottle with medications. Resident was so confused that it was unclear many pills she had taken. MD was in the facility, assessed resident, and gave order to send resident out to hospital for further evaluation. ADMN , DON notified. Review of Resident #1's Transfer Form, effective 07/18/23 at 8:02 AM, reflected Resident #1 was being sent to the hospital, and her oxygen was 98% via oxygen mask. Under treatments and devices currently required oxygen was not selected. Review of Resident #1's Physician Progress note, written by Physician E, dated 07/18/23 (did not include time of assessment) reflected Chief Complaint / Nature of Presenting Problem: Pill bag found in patient's room, patient not acting like herself . History Of Present Illness: [AGE] year-old lady admitted to [Facility Name] on 6/3/2023 for rehabilitation or status post hospitalization for acute on chronic respiratory failure with hypoxemia and COPD exacerbation The patient has a medical history significant for COPD, methamphetamine use, memory loss, acute respiratory failure with hypoxia traumatic brain injury in 1982. She presented to the hospital with shortness of breath, Patient: Patient seen and examined in room. Patient was not acting like herself. Unable to provide an answer for any question. Asked patient about the pill bag and she said her friend has brought it for her. And patient is build back following gabapentin 300 mg and 600 mg. Also found hydroxyzine 50 mg pills. Patient kept on repeating I am sorry I will not do this again. Patient unable to tell how many pills she has taken. Sending patient to ER . Physical Exam General .Excessive sedation. Unable to keep eyes open. Unable to have full conversation. Review of Resident #1's blood pressure readings from the facility EMR reflected her blood pressure on 07/18/23 at 7:35 AM (when LVN A found resident with a change in condition), and 8:22 AM (four minutes before EMS walked into the facility) the readings for both were 142/72. Record review of Resident #1's oxygen readings from the facility EMR reflected her oxygen saturation on 07/18/23 at 8:23 AM (three minutes before EMS walked into the building) was 98% via oxygen mask. No data for her oxygen level was entered at the time the nurse found her with a change in condition. All oxygen readings from 07/08/23 to 07/18/23 t 7:35 AM reading reflected it to be the only reading for via oxygen mask. All other readings were for room air (six) or oxygen via nasal cannula (19). Record review of the EMS company's patient care report, dated 07/18/23, stated the O2 sats on 7/18/23 between 8:34 AM and 9:28 AM ranged from 66-82 O2%. The report included notes which indicated Resident #1 did not have oxygen on when they arrived. During this the pt had been moved over to the cot, secured, and vitals obtained. Pt was then found to be severely hypoxic on room air and a nasal cannula was then noticed on the pt's wheelchair. Pt was asked if on O2 and the pt. said she was. Pt was promptly placed on O2 via nasal cannula and the pt's O2 saturations began to improve .Pt was then moved out to the MICU for further treatment of hypoxia. In the MICU pt O2 saturations showed to have stalled at approximately 83% on O2 via nasal cannula. Pt was then placed on a NRB mask and then transported to [hospital]. En route pt showed to become more altered and appeared sedated. Pt was able to aroused [sic] with gentle physical stimulation and was still able to answer questions but had a hard time staying awake. Pt report was called into the hospital to notify of the pt's condition and given an ETA. Pt continued to be monitored and no further interventions were made en route. Upon arrival at the hospital ( .) Pt's RN was made aware of the situation around the pt's condition and how the pt had not been on her o2 prior to EMS arrival for unknown reasons. Review of the Emergency Department Admission Sheet, dated 07/20/23, reflected Resident #1 arrived at the hospital on 7/18/23 at 9:31 AM complaining of dyspnea (shortness of breath). Per EMS Resident #1 was sent by nursing home staff for acute hypoxia (absence of enough oxygen in blood tissues) related to accidental drug overdose (Seroquel, Gabapentin and hydroxyzine.) Her primary admitting diagnosis was respiratory failure. Per the history of present illness documentation Resident #1's oxygen saturation percentage was in the 20s when EMS found her. They then placed her on a non-rebreather and her oxygen level improved rapidly. The ( .) vitals taken on 7/18/23 at 9:50 AM were blood pressure 148/70 , pulse 79, respirations 18 breaths per minute and oxygen blood saturation 100% on non-rebreather mask. According to the Physical exam Resident #1's appearance was somnolent, attention diminished, awakened to sternal rub, and moved all four extremities. Lab work collected on 7/18/23 at 9:58 AM revealed Resident #1's blood carbon dioxide levels to be over 100 (the normal range being 35-45), and a blood test of her oxygen reflected a result of 37 (the normal range being 80-105.) According to the ED deposition, due to an extensive history, physical exam and cardiopulmonary workup, Resident #1's presentation was consistent with COPD (lung disease) exacerbation. Despite typical ED treatment the resident did not improve to the point that which she would be able to return to the nursing facility safely and was admitted to the hospital for further treatment. An interview on 07/21/23 at 12:43 PM with the Administrator revealed he had not reported the incident with Resident #1 taking outside medications, because she stable, in no distress, and talking to him and other staff while she was in the facility. He stated they had investigated the issue with the family member bringing medications in, and the family member stated she had brought them, and given them directly to the resident. Observation of video sent to surveyor on 07/22/2023, by secure link, reviewed by surveyor on 07/24/2023 reflected: 07/18/23 at 8:08 AM, CNA B wheeled Resident #1 to nurses station, and placed her next to the front side of the station. When enlarging the video on the investigator's computer screen, Resident #1 did not appear to be wearing an oxygen cannula. No tubing was visible around her upper body/shoulders or on her face, and there was no indentation on her skin visible from the tubing. The back of her wheelchair was not visible due to the angle of the video, and the nurses station wall blocking the view. Resident #1's upper body was visible. She spoke and laughed with LVN A, who was inside the station, already seated at the computer, and was on the phone, the surveyor estimated a little more than arms-length away from the resident. LVN A could be seen turning her head frequently to look directly at Resident #1. The resident did not appear to be distressed, and sometimes appeared sleepy, but for a majority of the video was obviously awake and looking around. At 8:13 AM, the Administrator entered the front door of the facility and approached Resident #1, greeted her, placed his hand on her shoulder and turned into the hall where his office was located. He immediately turned and walked back to the station, and talked with LVN A, and they both looked at Resident #1 while they were talking. 8:14 AM CNA B returned with a can of soda, inserted a straw, and handed the can to Resident #1. Resident #1 was able to hold the can, manipulate the straw, drink, and set the can down on the station counter, with no apparent problems. Also at 8:14 AM the Administrator approached the resident, and leaned on the counter to talk with her. The resident appeared to be speaking during most of this conversation, appeared alert, and did not appear distressed. At 8:23 the Administrator walked away from the resident and entered the hall leading to his office. At 8:26 AM three EMS personnel could be seen entering the front door with a gurney. They approached LVN A and Resident #1. LVN D approached and had a conversation with them. LVN A was still on the phone and using the computer. EMS staff leaned on the counter and the gurney and conversed with Resident #1 while she drank her coke, and LVN D, walked away at 8:28 AM. At 8:32 Resident #1 unsteadily stood up, and placed herself on the gurney, while one EMS worker had his hand on her back, and held one of her hands. He assisted her getting her legs onto the gurney. The resident was lying on the gurney for approximately three minutes while EMS staff appeared to be arguing with LVN D and LVN A, two of the EMS personnel gestured emphatically with their hands as they spoke. One of them walked away from the conversation and applied the blood pressure cuff to Resident #1 at 8:33 AM. At 8:36 AM one EMS worker placed an oxygen cannula on Resident #1's face. At this time the other two EMS turned their attention to the resident, and appeared to be having a conversation with her. At 8:42 AM the EMS personnel walked toward the front door of the facility with Resident #1 on the gurney. The resident appeared to be awake and not in any distress when they rolled her away from the station. They stood at the door, and LVN A walked to the door and entered the code to exit at 8:43 AM. An interview with the complainant on 07/18/23 at 4:21 PM revealed Resident #1 went to the hospital after taking pills at the facility, from a bag a family member provided her, and the resident was not wearing her oxygen when EMS arrived. The resident was placed on oxygen by the EMS personnel, and when they checked her O2 SATS (oxygen saturation levels), she was at 29%, which was an indication she had been off her oxygen for some time. The complainant stated the documentation showed the nurse had taken the resident's vitals just before EMS arrived, and her oxygen level was at a normal level, but the resident was hypoxic when they arrived, and could not have become so that quickly. The complainant stated the resident was pleasant and cooperative, and a little altered and sedated and had a TBI (traumatic brain injury) but was still able to talk to them. An interview on 07/19/23 at 1:15 AM with LVN A revealed when she was waiting for EMS to come get a resident, she would monitor all the vital signs, which included oxygen, and document the time of the assessment, at that time. She said she found Resident #1 in her room, in bed, when she would normally be up, and when she spoke, she did not sound right. She said she took Resident #1's blood pressure, and the resident was apologetic and said she wouldn't do it again. When she asked her what she did, she found pills in a bag. The physician came into the room, and the vitals recorded at 8:22 AM were the ones she took at an earlier time, when the physician saw the resident. They figured out that the pills were gabapentin and hydralazine. The physician told LVN A to send Resident #1 to the hospital to be assessed. She said Resident #1 had COPD and always wore oxygen and only took it off to go to the bathroom. She said she took the vitals right when the situation occurred, when she discovered the resident with a change in condition, but did not take them again before EMS arrived, because the times were close enough together that she did not need to. She said the resident was at risk of passing out, but she was right at the nurse station, asking for soda, and talking, and in no distress, and did not need to have her vital signs monitored. An interview on 07/19/23 at 1:25 PM with CNA B revealed he was a PRN CNA and had been the one to get Resident #1 dressed and ready to go to the hospital. He said she did not have oxygen on when he saw her. An interview on 07/20/23 at 9:14 AM with Resident #1's family member revealed Resident #1 had to be held at the hospital because of her oxygen levels, and she was requiring too much oxygen. She said they needed to get her back to a level where she would be safe at the facility. She said when she was in the hospital, her oxygen requirement was seven liters, and they had her down three, and would be discharging her soon. An interview on 07/20/23 at 9:09 AM with the DON revealed she felt LVN A did a good job monitoring Resident #1. She said she would expect visual monitoring was appropriate in this case, and she had the resident in her line of vision, so she could notice whether she showed any changes, and could reassess her. She said she was not aware Resident #1 was not wearing her oxygen, but she barely wore oxygen, and she definitely did not recall her being on oxygen all the time. She said the resident was often up, walking around the facility, and not wearing her oxygen. She said she thought the resident told EMS as they were leaving she had taken Seroquel and gabapentin from the bag of pills her sister brought. She said she was alert, and talking, and drinking her coke without fumbling, and did not seem to be in any sort of distress, and was just twitching a little, and groggy, from the medication. She said she did not have any residents with continuous oxygen orders, including Resident #1. An interview on 07/20/23 at 9:33 AM with CNA B revealed saw Resident #1 trying to get up and staggering when he was passing breakfast trays on 07/18/23, so he went in to help her. He said she had her oxygen on then, but he had to help her change clothes and get ready for EMS, so he was not sure if the oxygen was on her when he took her to the front. He said she mostly used the oxygen in her room, but he did not see her using it often when she left her room. He said he saw her several times while she waited for EMS, and she did not appear to be in any sort of distress. An interview and observation on 07/20/23 at 10:33 AM in the hospital with Resident #1 revealed her to be alert, sitting up in bed, with four liters of oxygen running. She said she was always on oxygen, and only took it off to use the restroom. She said she felt great at the time of the interview, and it was not the pills that got her to the hospital, it was the oxygen. An interview on 07/20/23 at 10:14 AM with LVN C revealed if a resident with respiratory diagnoses was being sent out to the hospital, she would put their oxygen on them, and keep the monitor on their finger, and monitor their vitals. She said she would have oxygen on the resident, and would stay with them, or have someone else stay with them who could monitor their vital signs while she got the paperwork ready for EMS. She said Resident #1 often left her room without wearing oxygen, and it might have been ok to just visually monitor her , but she was not there when it happened, and was not sure of her condition when she was sent out. An interview on 07/20/23 at 11:02 AM with LVN D revealed the nurses had a class by a Respiratory Therapist a few months prior to this visit, because they were getting a resident who had a trach. She said they trained them on how to recognize respiratory distress, and what to do. She said if she was sending a resident out, who had COPD, she would monitor their oxygen by keeping the monitor on their finger, and keeping them by her, and checking their vitals every few minutes. She said she would not just use visual monitoring for oxygen , because you could not tell when someone's oxygen started to drop and by the time you saw signs it could already be very low. She said someone would need to be checking their vital signs, and keeping them on oxygen. LVN D said it did not make any difference whether the change in condition was due to their respiratory diagnoses, and they had those diagnoses all the time, and their respiratory status could be challenged by other issues, as well. An interview on 07/20/23 at 11:28 AM with Physician E revealed LVN A told her Resident #1 was not acting like herself, and was dizzy and sedated. She looked at the bag with the pills in it, the nurse found in the resident's room, and it had a lot of pills, hydralazine 300 mg and Neurontin 600 mg. She said Resident #1 did not look like herself, and started crying, and said she did not know what she took, because they did not know how much she took, of which pills, she told the nurse to send her to the hospital. When asked if she felt the resident needed to be monitored closely since one of the pills she might have taken (Seroquel) could cause respiratory distress, she answered EMS was there soon after and the resident was talking, so they were closely monitoring her. She said she was in the room with the resident around 7:30 AM to 7:45 AM. Physician E said the resident was on oxygen, but in the time between seeing Resident #1 and EMS arriving she saw other patients. She said Resident #1 was on continuous oxygen at her baseline and was always on continuous oxygen when she saw her, and was oxygen dependent. She said if someone who needed oxygen did not receive it for a long period, it could cause their CO2 to increase, and cause respiratory distress. She did not elaborate on what a long time meant. An interview on 07/20/23 at 12:51 PM with the DON and Administrator revealed the DON did not know if Resident #1 was on oxygen when the physician saw her, but she was normally not when she saw her, and was at 97-98 percent on room air. She said one of the State Surveyors said the resident was supposed to be on continuous oxygen, and they called corporate to check, and there were notes where she was on room air and was only on O2 in some of the notes. The Administrator said when the resident was waiting , she was stable, and was talking to him, and even got up to get on the gurney herself. The DON said orders were inputted by the nursing staff and sometimes the ADON would have to do it. The DON stated oxygen was a set order. She stated oxygen order set verbiage said something along the lines of 'may use oxygen via nasal cannula 2-3min/day.' The DON stated corporate was contacted to change the oxygen orders because the State Survey Agency questioned the facility about oxygen orders, so it made them go back and look at all the oxygen orders in the system since Resident #1's orders didn't specify continuous oxygen. She said the ADON was responsible for making sure the orders were correct in the system, but the former ADON was no longer with the facility about two weeks ago and now she only had one ADON. The administrator also stated the former ADON was the one responsible for making sure orders were inputted into the EMR correctly, since the residents' orders didn't display the correct orders. She explained since there was no one to fill the former ADON'S position no one had taken over the role of checking orders in the system to make sure they were correct. The Administrator stated he wasn't sure how often orders were assessed and monitored to know if a resident was on the correct medications, but he thought maybe every two months. An interview on 07/20/23 at 3:54 PM with the Medical Director revealed Resident #1 was on oxygen a majority of the time due to her congestive heart failure diagnosis. She said Resident #1 was very non-compliant and had been refusing things, including her bi-pap. She said she was able to go to the restroom without her oxygen, but usually needed it. She agreed that nurses could not tell what a resident's vital signs were by looking at them, and Resident #1 should have had hers monitored during the situation, with an unknown amount of medication in her system. She said she had tried to instill in staff at the facility to assess, perform interventions appropriately, and notify her. An interview with the DON on 07/21/23 at 1:50 PM revealed she did not believe the incident was an IJ, due to the resident being stable, and being closely visually monitored by LVN A, and because the resident very often was non-compliant with her oxygen. She said the resident was observed by multiple staff, and the Administrator spoke with her for several minutes and she was not showing any signs of respiratory distress, and she even got up herself to get on the gurney. She acknowledged during the interview that visual observation would not necessarily allow someone to see someone's vital signs, but said that visual observation was a crucial factor in monitoring condition, and that the nurses were educated to know signs of someone's oxygen levels dropping. She said that Resident #1 had returned on the previous evening (07/20/23), and she was doing well, and very happy to get back to the facility. An interview on 07/21/23 at 2:30 PM with the Administrator revealed he would share some additional information with the surveyors to consider, including the video footage, which showed the EMS staff arguing with his staff, and not assessing the resident immediately. He said they did not look concerned about her, and took a long time to arrive at the facility and a long time to get her to the hospital. He said he felt there was some retaliation going on, and that one of them had probably called in a complaint. He said the documentation the EMS company provided them, and the numbers the surveyors had asked them about did not match up, and there were details in the documentation by the company that their camera footage showed to not be accurate, including nowhere was her oxygen documented even close to the low percentages inquired about during this investigation. He said they had set up a meeting with the company to discuss their concerns about the behavior of their company's staff. Review of staff training records reflected the facility nursing staff attended a training given by a Respiratory therapist throughout the month of November in 2021. LVN signed in and earned a certificate for the training on 11/10/21. The training was focused on patients with a trach, but from the limited training materials available to the surveyor, also appeared to cover general respiratory emergencies. LVN A attended the training, and received a continuing education certificate. This was determined to be an Immediate Jeopardy (IJ) on 07/20/23 at 1:06 PM. The Administrator and the DON were notified. The Administrator and the DON were provided with the IJ template on 07/20/23 at 1:06 PM. An Immediate Jeopardy (IJ) situation was identified, regarding Resident #1 not having oxygen applied, on 07/20/23 at 1:06 PM. While the IJ was removed on 07/21/23, the facility remained out of compliance at a scope of isolated with a potential for actual harm, due to the facility's need to evaluate effectiveness of their corrective systems. The following Plan of Removal submitted by the facility was accepted on 07/21/23 at 8:57 AM: Problem: F689 Respiratory Care All residents have the potential to be affected by this deficient practice. Interventions: o As of 7/20/23, the resident remains in the hospital for evaluation. o All residents in the facility were assessed for any change of condition by the DON, ADON and Charge Nurses as of 7/20/23. No additional issues were found. o All residents with orders for oxygen continuous and as needed had oxygen saturation levels obtained as of 7/20/23 by the DON/ADON. No additional issues were found. o On 7/20/2023, the DON obtained clarification orders from the physician to ensure that accurate orders were in place in PCC, o LVN A was immediately suspended pending investigation on 7/20/2023. o LVN A will not be permitted to provide care to residents until the following 1:1 in-services have been completed. o Providing care to residents who are experiencing a change in condition or respiratory distress. o Notification of change of condition to the physician immediately. o Monitoring a resident for a change of condition until emergency services arrive which include vital signs and the need for oxygen supplementation every 15 minutes or sooner if a further decline is noted. o Charge nurses to follow physician orders to include oxygen orders. o Staff will educate residents and families to give all medications to the charge nurse if it is found that family or resident bring outside medications. In-services: o All charge nurses will be in-serviced by 7/21/23 by the DON/ADON regarding the following and all nurses not in-serviced by 7/21/23 will not be allowed to work their assigned position until completion of these in-services: This will be ongoing. DON and ADON were in-serviced by Compliance Nurse. o Notification of change of condition to the physician immediately. o Monitoring a resident for a change of condition until emergency services arrive which include vital signs and the need for oxygen supplementation every 15 minutes or sooner if a further decline is noted. o Charge nurses to follow physician orders to include oxygen orders. o Staff will educate residents and families to give all medications to the charge nurse if it is found that family or resident bring outside medications. o The medical director was notified by the administrator of this plan on 7/20/2023. An Ad Hoc QAPI meeting was held 7/20/2023. Monitoring: o Monitoring of this plan began on 7/20/2023 and will continue weekly x 4. o The DON and/or designee will monitor the vitals summary report from PCC at least 5 times per week to determine if vital signs including oxygen saturation remain within parameters and if not, the physician/NP will be notified. Monitoring began 7/20/2023 and will continue x 4 weeks. o The DON and/or designee will monitor Real Time clinical software and the PCC dashboard at least 5 times per week, indefinitely to ensure any new or worsened shortness of breath is communicated to the physician/NP and follow up as needed. Monitoring began 7/20/23 and will continue x 4 weeks. o DON and/or designee will review the order listing report in PCC and monitor accuracy of all orders for oxygen 5 x a week during morning meeting for 4 weeks. Monitoring began 7/20/23 and will continue x 4 weeks. Monitoring of POR included the following: Interviews on 07/20/23, and 07/21/23 with charge nurses covering all shifts (LVN A, LVN C, RN E, LVN F, LVN G, LVN H) revealed they had been trained on all aspects of the incident with Resident #1, which included placing oxygen on a resident while they waited for EMS, and checking the resident's vital signs at least every 15 minutes, and as needed. They also had been trained and were able to answer questions regarding procedures for entering orders into the EMR, including oxygen parameters. All nurses were able to state why it was crucial to monitor vitals and not only observe a resident visually when they were experiencing a change in condition. Record review of the monitoring tool for oxygen orders (for making sure orders were complete and accurate, due to Resident #1's order not having parameters.) Monitoring tool included four weeks of print-outs, and was completed through 07/21/23. Record review of the print-out of all residents with oxygen orders on 07/20/23, with notations of their oxygen levels, and whether they were on room air, or nasal cannula when assessed by a nurse. All levels were between 95% and 100%. Record review of in-service records for the plan of removal were reviewed, and of 26 charge nurses and administrative nurses in employment by the facility. Prior to exit on 07/21/23, the DON in-serviced 15 nurses in person, and of the remainder (who had not yet been in the facility), she in-serviced over the phone, except for one who was on an extended leave period, and one PRN nurse, who would be in-serviced before they worked in the facility again. The nurses who were in-serviced over the phone would also be inserviced in person when they returned to the facility fo [TRUNCATED]

Based on observation, interview and record review the facility failed to ensure, based on the comprehensive assessment of a resident, that each resident received treatment and care in accordance professional standards of practice, the comprehensive person-centered care plan and the residents' choices for one (Resident #1) of five residents reviewed for quality of care. The facility failed to place an oxygen cannula and monitor the vital signs for Resident #1 while she waited for EMS to arrive, after she ingested an unknown combination of prescription pills. This deficient practice resulted in actual harm, when Resident #1's oxygen levels dropped, resulting in her carbon dioxide levels being very high when she arrived at the hospital. An Immediate Jeopardy (IJ) situation was identified on 07/20/23 at 1:06 PM. While the IJ was removed on 07/21/23, the facility remained out of compliance at a scope of isolated with a severity of actual harm, due to the facility's need to evaluate effectiveness of their corrective systems. This failure could place residents at risk for respiratory distress (potentially leading to cardiac arrest), sedation, or a drop in blood pressure. Findings included: Review of Resident #1's face sheet, dated 07/21/23, reflected she was a [AGE] year-old female who was admitted to the facility on [DATE] with a primary diagnosis of acute respiratory failure with hypoxia (a lack of sufficient oxygen in body tissues), and diagnoses of COPD (chronic obstructive pulmonary disease- a disease which causes breathing problems, leading to low oxygen levels in the blood), heart failure, and traumatic brain injury. Review of Resident #1's admission MDS, dated [DATE], reflected Resident #1 had impaired vision, was able to be understood, and understood others. Resident #1 had a BIMS score of 11, which indicated moderate cognitive impairment. She had no psychosis or behaviors. Resident #1 required limited assistance from one person to transfer and bathe, but was able to walk, locomote using her wheelchair, eat, and perform hygiene on her own. She required extensive assistance from one person to get dressed. She was noted to have debility and/or cardiorespiratory (affecting heart function and breathing) conditions, which included heart disease, high blood pressure, history of pneumonia, respiratory failure, and COPD. Resident #1 used oxygen therapy and bi-pap or c-pap (a machine to help with breathing while sleeping.) Review of Resident #1's physician orders for July 2023 revealed the order started on 06/04/23 and stated Resident #1 may use oxygen at 3L/m via nasal canula during the day one time related to COPD but was discontinued and changed on 7/20/23 once readmitted from the hospital to represent the correct order that sated Resident #1 may use oxygen at 2-4 L/m via nasal cannula for oxygen <92% every shift related to COPD. Review of Resident #1's care plans reflected a care plan for oxygen use, revised 06/20/23. [Resident #1] has Oxygen Therapy. Goal: [Resident #1] will have no s/sx of poor oxygen absorption through the review date. Date Initiated: 06/12/2023 Revision on: 06/20/2023 Target Date: 06/19/2023- For residents who should be ambulatory, provide extension tubing or portable oxygen apparatus. Date Initiated: 06/15/2023 Created by: [ADON] - Monitor for s/sx of respiratory distress and report to MD PRN : Respirations, Pulse oximetry, Increased heart rate (Tachycardia), restlessness, Diaphoresis [excessive sweating], Headaches, Lethargy, Confusion, Atelectasis [partial or complete collapse of a lung], Hemoptysis [coughing blood from lungs], Cough, Pleuritic pain, Accessory muscle usage, Skin color. Date Initiated: 06/15/2023 Created by: (ADON)- Oxygen per nasal canula as ordered Date Initiated: 06/05/2023 Created by: (ADON) Revision on: 06/12/2023 oxygen as ordered Date Initiated: 06/15/2023 Created by: (ADON) Revision on: 06/19/2023 - Promote lung expansion and improve air exchange by positioning with proper body alignment (if tolerated, head of bed at 45 degrees). Date Initiated: 06/15/2023 Created by: (ADON) Also reflected were careplans for asthma (revised 06/20/23), congestive heart failure (revised 06/20/23), shortness of breath (Revised 06/20/23), hypertension (revised 06/20/23), altered respiratory status/ difficulty breathing/ shortness of breath re: Bi-pap (revised 06/20/23). Review of the facility transfer progress note, effective 07/18/23 at 8:02 AM reflected Resident #1 was transferred to the hospital for a change in condition. Review of Resident #1's progress note dated 07/18/23 at 7:43 AM, written by LVN A reflected Note Text: Resident observed in lying in bed unable to get to get self up. noted something was wrong, resident speech unclear, stating ' I dont know what is wrong with me, but I'm sorry' Resident was noted to have pills in a bag with no prescription bottle with medications. Resident was so confused that it was unclear many pills she had taken. MD was in the facility, assessed resident, and gave order to send resident out to hospital for further evaluation. ADMN , DON notified. Review of Resident #1's Transfer Form, effective 07/18/23 at 8:02 AM, reflected Resident #1 was being sent to the hospital, and her oxygen was 98% via oxygen mask. Under treatments and devices currently required oxygen was not selected. Review of Resident #1's Physician Progress note, written by Physician E, dated 07/18/23 (did not include time of assessment) reflected Chief Complaint / Nature of Presenting Problem: Pill bag found in patient's room, patient not acting like herself . History Of Present Illness: [AGE] year-old lady admitted to [Facility Name] on 6/3/2023 for rehabilitation or status post hospitalization for acute on chronic respiratory failure with hypoxemia and COPD exacerbation The patient has a medical history significant for COPD, methamphetamine use, memory loss, acute respiratory failure with hypoxia traumatic brain injury in 1982. She presented to the hospital with shortness of breath .Patient: Patient seen and examined in room. Patient was not acting like herself. Unable to provide an answer for any question. Asked patient about the pill bag and she said her friend has brought it for her. And patient is build back following gabapentin 300 mg and 600 mg. Also found hydroxyzine 50 mg pills. Patient kept on repeating I am sorry I will not do this again. Patient unable to tell how many pills she has taken. Sending patient to ER . Physical Exam General .Excessive sedation. Unable to keep eyes open. Unable to have full conversation. Review of Resident #1's blood pressure readings from the facility EMR reflected her blood pressure on 07/18/23 at 7:35 AM (when LVN A found resident with a change in condition), and 8:22 AM (four minutes before EMS walked into the facility) the readings for both were 142/72. Review of Resident #1's oxygen readings from the facility EMR reflected her oxygen saturation on 07/18/23 at 8:23 AM (three minutes before EMS walked into the building) was 98% via oxygen mask. No data for her oxygen level was entered at the time the nurse found her with a change in condition. All oxygen readings from 07/08/23 to 07/18/23 t 7:35 AM reading reflected it to be the only reading for via oxygen mask. All other readings were for room air (six) or oxygen via nasal cannula (19). Review of the EMS company's patient care report, dated 07/18/23, stated the O2 sats on 7/18/23 between 8:34 AM and 9:28 AM ranged from 66-82 O2%. The report included notes which indicated Resident #1 did not have oxygen on when they arrived. During this the pt had been moved over to the cot, secured, and vitals obtained. Pt was then found to be severely hypoxic on room air and a nasal cannula was then noticed on the pt's wheelchair. Pt was asked if on O2 and the pt. said she was. Pt was promptly placed on O2 via nasal cannula and the pt's O2 saturations began to improve .Pt was then moved out to the MICU for further treatment of hypoxia. In the MICU pt O2 saturations showed to have stalled at approximately 83% on O2 via nasal cannula. Pt was then placed on a NRB mask and then transported to [hospital]. En route pt showed to become more altered and appeared sedated. Pt was able to aroused [sic] with gentle physical stimulation and was still able to answer questions but had a hard time staying awake. Pt report was called into the hospital to notify of the pt's condition and given an ETA. Pt continued to be monitored and no further interventions were made en route. Upon arrival at the hospital ( .) Pt's RN was made aware of the situation around the pt's condition and how the pt had not been on her o2 prior to EMS arrival for unknown reasons. Review of the Emergency Department Admission Sheet, dated 07/20/23, reflected Resident #1 arrived at the hospital on 7/18/23 at 9:31 AM complaining of dyspnea (shortness of breath). Per EMS Resident #1 was sent by nursing home staff for acute hypoxia (absence of enough oxygen in blood tissues) related to accidental drug overdose (Seroquel, Gabapentin and hydroxyzine.) Her primary admitting diagnosis was respiratory failure. Per the history of present illness documentation Resident #1's oxygen saturation percentage was in the 20s when EMS found her. They then placed her on a non-rebreather and her oxygen level improved rapidly. The ( .) vitals taken on 7/18/23 at 9:50 AM were blood pressure 148/70 , pulse 79, respirations 18 breaths per minute and oxygen blood saturation 100% on non-rebreather mask. According to the Physical exam Resident #1's appearance was somnolent, attention diminished, awakened to sternal rub, and moved all four extremities. Lab work collected on 7/18/23 at 9:58 AM revealed Resident #1's blood carbon dioxide levels to be over 100 (the normal range being 35-45), and a blood test of her oxygen reflected a result of 37 (the normal range being 80-105.) According to the ED deposition, due to an extensive history, physical exam and cardiopulmonary workup, Resident #1's presentation was consistent with COPD (lung disease) exacerbation. Despite typical ED treatment the resident did not improve to the point that which she would be able to return to the nursing facility safely and was admitted to the hospital for further treatment. An interview on 07/21/23 at 12:43 PM with the Administrator revealed he had not reported the incident with Resident #1 taking outside medications, because she stable, in no distress, and talking to him and other staff while she was in the facility. He stated they had investigated the issue with the family member bringing medications in, and the family member stated she had brought them, and given them directly to the resident. Observation of video footage reflected: On 07/18/23 at 8:08 AM, CNA B wheeled Resident #1 to the nurses station, and placed her next to the front side of the nurses station. When enlarging the video on the State Surveyor's computer screen, Resident #1 did not appear to be wearing an oxygen cannula. No tubing was visible around her upper body/shoulders or on her face, and there was no indentation on her skin visible from the tubing. The back of her wheelchair was not visible due to the angle of the video, and the nurses station wall blocked the view. Resident #1's upper body was visible. She spoke and laughed with LVN A, who was inside the nurses station, already seated at the computer, and was on the phone. Other staff could be seen walking past the station, and into the nurses station, while the resident was seated next to it. LVN A could be seen turning her head frequently to look directly at Resident #1. The resident did not appear to be distressed, and sometimes appeared sleepy, but for a majority of the video was awake and looking around. At 8:13 AM, the Administrator entered the front door of the facility and approached Resident #1, greeted her, placed his hand on her shoulder and turned into the hall where his office was located. He immediately turned and walked back to the nurses' station, and talked with LVN A, and they both looked at Resident #1 while they talked. At 8:14 AM CNA B returned with a can of soda, inserted a straw, and handed the can to Resident #1. Resident #1 was able to hold the can, manipulate the straw, drink, and set the can down on the nurses' station counter, with no apparent problems. Also at 8:14 AM the Administrator approached the resident, and leaned on the counter to talk with her. The resident appeared to be speaking during most of this conversation, appeared alert, and did not appear distressed. During their conversation LVN A left her seat to use another computer at the nurses' station, and returned to her seat, and continued to use the computer and hold the phone to her ear. At 8:21 AM the Administrator pulled his phone out of his pocket and made a call. He ended the call approximately a minute and a half later. At 8:23 AM the Administrator walked away from the resident and entered the hall leading to his office. At the same time, LVN A exited the nurses' station, and followed him down the hall. At this time a woman in a white lab coat (identity unknown) briefly addressed Resident #1 and walked away, exiting the facility front door. Various other staff were present in the area of the nurses' station during the time LVN A was gone, but none appeared to address the resident, or directly observe her at this time. At 8:24 AM the last one of the staff (identify unknown by surveyor) who was near the nurses' station exited the facility front door, and LVN A returned to her computer near the resident. At 8:26 AM three EMS personnel could be seen entering the front door with a gurney. They approached LVN A and Resident #1. LVN D approached and had a conversation with them. LVN A was still on the phone and using the computer. EMS staff leaned on the counter and the gurney and conversed with Resident #1 while she drank her coke, and LVN D, walked away at 8:28 AM. At 8:28 AM a police officer entered the front door. EMS personnel addressed the officer, and gestured to Resident #1. At 8:30 AM the police officer approached Resident #1. LVN D addressed Resident #1, and they had a brief conversation, while EMS stood in the doorway of the lobby with their arms folded, watching. Resident #1 had a brief conversation with the police officer, and at 8:31 AM, EMS personnel lowered the gurney and removed bags from it (to make room for the resident.) At 8:32 AM Resident #1 unsteadily stood up, and placed herself on the gurney, while one EMS worker had his hand on her back, and held one of her hands. He assisted her getting her legs onto the gurney. The resident was lying on the gurney for approximately three minutes while EMS staff appeared to be arguing with LVN D and LVN A, two of the EMS personnel gestured emphatically with their hands as they spoke. One of them walked away from the conversation and applied the blood pressure cuff to Resident #1 at 8:33 AM. The LVN D left the video and returned shortly, and her facial expression appeared strained, and walked away again. At 8:36 AM one EMS worker placed an oxygen cannula on Resident #1's face. At this time the other two EMS turned their attention to the resident, and appeared to be having a conversation with her. They stood, as if waiting, until 8:38 AM, when one of the three EMS personnel entered the hallway to the Administrator's office. At 8:42 AM the EMS personnel walked toward the front door of the facility with Resident #1 on the gurney. The resident appeared to be awake and not in any distress when they rolled her away from the nurses' station. They stood at the door, and LVN A walked to the door and entered the code to exit at 8:43 AM. An interview with the complainant on 07/18/23 at 4:21 PM revealed Resident #1 went to the hospital after taking pills at the facility from a bag a family member provided her, and the resident was not wearing her oxygen when EMS arrived. The resident was placed on oxygen by the EMS personnel, and when they checked her O2 SATS (oxygen saturation levels), she was at 29%, which was an indication she had been off her oxygen for some time. The complainant stated the documentation showed the nurse had taken the resident's vitals just before EMS arrived, and her oxygen level was at a normal level, but the resident was hypoxic when they arrived, and could not have become so that quickly. The complainant stated the resident was pleasant and cooperative, and a little altered and sedated and had a TBI (traumatic brain injury) but was still able to talk to them. An interview on 07/19/23 at 1:15 AM with LVN A revealed when she was waiting for EMS to come get a resident , she would monitor all the vital signs, which included oxygen, and document the time of the assessment, at that time. She said she found Resident #1 in her room, in bed, when she would normally be up, and when she spoke, she did not sound right. She said she took Resident #1's blood pressure, and the resident was apologetic and said she wouldn't do it again. When she asked her what she did, she found pills in a bag. The physician came into the room, and the vitals recorded at 8:22 AM were the ones she took at an earlier time, when the physician saw the resident. They figured out that the pills were gabapentin and hydralazine. The physician told LVN A to send Resident #1 to the hospital to be assessed. She said Resident #1 had COPD and always wore oxygen and only took it off to go to the bathroom. She said she took the vitals right when the situation occurred, when she discovered the resident with a change in condition, but did not take them again before EMS arrived, because the times were close enough together that she did not need to. She said the resident was at risk of passing out, but she was right at the nurse station, asking for soda, and talking, and in no distress, and did not need to have her vital signs monitored. An interview on 07/19/23 at 1:25 PM with CNA B revealed he was a PRN CNA and had been the one to get Resident #1 dressed and ready to go to the hospital. He said she did not have oxygen on when he saw her. An interview on 07/20/23 at 9:14 AM with Resident #1's family member revealed Resident #1 had to be held at the hospital because of her oxygen levels, and she was requiring too much oxygen. She said they needed to get her back to a level where she would be safe at the facility. She said when she was in the hospital, her oxygen requirement was seven liters, and they had her down three, and would be discharging her soon. An interview on 07/20/23 at 9:09 AM with the DON revealed she felt LVN A did a good job monitoring Resident #1. She said she would expect visual monitoring was appropriate in this case, and she had the resident in her line of vision, so she could notice whether she showed any changes, and could reassess her. She said she was not aware Resident #1 was not wearing her oxygen, but she barely wore oxygen, and she definitely did not recall her being on oxygen all the time. She said the resident was often up, walking around the facility, and not wearing her oxygen. She said she thought the resident told EMS as they were leaving she had taken Seroquel and gabapentin from the bag of pills her sister brought. She said she was alert, and talking, and drinking her coke without fumbling, and did not seem to be in any sort of distress, and was just twitching a little, and groggy, from the medication. She said she did not have any residents with continuous oxygen orders, including Resident #1. An interview on 07/20/23 at 9:33 AM with CNA B revealed saw Resident #1 trying to get up and staggering when he was passing breakfast trays on 07/18/23, so he went in to help her. He said she had her oxygen on then, but he had to help her change clothes and get ready for EMS, so he was not sure if the oxygen was on her when he took her to the front. He said she mostly used the oxygen in her room, but he did not see her using it often when she left her room. He said he saw her several times while she waited for EMS, and she did not appear to be in any sort of distress. An interview and observation on 07/20/23 at 10:33 AM in the hospital with Resident #1 revealed her to be alert, sitting up in bed, with four liters of oxygen running. She said a family member brought her some pills from the pharmacy that she had been taking for a long time. She said she did not feel the nurse was giving her what she needed , so she asked her sister to pick them up from the pharmacy. She said she took some out of the bottles, and gave the rest to a nurse , and she should not have done that. She said she had taken Seroquel and hydralazine. She said she was always on oxygen, and only took it off to use the restroom. She said she felt great at the time of the interview, and it was not the pills that got her to the hospital, it was the oxygen. An interview on 07/20/23 at 10:14 AM with LVN C revealed if a resident with respiratory diagnoses was being sent out to the hospital, she would put their oxygen on them, and keep the monitor on their finger, and monitor their vitals. She said she would have oxygen on the resident, and would stay with them, or have someone else stay with them who could monitor their vital signs while she got the paperwork ready for EMS. She said Resident #1 often left her room without wearing oxygen, and it might have been ok to just visually monitor her , but she was not there when it happened, and was not sure of her condition when she was sent out. An interview on 07/20/23 at 11:02 AM with LVN D revealed the nurses had a class by a Respiratory Therapist a few months prior to this visit, because they were getting a resident who had a trach. She said they trained them on how to recognize respiratory distress, and what to do. She said if she was sending a resident out, who had COPD, she would monitor their oxygen by keeping the monitor on their finger, and keeping them by her, and checking their vitals every few minutes. She said she would not just use visual monitoring for oxygen , because you could not tell when someone's oxygen started to drop and by the time you saw signs it could already be very low. She said someone would need to be checking their vital signs, and keeping them on oxygen. LVN D said it did not make any difference whether the change in condition was due to their respiratory diagnoses, and they had those diagnoses all the time, and their respiratory status could be challenged by other issues, as well. An interview on 07/20/23 at 12:55 PM with the DON and Administrator revealed the DON did not know if Resident #1 was on oxygen when the physician saw her, but she was normally not when she saw her, and was at 97-98 percent on room air. She said they did not have anyone on orders for continuous oxygen, and that the orders in place (which had not included the parameters for O2 SATs) were a standard set of orders, and the nurses added how many liters. She said they had audited their O2 orders, and clarified them, and the nurses should clarify them when they received the physician orders. She said the physician and the ADON were responsible for making sure the orders entered were correct. She said one of the State Surveyors had said the resident was supposed to be on continuous oxygen, and they had called corporate to check, and there were notes where she was on room air, and was only on O2 in some of the notes. The Administrator said when the resident was waiting, she was stable, and was talking to him, and even got up to get on the gurney herself, and the EMS personnel took nine minutes to touch the resident, and it took them two minutes to leave with her because they were too busy arguing with his staff. He said the staff wanted them to take the resident to get checked out and were about to leave without taking the resident with them. An interview on 07/20/23 at 11:28 AM with Physician E revealed LVN A told her Resident #1 was not acting like herself, and was dizzy and sedated. She looked at the bag with the pills in it, the nurse found in the resident's room, and it had a lot of pills, hydralazine 300 mg and Neurontin 600 mg. She said Resident #1 did not look like herself, and started crying, and said she did not know what she took, because they did not know how much she took, of which pills, she told the nurse to send her to the hospital. When asked if she felt the resident needed to be monitored closely since one of the pills she might have taken (Seroquel) could cause respiratory distress, she answered EMS was there soon after and the resident was talking, so they were closely monitoring her. She said she was in the room with the resident around 7:30 AM to 7:45 AM. Physician E said the resident was on oxygen, but in the time between seeing Resident #1 and EMS arriving she saw other patients. She said Resident #1 was on continuous oxygen at her baseline and was always on continuous oxygen when she saw her, and was oxygen dependent. She said if someone who needed oxygen did not receive it for a long period, it could cause their CO2 to increase, and cause respiratory distress. She did not elaborate on what a long time meant. An interview on 07/20/23 at 3:54 PM with the Medical Director revealed Resident #1 was on oxygen the majority of the time due to her congestive heart failure diagnosis. She said Resident #1 was very non-compliant and had been refusing things, including her bi-pap. She said she was able to go to the restroom without her oxygen, but usually needed it. When asked by the surveyor if a nurse could tell a resident's vital signs by looking at them, she acknowledged that they could not. and stated Resident #1 should have had hers monitored during the situation, with an unknown amount of medication in her system. She said she had tried to instill in staff at the facility to assess, perform interventions appropriately, and notify her. When asked by the surveyor if being off oxygen could cause high carbon dioxide levels, she said it could. An interview with the DON on 07/21/23 at 1:50 PM revealed the was resident was stable, and being closely visually monitored by LVN A, the resident very often was non-compliant with her oxygen. She said the resident was observed by multiple staff, and the Administrator spoke with her for several minutes and she was not showing any signs of respiratory distress, and she even got up herself to get on the gurney. When asked by the surveyor if visual observation would allow someone to see a resident's vital signs, the DON acknowledged that it could not, and stated said that even so, visual observation was a crucial factor in monitoring conditions, and the nurses were educated to know signs of someone's oxygen levels dropping. She said Resident #1 returned on the previous evening (07/20/23), and she was doing well, and very happy to get back to the facility. An interview on 07/21/23 at 2:30 PM with the Administrator revealed EMS staff did not look concerned about Resident #1, and took a long time to arrive at the facility and a long time to get her to the hospital. He said he felt there was some retaliation going on against his staff, because the EMS staff had been argumentative with his staff, and not wanted to take Resident #1 because she initially said she did not want to go, and that one of them had probably called in a complaint. He said the documentation the EMS company provided them, and the numbers the State Surveyors had asked them about did not match up, and there were details in the documentation by the company that their camera footage showed to not be accurate, which included nowhere was her oxygen documented even close to the low percentages inquired about during this survey. He said they had set up a meeting with the company to discuss their concerns about the behavior of their company's staff, and he did not think this situation rose to the level of an IJ Record review of staff training records reflected the facility nursing staff attended a training given by a Respiratory therapist throughout the month of November in 2021. LVN A signed in and earned a certificate for the training on 11/10/21. The training was focused on patients with a trach and also appeared to cover general respiratory emergencies. LVN A attended the training and received a continuing education certificate. Record review of the facility policy for Notifying the Physician of Change in Status, revised 03/11/13, reflected The nurse will monitor and reassess the resident' s status and response to interventions. The facility failed to place an oxygen cannula and monitor the vital signs for Resident #1 while she waited for EMS to arrive, after she ingested an unknown combination of prescription pills. This deficient practice resulted in actual harm, when Resident #1's oxygen levels dropped, resulting in her carbon dioxide levels being very high when she arrived at the hospital. This was determined to be an Immediate Jeopardy (IJ) on 07/20/23 at 1:06 PM. The Administrator and the DON were notified. The Administrator and the DON were provided with the IJ template on 07/20/23 at 1:06 PM. The following Plan of Removal submitted by the facility was accepted on 07/21/23 at 8:57 AM. Plan of Removal: 07/20/23 Plan of Removal Problem: F684 Quality of Care All residents have the potential to be affected by this deficient practice. Interventions: o As of 7/20/23, the resident remains in the hospital for evaluation. o All residents in the facility were assessed for any change of condition by the DON, ADON and Charge Nurses as of 7/20/23. No additional issues were found. o All residents with orders for oxygen continuous and as needed had oxygen saturation levels obtained as of 7/20/23 by the DON/ADON. No additional issues were found. o On 7/20/2023, the DON obtained clarification orders from the physician to ensure that accurate orders were in place in PCC. o LVN A was immediately suspended pending investigation on 7/20/2023. o LVN A will not be permitted to provide care to residents until the following 1:1 in-services have been completed. o Providing care to residents who are experiencing a change in condition or respiratory distress. o Notification of change of condition to the physician immediately. o Monitoring a resident for a change of condition until emergency services arrive which include vital signs and the need for oxygen supplementation every 15 minutes or sooner if a further decline is noted. o Charge nurses to follow physician orders to include oxygen orders. o Staff will educate residents and families to give all medications to the charge nurse if it is found that family or resident bring outside medications. In-services: o All charge nurses will be in-serviced by 7/21/23 by the DON/ADON regarding the following and all nurses not in-serviced by 7/21/23 will not be allowed to work their assigned position until completion of these in-services: This will be ongoing. DON and ADON were in-serviced by Compliance Nurse. o Notification of change of condition to the physician immediately. o Monitoring a resident for a change of condition until emergency services arrive which include vital signs and the need for oxygen supplementation every 15 minutes or sooner if a further decline is noted. o Charge nurses to follow physician orders to include oxygen orders. o Staff will educate residents and families to give all medications to the charge nurse if it is found that family or resident bring outside medications. o The medical director was notified by the administrator of this plan on 7/20/2023. An Ad Hoc QAPI meeting was held 7/20/2023. Monitoring: o Monitoring of this plan began on 7/20/2023 and will continue weekly x 4. o The DON and/or designee will monitor the vitals summary report from PCC at least 5 times per week to determine if vital signs including oxygen saturation remain within parameters and if not, the physician/NP will be notified. Monitoring began 7/20/2023 and will continue x 4 weeks. o The DON and/or designee will monitor Real Time clinical software and the PCC dashboard at least 5 times per week, indefinitely to ensure any new or worsened shortness of breath is communicated to the physician/NP and follow up as needed. Monitoring began 7/20/23 and will continue x 4 weeks. o DON [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure residents remained free of accident hazards for two (Resident #1 and #2) of six residents reviewed for accidents. 1) The facility failed to ensure Resident #1 was safe utilizing a low air loss mattress and staff were able to set up the mattress appropriately, possibly contributing a fall from bed that resulted in a neck fracture, laceration to her forehead, and a hematoma to the back of her head. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at the severity level of actual harm this is not immediate jeopardy and a scope of isolated because the facility was still monitoring their plan of removal. 2) The facility failed to ensure Resident #2's environment remained free of accidents and hazards by placing a bed mattress next to her bed as a fall mat. Resident #2 fell and sustained a facial fracture. This failure put residents at risk for serious injury or death. Findings included: 1) Review of Resident #1's significant change MDS assessment dated [DATE] revealed she was [AGE] year-old female admitted to the facility to the facility [DATE]. Her [DIAGNOSES REDACTED]. and she was severely cognitively impaired. The resident required the extensive assistance of one staff with bed mobility and the total assistance of one staff for transfers. Review of Resident #1's care plan dated [DATE] revealed she was at risk for falls due to cognitive impairment and physical impairment. Approaches included to anticipate needs and provide prompt assistance. Review of Resident #1's Fall Risk Assessment Form dated [DATE] indicated she was at high risk for falls. Review of the facility's Provider Investigation Report dated [DATE] revealed Resident #1 was found on the floor next to her bed on her fall mat with a laceration to her forehead and hematoma to the left back of her skull. Upon return from the hospital the resident's [DIAGNOSES REDACTED]. Provider action taken post-investigation included a bolster mattress placed on the resident's bed (mattress with side bumpers), treatment for [REDACTED]. There was no evidence or statements of the staff being questioned as to what occurred to realize the air loss mattress was not at the correct settings putting the resident at risk for injury. Review of Resident #1's nurses notes dated [DATE] at 9:40 PM revealed the following: called to room by resident's roommate. (Resident #1) apparently fell out of bed and has large gash in middle of forehead and hematoma to back right side of skull.9:50 PM 911 here and resident had neck brace placed and was transferred to hospital. Review of Resident #1's hospital records dated [DATE] reflected the following: Final Impression/Diagnosis.1. Laceration of scalp.3. odontoid fracture with type II morphology and nonunion, 4. closed displaced fracture of first cervical vertebra (neck fracture beneath skull) According to the Neurological Institute of New York a type II odontoid fracture is a break that occurs through a specific part of C2, the second bone in the neck. (accessed on [DATE] from https://www.columbiaspine.org/condition/type-ii-odontoid-fracture/) Review of Resident #1's physician's telephone orders dated [DATE] revealed the following: air loss mattress, reposition every two hours while in bed Review of Resident #1's physician's telephone orders dated [DATE] revealed the following: D/C (discontinue) air loss mattress; bolster mattress. Observation on [DATE] at 11:55 AM of Resident #1 revealed she was sitting in her wheelchair at a dining room table. She was wearing a neck brace and there was a healing/closed laceration to her forehead. She was not able to verbalize when she was spoken to and appeared to have cognition impairment. Observation of her room revealed her bed had a scoop mattress in place. Interview on [DATE] at 2:14 PM with CNA A revealed Resident #1 had been switched to a low air loss mattress the day of the incident ([DATE]). He stated the bed appeared to be pumping up high and he had asked the nurse if the setting were accurate. He stated the nurse told him the setting were correct, but did not identify which nurse told him this. CNA A stated he put Resident #1 to bed between 8:30 PM to 9:00 PM. He said it was not more than 10 minutes later when he was told the resident had fallen out of the bed. CNA A stated he thought the low air loss mattress had been the cause of the fall. He stated Resident #1never had a fall prior to using that mattress, and that Resident #1 would lie still in her bed and never attempt to get up. CNA A stated the resident has a fall mat in place at the time of the fall and she was sent to the hospital. He stated the air loss mattress was taken off and replaced with a scoop mattress. According to Wound Care Solutions a low air loss mattress is composed of multiple inflatable air tubes that alternately inflate and deflate, mimicking the movement of a patient shifting in bed or being rotated by a caregiver, never leaving the patient in one position for any extended length of time. This action relieves pressure under the body . and helps ensure proper air circulation, helping to prevent, manage, and treat the occurrence of pressure wounds. (accessed on [DATE] from https://www.woundcareinc.com/resources/low-air-loss) Interview on [DATE] at 2:50 PM with LVN B revealed Resident #1's roommate came to the nurse's station to tell them the resident was on the floor. LVN B stated she found Resident #1 face down on the floor and with blood around her head. She stated there was a fall mat in place but it appeared the resident missed the mat entirely because she was not on it. LVN B said she spoke with the roommate who reported she did not see the fall but heard something and then saw Resident #1 on the floor. LVN B stated she thought the low air loss mattress was the cause of the fall because Resident #1 had never fallen out of bed or attempted to get up until her mattress had been switched to a low air loss mattress earlier that day. LVN B said the air loss mattress was removed after the fall and was replaced with a regular one. Interview on [DATE] at 10:35 AM with Resident #1's roommate revealed she did not recall Resident #1 having a fall or being on the floor. Interview on [DATE] at 11:35 AM with the DON revealed Resident #1 had been changed from a regular mattress to a low air loss mattress because she had developed a Stage 2 pressure ulcer to her sacrum. The DON stated she believed the new bed contributed to Resident #1's fall. She said she spoke with Resident #1's roommate who reported she heard Resident #1 crying and then saw Resident #1 on the floor. The DON stated the low air loss mattress settings were set according the resident's weight and the Wound Care Nurse would have been the one to check the settings on Resident #1's bed. Interview on [DATE] at 4:09 PM with the Wound Care Nurse revealed she was not at work when Resident #1's air loss mattress was set up. She stated the low air loss mattress settings would have been the responsibility of the charge nurse on duty when the mattress was set up. Interview on [DATE] at 10:46 AM with RN M revealed she was the charge nurse for Resident #1 on [DATE] during the 6:00 AM to 2:00 PM shift. She stated she had not checked the settings for Resident #1's low air loss mattress because it had not been completely set up when she left at the end of her shift. Interview on [DATE] at 12:14 PM with LVN B revealed she was not aware who checked the setting of Resident #1's low air loss mattress because when she arrived to work on the day of the incident (2:00 PM to 10:00 PM), the mattress was already set up. She said she had never been in-serviced on low air loss mattress settings and would not know the correct setting. LVN B stated she did not recall CNA A asking her about the low air loss mattress setting. Interview on [DATE] at 1:21 PM with the Administrator revealed the Maintenance Director would have gotten the low air loss mattress out of storage and put it in the resident's room, but he would not have been responsible for the setting of the low air loss mattress. The Administrator stated the Maintenance Director would not have known the appropriate settings for Resident #1's air loss mattress. Interview on [DATE] at 2:07 PM with the DON revealed the Maintenance Director would not have known the correct settings for Resident #1's low air loss mattress because he had never set one up during she time she had worked at the facility. The DON said she would have expected the charge nurse on duty to make sure the bed was set up correctly. Attempts to interview the Maintenance Director were unsuccessful because he was on vacation. Review of an undated Low Air Loss Mattress User Manual, which was provided by the facility reflected the following: .5 Usage: 5.1.6 Firm/Soft Buttons: (page 22) The patient comfort ranges from soft to firm. The comfort control LED displays the patient comfort pressure levels from 0(zero) to 9 and provides a guide to the caregiver to set the approximate comfort pressure level depending on the patient weight. Interview on [DATE] at 1:06 PM with a Representative for the Air Loss Mattress company revealed they suggest bed rails when using an air loss mattress to help prevent falls. He stated if a patient is not placed in the center of the bed and she are got too close to the side of the mattress, patients run the risk of falling out of the bed as it inflates. The air loss representative further stated if patients are placed on an air loss mattress for the first time they should watch it inflate and monitor for safety. Interview on [DATE] at 2:07 PM with the DON revealed she had been in-serviced again regarding thoroughly investigating self-reports on [DATE]. She stated the investigation needed to contain interviews and statements from staff reporting the incident, staff that had worked during the shift and the shift prior, and any and all staff involved with the resident. The DON stated her main focus when investigating the incident with Resident #1 was ensuring the low air loss mattress was removed. She stated she did not realize the risks associated with staff not verifying the settings to the air loss mattress. She stated she assumed the charge nurse to set up the mattress and now realized she could not assume the staff were knowledgeable in using the facility equipment. The DON stated at this time no one knew who actually set the low air loss mattress setting, and this put other residents at risk who used the same type of mattress. Interview on [DATE] at 2:34 PM with the Administrator revealed she had been re-inserviced in conducting investigations and she and the DON were given examples and re-trained on self-reports on [DATE]. She stated they would talk to more people who worked with the resident and not just those immediately involved. The Administrator stated going forward they would have written statements to look back on instead of remembering what they were told during the investigation. She further stated she was not aware there was a concern with Resident #1's air loss mattresses' settings because the DON had conducted the investigation of her fall. An Immediate Jeopardy was identified on [DATE]. The Administrator, the DON, and Regional Director of Clinical Services were notified of the Immediate Jeopardy on [DATE] and they were provided with a copy of the IJ template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Plan of Removal was accepted on [DATE] at 3:53 PM and included: Approaches: - All low air loss mattresses were replaced on [DATE] with an AIM (Air Immersion Mattress) mattress Responsible Persons: Administrator and DON; Monitoring by RDCS (Regional Director of Clinical Services) and RDO (Regional Director of Operations) - The following residents were on AIM mattresses for pressure ulcers: Residents #9, #10, #11, #12, and #13. The following residents received AIM mattresses on [DATE] as a replacement to the low air loss mattresses: Residents #14 and #15. Responsible Persons: DON, ADON, and RDCS; Monitoring: DON, ADON, RDCS - The AIM mattresses do not have alternating air and are set at default mode upon arrival and are manually pumped up if needed for resident comfort. Responsible Person: DON and ADON; Monitoring: RDCS - All Charge Nurses, Nurse Managers (ADON and DON) and CNAs will be educated on proper use of the AIM mattress by [DATE] in person or via telephone. Responsible Persons: RDCS and ADON; Monitoring: RDCS and RDO - Low air loss mattresses will not be allowed in the building. Responsible Person: Admin and DON; Monitoring: RDCS and RDO - The Admin and/or DON will notify all hospice and/or DME (Durable Medical Equipment) companies that low air loss mattresses will not be allowed in the building. Responsible Persons: Admin and DON; Monitoring: RDCS and RDO - Admin and DON educated [DATE] on how to properly investigate accidents to ensure that a thorough investigation is completed per the current guidelines provided in the Provider letter for incident reporting. Responsible Persons: RDCS - All accidents will be communicated to the Regional Team (RDCS and RDO) to ensure a proper investigation was completed and proper interventions were put into place. The following Information was presented in the Inservice: Power Point regarding Investigations and Reportable Events; PL ,[DATE] Abuse, Neglect, Exploitation, Misappropriation of Resident Property and Other Incidents that a Nursing Facility (NF) Must Report to the Health and Human Services and PL,[DATE] Incident Reporting Requirements Responsible Persons: Admin and DON; Monitoring: RDCS and RDO The following observations, interviews, and record reviews were conducted to verify the implementation of the facility's Plan of Removal: Review of in-services dated [DATE] and [DATE] revealed staff was in-serviced about the use of an AIM mattress and all its functions. The in-service indicated staff would do a return demonstration and verbalize understanding. Staff would be educated on default mode and manual pump of the bolsters and that the patient will still require change of position every two hours and CPR (cardiopulmonary resuscitation) could be conducted on the mattress with a backboard. Interview were conducted with charge nurses RN P, RN U, RN AA, RN BB, RN N, RN E and LVN K, B, DD, FF, L, HH, II, LL on [DATE] from 9:50 AM to 2:47 PM. The interviews revealed they had been in-serviced that the AIM mattresses would replace the air loss mattresses and those would no longer be used. They were also educated on the components of the AIM mattress and how to manually inflate the bolsters with the pump for residents that were high fall risk and only the charge nurses were allowed to adjust the air in the mattress. The staff stated the AIM mattress was already at default settings and did not need to be adjusted unless the resident complained of discomfort and at that time air could be let out of the head and belly area. Staff indicated adjustment of the air was to be done only by the nursing staff. Staff said once the resident was out of the bed, the bed's headrest and footrest was to be laid flat allowing the mattress to auto-self-inflate to atmospheric pressure. They were all instructed that CPR could be done on the AIM mattress after applying a backboard underneath the resident. Interview were conducted with CNAs Q, R, S, T, V, W, X, Y, Z, CC, EE, H, GG, JJ, KK, MM, and NN on [DATE] from 9:50 AM to 2:47 PM. The interviews revealed they had been in-serviced that the AIM mattressess would replace the air loss mattressed and those would no longer be used. They were also educated on the components of the AIM mattress and how to manually inflate the bolsters with the pump for residents that were high fall risk and only the charge nurses were allowed to adjust the air in the mattress. The staff stated the AIM mattress was already at default settings and did not need to be adjusted unless the resident complained of discomfort and at that time air could be let out of the head and belly area, to be done only by the nursing staff. Staff said once the resident was out of the bed, the bed's headrest and footrest was to be laid flat allowing the mattress to auto-self-inflate to atmospheric pressure. They were all instructed that CPR could be done on the AIM mattress after applying a backboard underneath the resident. Observation on [DATE] from 1:54 PM to 2:10 PM revealed Residents #9, #10, #11, #12, #13, #14 and #15 were all on AIM mattresses. Resident #12 was provided a bariatric AIM mattress and Resident #1 remained on a regular scoop mattress for fall prevention. Interview on [DATE] at 2:07 PM with the DON revealed she had been re-inserviced on thoroughly investigating self-reports. She stated the investigation needed to contain interviews and statements from staff reporting the incident, staff that had worked during the shift and the shift prior, and any and all staff involved with the resident. The DON stated her main focus when investigating the incident with Resident #1 was ensuring the low air loss mattress was removed. She stated she did not realize the risks associated with staff not verifying the settings to the air loss mattress. She stated she assumed the charge nurse to set up the mattress and now realized she could not assume the staff were knowledgeable in using the facility equipment. Interview on [DATE] at 2:34 PM with the Administrator revealed she had been re-inserviced in conducting investigations and she and the DON were given examples and re-trained on self-reports. She stated they would interview more people who worked with the resident and not just who was immediately involved. The Administrator stated going forward they would have written statements to look back on instead of remembering what they were told during the investigation. The Administrator, DON, and RDCS were notified on [DATE] at 3:46 PM that the Immediate Jeopardy was removed. While the IJ was removed on [DATE], the facility remained out of compliance at the severity level of actual harm this is not immediate jeopardy and a scope of isolated because the facility was still monitoring their plan of removal. 2) Review of Resident #2's significant change MDS assessment, dated [DATE], revealed she was a [AGE] year-old female admitted to the facility on [DATE]. The assessment reflected she had clear speech, was understood by others, could understand others, and her cognition was severely impaired. Resident #2 required limited assistance of one-person for transfers. She utilized a wheelchair and required staff assistance to stabilize when walking, turning around, moving on/off the toilet, performing surface-to-surface transfers, and moving from seated to a standing position. Resident #2's [DIAGNOSES REDACTED]. Review of Resident #2's fall risk assessment, dated [DATE], revealed she was a high fall risk. Review of Resident #2's comprehensive care plan, last reviewed/revised [DATE], revealed the following: Problem, [DATE] I am at risk of falls and is at risk for increased falls and fractures as evidence by: cognition impairment, history of falls, medications, and wandering. Approach, 1) Encourage resident to ask for assistance of staff 2) Ensure call light is in reach, answer promptly 3)Therapy to eval (evaluate) and treated per orders 4) Anticipate needs, provide prompt assistance 5) Assure lighting is adequate and areas are free of clutter 6) Encourage socialization and activity attendance as tolerated. Review of the facility's Provider Investigation Report (PIR), dated [DATE] and signed by the DON, revealed an incident occurred on [DATE] at 6:45 AM involving Resident #2. The PIR's Description of Injury reflected, Resident (#2) was found crying in the middle of her room, laying on her right side between her fall mat and wheelchair, right temporal bleeding. The PIR's Investigation Summary reflected: Resident (#2) found crying in the middle of her room, laying on her right side between her fall mat and wheelchair, right temporal bleeding. Returned from the hospital with acute right maxillary fracture (upper jaw bone) and right temporal and left fontal subdural hematoma. The PIR's Provider Action Taken Post-Investigation reflected, Readmitted [DATE] with new orders to discontinue [MEDICATION NAME] (antipsychotic medication), [MEDICATION NAME] (anticonvulsant medication), [MEDICATION NAME] (sedative), change [MEDICATION NAME] (antipsychotic medication) to 200 mg bid (twice a day) from 150 mg every night, [MED] #3 (narcotic pain medication) one tab every six hours as needed; therapy to evaluate, fall mat bedside. The PIR's investigation findings reflected the allegation of injury of unknown origin was confirmed. Attached to the PIR was an in-service sign-in sheet, dated [DATE], on injuries of unknown origin . The PIR did not contain evidence of statements from staff. Review of Resident #2's Nurse's Notes revealed a note dated [DATE] at 6:34 AM, written by LVN D. The note reflected while conducting rounds the nurse (LVN D) observed Resident #2 lying on the floor in the middle of her room crying with bleeding at her right temporal area. The area was cleaned with normal saline and a dry dressing was applied. No other injuries were observed. The mattress from the other bed in the room was observed on the floor at Resident #2's bedside. Resident #2 was unable to state exactly what happened and continued to cry. The note revealed 911 was called and the resident was sent to the hospital. In an interview with Resident #2 in her room on [DATE] at 1:15 PM the resident stated someone had pushed her down and she fell outside. Resident #2 denied falling in her room but stated she did get up by herself. Resident #2 said she was using a walker at the time of her fall and was not in a wheelchair . Resident #2 stated she had a contusion and broke her face near her right eye. During the interview, a fall mat was observed on the left side of Resident #2's bed. In an interview on [DATE] at 2:05 PM, LVN D stated on the date of the incident she went to Resident #2's room around 6:30 AM to check her blood glucose level. LVN D reviewed the nurses' note she wrote on the date of the incident. LVN D confirmed during rounds she found Resident#2 on the floor crying. She stated Resident #2 was bleeding and there was a mattress from the other bed (B bed) on the floor next to Resident #2's bed. LVN D stated Resident #2 might have tripped over the mattress on the floor. She stated Resident #2 was lying on her right side and could not state what happened. LVN D stated Resident #2 was sent to the hospital and the physician and DON were notified (LVN D did not specify when). LVN D stated she was not interviewed about the incident. In an interview on [DATE] at 1:04 PM, LVN D stated she did not know how the mattress from B bed got on the floor. She stated she informed the DON of Resident #2's fall and the DON came onto the unit to take a look. She stated the DON looked around the resident's room, asked how the bed was positioned, how the wheelchair was facing, why the mattress was on the floor and how the resident fell . In an interview on [DATE] at 3:31 PM, RN E stated she worked the 10:00 PM to 6:00 AM shift Thursday through Monday. RN E stated she had been looking for a fall mat (did not specify when) for Resident #2 and the aide (CNA F) on duty told her they used the mattress from the other bed as a fall mat. RN E stated the mattress was placed long ways so the resident could still get up and not stand on it. RN E stated if the resident fell she would hit her head on the mattress. RN E stated the aide on duty (CNA F) suggested to use the mattress as a fall mat. RN E stated the fall happened sometime after she left her shift. She stated on the day of the incident she was on the hall past 6:00 AM because the LVN D was late. She stated the two aides (no names provided) that came in (6:00 AM to 2:00 PM shift) were getting residents up and Resident #2 was one of them. RN E stated the aides were trying to get her into her wheelchair and she heard Resident #2 telling that she did not want to get up. She stated she went to the resident's room and the resident was refusing to be changed and wanted to go back to bed. She stated she told the aides to leave Resident #2 in bed because it was her right to choose if she got up or now. She stated that happened around 6:15 AM. RN E stated it was not appropriate to use the mattress as fall mat. RN E stated all she could say was other nurses had been using the mattress as a fall mat and had made statements that Resident #2 was throwing herself on the floor. She stated at the time it was just the aide and herself on the secured unit (where Resident #2 resided), and if she left the unit to locate a fall mat, that would have left the aide by herself. RN E stated no one had spoken to her about the incident. She stated Resident #2 was a high fall risk and would transfer herself in and out of bed. She stated the resident had [MEDICAL CONDITION] and she was unsteady. On [DATE] at 3:30 PM an attempt was made to contact CNA F. The attempt was unsuccessful and no return telephone call was received. In an interview on [DATE] at 1:34 PM the DON stated Resident #2 was a fall risk due to poor safety awareness. She stated Resident #2 utilized a wheelchair, but would stand up unassisted and transfer herself. She stated on the date of the fall incident LVN D (the day shift nurse) found Resident #2 on the floor during shift change. She stated it was reported to her the night shift staff had put the resident into bed and she attempted to get up unassisted throughout the night. The DON stated staff took the mattress from the other bed in the room and put it next to Resident #2' bed because she was attempting to get up. The DON stated the purpose of the mattress was for the prevention of falls and injuries. She stated she became aware the mattress was there due to documentation of the fall. She stated LVN D also told her the mattress was next to the resident's bed. The DON stated she had LVN D reenact how she found the resident and where things were located in the room. She stated RN E did what she thought was appropriate at the time instead of looking for a fall mat. The DON stated she would not have a problem with using a mattress as a fall mat for an immediate intervention until a fall mat could be placed by the bed. ; but for night shift she would not have a problem with it. She stated the mattress was placed next to the bed so Resident #2 would have had to step on it had she gotten up. The DON stated the mattress could potentially create a fall risk if and when the resident attempted to get in and out of bed on her own. She stated she thought Resident #2 has some facial fractures as a result of her fall, but would need to look at her chart. She stated she was not aware of staff using bed mattresses as fall mats prior to the incident. The DON stated she investigated how the fall occurred . She said she spoke to LVN D about the fall but did not speak to staff that worked the 6:00 AM to 2:00 PM or the 10:00 PM to 6:00 AM staff on the day of the incident. She stated an investigation consisted of talking to staff that were involved in the occurrence. She stated the Administrator oversaw investigations and delegated tasks. When asked what the policy was for investigating abuse, neglect or exploitation, the DON stated she would need to look at the policy as she was not familiar with exactly what it said . The DON stated she did not feel she needed to talk to RN E (10:00 PM to 6:00 AM nurse) about the incident because she had documented what had occurred throughout the night. In an interview on [DATE] at 3:07 PM the Administrator stated she could not recall the date of Resident #2's fall but it had happened in the past couple of months. When asked if anyone spoke to the staff that worked with Resident #2, the Administrator stated she would have thought the DON did. The Administrator reviewed the PIR of Resident #2's fall, and she could not say who the DON spoke with during the investigation. The Administrator stated she was not able to determine what the DON did during the investigation of Resident #2's by reviewing the PIR. The Administrator stated she believed the DON spoke with the nurse that found Resident #2 and the DON or the nurse spoke with the aides that were on shift to try to determine the cause of the fall. The Administrator stated she was not aware a mattress was used as a fall mat and it would not be appropriate to use a mattress as a fall mat. She stated they should have gone back to the source to find out why the mattress was there and who put it there, but she that information was not in the PIR. Review of the facility's Falls- Evaluation and Prevention policy, dated [DATE], revealed, It is the policy of this home to evaluate residents for their fall risk and develop interventions for prevention. Following a fall, the following steps should be undertaken: evaluate the environment where the fall occurred, noting any factors that may have contributed to the fall; if the fall was unwitnessed, initiate the investigation including witness statements from staff and residents. Try to determine who was the last person to see the resident prior to the fall and the resident's condition at that time. Education of staff related to fall prevention: providing a safe environment for residents.

Based on observation, interview and record review, it was determined the facility failed to ensure one (Resident #2) of five residents reviewed with a limited ROM received appropriate treatment and services to increase ROM and/or to prevent further decrease in ROM. Restorative exercises were not initiated until February 2014, almost a month from discharge with OT/PT Therapy. On three (02/10/14, 02/12/14 and 02/13/14) of five days, Resident #2 had no positioning devices for contractures. Hand and elbow splints recommended by the therapy department 12/26/13were never ordered, provided or followed-up on by the facility. Resident #2 had contractures of both arms and hands, which deteriorated from 50% to 25% of normal ROM. These failures contributed to Resident #2 experiencing a decline in ROM and could affect the five residents identified by the facility with contractures, including Resident #2, and placed them at risk for a further decrease in ROM, increased pain and discomfort with movement. Findings included: Review of Resident #2's admission MDS assessment, dated 10/19/13, revealed he was totally dependent on staff for bed mobility, transfers, dressing, eating and bathing and had functional limitations in ROM in both arms and both legs. The MDS assessment reflected no days of passive/active ROM or splint/brace assistance were provided. Review of Resident #2's MDS assessment, dated 01/19/14, revealed he was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment reflected Resident #2 was totally dependent on staff for bed mobility, transfers, dressing, eating and bathing and had functional limitations in ROM in both arms and both legs. Resident #2's MDS assessment also reflected no days of passive/active ROM or splint/brace assistance were provided. Resident #2's current Comprehensive Care Plan, dated 01/07/14, addressed contractures. The Goals included: "Contractures will not increase, skin breakdown will not occur, increased pain will be relieved with in (sic) hour of intervention and no injuries will occur over next 90 days." The Approaches included: "1)Provide pressure relieving devices on bed and chair 2) Monitor for increased pain/stiffness - provide meds/tx.s (treatments) - assess for relief 3) Assist with repositioning q (every) 2 hrs. (hours) using positioning devices to maintain proper body alignment, provide for comfort measures as needed 4) Keep contractured areas clean and dry, provide PROM (passive ROM) - do not force contractured areas open." Resident #2's current Comprehensive Care Plan, dated 02/10/14, addressed restorative care. The Goals included: "Will achieve the highest level of optimal functioning over the next 90 days." The Approaches included: "1) Perform restorative care per order - do not force or rush 2) Eval progress q month and prn (as needed) 3) Encourage/praise when goal is accomplished or attempted 4) Explain all tasks using terms, gestures resident can understand 5) Allow ample time, allow for rest periods - do not rush 6) Do not force limbs/joints Monitor for increase weakness, stiffness, pain - inform nurse 7) Keep M.D. (Medical Doctor) and R.P. (Responsible Party) informed of resident's progress." There were no care plans related to the use of any adaptive equipment for Resident #2's contractures. During orientation rounds with LVN G on 02/10/14 at 10:12 a.m., Resident #2 was observed in bed in his room. He was observed with contractures of both his arms and hands. No positioning devices were being applied to his contracted arms or hands for positioning. No towels or washcloths were observed in his hands for positioning. Observation on 02/10/14 at 12:30 p.m. revealed Resident #2 was lying in bed. There were no positioning devices or towels/washcloths applied to his contracted arms or hands for positioning. On 02/12/14 at 11:30 a.m., LVN I was asked about Resident #2's cognition and communication abilities. She stated Resident #2's family member worked with the resident, and he was now able to touch his nose and point to his mouth, when asked, as well as push his call light. However, LVN I did not provide any information related to the resident's ability to flex or extend his hands. She revealed the resident was able to answer yes/no questions by blinking his eyes. She stated his family member was at the facility daily. During this interview, the resident was observed lying in bed. There were no positioning devices, towels/washcloths applied to his contracted arms or hands for positioning. During an interview with Resident #2's family member on 02/12/14 at 5:00 p.m., he/she stated they used stuffed animals from the resident's room to position his arms, hands and legs to prevent further contractures. He/She said Resident #2 was supposed to have splints for his hands, but the order had to be approved by the ADM and hand splints were never received. At that time, the resident was observed lying in bed. There were no positioning devices, towels/washcloths, or stuffed animals applied to his contracted arms or hands for positioning. Observation on 02/13/14 at 9:32 a.m. revealed Resident #2 was lying in bed. There were no positioning devices, towels/washcloths, or stuffed animals applied to his contracted arms or hands for positioning. On 02/13/14 at 10:08 a.m., the COTA stated she gave the ADM photocopies of the splints that needed to be ordered for Resident #2 on 12/26/13. She stated she did not know why the splints were not ordered. The COTA provided copies of the documentation, which was given to the ADM regarding Resident #2's splints. The documentation included a handwritten note, dated 12/26/13, to the ADM for order approval and photocopies of the required hand/elbow splints. On 02/13/14 at 12:10 p.m., the ADM confirmed she received the order information from therapy for Resident #2's splints. She stated the Therapy Department ordered their own adaptive equipment for the residents receiving therapy. The ADM stated she gave the photocopies of the required hand/elbow splints back to the Director of Rehab (DOR) on 12/31/13. The ADM did not provide an explanation as to why there was no follow-up since 12/31/13 regarding Resident #2's splints. She said she would now look through the facility's storage to try and locate a splint for the resident to use. On 02/13/14 at 12:58 p.m., PTA J stated the facility was responsible for ordering adaptive equipment for residents. She stated the RTD had to approve the needed equipment and then the information was given to the ADM for ordering because the adaptive equipment came out of the facility's budget. In an interview with the ADM and DON on 02/13/14 at 1:10 p.m., the ADM stated therapy was able to order their own resident specific adaptive equipment through their RTD. The DON added that if an equipment need was identified by the nursing staff, it would be nursing's responsibility to place the order, and if an equipment need was identified by the Therapy Department, she believed therapy would place that order. The ADM stated there was no written p/p on how equipment was obtained. On 02/13/14 at 1:40 p.m., LVN G stated Resident #2 did not have adaptive equipment for his hand contractures. He stated he used the resident's stuffed animals provided by the family for arm and hand positioning. On 02/13/14 at 3:15 p.m., LVN K stated pillows and stuffed animals were used for Resident #2's positioning due to his contractures. During an interview on 02/13/14 at 4:15 p.m., OT L stated she assessed Resident #2's current ROM status on 02/13/14 at the request of the facility. OT L stated hand splints were still recommended to prevent further contractures and skin breakdown. On 02/13/14 at 4:18 p.m., OT L stated there had been a decline in Resident #2's ROM for his right and left upper extremities when compared to his OT assessment from 10/23/13. The Occupational Therapy Plan of Care Initial Assessment dated 10/23/13 for Resident #2 reflected he was able to complete up to 50% normal ROM for the right and left upper extremity. The Occupational Therapy Plan of Care Evaluation Only dated 02/13/14 and completed by OT L for Resident #2 reflected he was only able to complete up to 25% normal ROM for the right and left upper extremity. The OT assessment, dated 02/13/14, also reflected, "Pt (patient) is nonverbal and moans and cries with movement to BUE and BLE per Wong-Baker pain rating scale 10/10. At rest pain is 0/10. Pt presents with BUE and BLE severe flexion (the act of bending a limb), contractures. Therapist assessed BUE wrist, hand, and forearm for optimal positioning needs. Recommend BUE hand splints to maintain skin integrity, prevent pressure points and prevent skin breakdown. Educated (Resident #2's family member) on purpose of wrist/hand/finger splints and (he/she) demonstrated good understanding." On 02/13/14 at 5:30 p.m., the DOR stated the Therapy Department could not order equipment for residents without the ADM's approval. The DOR stated an evaluation and equipment recommendation had to be completed by the Therapy Department. He stated approval was then obtained from the RTD and, lastly, the ADM had to approve the purchase so that the order could be placed. During an interview with Resident #2's family member on 02/13/14 at 6:23 p.m., he/she said the resident was assessed by the Therapy department earlier that day (02/13/14), and the facility ordered hand splints for the resident, which he/she was told should arrive within a few business days. He/She also stated the Therapy Department had spoken to him/her about placing Resident #2 back on OT and PT. Observation on 02/13/14 at 6:27 p.m. revealed Resident #2 was lying in bed. There were no positioning devices or towels/washcloths applied to his contracted arms or hands for positioning. On 02/13/14 at 6:45 p.m., the ADM, DON and RN Consultant were informed of the concerns regarding Resident #2's decline according to his OT assessment on 02/13/14. On 02/13/14 at 6:58 p.m., the RTD stated a verbal order for overnight delivery was placed for Resident #2's hands splints, and he expected the delivery to be in no later than 02/17/14. The RTD stated the invoice would be sent with the delivery, and he would fax the documentation of receipt to the DADS' office if shipment arrived after exit on 02/14/14. On 02/14/14 at 8:50 a.m., CNA H stated she began working with Resident #2 at the beginning of February 2014. She stated therapy spoke with her at the beginning of January 2014 and informed her of the restorative care he would need after therapy. No explanation was given why the resident did not receive restorative care in January 2014. She stated she performed PROM with the resident daily, but often had a difficult time due to the resident's spasms, and his pain levels during the session. CNA H stated she would often request pain medication for the resident so that he could participate in the restorative care. CNA H revealed after working with the resident during the session, she would place a folded washcloth in his hands each day for a few hours. During an interview with the RTD and OT M on 02/14/14 at 9:06 a.m., the RTD stated OT L, a qualified OT professional, who was chosen by the facility to assess Resident #2, had not seen Resident #2 prior to 02/13/14 and, therefore, may not have been accurate in her assessment of the resident. Therefore OT M, who last evaluated the resident on 11/22/13 and was currently the Director of Therapy at another facility, had assessed Resident #2 during the evening of 02/13/14 after the facility was notified of the concern regarding Resident #2's ROM decline. During this interview, OT M stated Resident #2 had improved in his upper body ROM. When asked for documentation of any prior assessment of the resident's ROM for comparison, OT M stated she did not have any documentation of a prior assessment for comparison. She said during previous therapy sessions Resident #2 was evaluated in general for a variety of functional abilities and a specific assessment with ROM measurements was not conducted. She stated the resident's previous upper body assessment was documented as a gross percentage. OT M then stated she was going solely by her memory in determining the resident's ROM had improved. The assessment performed by OT M on 02/13/14 reflected Resident #2's right/left elbow flexion, wrist extension (an act or instance of extending), pronation (rotation of the hand or forearm so that the surface of the palm is facing downward or toward the back)/supination (rotation of the hand or forearm so that the palmar surface is facing upward) and hand were all within functional levels. The assessment also reflected the left wrist flexion was at zero and the right wrist flexion was at approximately 15 %. Resident #2's right/left shoulder flexions were at 33 %. Review of Resident #2's OT Therapist's Progress and Discharge Summary Notes, dated 02/13/14, from OT M, revealed the resident did not meet the following goals while in therapy: "The patient will achieve increased bilateral elbow extension to 135 degrees (- 45 degrees) to be able to participate in daily activities and improve hygiene of cubital fossa (a depression in the front of the elbow where the arm flexes). The patient will increase bilateral wrist ROM to 5 degrees extension and 5 degrees flexion." Although it was documented Resident #2 did not meet these particular goals, there was no documentation to indicate to what degree both his elbows extension and both wrists ROM was at the time of the OT Therapist's Progress and Discharge Summary Notes. Review of Resident #2's OT Therapist's Progress and Discharge Notes, electronically signed and dated by OT M on 02/13/14, reflected a change in the documentation previously given to the surveyor. The initial documentation reflected the following: " ... Splinting: Muscle Issues The patient will decrease B UE hypertonicity (extreme muscular or arterial tension) with application of B hand/wrist and elbow splints in order to reduce further progressing/development of contracture. Status: GOAL NOT MET - on 1/7/2014 Expected Timeline for Goal Met: 01/03/2014 Explanation: splints not ordered per administrator Start of Goal Status as of 12/20/2013 The Patient exhibits B UE hypertonicity without application of B hand, wrist and elbow splints. Prior Level as of 01/03/2014 The patient exhibits B UE hypertonicity with out (sic) application of wrist,/hand & elbow splint. End of Goal Status as of 01/07/2014 **GOAL NOT MET - on 1/7/2014 **The Patient exhibits B UE hypertonicity with out (sic) application of wrist,/ hand & elbow splint. Splinting Time The patient will tolerate B hand/wrist and elbow splints for 15 minutes without s/s (signs and symptoms) discomfort in order to prevent contractures. Status: GOAL NOT MET - on 1/7/2014 Expected Timeline for Goal Met: 01/03/2014 Explanation: splints not ordered per administrator Start of Goal Status as of 12/20/2013 The patient tolerates B hand/wrist and elbow splints for 0 minutes. Prior Level as of 01/03/2014 The patient tolerates B UE for 0 minutes. End of Goal Status as of 01/07/2014 **GOAL NOT MET - on 1/7/2014 **The patient tolerates B UE for 0 minutes ... Analysis of Functional Outcome / Clinical Impression Pt (Patient) made minimal progress during the course of OT tx (treatment) due to increased tone throughout the body. This was addressed with nursing and physician who made med changes. Pt con't (continues) to have hypertonicity that interferes with movement. OT recommends hand/wrist and elbow splints to prevent contracture and requested approval to order splints from the administrator but request was denied. OT has trained CNAs on ROM ex's (exercises) and they are independent with this. " The OT notes refer to the need for hand/elbow/wrist splints, which were not ordered "per the Administrator." Review of same OT Therapist's Progress and Discharge Notes, electronically signed and dated by OT M on 02/13/14, for Resident #2 and provided by the Therapy Department revealed the documentation had been adjusted regarding Resident #2's splinting needs. " ... Splinting: Muscle Issues The patient will decrease B UE hypertonicity with application of B hand/wrist and elbow splints in order to reduce further progressing/development of contracture. Status: GOAL NOT MET - on 1/7/2014 Expected Timeline for Goal Met: 01/03/2014 Explanation: progress ceased due to increased tone Start of Goal Status as of 12/20/2013 The Patient exhibits B UE hypertonicity without application of B hand, wrist and elbow splints. Prior Level as of 01/03/2014 The patient exhibits B UE hypertonicity with out (sic) application of wrist,/hand & elbow splint. End of Goal Status as of 01/07/2014 **GOAL NOT MET - on 1/7/2014 **The Patient exhibits B UE hypertonicity with out (sic) application of wrist,/ hand & elbow splint. Splinting Time The patient will tolerate B hand/wrist and elbow splints for 15 minutes without s/s discomfort in order to prevent contractures. Status: GOAL NOT MET - on 1/7/2014 Expected Timeline for Goal Met: 01/03/2014 Explanation: progress ceased due to increased tone Start of Goal Status as of 12/20/2013 The patient tolerates B hand/wrist and elbow splints for 0 minutes. Prior Level as of 01/03/2014 The patient tolerates B UE for 0 minutes. End of Goal Status as of 01/07/2014 **GOAL NOT MET - on 1/7/2014 **The patient tolerates B UE for 0 minutes ... Analysis of Functional Outcome / Clinical Impression Pt made minimal progress during the course of OT tx due to increased tone throughout the body. This was addressed with nursing and physician who made med changes. Pt con't to have hypertonicity that interferes with movement. Therapist recommends hand/wrist and elbow splints to prevent contracture. Therapist has trained CNAs on ROM ex's and they are independent with this .... " The second set of OT Notes from OT M have removed the lack of a splint as not being ordered per the Administrator. On 02/14/14 at 10:13 a.m., the surveyor requested to observe Resident #2's ability to extend his hands to within functional levels with or without assistance. At that time, the DOR stated OT L would be the most qualified person at the facility to demonstrate the resident's ability. An observation on 02/14/14 at 10:20 a.m. revealed Resident #2 was in his room with rolled washcloths in both of his hands. At that time, the RTD watched OT L demonstrate Resident #2's ability to extend his hands to within functional levels with PROM. The RTD stated the resident's hands would be considered within functional levels if his fingers could be extended with the palms of his hands open. OT L was able to extend the fingers on Resident #2's left hand with the palm open. However, when OT L attempted to extend his right hand, the resident's face turned red, he grimaced and cried out. At that point, OT L halted her attempt to extend his right hand. OT L commented that hand splints for the resident would be beneficial to prevent further contractures and [DIAGNOSES REDACTED]. On 02/14/14 at 11:25 a.m., the ADM stated she doubted the accuracy of OT L's OT assessment of Resident #2 on 02/13/14 because the OT incorrectly noted Resident #2 did not recognize family and friends regarding his cognition/orientation. At that time, the DON stated Resident #2 may not have performed well with OT L because he was not familiar with her. Therefore, OT M assessed Resident #2 during the evening on 02/13/14 because she had worked with the resident before. During an interview on 02/14/14 at 1:29 p.m., OT L stated she had been an OT for over nine years and began working at the facility on 01/09/14. Observation on 02/14/14 at 12:25 p.m. revealed Resident #2 lying in bed with rolled washcloths placed in his right and left hand. No hands splints were in use. On 02/14/14 at 3:50 p.m., the ADM stated she knew OT L was a qualified therapist, but Resident #2 did not know her, and she did not know him. The ADM stated Resident #2 did well for people with whom he was comfortable. She stated two splints were ordered, one hand splint and one elbow splint, not two hand splints, and there was no right or left side designated. The ADM also stated the 50% evaluation (from OT M's evalustion) was a general level of functioning for all of his upper extremities and did not address specific parts of the body. During an interview with Resident #2's family member on 02/14/14 at 4:05 p.m., he/she said the resident was assessed three times by the Therapy Department on 02/13/14. He/She stated he/she was present at all three assessments, and Resident #2 did not recognize any of the therapists, who had visited with him on 02/13/14 because there was no rapport. He/She stated OT L did a good job with the resident, because she spoke with the resident and engaged him in the conversation regarding his care. He/She said after the resident was discharged from therapy in January 2014, there was no intervention from the facility regarding Resident #2's splints. He/She stated the facility was now intervening regarding his contractures, because the surveyor had intervened. He/She stated "today" (02/14/14) was the first day he/she had seen the rolled washcloths in Resident #2's hands. He/She stated there had been times when he/she found his hands folded in a fist position and, therefore, he/she kept the resident's nails trimmed to prevent his nails from digging into his palms. Prior to exit on 02/14/14, no documentation of previous ROM measurements for Resident #2 was provided for comparison. During the facility exit on 02/14/14 at 5:10 p.m., the surveyor requested the invoice for Resident #2's ordered splints be faxed to the DADS office after receipt. As of 02/21/14 at 5:00 p.m., no invoice or other documentation regarding Resident#2's splints had been received by DADS. The facility's Form CMS-672, Resident Census and Conditions of Residents, signed by the DON on 02/10/14, reflected five residents had contractures and five residents had contractures on admission.