Every finding on record at Las Brisas Rehabilitation and Wellness Center

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and failed to ensure each resident received adequate assistance devices to prevent accidents for 1 (Resident #1) of 5 residents (Resident #1) reviewed for accidents and hazards. The facility failed to ensure the CNA and the dietary staff checked the temperature and sealed Resident #1's cup of hot coffee, which resulted in Resident #1 spilling tea in her bed, on her chest and down her right side, acquiring a second-degree burn to her right breast/chest area on 06/27/26 during breakfast. This failure could place residents at risk of potential accidents, injuries, or harm.Findings included: Record review of the Resident Face Sheet for Resident #1, dated 08/20/26, reflected Resident #1 was [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 was diagnosed with Type 2 Diabetes Mellitus (chronic condition characterized by insulin resistance and high blood sugar levels), Severe Morbid Obesity (complex chronic disease whose primary cause is an imbalance between calorie intake and energy expenditure causing body mass index to be 40 or greater), Peripheral Vascular Disease (common condition characterized by narrowed arteries that reduce blood flow to the limbs, primarily the legs, leading to symptoms leg pain and cramping) and Non-Pressure Chronic Ulcer of Skin (long-lasting open sore not caused by pressure commonly linked to conditions such as poor circulation, diabetes, infection, or trauma). Record review of the Quarterly MDS Assessment for Resident #1, dated 06/12/26, reflected Resident #1 scored a 15 out of 15 on the Brief Interview of Mental Status indicating Resident #1 was cognitively intact. Section GG (Functional Abilities) indicated Resident #1 required supervision or touching assistance for eating and rolling left to right. Record review of Care Plan for Resident #1, dated 08/10/2026, reflected, Problem: . [Resident #1] has a history of peripheral vascular disease.Goal: . [Resident #1] will have adequate blood flow to extremity as evidenced and skin to extremity will remain intact. Problem: .Category: Pressure Ulcer/Injury [Resident #1] is at risk for impaired skin integrity r/t [related to] impaired cognition, impaired mobility and incontinence. Goal: .Resident's skin will remain intact. Problem: [Resident #1] has a diagnosis of diabetes mellitus and receives insulin. Problem: Category: Activities [Resident #1] prefers in room activities. [Resident #1] refuses to get out of bed. She entertains herself talking with neighbor, watching her tv [television], and doing puzzles and reading.Goal: .Resident will demonstrate participation and enjoyment in activity as evidenced by increasing verbal commands and holding conversations with others outside her room. Problem: Category: ADLs Functional Status/Rehabilitation Potential [Resident #1] requires assistance with ADLs. Goal: .Resident will be assisted with all activities of daily living and be allowed to be as independent as possible.Approach: .Bed Mobility-Assist of 1-2. Eating-Supervision with setup assist.NOTE: Care Plan does not specify Resident #1 eating and drinking capabilities. Record review of Patient/Resident Incident/Accident Investigation for Resident #1, dated 06/27/26, reflected, This nurse was notified by the CNA. Resident need your help. Went to the resident's room, resident notify the nurse she poured her coffee on table on her anterior (front) chest, assessed the site and found superficial redness and resident said she is burning, applied Aquaphor and anti-biotic ointment by this nurse. Notified provider/DON/Supervisor will monitor resident.Describe patient's or resident's health condition at the conclusion of the investigation:.Continue to monitor to healed by wound care nurse/floor nurse. Staff to monitor coffee temp [temperature] before giving coffee. Record Review of SBAR (Situation, Background, Assessment, and Recommendation) Communication Form and Progress Note for Resident #1, dated 06/27/26, reflected, Situation: The change in condition, symptoms, or signs observed and evaluated is/are redness to right lateral body.Things that make the condition or symptom better are Aquaphor.8. Skin Evaluation.Describe symptoms or signs Redness on right lateral body.9. Pain Evaluation [checked] Not clinically applicable to the change in condition being reported. Does the resident have pain? [checked] No.Nursing Notes: Resident mistakenly poured a coffee on herself this morning, applied Aquaphor ointment, Notified the Provider. Record review of Skin Assessment for Resident #1, dated 06/27/26, reflected, Short Description: After Incident.Skin: Skin Temperature: [checked] warm Skin Moisture: [checked] Dry Skin color: [checked] Normal color.Skin turgor: [checked] Normal Alterations in skin? [checked] No Comments: Redness on Right Lateral Body related to accidental pouring of coffee. Record review of Progress Note for Resident #1, dated 06/27/26, reflected, This nurse was notified by CNA, resident need your help. Went to the resident's room and found that she spilled coffee on her anterior chest, assessed the site and found superficial redness and resident replied burning, this nurse applied Aquaphor and antibiotic ointment on the site, Notified the provider/DON/Weekend Supervisor, filled up [sic] the incident report, will continue monitor the site, vital signs were stable. Record review of Progress Note for Resident #1 dated 06/28/26 revealed Redness noted to right axillary [a pyramid-shaped space located at the junction of the upper limb and chest] area. No raises areas noted and resident denie any pain at this time. Skin remains warm dry and intact. Record review of Wound Evaluation and Management Summary for Resident #1dated 06/29/26 reflected .Focused Wound Exam.Burn Wound of the Right, Lateral Breast.Etiology.Burn.Further Etiology Detail Second Degree, Hot Liquid. Duration > [Greater than] 3 days Wound size (L x W x D) [Length times Width times Depth] 10 x 20.1 x Not Measurable cm.Dermis: Open area with exposed dermis. Record review of Progress Note for Resident #1dated 08/03/26 revealed Resident was assessed for pain prior to wound care. Resident denied pain at the time of assessment. No signs of discomfort were observed.burn to right breast (1.6cm x 1.8cm x not measurable) . Record review of Wound Evaluation and Management Summary for Resident #1 dated 07/07/26 reflected .Focused Wound Exam.Burn Wound of the Right, Lateral Breast.Etiology.Burn.Further Etiology Detail Second Degree [partial thickness burn, damages the outer and middle layers of skin. Characterized by blistering-typically heal in 7 to 21 days], Hot Liquid. Duration > [Greater than] 7 days Wound size (L x W x D) [Length times Width times Depth] 10 x 20.1 x Not Measurable cm.Dermis: Open area with exposed dermis. Record review of Wound Evaluation and Management Summary for Resident #1dated 07/14/26 reflected Focused Wound Exam.Burn Wound of the Right, Lateral Breast.Etiology.Burn.Further Etiology Detail Second Degree, Hot Liquid. Duration > [Greater than] 18 days Wound size (L x W x D) [Length times Width times Depth] 2.8 x 2.1 x Not Measurable cm.Dermis: Open area with exposed dermis.Burn wound of the right, lateral breast-improved evidenced by decreased surface area.Debridement History: This wound is undergoing autolytic [normal body healing] autolytic debridement. Record review of Wound Evaluation and Management Summary for Resident #1dated 07/21/26 reflected Focused Wound Exam.Burn Wound of the Right, Lateral Breast.Etiology.Burn.Further Etiology Detail Second Degree, Hot Liquid. Duration > [Greater than] 25 days Wound size (L x W x D) [Length times Width times Depth] 1.5 x 1.5 Not Measurable cm.Dermis: Open area with exposed dermis.Burn wound of the right, lateral breast-improved evidenced by decreased surface area.Debridement History: This wound is undergoing autolytic [normal body healing] autolytic debridement. Record review of Wound Evaluation and Management Summary for Resident #1dated 08/04/26 reflected Focused Wound Exam.Burn Wound of the Right, Lateral Breast.Etiology.Burn.Further Etiology Detail Second Degree, Hot Liquid. Duration > [Greater than] 39 days Wound size (L x W x D) [Length times Width times Depth] 1.3 x 1.5 Not Measurable cm.Dermis: Open area with exposed dermis.Burn wound of the right, lateral breast-improved evidenced by decreased surface area.Debridement History: This wound is undergoing autolytic [normal body healing] autolytic debridement. Record review of Wound Evaluation and Management Summary for Resident #1dated 08/11/26 reflected Focused Wound Exam.Burn Wound of the Right, Lateral Breast.Etiology.Burn.Further Etiology Detail Second Degree, Hot Liquid. Duration > [Greater than] 39 days Wound size (L x W x D) [Length times Width times Depth] 1.1 x 1.2 Not Measurable cm.Dermis: Open area with exposed dermis.Burn wound of the right, lateral breast-improved evidenced by decreased surface area.Debridement History: This wound is undergoing autolytic [normal body healing] autolytic debridement. Record review of Wound Evaluation and Management Summary for Resident #1dated 08/18/26 reflected .Focused Wound Exam.Burn Wound of the Right, Lateral Breast.Etiology.Burn.Further Etiology Detail Second Degree, Hot Liquid. Duration > [Greater than] 50 days Wound progress: Resolved Anatomic location of previously existing wound examined today: Epithelialized and Resolved. Follow up only as needed. Observation and interview with Resident #1 on 08/20/2026 at 8:41 a.m. revealed she poured coffee on her chest, and the coffee ran down her side. Resident #1 stated she could not clothes away from her body to stop the burn until the staff came in and turned her. Resident #1 stated it felt worse than it was and stated the wound was healed. Resident #1 stated she was drinking out of her own personal coffee cup. She stated the coffee cup was on her overbed table. Resident #1 pointed out her overbed table which was observed to be covered with personal belongings on approximately half of the table. Resident #1 stated she reached for something off her tray and hit the coffee cup causing it to spill and fall to the floor. Resident #1 stated she only drank coffee in the mornings. Resident #1 stated the CNAs or nurse would come in with a cup or grab her cup and walk out in the hallway to fill it and return it to her. Resident #1 stated she did not keep a lid on her cups. Resident #1 stated she had never had spilled coffee previously. Resident #1 stated she utilized the facility's cups, without a lid, since this incident.NOTE: At no point during the investigation was an observation able to made of Resident #1 with a cup of coffee. In an interview with Former Wound Care Nurse on 08/20/2026 at 9:07 a.m. revealed she saw of the burn on Resident #1. Former Wound Care Nurse stated she did not do the treatments but saw the wound with the Wound Care Physician. Former Wound Care Nurse stated there was redness but no open areas. Former Wound Care Nurse stated Resident #1 was ordered an ointment and no other treatments. In an interview with LVN C on 08/20/26 at 9:52 a.m. revealed the CNAs passed the coffee and notified her of a spill in Resident #1's room. LVN C did not remember which CNA notified her. LVN C stated when she assessed the burn there was only redness, so she applied ointment and notified the physician. LVN C stated Resident #1 told her she was trying to reach for something and hit the cup of coffee. LVN C went on to explain that in the morning a carafe (serving container) of coffee was sent out with the trays. LVN C stated when the breakfast trays were passed, the CNAs would fill the cups of coffee and took them directly to the residents. Observation on 08/20/26 at 12:08 p.m. revealed nursing staff requested coffee for a resident in the dining room. The Dietary Manager went to the coffee maker and poured a cup of coffee. The Dietary Manager was asked to take the temperature of the coffee, which was 176 degrees F. The Dietary Manager stated he posted a temperature log and noted the temperature at the bottom of the posting was the temperature coffee was to be served at. Coffee was given to the staff in the dining room and given directly to Resident #2. Observation on 08/20/26 at 12:22 p.m. revealed a resident requested a cup of hot milk. The Dietary Manager pulled the cup of milk from the refrigerator and put it directly into the microwave. The Dietary Manager did not take the temperature of the milk and the hot milk was delivered directly to the resident with a piece of plastic wrap on it. Dietary Manager was asked to take the temperature of the milk. The Dietary Manager went to the dining room approximately 2-3 minutes later, after the lid was removed and remained open. The temperature was 125.1 degrees F. It was not observed how long the milk was in the microwave. Record review of Hot Temperature Log Sheet - Both Start and Serve Monitoring, dated 10/15/25, revealed .Hot Beverage Guide: Start 205-156 [degrees] F.Serve [less than or equal too]155 [degrees] F. Cooks/Aides must record all temperatures prior to serving. Inform supervisor of any equipment issues immediately. In an interview with the Administrator on 08/20/26 at 1:47 p.m. revealed if a resident was burned from hot coffee was handled differently depending on the resident and whether they were alert and oriented. The Administrator stated it would be up to the facility to determine if the residents were able to handle hot liquids safely. The Administrator nursing would establish the resident's ability. The Administrator stated the facility did not do a general assessment to assess each resident's ability to handle hot liquids. If there was a burn the physician and family were notified. The Administrator stated that Resident #1 was seen by wound care. Resident #1 was alert and oriented and he did not feel that anything additional needed to be done. The Administrator stated noting someone required Supervision during eating meant to him that one staff member should we with the resident while eating and drinking. The Administrator stated he would be getting therapy involved to assess Resident #1. The Administrator stated he reviewed the policy pertaining to hot liquids and stated it did not indicate that the facility was required to conduct temperature checks. The Administrator stated that temperatures were taken today (08/20/26) but stated they had never previously had issues with coffee burns. The Administrator stated he did not feel there was a risk but stated they would be working on a mitigation plan to ensure no one else was burned by the coffee. The Administrator was not able to specify the temperature of the coffee on the day Resident #1 spilled coffee on herself, 06/27/26. In an interview with the Dietary Manager on 08/20/26 at 2:06 pm., revealed he had not previously conducted any education with the dietary staff about hot liquid temperatures but stated he would that day (08/20/26). The Dietary Manager stated he would be providing a thermometer and making sure liquids were tested before going out of the kitchen. The Dietary Manager was not aware of anyone being burned by any hot liquid that went out of the kitchen. In an interview with the DON on 08/20/26 at 2:12 p.m. revealed she was contacted after Resident #1 spilled the coffee. The nurse that called her was LVN C. The DON stated LVN C did an assessment and called the physician and obtained physician's orders on treatment for the burn. The DON stated the Former Wound Care Nurse did a follow-up assessment as well. The DON stated she did a training with all staff about ensuring the coffee was served at a safe temperature. The DON stated this was determined by whether or not the coffee was hot to the CNA and/or if steam could be seen coming out of the cup. The DON stated it was stressed that if the temperature was too hot for the staff it was too hot for the resident. The DON stated training was conducted on 07/06/26. The DON stated she had never seen the facility's policy regarding hot liquids. The DON stated there were no assessments being conducted to determine each resident's ability to safely handle hot liquids. The DON stated she was not aware of any other burns. The DON stated the staff had not been provided with thermometers to take temperatures of the coffee. The DON stated she was not able to specify the temperature the day Resident #1 spilled coffee on herself, 06/27/26. The DON stated Resident #1 was able to feed herself and handle her own drinks. Resident #1 required her tray to be set up during meals, and to be sat up in bed. Record review of an In-Service Training Attendance Record, dated 07/06/26, reflected, .Preventing Coffee Burns in Residents Goal: Prevent burns and promote safe coffee/tea service. -Service coffee and other hot beverages at a safe temperature.-Check the temperature before handing a hot drink to a resident.-Use cups with secure lids when appropriate.-Keep hot beverages on a stable surface and away from edges.-Never place hot drinks where a resident could easily knock them over.-Consider the resident's mobility, vision, cognition, and ability to safely handle hot liquids.-Assist residents who need help holding or drinking hot beverages.-Report and document any spills, burns, or safety concerns immediately. Record review of Guidelines to Reduce the Risk of Burns from Hot Beverages, dated 10/15/25, reflected, .Policy: Precautions should be implemented to limit the risk of burns from hot beverages (coffee, tea, etc.). Procedures:1. Hot beverages should be consumed at temperatures between 155 [degrees] F and 175 [degrees] F. Palatability is affected by temperature and varies from person to person, based on individual preference. 2. Commercial coffee brewing equipment is designed to heat water and hold coffee at desirable temperatures. A. Coffee should be brewed at temperatures between 195 [degrees] F and 205 [degrees] F to extract the full flavor. Storing coffee at temperatures between 175 [degrees]F and 190 [degrees] F will maintain the fresh brewed flavor for a limited period.4. Facility staff should pour all hot beverages.9. When serving hot beverages to patients or residents:A. Transfer the beverage from its brewing urn to a serving container. Beverages served directly from the brewing urn will be hotter.B. Do not overfill cups.C. Explain to patient/resident that a hot beverage is being served.D. Place cup away from the edge of the table and within patient's/resident's field of vision and reach of dominant hand. E. Remove lids to allow beverage to cool faster.11. When serving hot beverages to patients or residents with behavior or medication conditions that put them at risk for spills:A. Evaluate the patient's/resident's ability to manage hot beverages independently.B. Provide assistance and/or supervision as needed.C. Consider providing a lid for the coffee cup of a 'travel mug'.D. Allow hot beverage to cool before serving.E. Suggest patient/resident add ice to hot beverages before serving.F. Encourage consumption of cold beverages.G. Ensure all appropriate staff are aware of those residents needing supervision.H. Ensure the patient's/resident's care plan reflects any and all needed safeguards.

Based on observation, interview and record review, the facility failed to maintain an effective pest control program to keep the facility free of pests for one (Hall 100) of six halls and 1 (Resident #6) of 13 residents (identifier) observed for pest control. The facility failed to maintain pest control and Resident #6 was stung multiple times by fire ants, in her bed, on 08/02/26. The noncompliance was identified as PNC. The noncompliance began on 08/03/26 and ended on 08/13/26 The facility had corrected the noncompliance before the survey began. This failure could residents by placing them at risk for the potential spread of infection, allergic reaction, bites, and decreased quality of life.Findings included: Record review of Resident Face Sheet for Resident #6 dated 08/21/26 reflected Resident #6 was a [AGE] year-old female who was admitted to the facility on [DATE] and discharged on 08/13/26. Resident #6 was diagnosed with Acute Respiratory Failure with Hypoxia (life-threatening medical emergency where your lungs suddenly fail to get enough oxygen into your blood), Hypertension (high blood pressure), Hypothyroidism (common medical condition where your butterfly-shaped thyroid gland does not make enough thyroid hormones to control how your body uses energy) and Hyperlipidemia (common medical condition where you have high levels of fats, such as cholesterol and triglycerides, circulating in your blood). Record review of admission MDS assessment for Resident #6, dated 08/05/26, reflected Resident #6 scored a 13 on the BIMS indicating Resident #6's thinking and memory skills were cognitively intact. Record review of SBAR Communication Form for Resident #6 dated 08/02/26 reflected .The change in condition, symptoms, or signs observed and evaluated is/are snt [ant sic] bites.Things that make the condition or symptoms worse are bites from ants. Things that make condition or symptom better are cream/PRN meds [as needed medications].8. Skin Evaluation [checked] Itching [checked Rash. Describe symptoms or signs ant bites.9. Pain Evaluation.Is the pain? .Description/location of pain: itching and burning from bites. Intensity of Pain (rate on scale of 1-10, with 10 being the worst): 3.Recommendations of Primary Clinicians (if any) hydrocortison [sic] cream BID [two times per day] and Benadryl 25mg Q6 hours PRN.Record review of Progress Note for Resident #6 , dated 08/02/26, reflected [Resident #6] on the call light and made the staff aware she has ants in her bed. The patient was removed from the room and relocated. The patient's skin assessed and its noted that she has ant bites and redness to the lower abdomen, and flank. Offered patient a shower and she declined but she allowed the CNA to wipe her down with a wet moist cloth, then cream applied.The on call NP [nurse practitioner] notified of the incident and new orders 1) hydrocortisone cream BID and 2) Benadryl 25mg 1 tab PO every 6 hours PRN itching. DON notified. Record review of Patient/Resident Incident/Accident Investigation Worksheet involving Resident #6, dated 08/02/26 at 4:55 a.m. reflected, .Secondary Injury [checked] other ant bite right lower abd [abdomen].Describe exactly what happened: Resident on the call light and made staff aware that she has ants in her bed. The patient was moved from the room and relocated to {room number}. The patient's skin assesded and noted she has ant bites and redness to right lower abd and offered patient a shower and she declined but allowed the CNA to wipe her down with west moist cloth. Then cream is applied, patient is due morning medication and administered. The on call NP notified of incident and orders given.Findings and Analysis ant bite to lower Abd/Flank [abdomen and side] area .Assess skin with treatment order per MD/NP Bed bath/Refused shower, Moved to [to a different room], Monitor for ants q shift. Nurse to monitor site and apply Hydrocortisone [sic] cream BID. Nurse will monitor bites under [until sic] dry. Record review of Service Inspection Report, dated 08/03/26, reflected pest control was at the building to perform service. Ants were reported in several rooms 112, 108, 106, 105 and 107 were vacant [at the time of inspection]. Inspection was conducted. No visible signs were visible. A crack and crevice application was applied. 110 and 102 occupied a thorough inspection was completed. No visible evidence was observed. Ant gel bait was strategically placed. Exterior walls were walked and inspected. Nuisance ants observed on foundation. Entering a hole in the mortar. Ant activity was observed on the surrounding grounds. A liquid residual was applied to the foundation and exterior walls. Ground activity was also addressed with a liquid residual treatment.Fire ants reported in multiple rooms. Bites reported. Rooms are 106, 107, 110, and 112.NOTE: This was not a regularly scheduled visit. The facility called them due to concerns of ants and ant bites. Record review of a Service Inspection Report, dated 08/10/26, reflected pest control was at the building to perform regularly scheduled pest control service. The logbook was reviewed and noted ant concerns in rooms 522, 419 and 508. All the rooms were inspected and treated. Preventative inspections were completed and treated on 200 hall. Exterior was inspected and treated as needed, with no concerns of ants noted. Record review of Progress Notes for Resident #6, dated 08/13/26, reflected, [Resident #6] discharge home with family. No complain [sic] of pain or any other thing before discharge. Nurse assessed skin and noted some dry skin from ants [sic] bites. Area appears to be healing well, no redness, no s/s infection noted and no discomfort to the area. Record review of a Service Inspection Report, dated 08/13/26, reflected pest control was at the building for a targeted pest control service following reports of ant activity. Record review of Physician Orders, dated 08/19/26, reflected, Resident #6 was ordered Benadryl 25mg as needed starting on 08/02/26. Resident #6 was ordered Hydrocortisone Cream two times per day starting on 08/02/26. In an interview with CMA D on 08/19/26 10:37 a.m. revealed she had not observed any ants or pests. In an interview with Housekeeper E on 08/19/26 at 10:38 a.m. revealed she had not observed ants and pests while cleaning rooms and corridors in the facility. In an interview with Housekeeper F on 08/19/26 at 10:40 a.m. revealed she had not observed any ants or pests in the facility while cleaning. In an interview with the Maintenance Director on 08/19/26 at 10:41 a.m. revealed he had worked at the facility for one week. The Maintenance Director stated he was made aware of the facility having ants and, as a result, they were working with pest control and deep cleaning rooms throughout the facility. In an interview with Housekeeper G on 08/19/26 at 10:43 a.m. revealed previously there were issues on 100 hall but stated pest control treated both the exterior and interior of the facility. Housekeeper G stated she had not seen any ants since then. Housekeeper G was not able to specify exactly when she saw ants on Hall 100. Observation on 08/19/26 from 12:30 p.m. to 1:00 p.m. revealed a visual inspection around the entire facility and grounds was conducted. There were no active ant mounds seen. There was evidence of granule treatment on the outside of windows and in the flower beds. No fire ants were observed. In an interview with the DON and the Administrator on 08/19/26 at 1:23 p.m. revealed the DON stated they ensured the doctor was contacted and Resident #6 was moved to a different room. The DON stated Resident #6 was alert and oriented and her spouse was normally at the bedside, but was not in the room at the time of the incident. The DON stated Resident #6 had not made any complaints about ants prior to that night (08/02/26). The DON stated she took the Medical Director in to see Resident #6 the following day, and no additional medication orders were given. The DON stated she observed multiple ant bites to the right flank (side) area. The Administrator stated the pest control company was contacted and they on 08/13/26 treated the entire facility, focusing on the 100 hall, inside and outside. They stated Maintenance and Housekeeping were checking the rooms throughout the day, unoccupied and occupied rooms. The DON stated there were no additional complaints of pests or ants in any other room since this incident. The DON stated Resident #6 had since been discharged home as she was only in the facility for short term therapy. The DON and the Administrator were not able to determine exactly what caused the ants to get into Resident #6's room. Resident #6 had only been in the room a couple of days. In an interview with RN H on 08/19/26 at 1:40 p.m. revealed she was a new employee of the facility. RN H stated she had not observed any fire ants and had seen no ant bites. RN H stated she had not received any concerns of pests. Observation and interview with Resident #12 on 08/19/26 at 1:41 p.m. revealed Resident #12 was in a room on 100 hall. Resident #12 stated he had not seen or had any problems with ants. There was no observation of ants in the room. Observation and interview with Resident #7 on 08/19/26 1:47 p.m. revealed Resident #7 was in a room on 100 hall . Resident #7 denied seeing any ants in her room. There was not evidence of ants in her room. There was what appeared to be crumbs and other debris at her bedside. Observation and interview with Resident #3 on 08/19/26 1:48 p.m. revealed Resident #3 was in a room on 100 hall . Resident #3 stated she previously saw ants in her room a few weeks ago. Resident #3 stated pest control treated her room. There were glue strips under the HVAC and in the window seal there were multiple dead ants observed. There was no live ant activity. Observation and interview with Resident #8 on 08/19/26 at 1:53 p.m. revealed Resident #8 was in a room on 100 hall . Resident #8 denied seeing any ants in her room. There was no evidence of ant activity in her room. Observation and interview with Resident #9's family member on 08/19/26 at 1:55 p.m. revealed Resident #9's family member stated they had no problems with ants. There was a glue strip observed under the HVAC which had many dead ants on it. There was no live ant activity. Observation on 08/19/26 at 1:56 p.m. revealed room [ROOM NUMBER] was vacant. There were two dead ants on the top of the HVAC and approximately 8 dead ants observed on the window track. There was no live ant activity. Observation and interview with Resident #10 on 08/19/26 at 1:58 p.m. revealed Resident #10 was in a room on 100 hall . Resident #10 stated he had not observed any ants in his room. There were dead ants observed in the window seal and on the glue strip under his HVAC. There was no live ant activity. Observation on 08/19/26 at 2:00 p.m. revealed room [ROOM NUMBER] was vacant. There were approximately 12 dead ants on the floor under the HVAC. There was no live ant activity. Observation and interview with Resident #11 on 08/19/26 at 2:01 p.m. revealed Resident #11 was in a room on 100 hall. Resident #11 stated they had not seen any ants in their room. There was no evidence of ant activity. In an interview with LVN A on 08/19/26 at 2:19 p.m. revealed she heard about the facility having ants a couple weeks ago but had no seen any ants herself. Record review of the facility's policy titled, Pest Control, dated 10/15/25, reflected, .Facility will maintain an effective pest control program to prevent or eliminate infestation.4. Repairs will be performed as needed to prevent pest access to facility or to hiding spaces in walls and equipment. Water leaks will be repaired and standing water will be eliminated whenever possible. 5. Proper sanitation will be maintained, and clutter will be reduced to prevent food and harborage of pests. 6. Pest management decisions will be based on the results of regular inspections. The noncompliance was identified as PNC. The non-compliance began on 08/03/26 and ended on 08/13/26. The facility had corrected the noncompliance before the survey began.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 (identifier) kitchen reviewed for professional standards. Dietary Manager and Dietary Aide B were observed without proper hair restraint on head and facial hair. This failure could place residents at risk of food contamination.Findings included: Observation on 08/19/26 at 9:18 a.m. revealed the Dietary Manager was observed with no beard covering while walking around in the kitchen and through the food preparation areas. Observation on 08/19/26 at 11:48 a.m. revealed the Dietary Manager was not wearing a hair restraint or a beard covering. The Dietary Manager was observed putting on a beard covering but it remained around his neck and not covering his beard. The Dietary Manager was walking around in the kitchen preparing for lunch to be served out. Observation on 08/19/2026 at 12:04 p.m. revealed Dietary Aid B was observed walking through the food preparation area, next to the steam table with no hair restraint. Dietary Aid B then put on a hair restraint but did not cover his sideburns, the back of his hair or his mustache. Dietary Aide B's hair in the back was approximately 1-2 inches long, his mustache and sideburns were approximately 1inches long. In an interview with the Administrator on 08/20/26 at 1:47 p.m. revealed all employees in the kitchen should be wearing a hair restraint and the men should be wearing a beard covering. The Administrator stated there was concern of food contamination if hair restraints were not utilized. In an interview with Dietary Aid B on 08/20/26 at 2:05 p.m. revealed he should have put on a hair net when he went into the kitchen. He stated hair restraints were used to keep hair out of the food. Observation and interview with the Dietary Manager on 08/20/26 at 2:06 p.m. revealed the Dietary Manager was not wearing a hair restraint or a beard covering. The Dietary Manager stated everyone that was in the kitchen should have on a hair restraint and a beard covering for anything a 1/4 inch or longer. The Dietary Manager stated sideburns and mustaches should be covered as well. The Dietary Manager stated the hair restraints were used to prevent food contamination. Record review of the facility's Dress Code-Nutrition Policies and Procedures, dated 10/15/25, reflected, Policy: The Dietary Department employees will adhere to a facility dress code that facilitates safe, sanitary meal production and service, and will present a professional appearance. Procedures: Dietary staff involved in food production adheres to the department dress code that includes:.6. Appropriate hair restraints (hair covers or nets, beard restraints) while involved in food production activities.8. Employees are compliant with all applicable county, state, and federal regulations.

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 except when to do so would endanger the health or safety of the resident or other residents for 1 of 9 residents (Resident#5) reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system was within reach of Resident #5 when the resident was lying in bed, even when staff knew Resident #5 was unable to use due to her physical condition and contractures, on 08/20/2026 at 12:51pm. This failure could place residents at risk of being unable to have a means of directly contacting caregivers for assistance. Findings included: A record review of Resident #5's MDS quarterly assessment, dated 06/23/26, reflected a [AGE] year-old female with a BIMS score 12 of 15, which indicated moderate cognitive impairment. Resident #5 was admitted to the facility on [DATE] with diagnoses including hypertension (elevated blood pressure), Non-Alzheimer's Dementia (brain disorders that cause a decline in thinking and daily functioning due to causes other than Alzheimer's disease), Parkinson's Disease (a slow brain disorder that damages nerve cells and makes it hard to control movement), and Unspecified lack of coordination (poor muscle control that causes clumsy movements). The review further reflected the resident was totally dependent on staff for the ADLs. A record review of Resident #5's Comprehensive Care Plan, dated 06/22/26, reflected, Focus. Resident had actual fall 1/7/2026, actual fall on 4/14/26 with no injury. Category: Falls. [Resident #5] has impaired balance during transfers . Goal. Resident will remain free from injury. Interventions. Keep bed in lowest position with brakes locked.Keep call light within reach. Observation on 08/20/26 at 12:35 PM revealed Resident #5 heard yelling for help with eating when surveyor walked past her room. Resident #5 yelled again when a tray cart was being pushed down the hall. A staff member was observed entering the Resident #5's room within five minutes of Resident #5 beginning to yell for assistance. Observation revealed Resident #5 would yell when someone would walk past her door to get their attention. Observation and interview on 08/20/26 at 12:51 PM revealed Resident #5 was lying in bed with both arms extended to her sides in a stiff position and uncontrollable movements. Observation revealed Resident #5 was yelling for help. Observation revealed Resident #5's call light was hanging over the bedside table next to the bed. Interview with Resident # 5 revealed she could not reach the call light. Resident #5 did not verbalize any concerns related to calling for help and receiving assistance. LVN H walked into Resident #5's room and put the call light in the bed next to Resident #5. Interview with LVN H revealed she came into Resident #5's room because Resident #5 was yelling. LVN H stated Resident #5 will only yell when she needs assistance. Resident #5 was unable to push the call light button related to her stiff arms, bilateral hand contractures, involuntary, repetitive, and purposeless hands movements. LVN H stated the call light was not within reach of Resident #5 and she could not use the call light device due to her condition. Interview on 08/20/26 at 1:11 PM, LVN H stated they rounded on Resident #5 every 2 hours. LVN H stated they will come to the room if Resident #5 is yelling. LVN H stated the resident will only yell if she needs help. LVN H stated that was the only call light device they had for Resident #5, and they knew she could not use it, and they were doing rounds on her frequently and she yelled any time she needed help. LVN H stated the risk to the resident could be not getting help on time, could be a fall and possible injury. LVN H stated it was the responsibility of all the staff to make sure the call light was within resident reach and usable by the residents before exiting the room. Interview on 08/20/26 at 1:55 PM, the DON stated the call-light should always be accessible to the residents, and it was the responsibility of all staff to make sure the call lights were always within reach of the residents. The DON stated they knew Resident #5 could not use the call light device they gave her, and they moved her close to the nursing station for that reason. The DON stated there was a lot of staff and resident activity near the nursing station. The DON stated staff could hear her yelling or shouting for help. The DON stated staff rounded every 2 hours for Resident # 5. The DON stated they tried to soft touch call light button, but Resident #5 could not use it because of the contraction of her hands. The DON stated the facility did not offer a head touch call light device for Resident #5 to use and she did not know if the Resident could use that kind of call light. The DON stated the risk to the residents, if they could not reach the call light, was they could not call for help, if there was a fall, an injury and they would not get the help they needed. Interview on 08/21/26 at 9:47 AM, the DON stated a baby monitor had been added to Resident #5's room for the nursing team to be able to see Resident #5 from the nurse's station. The DON also stated should be adding a touch/pad alarm to place at Resident #5's shoulder so that she was able to turn her head to trigger the call light. Record review of Resident Council Meeting Minutes dated 06/16/26 reflected there were no concerns with call light response. Record review of Resident Council Meeting Minutes dated 07/21/26 reflected there were no concerns with call light response. Record review of Grievances for May, June, and July 2026 reflected there were no concerns with call light response. Record review of the facility's policy, Nursing Policy and Procedures- Call Lights, Responding to, revised May 5, 2023, reflected, The staff will respond to call lights or other requests for assistance to meet the patient's/resident's needs. 6. When leaving the patient or resident room, ensure the call light is placed within the patient's/resident's reach.

Based on observation, interview, and record review the facility failed to maintain a clean, sanitary, comfortable, and homelike environment for 1 (room [ROOM NUMBER]) of 13 rooms and 1 (Resident #3) of 13 residents on Hall 100 reviewed for environment. The facility failed to properly clean room [ROOM NUMBER] where Resident #3 resided. The floor and wall were spattered with a tan colored substance. This failure could place residents at risk for living in an unclean, unsanitary, or unclean environment.Findings included: Record review of the Resident Face Sheet for Resident #3, dated 08/21/26, revealed Resident #3 was a [AGE] year-old female who was admitted on [DATE]. Resident #3 was diagnosed with Chronic Respiratory Failure with Hypoxia (long-term condition where the respiratory system fails to provide enough oxygen to the blood), Dysphagia, Oropharyngeal Phase (difficulty moving food and liquid from mouth, through the throat, and into the esophagus), and Shortness of Breath. Record review of the Care Plan for Resident #3, dated 06/15/26, revealed, [Resident #3] has a trach [tracheostomy: surgically created hole in the front of the neck and into the windpipe to help a person] ., [Resident #3] requires tube feeding R/T [related to] Dysphagia and Trach. [Resident #3] has impaired communication related to tracheostomy tube, she uses writing as a means of communication. Observation on 08/19/26 at 1:48 p.m. revealed Resident #3 lying in bed watching television, and tube feeding was running. On the wall behind Resident #3's bed, next to the window (approximately 5 feet up on the wall), on the floor and on the base of the IV (intravenous) pole where the tube feeding formula was hanging, there were tan colored spots. The floor was sticky to step on, but the substance was otherwise dry. Resident #3 did not indicate how it made her feel that her room was not properly cleaned In an interview with Resident #3 on 08/19/26 at 2:16 p.m. revealed Resident #3 wrote that the spatter on the wall was tube feeding formula. Resident #3 wrote the formula was on the wall for months, maybe even a year. Resident #3 wrote on a piece of paper she did not see housekeeping daily but about one time per week. Resident #3 demonstrated a syringe put on her tube feeding and the nurse plunged the syringe and indicated the tube feeding formula spewed out when her tube feeding was clogged. When the tube feeding spewed out it would go all over the wall and floor and was not cleaned up by anyone per Resident #3. Observation and interview with LVN A on 08/19/26 at 2:19 p.m. revealed LVN A stated the spatter on the wall appeared to be tube feeding formula. LVN A stated the formula should have been wiped up by the nurse and then housekeeping cleaned the rooms each day. In an interview with the DON on 08/21/26 at 9:47 a.m. revealed LVN A stated there was formula on the wall of Resident #3's room. The DON stated she had never noticed the formula previously. The DON stated Resident #3 told her it was coke on the wall. The DON stated housekeeping attempted to clean the wall but the spatter would not budge. The DON stated she was not sure how long the spatter was on the wall or floor but stated it should have been cleaned by the nurse immediately upon the incident with housekeeping coming behind and doing their normal daily cleaning. The DON stated she had not had concerns with housekeeping cleaning rooms. In an interview with the Administrator on 08/21/26 at 11:27 a.m. revealed resident rooms were cleaned by housekeeping on a daily basis. The Administrator stated he had not had any concerns with housekeeping. The Administrator stated if there was an incident where coke or tube feeding formula was sprayed on the walls and/or floor it should have been immediately cleaned up by the nurse and then followed up with cleaning by housekeeping. The Administrator stated he had not seen the spatter on the wall previously and did not know how long it was on the wall but would get it cleaned and/or painted. Record review of the facility's policy titled, Resident Rights-Environmental dated 11/01/17, reflected, POLICY: The Facility provides the patient/resident with an environment that preserves dignity, privacy and contributes to a positive self-image. Resident rooms are designed and equipped for adequate nursing care comfort and privacy of residents. Promoting and preserving resident independence and self-sufficiency should be considered when arranging the resident living space.11. The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. Record review of the facility's policy titled, Maintenance/Housekeeping Policies and Procedures, dated 03/06, reflected, General Cleaning Wall Washing Procedure: A procedure by which walls are cleaned. When Used: Wall washing is used as a routine cleaning procedure at least quarterly and more frequently as required. This routine is not to be confused with the spot washing that is required in individual cleaning procedures. Expected Results: A wall that is free from dust, dirt, soil, foreign matter and smoke deposits.

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 1 of 9 residents (Resident #4) observed for infection control. LVN I failed to complete hands hygiene during Resident #4's incontinent care on 08/20/2026. This failure could place residents at risk of cross contamination which could result in infections or illness.Findings included: A record review of Resident#4's MDS quarterly assessment, dated 06/09/26, reflected an [AGE] year-old female with a BIMS score 00 of 15, which indicated severe cognitive impairment. Resident #4 was admitted to the facility on [DATE] with diagnoses including Non-Alzheimer's Dementia (brain disorders that cause a decline in thinking and daily functioning due to causes other than Alzheimer's disease) and Neurocognitive disorder with Lewy bodies (a progressive brain disorder caused by abnormal protein clumps that damage nerve cells and affect thinking, movement, and behavior). Further review revealed Resident #4 was always incontinent of bowel and bladder, and she was totally dependent on staff for the ADLs (Activities of Daily Living). Observation on 08/20/26 at 9:03 AM revealed LVN I (Wound care nurse) entered Resident #4's room to assess her buttocks skin area. LVN I washed her hands, put on a gown, and gloves. LVN I uncovered Resident #4 and unfastened her brief. Resident #4 had a bowel movement. LVN I got a box of wipes, clean briefs, and put them over the bed table. LVN I cleaned Resident #4's front private area with wipes, using one wipe per stroke front to back. LVN I turned Resident #4 to her right side. LVN I clean resident#4 buttocks area using one wipe per stroke, front to back, and dispose of the dirty brief in the trash can. She cleaned Resident#4 buttocks area more, she got the clean brief put it on Resident #4 without changing glove or performing any form of hands hygiene (washing hands or sanitizing hands with hands sanitizer). LVN I covered Resident #4, removed gloves, gown, and washed hands. She exited the room and disposed of the trash bag in the biohazard room. Interview on 08/20/26 at 09:23 AM, LVN I stated she should have changed her gloves and performed hand hygiene after she provided incontinence care to Resident #4 before putting the clean brief on the resident. LVN I stated not washing her hands or using hand sanitizer between glove changes could cause an infection control problem for the residents. She stated that by not following proper hands hygiene, and proper use of gloves could cause cross contamination and development of infections for the residents. In an interview on 08/20/26 at 1:55 PM the DON, she stated infection control was important during care. The DON stated during care the staff were to use the hand sanitizer or wash their hands if they were physically soiled. The DON stated the staff were expected to complete hand hygiene before care and after care, she also stated during incontinent care the staff were supposed to change gloves and use hand sanitizer when taking off the dirty brief before applying the clean brief. The DON stated hand hygiene was to be completed for infection control. The DON said she was the infection preventionist and in-service on infection control was done upon hire, monthly, and she did random unannounced observation on the staff. Review of the facility's policy, Infection Prevention and Control Policies and Procedures- Hand Hygiene/Handwashing, revised on 2022, reflected, Hand Hygiene/Hand washing is the most important component for preventing the spread of infection Hand hygiene. A general term that applies to either hand washing, antiseptic hand wash, antiseptic hand rub, or surgical hand antisepsis. Hand hygiene/hand washing is done: After contact with a contaminated object or source where there is a concentration of microorganisms, such as, mucous membranes . Before putting on gloves, when changing into a fresh pair of gloves, and immediately after removing gloves

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety. The facility failed to ensure that food items stored in the dry storage area were labeled with the item description (handwritten or manufacturer's label) and included the date opened, and the use by/consume by or expiration date.The facility failed to ensure that stored canned goods had uncompromised seals and were free from dents.These failures could have placed residents at risk for food-borne illness and cross contamination. Observation of the dry storage area on 01/06/2026 at 8:15 a.m. revealed the following:2 cans of jellied cranberry sauce, 14 ounces, expired 11/29/2025, the facility's written received date was 12/01/2024.2 squeezable plastic dijon mustards, 24 ounces, expired 07/09/2024, the facility's written received date was 04/2025.2 large bags of rice cereal that were not in their original containers and had no item description and no expiration or best-by date.1 package of yellow corn tortillas 85 ounces, expired 04/21/2025, the facility's written received date was 06/29/2025.1 jar of coleslaw dressing, 128 ounces, had no expiration date; the facility's written received date was 01/05/2026.1 can of dark red kidney beans 111 ounces had a dent on the bottom front seam.During an interview with the Dietary Manager on January 6, 2026, at 8:42 am it was revealed that all the kitchen staff were responsible for unloading the delivery truck and putting labels on the food. He said the label should include the received date and the date the item was opened, the date received is added to the label, so they know what items to use first. He said if staff find dented cans, they put them in his office. He said if food was expired, staff would have immediately thrown it away. When asked how staff determined the expiration date when an item had no expiration date, he said he didn't know. He added that the original box that they receive the items in has the expiration and best buy date and that's the date that should be put on the food removed from the original container. During an interview with Kitchen Aide A on January 6, 2026, at 9:33 am it was revealed that all kitchen staff were responsible for unloading the delivery truck and placing labels on the food, and that the label should include the date the food was received. Record review of the facility's Food Storage Policy, dated 07/21/2023 revealed the following statement: Label and date new food items removed from their original containers. When inspecting canned foods, look for the following signs: Badly dented cans. Review of the U.S. FDA Food Code 2022 reflected: Definitions 3. Food Receiving and Storage - When food, food products or beverages are delivered to the nursing home, facility staff must inspect these items for safe transport and quality upon receipt and ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all PHF/TCS foods stored in the refrigerator or freezer as indicated.

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 one of four (LVN A) staff members and four of six residents (Residents #22, #65, #67, & #84) reviewed for infection control procedures. LVN A failed to perform hand hygiene after direct contact with Residents #22, #65, #67, and #84 while serving meals in the dining room. This failure could place residents at risk for healthcare associated cross contamination and infections.Findings included: Record review of Resident #22's admission MDS assessment, dated 12/13/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #22 had diagnoses which included: atrial fib (fast heart rate), hypertension (high blood pressure), and diabetes (high blood sugar). Resident #22 was moderately cognitively impaired and able to make decisions and required assistance of one staff for activities of daily living. Record review of Resident #65's quarterly MDS Assessment, dated 12/06/2025, revealed an [AGE] year-old female who was readmitted to the facility on [DATE]. Resident #65 had diagnoses which included: dementia (brain disease that effects memory), hypertension (increased blood pressure), and depression (mental illness). Resident #65's, severely impaired for cognition and unable to make decisions and required one staff for assistance with activities of daily living. Record review of Resident #67's annual MDS Assessment, dated 11/21/2025, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #85 had diagnosis which included: Cancer (killing of tissue), hypertension (increased blood pressure), and dementia (confusion and forgetfulness). Resident #67 was moderately impaired for cognition and required one staff for assistance with activities of daily living. Record review of Resident #84's annual MDS Assessment, dated 11/04/2025, revealed an [AGE] year-old female who admitted to the facility on [DATE]. Resident #84 had diagnosis which included: Hypertension (high blood pressure), Alzheimer's (confusion and forgetfulness), and chronic pain (pain all the time). Resident #84 was severely cognitive and unable to make decisions and required assistance of one staff for activities of daily living. Observation on 01/06/2026 beginning at 8:00 a.m., revealed LVN A had entered the main dining room, and did not use hand sanitizer. LVN A took four trays from the kitchen and placed them on a cart, used no hand sanitizer and served all four trays. LVN A served a breakfast tray to Resident #67, touched table in the dining room, touched the hand and shoulder of Resident #67 and prepared the meal tray for the resident to eat her breakfast. LVN A did not have gloves on. LVN A was observed not to wash his hands or use hand sanitizer, available in the hallway. Observation on 01/06/2026 beginning at 8:07 a.m., LVN A was observed serving and setting up Resident #84, #22, and #65's breakfast trays, unwrapped the utensils, and removed tops off of drinks, for each resident. She did not complete hand hygiene before going to the next resident. An interview on 01/06/2026 at 1:00 p.m., LVN A stated she did not complete hand hygiene after having direct contact with residents. LVN A stated she was supposed to use the hand sanitizer in between serving each tray. LVN A said she had been educated on completing hand hygiene. LVN A stated she did not sanitize her hands, because she was trying to get the breakfast trays served, so the food would not be cold. An interview with the DON on 01/08/2026 at 11:30 a.m., revealed all staff must complete hand hygiene after having contact with residents. He stated all staff were trained to wash their hands with soap and water prior to tray service, then use hand sanitizer between each tray. The DON stated if the staff did not use appropriate hygiene, they could spread germs to the residents and themselves. Record review of an in-service log dated 12/07/2025 revealed LVN A received handwashing and hand sanitizing training, to prevent the spread of infection. Record review of the Facility's Policy titled Infection Prevention and Control Policies revised May 2023 reflected: Subject: Handwashing/Hand Policy: Proper hand hygiene/hand washing technique will be accomplished at all times that handwashing is indicate. Hand Hygiene/Hand washing is the most important component for preventing the spread of infection, Maintaining clean hands is important for patients/residents/visitors/ as well as staff. 1. Hand hygiene/handwashing is done A. before patient /resident contact.After: . B. After patient/resident contact.J. Contact with environmental surfaces in the immediate vicinity of patients/residents.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's main kitchen reviewed for food safety. 1. The facility failed to ensure ice machine #1 and #2's filters and vents were free from dirt and dust. 2.The facility failed to ensure food items in the refrigerator, freezer and dry storage room were labeled and stored in accordance with the professional standards for food service. 3. The facility failed to discard items stored in refrigerator, freezers or dry storage that were not properly labeled or past the 'best buy', discard by or expiration dates. 4. The facility failed to ensure Handwashing sink #1's garbage receptacle contained only paper towels. 5. The facility failed to have Dietary staff wash hands or change gloves when they touched other surfaces while handling food or upon re-entering the kitchen. 6. The facility failed to ensure there were no pest around the food items in the kitchen. These failures could place residents at risk for food-borne illness and cross contamination. Findings Included: Observation of the Kitchen on [DATE] at 10:23 AM revealed the following: -On prep table, to the left of the walk-in refrigerator, there was an extra-large metal pan containing uncooked broccoli. It was uncovered, no label of item description, no prep date and no discard by date. -Under this prep table were 3 extra-large bins with clear lids. The bin on the left side contained flour; it had a sticker that read use by [DATE]. There was no label of item description and no opened date. -The middle extra-large bin with lid containing rice had a sticker that read use by [DATE]. There was no item of label description, no opened date. -On top of the bin containing the rice was a fruit fly (small dark-colored winged insect). -The bin on the right side contained granulated sugar; it had a sticker that read use by [DATE]. There was no item of label description, no opened date. -Across from receiving side of the steam table, a long prep table: -Ice Machine #1 plastic vents, located on the left and right side of the machine, the vent slats and filters had dust on them. -On the bottom shelf of the prep table was a 2-drawer clear bin with the 2nd bin being labeled Tea. The drawer was left opened, revealing a large clear plastic bag containing two extra-large tea bags, left opened to air. There was no opened date and no discard by date. -At the end of the receiving side of the steam table: Ice Machine#2-on the left side of the machine, just above the ice chest compartment, there was a dried white calcified/hardened substance along the side of the machine. -Ice Machine#2: the 2 vents on the front-facing top portion of the machine were dusty. The filters behind each vent slid out easily and were noted to be dirty and dusty as well as the front of the machine had streaks and greasy/residue smudges. Observations of the reach-in refrigerator #2 on [DATE] at 10:31 AM revealed the following: -Unit had a top vent that had dust and fibers on it. -Right side: Top shelf- Large clear plastic drink dispenser with a spout contained a light brown liquid there was no label of item description, no prep date, and no discard by date. -2nd shelf from top: extra-large clear plastic container with spout with dark colored purple liquid and ice, there was no label of item description, no prep date and no discard by date. -Bottom shelf: ,d+[DATE].34 gal. box with approximately 15 -4 oz vanilla shakes and ,d+[DATE]oz strawberry shakes. There was no label for the strawberry shakes inside, no opened date and no discard by date. -Left side, top shelf: ,d+[DATE] oz white carton of vanilla nutritional drink opened [DATE], manufacturer's expiration date [DATE], there was no facility discard by date. -,d+[DATE] oz carton of Prune juice, previously opened, manufacturer's expiration date [DATE]. There was no opened date and no discard by date. -,d+[DATE].7 oz. Hazelnut coffee creamer, previously opened, dated [DATE]. There was no discard by date. -Bottom shelf: ,d+[DATE].34 gal box of approximately ,d+[DATE] oz strawberry shakes. There was no discard by date or no manufacturer's expiration date. Observations of the walk-in refrigerator on [DATE] at 10:54 AM revealed the following: -Left side, 2nd shelf from top:1 small clear container covered with plastic wrap, containing cooked light-colored meat, there was no label of item description, no prep date; it was dated use by [DATE]. -1 medium clear square container covered with plastic wrap with cooked light-colored meat, there was no label of item description, no prep date; it was dated (facility sticker) use by [DATE]. -,d+[DATE] oz plastic container with lid of chicken flavored base, previously opened, no open date and no discard by date. ,d+[DATE] oz container with lid of plain cream cheese, previously opened, dated [DATE], manufacturer expiration date [DATE], there was no facility discard by date. -,d+[DATE] oz Honey vanilla Greek yogurt in a plastic container with lid dated [DATE], previously opened, manufacturer's expiration date [DATE], there was no facility discard by date. -,d+[DATE] oz. chopped garlic in a plastic container with lid, previously opened, no opened date, manufacturer's expiration date [DATE]. - On the 3rd shelf from the top: 1 tray labeled (with facility sticker) use by[DATE]. The tray contained six plastic bowls, five were covered with foil and on with a plastic lid, they contained oatmeal. There was no label of item description, no prep date. -On Bottom shelf: 1 extra large zip top bag with thawed raw chicken, dated [DATE]. There was no label of item description, no pulled date label, no clear discard by date, no pan beneath to catch any drippings of fluid from the bag of meat. -On the 2nd shelf, 2nd row down from top: 1- large zip top bag with yellow sliced cheese dated [DATE], there was no label of item description, no opened date. -1 Large zip top bag with cubed yellow cheese dated [DATE], there was not label of item description, no discard by date, no clear opened date. -In the middle of the room (refrigerator space): 1-tray with 77 plastic bowls with lids that contained pineapple pieces and in some bowls fruit cocktail. There was no label of item descriptions, no prep date, no discard by date. -On the Right side:1 extra-large clear square container covered with plastic wrap contained cooked beans in liquid, dated use by [DATE]. There was not label of item description, no prep date. -1 small square clear container covered with plastic wrap, previously opened, contained darked colored/purple jelly, dated use by [DATE]. There was no opened date, no label of item description. -1 Large zip top bag with a half of a cantaloupe (previously cut), dated use by[DATE], there was no label of item description, no prep date. -1 large zip top bag with previously diced green bell peppers, that had begun to release liquid, dated use by [DATE], there was no label of item description, no prep date. In the left lower corner was a small area where the bell peppers had started turning brown and soggy/mushy. -1 Large zip top bag with approximately eight corndogs dated use by [DATE], there was no label of item description, no prep date. -1 Large zip top bag with approximately 11 previously sliced red tomatoes dated [DATE] and use by [DATE]. The tomatoes had started to produced there own liquid in the bag, darkened in color and were soft (easily squished between fingers) to touch. Observations of the Walk-in freezer on [DATE] at 11:15 AM revealed the following: -1 Extra-large clear plastic bag, previously opened, tied closed, contained approximately 15 biscuits. There was no label of item description and no opened date. -1 Large clear plastic bag with approximately 8 hot dogs buns, sitting on two bags of ice (a portion of each bag of ice underneath the buns). There was no label of item description and a small amount of ice crystals had formed inside the bag. -1 Large clear plastic bag with shredded white cheese, dated use by [DATE]. There was no label of item description and ice crystal had formed on the inside right side of the bag on the cheese. *Also, frozen cheese when thawed can be dry, changed in texture and not melt properly. Observations of the Dry Storage on [DATE] at 11:18 AM revealed the following: -On left side, top shelf: ,d+[DATE] lbs. plastic container with lid contained creamy peanut butter, previously opened. The date written was illegible and the manufacturer's expiration date had been smudged off. There was no open date and no discard by date. 1-medium box of black tea bags, torn opened, left opened to air. There was no opened date and no discard by date. -,d+[DATE] oz. bottle of chocolate syrup, previously opened, there was no opened date, no discard by date. -1- Extra-large zip top bag with a previously opened package of uncooked linguine noodles. There was no open date, no discard by date. -1 Extra-large bag of uncooked noodles, previously opened, wrapped in plastic wrap, there was no opened date, no label of item description and no discard by date. Observations of the Kitchen on [DATE] at 11:52 AM revealed the following: -A fruit fly noted flying over and landing in iced/condiment area on the end of the steam table where a salad (covered in plastic wrap), fruit and cartons of shakes and milk were kept during service -Dietary Manager came back into kitchen from the dining room, he was not noted washing his hands or donned new gloves. He stood at the end of the steam table then went over to the prep table with the microwave on it and grabbed some meal tickets. -The Dietary manger was not to go on the other side of the steam table (receiving side) came back into the kitchen (on the serving side) and was not noted to wash his hands or donned new gloves. In an interview on [DATE] at 11:40 AM with the Dietary Manager, he stated he had been there since [DATE]. He was unsure if the kitchen maintained the emergency water but later confirmed he ordered the water if it got low or expired. The Dietary Manager stated they kept leftovers in the refrigerator for 3 days. He stated opened dairy products were kept ,d+[DATE] days in the refrigerator, cheese was kept once opened, up to 30 days. In an interview on [DATE] at 12:50 PM with the Dietary Manager, he stated they used the use by sticker to show when the item should be used by. When asked about the raw chicken at the bottom the refrigerator, he stated it was supposed to be thawed in the refrigerator for 2 days but he could not say when the item was pulled because it did not have a pull date, and it was already thawed. He stated it had to be pulled before today, [DATE] since it was thawed and should have only been in there 2 days before use, well before the dated stick of [DATE]. He stated some dates on the items were the dates the item was received, some dates were the date it was opened but he could to answer why it was not identified so you know which date was for what. He stated they cleaned the vents & filters frequently then he was shown the state of the filter in the free-standing ice machine. He did not reply. He stated his staff know they were supposed to date items and now they will have to have an in-service on the items brought to his attention. He stated he washed his hands when asked why he was not noted washing his hands or putting on new gloves. He sated he went back twice to wash his hands. Review of the facility's Nutrition Services Policy & Procedures Food Safety Receiving and Storage dated 2020: Revision ,d+[DATE], reflected Policy: Food will be received ad stored by methods to minimize contamination and bacteria growth. Procedure: . 3. Keep receiving area clean and well lighted. 4. Compare delivery invoices against products ordered and products delivered. 5. Inspect food when it is delivered to the facility and prior to storage for signs of contamination. Food packages shall be in good condition to protect the integrity of the contents so that the food is not exposed to adulteration or potential contaminants. Examples of signs of contamination include: A. Cans with badly swollen sides or ends, flawed seals or seams, rust, dents, or leaks. B. Frozen foods that are partially thawed. Foods that have been thawed and then refrozen can be contaminated; check for large ice crystals, solid areas of ice, discolored or dried-out food, or misshapen items. C. Signs of insects in fresh produce. D. Dried fruits and vegetables, cereals and other grain products, sugar, flour, and rice received in wet or broken packaging. Dampness or mold can be signs of spoilage or bacterial growth. Holes or tears can be signs of pest infestation. E. Inappropriate odors, colors, or textures in cold foods. 6. Check expiration dates and use-by dates to assure the dates are within acceptable parameters. 7. Refuse contaminated food and return to the vendor for credit. If the food cannot be returned immediately, store it away from other food and supplies to prevent contamination. Dented cans are stored in a designated location (labeled dented cans) until they can be returned to the vendor. 9. When adding newly delivered food into current inventory, use the FIFO (First In, First Out) method so old stock is rotated to the front and utilized first. General Food Storage Guidelines: 1. Store food in a manner to allow air circulation around food. 2. Store food in its original packaging if the packaging is clean, dry, and intact. 3. Place food that is repackaged in a leak-proof, pest-proof, non-absorbent, sanitary container with a tight-fitting lid. Label both the container and its lid with the common name of the contents, the date it was transferred to the new container, and the discard date. It is recommended that food stored in bins (e.g. flour or sugar) be removed from its original packaging. Dry Storage Guidelines: . 2. Tightly seal opened packages to prevent contamination or place food in covered containers. 3. Containers holding food or food ingredients that are removed from their original packages such as cooking oils, flour, sugar, herbs, and spices are identified with the common name of the food. 5. Dry storage areas are well ventilated and pest free. Refrigerated Storage Guidelines: . 9. Prevent meat and poultry juices from getting into other foods.12. Refrigerated, ready to eat Time/Temperature Control for Safety Foods (TCS) are properly covered, labeled, dated with a use-by date, and refrigerated immediately. [NAME] them clearly to indicate the date by which the food shall be consumed or discarded. The day of preparation or day original container is opened shall be considered day 1. Follow USDA guidelines for food storage. 13. In the case of commercially processed food, the date marked by the facility may not exceed a manufacturer's use-by date. 14. Refrigerated condiments and salad dressings are properly covered, labeled, and clearly marked to indicate a use by date two months from the date opened. Review of the U.S. FDA Food Code 2022 reflected: Chapter 2 . section ,d+[DATE] Hands and Arms. ,d+[DATE].11 Clean Condition. Food Employees shall keep their hand and exposed portions of their arms clean. ,d+[DATE].12 Cleaning Procedure. (C). To avoid recontaminating their hands or surrogate prosthetic devices, food employees may use disposable paper towels or similar clean barriers when touching surfaces such as manually operated faucet handles on a Handwashing Sink or the handle of a restroom door. ,d+[DATE].14 When to Wash. Food Employees shall clean their hands and exposed portions of their arms as specified under section ,d+[DATE].12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single service and single-use articles. and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; (B) After using the toilet room; (C) After caring for or handling service animals or aquatic animals as specified in ,d+[DATE].11(B); (D) Except as specified in ,d+[DATE].11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco products, eating, or drinking; (E) After handling soiled equipment or utensils; (F) During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; (G) When switching between working with raw food and working with ready-to-eat food; (H) Before donning gloves to initiate a task that involves working with food; and (I) After engaging in other activities that contaminate the hands. Section ,d+[DATE].15 Where to Wash. Food Employees shall clean their hands in a Handwashing Sink or approved automatic handwashing facility and may not clean their hands in a sink used for food preparation or ware washing, or in a service sink or a curbed cleaning facility used for the disposal of mop water and similar liquid waste. Chapter 3 . section ,d+[DATE].11 Compliance and Food Law: . C. Packaged Food shall be labeled as specified in LAW, including 21 CFR 101 Food Labeling [* .(b) A food which is subject to the requirements of section 403(k) of the act shall bear labeling, even though such food is not in package form. (c) A statement of artificial flavoring, artificial coloring, or chemical preservative shall be placed on the food or on its container or wrapper, or on any two or all three of these, as may be necessary to render such statement likely to be read by the ordinary person under customary conditions of purchase and use of such food. The specific artificial color used in a food shall be identified on the labeling when so required by regulation in part 74 of this chapter to assure safe conditions of use for the color additive.], 9 CFR 317 Labeling, [*(a) When, in an official establishment, any inspected and passed product is placed in any receptacle or covering constituting an immediate container, there shall be affixed to such container a label .Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under S ,d+[DATE].18. Section ,d+[DATE].12 Food Storage Containers, Identified with Common Name of Food: Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food. Section ,d+[DATE].17 . Commercial processed food: Open and hold cold . B. 1. The day the original container is opened in the food establishment shall be counted as Day 1. 2. The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. C. 2. Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section. 3. Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section. Definitions 3. Food Receiving and Storage - When food, food products or beverages are delivered to the nursing home, facility staff must inspect these items for safe transport and quality upon receipt and ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all PHF/TCS foods stored in the refrigerator or freezer as indicated. Chapter 5 . Section ,d+[DATE].11 Using a Handwashing Sink (A) A Handwashing Sink shall be maintained so that it is accessible at all times for Employee use. Section ,d+[DATE].16 Storage Areas, Rooms, and Receptacles, Capacity and Availability . (B) A receptacle shall be provided in each area of the Food establishment or premises where refuse is generated or commonly discarded, or where recyclables or returnables are placed. (C) If disposable towels are used at handwashing lavatories, a waste receptacle shall be located at each lavatory or group of adjacent lavatories. Section ,d+[DATE].113 Covering Receptacles. Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered: . www.fda.gov Review of the USDA website reflected: The United States Department of Agriculture's Food Safety and Inspection Service inspects only meat, poultry and egg products. The United States Food and Drug Administration inspects other foods. Yogurt can be stored in the refrigerator (40 F) one to two weeks or frozen (0 F) for one to two months. Soft cheeses such as cottage cheese, ricotta or Brie can be refrigerated one week but they don't freeze well. Hard cheeses such as cheddar, Swiss and Parmesan can be stored in the refrigerator six months before opening the package and three to four weeks after opening. It can also be frozen six months. Processed cheese slices don't freeze well but can be kept in the refrigerator one to two months. Milk can be refrigerated seven days; buttermilk, about two weeks. Milk or buttermilk may be frozen for about three months. Sour cream is safe in the refrigerator about one to three weeks but doesn't freeze well www.askusda.gov

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 2 of 3 (LVN A, and MA B) staff members and 4 of 6 residents (Residents #13, #28, #40, and #72) reviewed for infection control procedures. LVN A failed to disinfect the blood pressure cuff (machine used for checking blood pressure) in between blood pressure checks for Residents #28, and #72. MA B failed to disinfect the blood pressure cuff in between blood pressure checks for Residents #13 and #40. This failure could place residents at risk for cross contamination and infections. Findings included: Record review of Resident #72's admission MDS assessment, dated 08/20/24, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #72 had diagnoses which included: Hypertension (high blood pressure), and bipolar disorder (mental illness). Resident #72 was cognitive and able to make decisions and required assistance of one staff for activities of daily living. Record review of Resident #72's physician orders dated 08/20/24 reflected, amlodipine (high blood pressure) 5mg give one tab by mouth one time a day and to obtain blood pressure one time a day on each shift. Record review of Resident #28's other payment MDS Assessment, dated 08/15/24, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #28 had diagnoses which included: diabetes (increased blood sugar), hypertension (increased blood pressure), and dizziness. Resident #28's was cognitively able make all decisions for himself and required one staff for assistance with activities of daily living. Record review of Resident #28's physician orders dated 10/19/23 (open ended) reflected, Metoprolol tartrate (high blood pressure) 25 mg give one tab by mouth two times a day, and to obtain blood pressure one time a day on each shift. Record review of Resident #40's other payment MDS Assessment, dated 08/20/20, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #40 had diagnoses which included: Hypertension (increased blood pressure), atrial fibrillation (heart rate), and chronic kidney disease (kidneys work slower). Resident #40 was cognitively able to make decisions and required one staff for assistance with activities of daily living. Record review of Resident #40's physician orders dated 05/16/24 (open ended order) reflected, metoprolol succinate (high blood pressure) 50mg give one tab by mouth one time a day and to obtain blood pressure one time a day on each shift. Record review of Resident #13's other payment MDS Assessment, dated 09/06/24, revealed a [AGE] year-old female who admitted to the facility on [DATE]. Resident #13 had diagnoses which included: Cerebral infarction (stroke), Hemiplegia (cannot use her right arm or leg), and Aphasia (unable to speak). Resident #13 was moderately cognitively impaired and unable to make decisions and required assistance of one staff for activities of daily living. Record review of Resident #13's physician orders dated 10/02/23 (open ended order) reflected, amlodipine (high blood pressure) 5mg give one tab by mouth two times a day and to obtain blood pressure one time a day on each shift. Observation on 09/30/24 at 10:25 a.m., revealed LVN A performing morning medication pass, during which time she checked the blood pressure on Resident #72. LVN A failed to sanitize the blood pressure cuff before or after using it on Resident #72. Observation on 09/30/24 at 10:45 a.m., revealed LVN A performing morning medication pass, during which time she checked the blood pressure, on Resident #28, used the same blood pressure cuff used on Resident #72. LVN A failed to sanitize the blood pressure cuff before or after using it on Resident #28. Observation on 10/01/24 at 8:30 a.m., revealed MA B performing morning medication pass, during which time she checked the blood pressure on Resident #40. MA B failed to sanitize the blood pressure cuff before or after using it on Resident #40. Observation on 10/01/24 at 9:00 a.m., revealed MA B performing morning medication pass, during which time she checked the blood pressure on Resident #13, used the same blood pressure cuff used on Resident #40. MA B failed to sanitize the blood pressure cuff before or after using it on Resident #13. An interview on 09/30/24 at 10:55 a.m., LVN A stated she did not think about cleaning the blood pressure cuff between usage, she had forgotten. LVN A stated she wore gloves between each usage when she took the blood pressure and used hand sanitizer. LVN A stated if the cuff was on the residents and then not cleaned it could spread germs to others. An interview on 10/01/24 at 8:55 a.m., MA B revealed the MA did not know she was supposed to clean the blood pressure cuff between use. The MA stated she did use her hand sanitizer and she thought that was enough. The MA stated that makes sense to her because if another resident had an infection it could spread to another resident from the blood pressure cuff. An interview with the DON, who was the infection control preventionist on 10/01/24 at 4:45 p.m., revealed the DON had only been at the facility for one month. The DON stated that all direct care staff must clean equipment, including blood pressure cuffs after having contact with each resident. The DON stated, the staff has available the disinfectant wipes that will kill all germs. The DON stated the staff would be in-serviced on infection control and he would perform teaching concerning infection control. If they do not clean the blood pressure cuffs appropriately, they could spread germs to themselves and the residents. Record review of an in-service log dated 05/31/24 revealed LVN A, had received cleaning and properly storing equipment after each use and MA B had not received the training. Record review of the Facility's Policy titled Infection control dated May 2023, reflected: Purpose: To establish a facility wide program that incorporates a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases. The program covers all resident, staff 3. the infection control Prevention and control Program is administered by an Infection Preventionist who is qualified by education and special training . 6. Staff development E. Staff is provided with information and training on .6) proper handling of linens, waste, equipment and supplies .10) Cleaning , disinfecting, and sanitation procedures . Record review of the Facility's Policy titled Infection control-Cleaning and Disinfecting Resident Care items and Equipment dated May 2023 reflected: It is the policy of this home to clean and disinfect resident-care equipment, including reusable items and durable medical equipment . non critical items are those that come in contact with intact skin but not mucous membranes . non-critical resident-care items include bedpans, blood pressure, cuffs

Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for five (two unused halls) of three halls (Halls 400, 500, and 600) and the nurse's station, private dining room, kitchen, the unused dining room next to private dining room, and main dining room reviewed for pest control program. The facility had live fruit flies in areas of the facility including the nurse's station, Halls 400, 500, 600, nurse's station, private dining home, unused dining room next to the private dining room, lobby, and the main dining room. This failure could place residents at risk for spread of infection, cross-contamination, and decreased quality of life. Findings included: An observation on 09/30/24 at 9:00 a.m., revealed in the private dining room there were three live fruit flies flying around the private dining area. An observation on 09/30/24 at 9:15 a.m., revealed a group of 5-10 live fruit flies flying around in the dining area, not being used at this time, next to the private dining area, where survey team was working. An observation on 09/30/24 at 9:30 a.m., revealed 7-10 live fruit flies flying down the service hallway. This hallway had the laundry, a training classroom, the employee break room, and the entrance to the kitchen. An observation on 09/30/24 at 10:00 a.m., revealed three live fruit flies in the three-compartment sink drain, in the kitchen. There were three live fruit flies flying around the steam table. An observation on 09/30/24 at 10:20 a.m., revealed a live fruit fly crawling across the overbed table in room [ROOM NUMBER]. Resident #1 stated these little flies were bad. Resident #1 stated she had told several staff members, but the little flies continued to be here. Resident #1 stated that any food you had the little flies would just swarm around it. The resident stated she had been seeing the little flies for about a month, and she did not recall seeing any pest control workers here. An observation on 09/30/24 at 11:30 a.m., revealed in the main dining room, six different resident's tables had fruit flies crawling on the tables. There had been no food served at this time, one table had a cold cup of coffee sitting on it with two dead fruit flies floating in it. An observation on 09/30/24 at 11:45 a.m., revealed a live fruit fly on the wall of Hall 400, outside of room [ROOM NUMBER], there were no residents in the room at the time. An observation on 09/30/24 at 1:00 p.m., revealed three live fruit flies crawling on the only used nurses station in the facility. An observation and interview on 09/30/24 at 1:15 p.m., revealed three live fruit flies swarming around a linen barrel, that had a lid on it. The barrel was sitting outside the laundry room door. An observation on 10/01/24 at 8:00 a.m., revealed a swarm of live fruit flies flying down the service hallway. An observation on 10/01/24 at 8:10 a.m., revealed a swarm of live fruit flies flying around the head of the MA B administering medications on Hall 400. The MA stated these little flies are bad. MA B said she told the maintenance man about the little Pest, about 2 weeks ago, but nothing has changed, the flies were still here. She had not seen any pest control at the facility and now the maintenance man was out of the country. MA B stated she did not know what the process was for reporting the flies, she just told the maintenance man. An observation on 10/01/24 at 8:15 a.m., revealed a bag of trash that had been left from the day before in the private dining room. The Surveyor had to tie up the trash bags, there were more than fifteen live fruit flies in the room. The live fruit flies remained in the room for the rest of the day. An observation on 10/01/24 at 11:00 a.m., revealed two live fruit flies crawling across the top of the medication cart on Hall 500. An observation on 10/01/24 at 2:00 p.m., revealed a swarm live fruit flies flying down Hall 600. An observation on 10/01/24 at 2:30 p.m. revealed the surveyor had conducted a phone interview in the smaller dining room that was adjacent to the private dining room . During the interview a live fruit fly attempted to fly up the nose of the surveyor, causing her to gag and cough. An interview on 10/01/24 at 4:30 p.m., with the Administrator revealed he was not aware that the facility had pest of any kind. The Administrator stated he would contact his pest control company and tell them. The Administrator was not sure of the process for the staff or anyone to report pest problems. The Administrator stated that if the bugs were not killed they could spread germs, because bugs have germs. Record review of the pest control book, located at the nurse station reflected a log with no notations of flies. Record review of facility provided pest control visits revealed, in part, dates and treatments as follows: Treatment dates and services performed: -09-24-2024-after inspection . no verification of fruit flies . preventative treatment for cockroaches and rodents -08-29-2024-after inspection . no verification of fruit flies . preventative treatment for cockroaches and rodents -07-26-2024-after inspection . no verification of fruit flies . preventative treatment for cockroaches and rodents -06-17-2024-after inspection . no verification of fruit flies . preventative treatment for cockroaches and rodents Record review of the facility's policy revised, June 2023 and titled Pest control Program reflected Facility will maintain and effective pest control program to prevent or eliminate infestation of pests and rodents .1. Contracted pest elimination service will provide monthly service for the most common pests such as rodents, cockroaches, and other crawling invaders .2. Facility staff will: A. Note and report any evidence of pest activity . B. Report sighting of live pest immediately . C. make notes of the exact location of where the pest sighting occurred and inform .

Based on observation, interview and record review, the facility failed to ensure it was free of a medication error rate of five percent (5%) or greater for 2 of 29 opportunities during medication pass resulting in an 6 percent (6%) error rate for two (Residents #13, and #65) of 6 residents observed for medication pass. 1. MA B failed to administer Resident #13's Cranberry tablets 500mg (for urine retention) due to not having the tablets available. 2. MA B failed to administer Resident #65's Solonpas (Central nervous system, anti-inflammatory agent, for pain) to bilateral knees one time a day. MA B provided the patches to the resident and left the room, not observing if the resident applied them to her knees correctly. These failures could place residents at risk for not receiving therapeutic dosages of their medications as ordered by the physician and a decreased health status. Findings included: Review of Resident #13's Physician's Order dated 10/01/24 and updated 10/01/24 reflected, Cranberry tablet 500mg to be given by mouth one tablet twice a day. Review of Resident #13's Medication Administration Record reflected there had not been any doses of the Cranberry 500mg tablet to give to Resident #13 for the past three days, prior to 10/01/2024. Observation on 10/01/24 at 8:45 a.m., revealed MA B did not administered the following medication to Resident 13 during morning medications. MA B did not provide the Cranberry 500mg BID to the resident, due to not having the medication available. Review of Resident #65's physician's order dated 08/12/24 reflected Solonpas adhesive patch 1 patch once a day apply to bilateral (both) knees (on for 12 hours and off for 12 hours). Observation on 10/01/24 at 8:45 a.m., revealed MA B administered the following medication to Resident #65 Solonpas patch to the bilateral knees for pain. MA B gave the Solanpas patch to Resident #65 , left the room and did not observe the resident placing the patches on her knees as ordered. In an interview on 10/01/24 at 9:00 a.m. with MA B, she stated you are supposed to let the nurse know if you do not have medication available to give, sometimes the medication room was checked to see if there were medications available. This resident (#13) sometimes will not take all her medication anyway and if the medication comes, she can have it at 5:00 p.m. this evening. The MA agreed that would have the resident missing a dose. The MA stated the resident could suffer harm if they did not get the medications the doctor had ordered correctly. The MA stated that the medications should be given using the three rules of dispensing, 1) look at the order on the MAR, 2) pull the medications and compare, 3) place in the cup and check one last time that you were giving the correct medication. Then you enter the room, explain to the resident what you were giving and stay with the resident while they take the medications and make sure they have taken them. The MA stated she was not sure why she does not do that with Resident #65, maybe because she was alert and there for rehabilitation. MA B stated she leaves the patches and the resident placed them on when she wants. The MA stated she did not really consider the patches a medication, she thought it was okay that the resident place her own patches on herself when she wants to. In an interview on 10/01/24 at 11:00 a.m. with Resident #65 revealed the resident was very happy at the facility and she was trying to leave to go home soon, but she had not done well with therapy, the facility thought she was not safe yet to go home. Resident #65 stated the care here was great and she loved the staff, they were all good to her. The resident stated the patches she had always used, and MA B did leave them for her if she was not interested in placing the patches on at the time. Resident # 65 stated she would always place them on her knees later. The resident stated the other staff would not let me keep them, they would insist on placing the patches on. In an interview on 10/01/24 at 4:45 p.m., the DON who had only been there a month, revealed the staff who administer medications should always practice best practices. The DON stated the best practice would be to follow the three basic rules prior to administering the medications, then the staff should stay while the resident takes the medications or applies the medications and then assure the resident had taken the meds. The DON stated the staff should never leave any type of medications in the room with the resident. The DON stated this was unsafe and something could happen, the resident could not take the medication or not apply the medication, this could cause possible harm to that resident as well as other residents that could take the medicine from the resident's room. The DON stated if the medication was not available, he needed to know. He can order the medication and had ordered the cranberry when he was informed that it was needed, and the resident could receive the medications as ordered. The DON stated he would see that the staff that administering medications had additional training, with follow-up for compliance. Review of the facility policy and procedure Medication Management Program revised May 2023 reflected, The facility implements a Medication Management program to meet the pharmaceutical needs of patients and residents, according to established standards for practice and regulatory requirements . Preparing for medication pass .4. D. the 8 Rights for administering medication: 1) The right Patient/Resident 2) The right Drug, 3) The right Dose, 4) The right time, 5) The right Route, 6) The right charting, .Administering medications .J. If applying a transdermal patch .The location of administration site must be documented, .10. The authorized staff member or licensed nurse must remain with the resident while the medication is swallowed. Never leave medication in a resident room without order to do so .15. If a medication is unavailable , contact the pharmacy and document accordingly. Notify physician for possible alternatives available in e-kits at time of discovery.

Based on observation, interview, and record review, the facility failed to provide a locked and permanently affixed compartment for storage of all controlled drugs for 1 of 1 medication rooms reviewed for medication storage. The facility failed to ensure the lockbox in the medication room refrigerator was locked that contained eight syringes of Ativan Benadryl cream (schedule IV, controlled medication). This failure could place residents receiving medication at risk for drug diversion or misuse of medications. Findings included: During an observation of the medication room on 10/01/24 at 4:03 p.m., with ADON C present there was an unlocked lockbox in the only medication refrigerator. Eight syringes of Ativan Benadryl cream (schedule IV, controlled medication) were located in the unlocked lockbox. In an interview on 10/01/24 at 4:03 p.m., ADON C stated the lockbox should always be locked, was unaware why it was unlocked, and the lockbox was monitored by the ADONs and DON. ADON C did not describe how often or how the lockbox was monitored. ADON C reported that the risk of not having controlled substances properly secured was that the wrong staff could have accessed the medications, and medications could have went missing. ADON C also stated that all controlled medications were counted at every shift change by the off-going and on-coming nurse. In an interview on 10/01/24 at 4:20 p.m., the DON stated the DON and ADONs were responsible for monitoring the lockboxes and ensure medications were stored properly. The DON did not state how often it was being monitored or when the last time it was checked. DON reported the risk for medications not being secured properly was the resident's medications could go missing. Record review of the facility's policy titled Pharmacy Services Policies and Procedures, with a revision date of 4/17/2024, stated 3. All controlled medications must be maintained in separately locked, permanently-affixed compartments.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 4 (Residents #3, #30,#36, and #38) of 48 residents observed for wheelchairs, in that: The facility failed to properly maintain wheelchairs for Residents #3, #30, #36, and #38. The wheelchair arm rest pads were torn and cracked with exposed interior foam. The arm rest pads could not appropriately be cleaned due to the cracked and exposed foam. There was a posed safety problem as the cracked arm rest pads could cause injury to the residents. These failures could place residents at risk for diminished quality of life and at risk for skin issues and discomfort due to the lack of a well-kept wheelchairs. Findings included: 1. Review of Resident #3s quarterly MDS assessment, dated 07/27/2023, reflected she was an [AGE] year-old female admitted to the facility on [DATE], with the following diagnoses: lack of coordination. Resident #3 was severely impaired for decision making. Review of the Resident #3's plan of care dated 08/15/2023 with updates reflected goals and approaches to include wheelchair mobility. An observation on 09/11/2023 at 12:20 p.m., revealed Resident #3's right side and left side arm rest on the wheelchair was cracked with jagged edges, and the interior padding was exposed. The arm pads were not appropriately cleaned. 2. Review of Resident #31's quarterly MDS assessment, dated 08/03/2023, reflected she was an [AGE] year-old female admitted to the facility on [DATE], with the following diagnoses: Alzheimer's, muscle weakness, and lack of coordination. Resident #31's was severely impaired for decision making. The resident was unable to answer any questions. Review of the Resident #31's plan of care dated 07/20/23 with updates reflected goals and approaches to include wheelchair mobility. An observation on 09/11/23 at 12:12 p.m., revealed Resident #31's left arm rest was cracked with jagged edges on the wheelchair with the interior padding exposed. The arm pads were not appropriately cleaned. 3. Review of Resident #36's quarterly MDS assessment, dated 08/24/2023, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with the following diagnosis: Gout, and neuralgia. Resident #31 was severely impaired for decision making. Resident #36 is unable to answer any questions. Review of the Resident #36's plan of care dated 08/15/2023 with updates reflected goals and approaches to include wheelchair mobility. An observation on 09/11/23 at 12:15 p.m., revealed Resident #36's right and left arm rest was cracked with jagged edges on the wheelchair with the interior padding exposed. The arm pads were not appropriately cleaned. 4. Review of Resident #38's admission MDS assessment, dated 07/06/2023, reflected she was an [AGE] year-old female admitted to the facility on [DATE], with the following diagnoses: Cerebral infraction (stroke), lack of coordination, and Alzheimer. Resident #38 was severely impaired for decision making. Resident # 38 was unable to answer any questions. Review of the Resident #38's plan of care dated 07/06/2023 reflected goals and approaches to include wheelchair mobility. An observation and interview on 09/11/2023 at 12:20 p.m., revealed Resident #38's right side arm rest was missing and left side arm rest on the wheelchair was cracked with jagged edges, and the interior padding was exposed. The arm pads were not appropriately cleaned. Interview on 09/13/23 at 11:00 a.m. with CNA B revealed when a resident has something wrong with their wheelchair, she would report it to the nurse. CNA B stated she did not know anything about a maintenance log at the nurse's station and she was unaware of any wheelchairs that required maintenance to the arm rest. Interview on 09/13/23 at 12:00 p.m. with LVN A revealed if the resident had a problem with a wheelchair, she would inform the therapy department. The therapy department would order the part that was needed and fix the wheelchair. LVN A stated maintenance was not involved. LVN A was not aware of any wheelchairs requiring new arm rest., she did state there was maintenance logbook at the nurses station, and book was for the staff to let the maintenance know of areas in the facility that require repair, like a broken toilet. Interview on 09/13/23 at 12:20 p.m. with the Director of Rehab revealed the therapy staff would assist in repairing wheelchairs. The Director of Rehab stated if the staff informed us and the parts are ordered we can repair them. The Director of rehab stated the maintenance department use to help, but we have been assisting. The Director of Rehab stated she was unaware of any wheelchairs that need new arm rest. Interview on 09/13/23 at 1:00 p.m. with the interim Administrator and the DON revealed the process was supposed to be the staff wrote in the maintenance log at the nurse's station concerning the problems, such as wheelchairs that require new arm rest. The Maintenance man would check the book daily order the parts, if needed, and repair the wheelchair. The Administrator was supposed to oversee this process. The DON stated there had not been anyone in the maintenance position for three months and she was unaware there were any wheelchairs that required new arm rest. The interim Administrator and the DON both said they would perform a sweep and get the wheelchairs repaired right away because this could affect their resident's mobility. Record review of the maintenance log reflected no documentation concerning broken or missing wheelchair arm rest. Review of the facility policy and procedure Wheelchair safety: Use and Maintenance revised dated May 5th 2023 reflected, The Facility promotes patient, resident and staff safety through the appropriate use and maintenance of wheelchairs 4. Wheelchair Maintenance and Servicing. A. Wheelchairs will be inspected and receive preventive maintenance as needed. B. Resident, patients, and staff remove equipment from service that is defective or requires maintenance or repair. C. Common replacement items include arm, leg, and footrests, cushions, seats, back supports, front and rear wheel assemblies, and brakes. 32581

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for three (Residents #24, #127, and #128) of five residents reviewed for infection control. RN C failed to disinfect the glucometer machine (an instrument for measuring the concentration of glucose in the blood) in between resident use, for Residents #127, and #24. LVN D failed to disinfect the glucometer machine (an instrument for measuring the concentration of glucose in the blood) after resident use, for Resident #128. This failure could place residents at-risk of cross contamination which could result in infections or illness. Findings included: Resident #128 Review on 09/11/23 of Resident #128's EHR revealed the resident was a [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses including: Diabetes (elevated blood sugar) and cerebral infarction (stroke). Review of Resident #128's new admission MDS dated [DATE], revealed was severely impaired cognition for decision making, her functional status indicated he needed one person assist only with her ADLs. Record review of Resident #128's physician orders dated 08/30/23 reflected Novolog FlexPen U-100 Insulin per sliding scale following a fasting blood check four times a day for diabetes mellites type two (elevated blood sugar), acuchecks (an instrument for measuring the concentration of glucose in the blood) four times a day. Resident #127 Review on 09/11/23 of Resident #127's EHR revealed the resident was a [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses including: Diabetes (elevated blood sugar), and cardiovascular accident (stroke) . Review of Resident #127's 5-day MDS, dated [DATE] revealed a BIMs score of 12, indicating she was mildly impaired cognition for decision making, her functional status indicated he needed assist of one staff with her activities of daily living. Record review of Resident #127's physician orders dated 09/06/23 reflected insulin glargine 100 units/ml give 6 units two times a day, insulin lispro 100 units/ml per sliding scale three times a day before meals, and metformin 500mg two times a day for diabetes mellites type two (elevated blood sugar), acuchecks (an instrument for measuring the concentration of glucose in the blood) three times a day before meals. Resident #24 Review on 09/11/23 of Resident #24's EHR revealed the resident was a [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses including: Diabetes (elevated blood sugar), and cardio obstructive pulmonary dieses (short of breath) . Review of Resident #24's quarterly MDS, dated [DATE] revealed a BIMs score of 15, indicating she was cognitively intact for decision making, her functional status indicated he needed assist of two staff with her activities of daily living. Record review of Resident #24's physician orders dated 09/12/23 reflected insulin aspart 100 units/ml give per sliding scale three times a day, Lantus solution U-100 Insulin give 30 units two time a day, for diabetes mellites type two (elevated blood sugar), acuchecks (an instrument for measuring the concentration of glucose in the blood) three times a day before meals. Observation on 09/11/23 at 11:41 a.m. revealed LVN D performed a blood sugar test on Resident #128. LVN D sanitized the glucometer machine (an instrument for measuring the concentration of glucose in the blood) without using the appropriate sanitizing wipes, using an alcohol swab instead before and after testing Resident #128's blood. Interview on 09/11/23 at 11:50 a.m., LVN D stated reusable equipment, like blood glucometers, should be sanitized with wipes purple top that she had on her medication cart between each resident use to prevent transmitting an infection from one resident to another. She stated she was supposed to cleanse the blood glucometer in-between each usage, as she had been instructed, but she did not know why she had not done it this time. LVN D stated that if the equipment that was used on the residents was not cleaned correctly it could cross contaminate causing a spread of infection. Observation on 09/12/23 at 11:15 a.m. revealed RN C performed a blood sugar test on Resident #127. LVN C sanitized the glucometer machine (an instrument for measuring the concentration of glucose in the blood) without using the appropriate sanitizing wipes, using an alcohol swab instead before and after testing Resident #127's blood. Observation on 09/12/23 at 11:22 a.m. revealed RN C performed a blood sugar test on Resident #24. LVN C sanitized the glucometer machine (an instrument for measuring the concentration of glucose in the blood) without using the appropriate sanitizing wipes, using an alcohol swab instead before and after testing Resident #24's blood. While in the room RN C dropped the glucometer on the floor after checking the blood sugar. RN C exited the room wiped the glucometer off with an alcohol swab and place back in the drawer of the medication cart. Interview on 09/12/23 at 11:a.m. with RN C revealed she was an agency nurse that worked at the hospital fulltime, and she filled in extra at nursing facilities. RN C stated she had done very few glucometers checks at the hospital and when she had she always cleaned with the sanitizing wipes purple top that the hospital had, I was not aware that the nursing facility had sanitizing wipes. RN C opened the bottom drawer, and the sanitizing wipes purple top were on the cart. The RN closed the drawer and did not use the purple top wipes. Interview on 09/13/23 at 8:30 a.m. with the DON she stated that her expectation was that staff would sanitize all reusable equipment between each resident use. She stated that not doing so placed residents at risk of cross contamination of infections from one resident to another. She stated there was plenty of supplies for the nursing staff to have the sanitization wipes that are EPA-registered disinfectant, on all the medication carts. The DON stated there had recently been conducted an in-service for the staff on infection control and cleaning equipment, even the agency nurses have been in-serviced. The DON stated alcohol swabs are less than the recommended base of alcohol and they will not clean the glucometers appropriately for all the bacteria that cause infections. Review of the in-service records dated 08/01/23 reflected in service training topic Glucometer Acuchecks [brand name of the glucometer] disinfection LVNs D name was on the list RN Cs was not further review reflected follow-up activity with competencies review there was a competency test for LVN C presented follow-up competencies reports. Review of facility's Infection prevention and control policies and procedures, revised May 15 2023, reflected the following: cleaning and disinfection procedures 2. Alcohol is not approved for disinfecting items which are potentially contaminated with blood . 3. Blood glucose meters and point of care testing devices are at high risk of becoming contaminated with bloodborne pathogens such as HBV, HCV, and HIV. Transmission of these viruses from individual to individual has been documented due to contaminated blood glucose devices. According to the CDC, cleaning, and disinfection of meters between resident uses can prevent transmission of these viruses through indirect contact. 5. Use an EPA disinfectant wipe which is labeled effective against TB or HBV, HCV and HIV to remove any visible contaminants, soil or other debris. 6. Use a second EPA disinfectant wipe to disinfect the device surfaces, ensuring adequate contact time.

Based on observation, interview, and record review the facility failed to ensure residents had the right to be free from abuse and neglect for 2 (Resident #1 and Resident #2) of 2 residents reviewed for abuse and neglect, in that: 1) On 08/13/23, CNA A engaged in name-calling, used profanity, made an offensive gesture, interrupted, put down, and demeaned when verbally attacked Resident #1. 2) On 08/13/23, CNA A threw a pack of disposable wet wipes at Resident #1's stomach. 3) On 08/13/23, CNA A used profanity and made an offensive gesture at Resident #2. This failure could place residents at risk of immediate and long-term consequences, including anxiety, emotional distress, chronic stress, depression, feelings of shame, hopelessness, and at risk of psychosocial harm. Findings included: Record review of Resident #1's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE], latest re-admission 07/05/23. Resident #1 had diagnoses of Other epilepsy, not intractable (can be treated), without status epilepticus (a disorder characterized by recurrent seizure activity without recovery between seizures, that may or may not be associated with loss of consciousness or convulsions (rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement)); TIA (a stroke that lasts only a few minutes); MDD (a mood disorder that causes a persistent feeling of sadness and loss of interest); morbid (severe) obesity due to excess calories; MS (a condition that can affect the brain and spinal cord, causing a wide range of potential symptoms, including problems with vision, arm or leg movement, sensation, or balance); T2DM (a disorder in which the body does not produce enough or respond normally to insulin, causing blood sugar (glucose) levels to be abnormally high); hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one entire side of the body) following cerebral infarction affecting left non-dominant side. Record review of Resident #1's Quarterly MDS (a standardized assessment tool that measures health status in nursing home residents) assessment, dated 07/26/23, revealed a BIMS score of 15, which suggested Resident #1 was cognitively intact (being able to follow two simple commands; has sufficient judgment, planning, organization, self-control, and the persistence needed to manage the normal demands of ADL). The Quarterly MDS assessment reflected Resident #1 required set-up help only with ADLs and one-person physical assist with toileting and bathing. Resident #1 had a functional limitation in range of motion on one side of upper and lower extremities. Resident #1 was occasionally incontinent of bladder and frequently incontinent of bowel. The Quarterly MDS did not indicate Resident #1 had any behavioral symptoms or rejection of care during the MDS review period. A review of Resident #1's comprehensive care plan, last reviewed/revised on 08/05/23, indicated that Resident #1 had a dx of MS [Problem start date: 08/09/23]; a dx of seizures [Problem start date: 05/02/23]; incontinence of bowel and bladder [Problem start date: 03/21/23]; risk for falling [Problem start date: 03/21/23] r/t weakness, dx of MS, CVA, and Lupus (Systemic Lupus Erythematosus) (an autoimmune disease that can cause joint pain, fever, skin rashes and organ damage); and required assistance with ADLs [Problem start date: 03/04/23] - including toileting with the assist of one person [Approach start date: 04/03/23] and instruct in proper self-care techniques using self-cleaning device [Approach start date: 05/18/23]. Record review of Resident #1's progress notes, revealed a progress note dated 08/13/23 at 9:42 PM, entered by LVN B. The progress note reflected a statement from [Resident #1's viewpoint]: [Resident #1] was in the bathroom having a BM and turned on the call light for help to get wiped. [Resident #1] asked Resident #2 to call for help . it had been a while and the call light had not been answered. Resident #2 went to the nurses' station and informed CNA C that it had been about an hour since Resident #1 turned on the call light and needed help to get wiped. CNA C told CNA A (the CNA assigned to Resident #1) that Resident #1 said she was in the bathroom for an hour. CNA A lost her temper and said it had not been an hour. CNA A confronted Resident #1 (who was still sitting on the toilet), called Resident #1 a liar, that everyone was tired of her, and CNA A threw a pack of wipes and hit Resident #1's lower abdomen. CNA A raised her middle finger (an obscene gesture made by pointing the middle finger upward while folding the other fingers against the palm) at Resident #1 and said F--- (a four-letter swear word) you, wipe yourself, you are stupid. CNA A walked down the hall and grabbed her backpack. CNA A passed LVN B who was coming out of the last room on Hall 600 . [CNA A] was very upset and yelling but [LVN B] could not understand what CNA A was yelling as she left the unit. [LVN B] returned to the nurses' station and was approached by Resident #2 who asked to report the inappropriate confrontation that happened between [Resident #2] and CNA A. Resident #2 said that CNA C witnessed CNA A raise her middle finger and curse [at Resident #2], but CNA C denied she heard anything. CNA D assisted Resident #1 out of the bathroom. Resident #1 called the DON, then called her [Resident #1's family member] . LVN B overheard Resident #1 on the phone speaking with a 911 dispatcher when she entered the room to assess Resident #1. LVN B measured Resident #1's vitals, performed a HTT assessment and took Resident #1's statement. LVN B accepted a call from the DON when she returned to the nurses' station and acknowledged understanding to complete incident reports. LVN B notified the NP and family member. Record review of CNA A's clock in/out sheet reflected on 08/13/23, a clock in time of 5:53 PM and a clock out time at 7:40 PM = 1 hours, 46 minutes, and 48 seconds. During an observation and interview on 08/15/23 at 11:10 AM, Resident #1 appeared groomed and dressed appropriate to clinical situation. Resident #1 was sitting upright in a manual wheelchair. No visible injuries or behavior were suggested of physical abuse, neglect, or SQC. Resident #1 was A, A & O to awareness of self, place, time, and situation. Resident #1 indicated on Sunday [08/13/23] after 7:00 PM, she was in the bathroom and turned the call light on to be wiped after she had a BM. Resident #1 stated that no one came, and it had been a little while since she turned the call light on. Resident #1 said that she could not give an amount of time because she did not have her phone and there was not a clock in the bathroom. Resident #1 said that she called out to Resident #2 to locate someone because no one answered the call light. Resident #1 said that CNA A appeared shortly after, enraged and yelling that [Resident #1] had not been waiting for an hour for someone to answer the call light. Resident #1 said that when she tried to tell CNA A that she never said she waited for an hour and just needed to be assisted, CNA A was argumentative, would interrupt when [Resident #1] spoke, said no one wanted [Resident #1] there (at the SNF), always causing confusion, and told Resident #1 to stop lying. Resident #1 said that CNA A raised her middle finger (as an obscene hand gesture) at Resident #1, said F--- (a four-letter swear word) you, threw a pack of wipes at Resident #1's stomach as hard as she could, said you can do it yourself, and left. Resident #1 described the pack of wipes (100-pack) as half full. Resident #1 said that Resident #2 followed behind CNA A telling her that she did not have to talk to [Resident #1] like that. Resident #1 said she turned the call light on again and another CNA (CNA D) answered the call light, wiped, and assisted Resident #1 out of the bathroom. Resident #1 said she feared that she suffered physical harm when CNA A threw the pack of wipes at her stomach. Resident #1 said that her stomach hurt after the pack of wipes hit her stomach and currently felt a dull, intermittent, tightness, cramping, and knots in her stomach where the pack of wipes hit her stomach. Resident #1 stated that she often experienced intermittent stomach discomfort related to stress, anxiety, and when upset. Resident #1 said that she called the DON immediately after coming out the bathroom, around 7:30 PM, to report the incident and then called 911. Resident #1 said that an officer came to take her statement. Resident #1 said on the next day [Monday, 08/14/23] the DON and LBSW came to her room to follow up after the incident and asked how she was doing. Resident #1 stated that she recounted the incident and told them that she felt better. Resident #1 said she did not need to go to the hospital for evaluation or treatment, that she felt safe, and never had a similar past encounter with CNA A. During an interview on 08/15/23 at 11:19 AM, Resident #2 (Resident #1's roommate) stated that she recalled the incident on Sunday (08/13/23). Resident #2 said she heard Resident #1 call out to find someone because no one answered the call light. Resident #2 said she did not know how long Resident #1 was in the bathroom, she just remembered that she took a nap after Resident #1 went to the restroom. Resident #2 said that she left out the room and saw CNA C sitting halfway down the hallway near the nurses' station and told her that Resident #1 needed help, that she been on the toilet for an hour waiting for someone to answer the call light. Resident #2 said that CNA C replied that Resident #1 was a liar, . everyday it's something, always complaining . Resident #2 said CNA C approached CNA A when she came out another resident's room and told her that Resident #1 said she waited an hour, and no one answered the call light. Resident #2 said that CNA A started fussing and headed towards Resident #1's room. Resident #2 described the incident as told by Resident #1. Resident #2 said she followed CNA A out the room and told her that she did not need to talk to Resident #1 like she did when all she needed was help. Resident #2 said that CNA A cursed at her, put up her middle finger, grabbed her personal bag and went down the hall to exit building. Resident #2 said that the way CNA A spoke at her affected emotionally. Resident #2 said that she reported the incident to the nurse. Resident #2 said she felt safe and denied a similar past encounter with CNA A. During an interview on 08/15/23 at 12:04 PM, the LBSW said that she worked at the SNF for less than one year. The LBSW said that she was familiar with Resident #1. The LBSW described Resident #1 as alert, fully oriented, was self-aware, and did alright for herself. The LBSW said that Resident #1 participated in self-care within functional limits but was fixated that she needed assistance with toileting. The LBSW said that Resident #1 could wipe own self from what she knew. The LBSW said that she and the DON followed up with Resident #1 on Monday (08/14/23) to follow up on an altercation that occurred the night before (Sunday, 08/13/23). The LBSW said that the altercation was reported as alleged physical and verbal abuse. The LBSW said that Resident #1 reported that CNA A verbally and physically abused her (Sunday night). The LBSW denied any mental assessments that were conducted that pertained to the alleged abuse or any interventions taken to assist Resident #1. The LBSW said that Resident #1 said she felt better and safe when interviewed on Monday (08/14/23). The LBSW said that an in-service was done, and she conducted resident safe surveys that did not bring forward concerns of CNA A's or other staff behavior. During an interview on 08/15/23 at 1:15 PM, the NFA indicated she first learned of the incident on 08/13/23 at 8:30 PM from the DON and reported to HHSC on 08/14/23 via TULIP (Incidents Submission Portal for Long-Term Care Providers). The NFA said that she was responsible for the initial reporting and overall investigation of the alleged abuse because she was the Abuse Coordinator. The NFA said action was immediately taken to ensure all residents were protected and an investigation was initiated. The NFA indicated staff interviews, safe surveys, and an ANE in-service were conducted as part of the investigation and to prevent reoccurrence. The NFA stated Resident #1 was protected from the alleged perpetrator when CNA A removed herself from the premises. CNA A was not allowed in the facility or on the premises to protect the residents. The NFA said that the DON and LBSW were also involved with the ongoing investigation. The NFA said that she did not currently have a lot of information. The NFA stated she still had interviews to complete and the LBSW needed to complete resident safe surveys. The NFA stated that there were no known previous warnings or similar incidents with CNA A at the facility. The NFA said that she never observed or was reported that CNA A exhibited inappropriate behaviors toward Resident #1 or other residents in the past. The NFA said that there were no known resident/family grievances or problems identified with care delivery provided by CNA A. The NFA indicated that she performed surveillance daily to monitor for potential abuse. The NFA stated a process in place to protect and prevent resident ANE was leadership rounded throughout the facility at different times and across shifts to monitor for potential or actual reported allegations of abuse and the delivery of care and services by direct care staff. The NFA said that it is her expectation of all staff to be polite, respectful, and to meet resident needs. Record review of the facility's self-report dated 08/14/23, submitted by the NFA, indicated the NFA first learned of the incident on 08/13/23 at 8:30 PM. The incident occurred 08/13/23 around 7:45 PM. A brief narrative summary of the reportable incident revealed Resident #1 stated CNA A threw wet wipes at her [Resident #1] stomach and said, fuck you. Resident #2 was a witness to the incident. LVN B immediately assessed Resident #1 and performed a HTT assessment was completed - no injury noted. CNA A removed herself from the premises. LVN B reported the incident to the MD/NP, family member, and DON. Resident #1 called 911. When the officer arrived, Resident #1 gave a statement (account of what happened) to the officer and obtained a report number. Record review of an interview worksheet dated 08/15/23, signed by HR reflected the staff name: CNA A; shift worked: 6P - 6A; reason for interview: Complaint revealed was going about 7 - 7:30 PM CNA C told CNA A that Resident #1 called somebody and told them the call light was on for one hour. CNA A went to Resident #1's room and said that she was just in the room to check everything, and the call light was not on for an hour. CNA A asked Resident #1 when calls were made why not tell them the . (the rest of the sentence was covered up with a correction product) . then Resident #1 (a caret symbol pointed up at the covered section above) cursed her out and called her stupid. CNA A said she got upset because she got called stupid and that she was not doing this tonight and told the nurse she was going home. Record review of an interview worksheet dated 08/15/23, signed by HR reflected the staff name: CNA C; shift worked: 6P - 6A; reason for interview: Complaint revealed Resident #2 came out saying light was on for one hour. CNA C found CNA A. CNA A went to [Resident #1] room. Moments later CNA C heard cursing and arguing. CNA A came out saying she was quitting because Resident #1 called her stupid. Record review of an interview worksheet dated 08/15/23 (over an area covered up with a correction product), signed by HR reflected the staff name: CNA D; shift worked: 08/13/23; reason for interview: Complaint revealed Didn't see anything. DON told [CNA D] to go help CNA A. Heard cursing and fussing at nurses' station by the time she got here. Went to help Resident #1, was on the toilet, and on the phone with her [family member]. [Family member told her to call police. CNA D asked Resident #1 why were wipes everywhere and Resident #1 said that CNA A threw them at her. During an interview on 08/16/23 at 11:08 AM, the DON stated that she worked at the SNF for less than six months. The DON said that her role and responsibility was protective oversight of residents. The DON said that on Sunday (08/13/23) she received two phone calls back-to-back from Resident #1, then a text that said . call me back or I will call 911. The DON said that she replied by text, give me ten minutes. The DON stated that she called Resident #1 back in seven minutes, at 7:39 PM (Sunday 08/13/23). The DON said that Resident #1 stated CNA A not only verbally, but physically abused her. The DON said that what she understood was that there was a disagreement about how long Resident #1 been on toilet . CNA A confronted Resident #1 about how much time elapsed since the call light was turned on, CNA A called Resident #1 a liar, and CNA A threw a pack of wipes at Resident #1 stomach after she [CNA A] became upset. Resident #1 had also reported that Resident #2 spoke up for Resident #1 and CNA A cursed at Resident #2. The DON said that she called the facility and spoke with and interviewed the nurses on shift, enquired if CNA A was present, and was told CNA A left the facility. LVN B identified self as the assigned nurse for Resident #1. The DON asked LVN B to assess Resident #1 and get statements from both Resident #1 and Resident #2. The DON said that she called back to ensure it was completed, that incident reports were completed, MD/NP, and family were notified. The DON said that LVN B informed that Resident #1 had already called police. The DON said that she followed up and interviewed Resident #1 the next day (Monday, 08/24/23) and started an ANE in-service with all staff. The DON said that she never observed or was told that CNA A exhibited inappropriate behaviors toward Resident #1 or other residents. The DON said that she was told that Resident #1 was rude and vulgar to staff and often made staff feel uncomfortable when assisted with wiping Resident #1 after a BM. The DON said that she oversaw that an adaptive device to clean self after a BM was provided and therapy trained Resident #1 to use the appliance; staff were educated and would encourage Resident #1 to use within limits and staff would assist as needed. The DON said she expected staff to be always courteous to residents, even if a resident was rude; staff should always speak to and care for residents with dignity and respect. HR was not available for an interview before Investigator exited on 08/16/23. During a phone interview on 08/16/23 at 1:50 PM, CNA A indicated that she worked at the SNF in the past and was re-hired nine months ago. CNA A stated she worked as a full-time employee until she left on 08/13/23. CNA A said that she received training on ANE during the new hire orientation and participated in ANE in-services. CNA A defined Abuse as afflicting injury or harm to someone - physical or verbal. CNA A defined Neglect as failure to give care to a resident. CNA A indicated before the incident, there was an appropriate staff/resident interaction with Resident #1. CNA A said that she worked with Resident #1 on Saturday, 08/12/23 and Sunday, 08/13/23. CNA A said that she was scheduled 6P to 6A on Sunday, 08/13/23. CNA A said that as she entered another resident's room to provide care (four rooms down from Resident #1's room), another CNA told her that Resident #1 waited for an hour for someone to answer call light. CNA A said that she vented out loud that there were no call lights on and went to Resident #1's room. CNA A said she stood in the doorway of the bathroom and told Resident #1 that the call light was not on for an hour. CNA A said that Resident #1 started cursing and CNA A told her to tell the truth and stop trying to get people in trouble . say exactly the way it is. CNA A said that she tried to be calm when Resident #1 called her stupid. CNA A said that she told Resident #1 . cannot take care of you and be stupid . I'm not doing this today . not in the mood for this today . CNA A said she was holding a pack of wipes to assist Resident #1 and threw them on the box next to the toilet and left out the room. CNA A said that she felt like she was not in the right frame of mind after the altercation. CNA A did not confirm or deny that she raised her middle finger (as an obscene hand gesture) at Resident #1 and Resident #2 or said F--- (a four-letter swear word) you to Resident #1. CNA A said she told CNA C as she walked down the hallway and the nurse at the nurses' station that she was going home and left the facility. CNA A said when she got home, she texted the Scheduler I quit. CNA A said that she was upset and felt that she did not deserve for Resident #1 to call her stupid and speak to her in that manner. During an interview with sampled residents on 08/16/23 between 3:00 PM and 4:00 PM resided on the same hall as Resident #1 denied staff had negative behaviors, any threatening interactions with administration or personnel, or voiced concerns about QOC/QOL. During an interview, the sample residents confirmed that they felt safe, were treated with dignity, and their rights respected. Interview with residents indicated no concerns with staff responsiveness to their care needs. During a phone interview on 08/17/2023 at 3:14 PM, LVN B stated that she worked as an agency nurse on 08/13/23. LVN B said that she was coming out of a room on the 600 Hall when CNA A passed by her, shouting, and appeared very upset. LVN B said that she did not know what was going on and could not understand what CNA A was yelling. LVN B said that when she returned to the nurses' station, Resident #2 approached and stated she wanted to report the behavior of CNA A toward her [Resident #2] and Resident #1. LVN B said that Resident #2 reported that CNA A yelled and cursed at Resident #1 and Resident #2. LVN B said that Resident #2 stated that CNA A threw a pack of wipes at Resident #1, raised her middle finger, and told Resident #1 F--- you. LVN B said that she immediately went to check on Resident #1, performed an assessment, visually inspected the area Resident #1 said she was hit with the wipes - did not observe any discoloration or any sign of injury, and Resident #1 denied pain at the area. LVN B said that she received a call from the DON who instructed to complete an incident report. LVN B said the police came later and took a statement from Resident #1. CNA C was not available for interview before Investigator exit on 08/16/23. CNA C signature was not noted on the ANE in-service sign in sheet when reviewed by Investigator on 08/16/23. Record review of the facility's Abuse, Neglect, Exploitation, or Mistreatment policy revised 10/01/2020, reflected in part, the following: POLICY: 1. The facility's leadership prohibits neglect, mental, physical and/or verbal abuse . 2. The facility ensures that alleged violations involving abuse, neglect, exploitation or mistreatment . are reported immediately DEFINITIONS by CMS section 483.5 1. Abuse is the willful infliction of injury . 5. Mistreatment means inappropriate treatment of a resident 6. Neglect is the failure of the facility . to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. PROCEDURES: Facility Leadership General Procedures: 1. Report immediately . not later than 24 hours if the events that cause the allegation do not result in bodily injury . 2. Conduct a prompt investigation of any allegation of suspected abuse, neglect or exploitation or mistreatment and implement immediate action to safeguard resident. Component I: Screening 1. Pre-employment background screening is mandated for all facility employees Component II: Training 1. All employees and volunteers receive ongoing abuse prohibition education . III: Prevention 1. Abuse Prohibition Handout 2. Abuse Prohibition poster 3. The In-Touch with Compliance Hot Line 4. Adequate supervision of staff is maintained to identify and prevent inappropriate behaviors, such as: A. The use of derogatory/harassing language B. Rough handling C. Ignoring the patients/resident's needs requests 5. Ongoing assessment, care planning, and monitoring of those patients/residents with special needs that may lead to neglect . Component IV: Identification 1. Assess suspected or alleged reports of abuse or neglect . Component V: Reporting/Response 1. Immediately and verbally report all alleged violations concerning abuse, neglect, or misappropriation of property to the Facility Abuse Coordinator . Component VI: Investigation Component VII: Protection During the investigation, the facility protects the patient/resident, as appropriate . Record review of CNA A's employee records indicated hire date 11/10/22. A background check was completed 11/04/22. An EMR/NAR was last checked on 04/05/23. Review of CNA A's personnel file did not identify any other allegations nor concerns. CNA A did not have any related disciplinary actions or warnings in their file.

Based on observation, interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 2 of 5 residents (Residents #1 and Resident #2) reviewed for quality of care. The facility failed to ensure that residents receive treatment and care in accordance with the comprehensive person-centered care plan, and the residents' choices when needing help due to call light malfunction. An Immediate Jeopardy (IJ) was identified on 06/16/23. While the IJ was removed on 06/16/23, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm and a scope of isolated due to the facility still monitoring the effectiveness of their Plan of Removal. This failure could place the residents at risk of injury and not being able to obtain assistance or care as needed. Findings include: Record review of Resident #1's electronic Face Sheet, dated 05/31/23, revealed a [AGE] year-old male admitted to the facility on [DATE]. Resident #1 had diagnoses which included the following: epilepsy (a disorder of the brain characterized by repeated seizures), transient cerebral ischemic attack (a stroke that lasts only a few minutes), lack of coordination, systemic lupus erythematosus (autoimmune disease in which the immune system attacks its own tissues), muscle weakness, schizophrenia, diabetes mellitus, hemiplegia (a one-sided muscle paralysis or weakness), hypertension (high blood pressure), multiple sclerosis (a potentially disabling disease of the brain and spinal cord), and difficulty walking. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS score of 15, which indicated Resident #1's cognition was intact. The MDS revealed Resident #1 had seizure disorder or epilepsy and required one person assistance for the following ADLs: transferring, locomotion on/off unit, dressing, toilet use, and personal hygiene. Further review of the MDS revealed Resident #1 was occasionally incontinent of urine, and frequently incontinent of bowel and needed assistance for toileting hygiene. Record review of Resident #1's care plan, last revised on 04/03/23, revealed Resident #1 was at risk for falling due to weakness, and diagnosis of multiple sclerosis, stroke, and lupus. The interventions included Assist resident with all transfers and encourage resident to call for assistance and not to attempt to transfer self.; Keep call light in reach at all times.; and Provide toileting assistance as needed. The care plan revealed Resident #1 had seizures due to diagnosis of epilepsy. The interventions included Monitor resident for impending seizure symptoms and respond quickly when noted; Changes in consciousness, fixed staring, jerking of arms and legs; Monitor seizure drug level lab boluses as ordered by MD; and Protect resident from injury during a seizure. Use pillows to pad body if in bed, safely lower to the ground to prevent falls if upright, use tongue blade to protect tongue biting. Further review revealed, Resident #1 required ADL assistance with toileting and intervention included one person was to assist. Record review of Resident #1's electronic clinical record revealed a progress note by LVN B, dated 05/01/23 at 7:08 PM which reflected This nurse was called to resident restroom thinking she might be having a stroke, assessed resident noted facial and mouth drooping to left. Resident A&O (alert & oriented), V/s (vitals) obtain b/p (blood pressure) 113/74, p (pulse)76, r (respiration)19, t (temperature) 97.0. Assisted resident back to bed, and notified [physician], order received to transfer to ER (emergency room ). 911 was called to the facility and resident was send to [hospital] for further [NAME] (evaluation);/TX (treatment). RP (representative) notified [RP] unable to reach as this time. LVM (leave voicemail). Record review of Resident #1's hospital records, dated 05/01/23, revealed Per EMS, they state they were called by nursing home staff for a stroke the pt (patient) began experiencing approximately 40 minutes pta (Patient Transport Ambulance). On EMS arrival, they noted the pt was experiencing a questionable, focal seizure localized to the facial region with L-sided (left) gaze deviation. The record revealed labs were conducted and diagnosis revealed Resident #1 was ruled out for a stroke. The record revealed resident was discharged and diagnosis included recurrent seizure. In an interview on 05/31/23 at 12:14 PM, Resident #1 stated the call light in her room was fixed yesterday (05/30/23) but prior to yesterday, the call light was not working for about 2-3 weeks. She stated the facility had provided a bell, but staff were not responding when she pressed the bell, and they would tell her they could not hear it ringing. Resident #1 stated she had to use her cell phone to call to the nurse's station to get help. She stated sometimes they would not answer the phones. Resident #1 stated on 05/01/23 she was in the bathroom and thought she was having a stroke. Resident #1 stated she had a stroke before and she also had epilepsy, so she was accustomed to reoccurring seizures. Resident #1 stated on 05/01/23 it felt more like a stroke because she could not feel the left side of her face and body, which did not normally happen when she had seizures. Resident #1 stated she was in the bathroom yelling for help and no one came until 30-45 minutes. She stated the call light in the bathroom was not working and the facility had not provided accommodations for emergencies in the bathroom. Resident #1 stated once the nurse arrived, they assessed her, and she was sent to the hospital. She stated at the hospital it was determined she did not have a stroke and it was a seizure. She stated she did not have any injuries from the incident. Resident #1 stated she had spoken to the DON about her concerns with the call light not working, especially in the bathroom. She stated the DON advised her that staff were supposed to be doing rounds every 15 minutes, but she stated that was not being done because she had been in the bathroom for almost 45 minutes. Record review of Resident #2's electronic Face Sheet, dated 05/31/23, revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #2 had diagnoses which included the following: paraplegia (the inability to voluntarily move the lower parts of the body), heart disease, muscle weakness, lack of coordination and muscle wasting atrophy (the decrease in size and wasting of muscle tissue). Record review of Resident #2's Quarterly MDS, dated [DATE], revealed a BIMS score of 15, which indicated Resident #2's cognition was intact. In an interview on 05/31/23 at 12:35 PM, Resident #2 stated she heard Resident #1 in the bathroom screaming. She said it sounded like she was saying help, but her voice did not sound normal. Resident #2 stated she knew something was wrong. She stated the call lights were not working and they gave her a bell, but it was not in reach. Resident #2 stated it did not matter about the bell anyway, because staff never heard them. Resident #2 stated she used her cell phone to call to the nurse's station. She stated when they answered (she does not know who) she told them something was wrong with Resident #1, and she needed help in the bathroom. Resident #2 stated they told her they would come help. She stated about 30 minutes had passed and no one came to help, so she attempted to call the nurse's station again, but no one answered. Resident #2 stated as time was passing Resident #1's speech was becoming clearer, and she heard her screaming she was having a stroke. Resident #2 stated she was a paraplegic, so she could not get out of bed to find help. Resident #2 stated she called the nurse's station a third time. She stated someone answered the phone (does not know who) and she told them she believed Resident #1 was having a stroke. She said a nurse (does not know name) came about 5 minutes after the third call. Resident #2 stated she believed Resident #1 was in the bathroom for about 45 minutes before the nurse came to the room. In an interview on 05/31/23 at 1:27 PM, the facility's Maintenance Director (MD) stated he started at the facility about 2 weeks ago and there was already an issue with the call light system. He stated there was a bad storm, and the lightning struck the building, which caused the call light system to malfunction. He stated from his understanding a tech company came out and had ordered the equipment to fix the system. He stated he was not sure exactly what date because this was done prior to him working at the facility. He stated the equipment took several weeks to come in and the company returned he believed on 05/19/23 and they replaced the malfunctioned equipment. He stated the system went out again and the company came back out and then realized there was an issue with the call light system at the nurse's station, so they had to order more equipment to fix that. He stated the company returned yesterday (05/30/23) with equipment for the nurse's station and everything was working. He stated later yesterday evening, they found out that some of the call lights were still not working. The MD stated the tech company was currently in the building and they were conducting an audit on which rooms were not working. He stated its difficult to account for which rooms are working because one minute they are working and the next they are not. In an interview on 05/31/23 at 2:15 PM, the Administrator stated the call light system first went out on 04/06/23. She stated the MD at that time was trying to fix the system and realized he was unable to, so they called a tech company to come help. She stated the tech company came on 04/11/23 and discovered equipment was burned due to the lightening and they had to order new equipment. The Administrator stated equipment did not come in until 05/16/23. She stated they provided bells to the residents and staff were doing round every 15 minutes. She stated there were no bells provided for the bathroom and that is why staff were doing rounds every 15 minutes. She stated the tech company replaced the equipment and call lights were working. She stated on 05/24/23 it was discovered the call light were no longer working and they called the tech company back out. The Administrator stated the facility went back to using bells and doing rounds every 15 minutes. She stated the tech company explained the equipment at the nurse's station was burned out and had to be replaced. She stated they ordered more parts, and they returned yesterday (05/30/23) to install the new equipment. The Administrator stated yesterday the call lights were working after the tech left, and then later in the evening they learned they were out again in some rooms. She stated the tech was currently in the building working on the call lights. She stated she was aware of the incident with Resident #1 on 05/01/23. The Administrator stated staff were expected to complete rounds every 15 minutes, so staff were in-serviced on making sure they are doing rounds every 15 minutes, after this incident occurred. In an interview on 06/01/23 at 9:30 AM, LVN B stated on 05/01/23 she was at the nurse's station charting and Resident #2 called and stated Resident #1 was in the bathroom, and she believed she was having a stroke. LVN B stated she immediately went to the room. She stated she assessed the resident for injuries and took her vitals. She stated there were no injuries and her vitals were stable, but Resident #1's face was droopy she believed on the left side. She stated she notified the DON, family, and doctor. LVN B stated she received orders from the doctor to send Resident #1 to hospital, so she called 911. LVN B stated she only spoke to Resident #2 twice and she immediately went to the resident's room. She stated the call lights system were not working and residents were provided bells to notify for help. LVN B stated CNAs were doing rounds every 15 minutes. She stated she did not know how long Resident #1 was in the bathroom nor the last time a CNA had checked on her. An observation and interview on 05/31/23 at 2:43 PM revealed as the Investigator approached Resident #1's room, Resident #1 was screaming from the bathroom I need help. MA A was observed standing behind the medication cart in front of the room next to Resident # 1's room. Resident #2 was observed lying in bed. Resident #2 stated she had been in the bathroom screaming for help for about 30 minutes. Resident #2 stated the call light was working earlier this morning, but she believed it had gone out again. Resident #1 was asked, while she was in the bathroom, if she pressed the call light and she stated yes but she believed it was not working again. The Investigator went into the hall and advised MA A that Resident #1 was in the bathroom screaming for help. MA A stated she would get a CNA to help. MA A was observed to continue to stand at the medication cart. The investigator went on the adjacent halls to look for help but was unable to find anyone to come help. When the Investigator returned to Resident #1's hall, MA A was observed to be standing in the same spot. When the Investigator asked Resident #2 was anyone in the bathroom with Resident #1, she stated no, and staff had still not come to help. In an interview on 05/31/23 at 3:16 PM, Resident #1 stated she made a bowel movement and needed help wiping herself. She stated she was sometimes incontinent with her bowels and had accidents, but she made it to the toilet this time. Resident #1 stated she was unable to reach her bottom to clean herself after a bowel movement due to some of her medical conditions. She stated she pressed the call light for help, but she believed it stopped working. She stated the facility had fixed it yesterday (05/30/23) and it worked earlier in the morning but must have stopped. She stated she was screaming for help for about 30-40 minutes. In a record review and interview on 06/01/23 at 12:24, the DON, she stated was aware of the incident on 05/01/23 with Resident #1. She stated since the call lights were out, the residents were given bells to call for help and the staff were doing rounds every 15 minutes. She stated Resident #1 and Resident #2 did tell her that Resident #1 was in the bathroom for about 30 minutes and staff had not come in to help. The DON stated she did speak to the nurse, who answered the first phone call made by Resident #2, but she couldn't recall which nurse it was, but the nurse told her she was in the middle of working with another resident and was checking their chart, when Resident #2 called. The DON stated the nurse advised her that when Resident #2 called she said Resident #1 needed help in the bathroom. She stated the nurse said she did not tell her it was emergency and she assumed she needed help with toileting. The DON stated nurse told her there was no one in the halls to ask them to check on Resident #1, so she went to finish up with her current situation and then was going to check on Resident #1. She stated when Resident #2 called the second time and spoke to LVN B and said Resident #1 was having a stroke in the bathroom, LVN B went to the room right away. The DON stated if staff would have been completing rounds every 15 minutes on 05/01/23 this would not have happened. She stated she in-serviced all direct care staff that had to do 15-minute rounds the following day. The DON stated she was made aware of the incident with Resident #1 not receiving help with toileting. She stated her expectations was for all CMAs, CNAs, and nurses to help with toileting and incontinence care. The DON stated she also in-serviced staff to continue with doing rounds every 15 minutes due to issues with call lights. She stated incontinence care was not a job only for CNAs. She stated she answered call lights to provide incontinence care and had wiped resident's bottoms, so her expectation was for all other staff to do the same. The DON provided an in-service titled Incontinence Care dated 05/31/23 and stated she started in-servicing yesterday (05/31/23) by going to each direct care staff personally and explaining her expectations regarding incontinence care. She stated she was still meeting individually with staff who did not work yesterday. In an interview on 06/16/23 at 12:28 PM, CNA C stated she was covering Resident #1's hall the day she was sent out to the hospital. She stated did not know exactly what happened to Resident #1, but what she recalled was her coming out of another resident's room and saw the paramedics taking Resident #1 out on a stretcher. CNA C stated she was giving showers to the residents during the time of the incident. She stated the call light system was not working so residents were given bells and they were doing 15-minute rounds. CNA C stated showers took longer than 15 minutes, so she let the nurse know when she was giving showers, so they could do the rounds. She stated even though showers take longer than 15 minutes, she would still complete rounds. CNA C stated once she is done with a resident's shower, she would do a round and then get started on the next shower. In an interview on 06/16/23 at 11:18 PM, the DON stated Resident #1 was alert and oriented, so she advised her to take her phone with her to the bathroom and provided her personal cell phone number to call if she needed help and was unable to get anyone. She stated the 15-minute rounds meant the CNAs were going up and down the hall listening for bells or anyone calling for help. She stated it did not mean they were going to each resident rooms because they were not able to complete that. She stated staff who were assigned to the hall could have been helping a resident, which could take over 15 minutes. The DON stated the expectation was once staff were finished with the resident if it took over 15 minutes, they should do rounds before moving on to the next task. The DON stated their corporate approved 1 additional staff per shift to help with the rounds. She stated the corporate would not approve any additional people, due to budget constraints. The DON stated staff were documenting the rounds and she was responsible for monitoring. She stated she checked the sheets three times per week. A record review of the facility document titled Q 15- Minute Checks- 600 (hall) PM Shift, dated 05/01/23, revealed from the timeframes of 6:00 PM to 4:45 AM, 15-minute checks were completed and checked off. The document did not have a staff signature on it, just a check mark. A record review of the facility's policy titled Statement of Resident Rights, undated, revealed You, the resident, do not give up any rights when you enter a nursing facility. The Facility must encourage and assist you to fully exercise your rights . You have a right to: 1. All care necessary for you to have the highest possible level of health; 2. Safe, decent, and clean conditions; 4. Be treated with courtesy, consideration, and respect . A record review of the facility policy titled Emergency Disaster and Life Safety Policies and Procedures, dated 02/01/20, revealed 4. Nursing personnel: D. Will establish and maintain a medical communication system to all areas not equipped with patent/resident call lights. This may include but is not limited to: 1. Use of bells or other devices 2. Runners to convey information 3. Periodic or routine rounds . This failure resulted in an identification of an Immediate Jeopardy on 06/16/2023 at 4:45 PM. The Administrator was informed and provided the IJ template on 06/16/2023 at 4:49 PM and a Plan of Removal (POR) was requested. The Plan of Removal reflected: F558 - Reasonable accommodations of needs/preferences Resident identified with no negative outcomes Call light system failure identified on 4/6/23. Diversify notified immediately for request a quote for repair of the call light system Repair quote for call light system repair from Diversify received on 4/11/23 Diversify returned on 5/24/23 after receiving the needed part for repair of the call light system. Once there, Diversify identified a more complex issue and were required to involve additional technicians and additional electrical repair 6/2/23 Diversify returned to continue repairs 6/9/23 Diversify returned and were able to partially repair the call light system 6/12/23 Diversify returned and completely repaired the call light system Residents who reside in the facility have the potential to be affected by this alleged deficient practice. In the event of call light system failure 15-minute checks will be initiated to monitor residents for needs and will continue until the call light system has been repaired. A monitoring tool will be used to document the 15-minute checks and will be used until call light system is repaired In the event the call light system fails affected residents will be provided bells. In the event of call light system failure, a resident council meeting will be held to inform residents of plan for alerting staff for assistance and the plan for the repair of the call light system In the event of call light system failure, the administrator will contact companies to obtain quotes for repairs of the call light system Facility employees will be educated on the plan that was initiated: Immediate notification to administrator of call light failure residents will have handheld call bells to alert the nursing staff for assistance in the event of call light failure An assignment will be made by the administrator and/or Director of Nursing for 15-minute checks on residents to monitor for residents needs in the event of call light failure Any employee not receiving this education by 6/16/23 will receive before their next scheduled shift. This will include any agency personnel and new hire orientation. Maintenance Director will perform weekly preventive maintenance to validate the call light system is functioning properly for 4 weeks, then monthly. Regional Maintenance Director will validate monthly preventive maintenance completed. Director of Nursing and Administrator will make rounds throughout the day to validate that the call light system is functioning properly, and resident needs are being met. In the event of call light system failure, Clinical Consultant will validate 15-minute checks completed weekly. Any concerns will be addressed at time of discovery. The medical director was informed of the Immediate Jeopardy and the contents of this plan on 6/16/23. An ad hoc Quality Assurance Performance Improvement meeting will be held on 6/16/23. The Plan of Removal was accepted on 06/16/23 at 6:12 PM. Monitoring of the plan of removal included: Observations and interviews were conducted on 06/16/23 from 1:45 PM to 3:05 PM on various rooms and revealed Rooms 401, 405, 406, 408, 413, 418, 419, 503, 506, 510, 511, 517, 518, 521, 522, 603, 604, and 608 call lights were working. Interviews with the residents of these rooms revealed the call lights had been working for approximately one week and staff were responding. Interviews with the 2 RNs, 1 LVN, 2 CMAs, 5 CNAs, who worked multiple shifts, revealed the call lights had been working for approximately one week and they knew the protocols should the call lights go out, which included residents would be provided bells and they were required to complete 15-minutes rounds. A record review on 06/16/23 of a memo from the tech company who fixed the call light system, dated 06/16/23, reflected the following To Whom It May Concern: As of June 12, 2023, our technicians have completed work to make sure that all devices on 400, 500, and 600 halls are operating for nurse call emergency calls for the rooms. By Friday, June 9 we were able to have most of the rooms up with the exceptions of a few devices needed to be ordered. In an observation and interview on 06/16/23 at 6:17 PM, the DON was observed providing in-services on expectations (report to DON/Administrator, bells, 15-minute checks) should call light system go out to 3 nurses and 4 CNAs. The DON stated she would continue to in-service the night and weekend staff. She stated all staff would be required to complete in-service, prior to starting their shift. The DON stated she would be responsible for doing rounds to ensure the call light system was working and were being answered. The Administrator were informed the Immediate Jeopardy was removed on 06/16/23 at 6:20 PM. The facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm and a scope of isolated, due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review, the facility failed to be adequately equipped to allow resident to call for assistance for 2 of 5 residents (Residents #1 and Resident #2) reviewed for accommodation of needs. The facility failed to be adequately equipped to allow residents to call for staff assistance when needing help due to call light malfunction. An Immediate Jeopardy (IJ) was identified on 06/16/23. While the IJ was removed on 06/16/23, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm and a scope of isolated due to the facility still monitoring the effectiveness of their Plan of Removal. This failure could place the residents at risk of injury and not being able to obtain assistance or care as needed. Findings include: Record review of Resident #1's electronic Face Sheet, dated 05/31/23, revealed a [AGE] year-old male admitted to the facility on [DATE]. Resident #1 had diagnoses which included the following: epilepsy (a disorder of the brain characterized by repeated seizures), transient cerebral ischemic attack (a stroke that lasts only a few minutes), lack of coordination, systemic lupus erythematosus (autoimmune disease in which the immune system attacks its own tissues), muscle weakness, schizophrenia, diabetes mellitus, hemiplegia (a one-sided muscle paralysis or weakness), hypertension (high blood pressure), multiple sclerosis (a potentially disabling disease of the brain and spinal cord), and difficulty walking. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS score of 15, which indicated Resident #1's cognition was intact. The MDS revealed Resident #1 had seizure disorder or epilepsy and required one person assistance for the following ADLs: transferring, locomotion on/off unit, dressing, toilet use, and personal hygiene. Further review of the MDS revealed Resident #1 was occasionally incontinent of urine, and frequently incontinent of bowel and needed assistance for toileting hygiene. Record review of Resident #1's care plan, last revised on 04/03/23, revealed Resident #1 was at risk for falling due to weakness, and diagnosis of multiple sclerosis, stroke, and lupus. The interventions included Assist resident with all transfers and encourage resident to call for assistance and not to attempt to transfer self.; Keep call light in reach at all times.; and Provide toileting assistance as needed. The care plan revealed Resident #1 had seizures due to diagnosis of epilepsy. The interventions included Monitor resident for impending seizure symptoms and respond quickly when noted; Changes in consciousness, fixed staring, jerking of arms and legs; Monitor seizure drug level lab boluses as ordered by MD; and Protect resident from injury during a seizure. Use pillows to pad body if in bed, safely lower to the ground to prevent falls if upright, use tongue blade to protect tongue biting. Further review revealed, Resident #1 required ADL assistance with toileting and intervention included one person was to assist. Record review of Resident #1's electronic clinical record revealed a progress note by LVN B, dated 05/01/23 at 7:08 PM which reflected This nurse was called to resident restroom thinking she might be having a stroke, assessed resident noted facial and mouth drooping to left. Resident A&O (alert & oriented), V/s (vitals) obtain b/p (blood pressure) 113/74, p (pulse)76, r (respiration)19, t (temperature) 97.0. Assisted resident back to bed, and notified [physician], order received to transfer to ER (emergency room ). 911 was called to the facility and resident was send to [hospital] for further [NAME] (evaluation);/TX (treatment). RP (representative) notified [RP] unable to reach as this time. LVM (leave voicemail). Record review of Resident #1's hospital records, dated 05/01/23, revealed Per EMS, they state they were called by nursing home staff for a stroke the pt (patient) began experiencing approximately 40 minutes pta (Patient Transport Ambulance). On EMS arrival, they noted the pt was experiencing a questionable, focal seizure localized to the facial region with L-sided (left) gaze deviation. The record revealed labs were conducted and diagnosis revealed Resident #1 was ruled out for a stroke. The record revealed resident was discharged and diagnosis included recurrent seizure. In an interview on 05/31/23 at 12:14 PM, Resident #1 stated the call light in her room was fixed yesterday (05/30/23) but prior to yesterday, the call light was not working for about 2-3 weeks. She stated the facility had provided a bell, but staff were not responding when she pressed the bell, and they would tell her they could not hear it ringing. Resident #1 stated she had to use her cell phone to call to the nurse's station to get help. She stated sometimes they would not answer the phones. Resident #1 stated on 05/01/23 she was in the bathroom and thought she was having a stroke. Resident #1 stated she had a stroke before and she also had epilepsy, so she was accustomed to reoccurring seizures. Resident #1 stated on 05/01/23 it felt more like a stroke because she could not feel the left side of her face and body, which did not normally happen when she had seizures. Resident #1 stated she was in the bathroom yelling for help and no one came until 30-45 minutes. She stated the call light in the bathroom was not working and the facility had not provided accommodations for emergencies in the bathroom. Resident #1 stated once the nurse arrived, they assessed her, and she was sent to the hospital. She stated at the hospital it was determined she did not have a stroke and it was a seizure. She stated she did not have any injuries from the incident. Resident #1 stated she had spoken to the DON about her concerns with the call light not working, especially in the bathroom. She stated the DON advised her that staff were supposed to be doing rounds every 15 minutes, but she stated that was not being done because she had been in the bathroom for almost 45 minutes. Record review of Resident #2's electronic Face Sheet, dated 05/31/23, revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #2 had diagnoses which included the following: paraplegia (the inability to voluntarily move the lower parts of the body), heart disease, muscle weakness, lack of coordination and muscle wasting atrophy (the decrease in size and wasting of muscle tissue). Record review of Resident #2's Quarterly MDS, dated [DATE], revealed a BIMS score of 15, which indicated Resident #2's cognition was intact. In an interview on 05/31/23 at 12:35 PM, Resident #2 stated she heard Resident #1 in the bathroom screaming. She said it sounded like she was saying help, but her voice did not sound normal. Resident #2 stated she knew something was wrong. She stated the call lights were not working and they gave her a bell, but it was not in reach. Resident #2 stated it did not matter about the bell anyway, because staff never heard them. Resident #2 stated she used her cell phone to call to the nurse's station. She stated when they answered (she does not know who) she told them something was wrong with Resident #1, and she needed help in the bathroom. Resident #2 stated they told her they would come help. She stated about 30 minutes had passed and no one came to help, so she attempted to call the nurse's station again, but no one answered. Resident #2 stated as time was passing Resident #1's speech was becoming clearer, and she heard her screaming she was having a stroke. Resident #2 stated she was a paraplegic, so she could not get out of bed to find help. Resident #2 stated she called the nurse's station a third time. She stated someone answered the phone (does not know who) and she told them she believed Resident #1 was having a stroke. She said a nurse (does not know name) came about 5 minutes after the third call. Resident #2 stated she believed Resident #1 was in the bathroom for about 45 minutes before the nurse came to the room. In an interview on 05/31/23 at 1:27 PM, the facility's Maintenance Director (MD) stated he started at the facility about 2 weeks ago and there was already an issue with the call light system. He stated there was a bad storm, and the lightning struck the building, which caused the call light system to malfunction. He stated from his understanding a tech company came out and had ordered the equipment to fix the system. He stated he was not sure exactly what date because this was done prior to him working at the facility. He stated the equipment took several weeks to come in and the company returned he believed on 05/19/23 and they replaced the malfunctioned equipment. He stated the system went out again and the company came back out and then realized there was an issue with the call light system at the nurse's station, so they had to order more equipment to fix that. He stated the company returned yesterday (05/30/23) with equipment for the nurse's station and everything was working. He stated later yesterday evening, they found out that some of the call lights were still not working. The MD stated the tech company was currently in the building and they were conducting an audit on which rooms were not working. He stated its difficult to account for which rooms are working because one minute they are working and the next they are not. In an interview on 05/31/23 at 2:15 PM, the Administrator stated the call light system first went out on 04/06/23. She stated the MD at that time was trying to fix the system and realized he was unable to, so they called a tech company to come help. She stated the tech company came on 04/11/23 and discovered equipment was burned due to the lightening and they had to order new equipment. The Administrator stated equipment did not come in until 05/16/23. She stated they provided bells to the residents and staff were doing round every 15 minutes. She stated there were no bells provided for the bathroom and that is why staff were doing rounds every 15 minutes. She stated the tech company replaced the equipment and call lights were working. She stated on 05/24/23 it was discovered the call light were no longer working and they called the tech company back out. The Administrator stated the facility went back to using bells and doing rounds every 15 minutes. She stated the tech company explained the equipment at the nurse's station was burned out and had to be replaced. She stated they ordered more parts, and they returned yesterday (05/30/23) to install the new equipment. The Administrator stated yesterday the call lights were working after the tech left, and then later in the evening they learned they were out again in some rooms. She stated the tech was currently in the building working on the call lights. She stated she was aware of the incident with Resident #1 on 05/01/23. The Administrator stated staff were expected to complete rounds every 15 minutes, so staff were in-serviced on making sure they are doing rounds every 15 minutes, after this incident occurred. In an interview on 06/01/23 at 9:30 AM, LVN B stated on 05/01/23 she was at the nurse's station charting and Resident #2 called and stated Resident #1 was in the bathroom, and she believed she was having a stroke. LVN B stated she immediately went to the room. She stated she assessed the resident for injuries and took her vitals. She stated there were no injuries and her vitals were stable, but Resident #1's face was droopy she believed on the left side. She stated she notified the DON, family, and doctor. LVN B stated she received orders from the doctor to send Resident #1 to hospital, so she called 911. LVN B stated she only spoke to Resident #2 twice and she immediately went to the resident's room. She stated the call lights system were not working and residents were provided bells to notify for help. LVN B stated CNAs were doing rounds every 15 minutes. She stated she did not know how long Resident #1 was in the bathroom nor the last time a CNA had checked on her. An observation and interview on 05/31/23 at 2:43 PM revealed as the Investigator approached Resident #1's room, Resident #1 was screaming from the bathroom I need help. MA A was observed standing behind the medication cart in front of the room next to Resident # 1's room. Resident #2 was observed lying in bed. Resident #2 stated she had been in the bathroom screaming for help for about 30 minutes. Resident #2 stated the call light was working earlier this morning, but she believed it had gone out again. Resident #1 was asked, while she was in the bathroom, if she pressed the call light and she stated yes but she believed it was not working again. The Investigator went into the hall and advised MA A that Resident #1 was in the bathroom screaming for help. MA A stated she would get a CNA to help. MA A was observed to continue to stand at the medication cart. The investigator went on the adjacent halls to look for help but was unable to find anyone to come help. When the Investigator returned to Resident #1's hall, MA A was observed to be standing in the same spot. When the Investigator asked Resident #2 was anyone in the bathroom with Resident #1, she stated no, and staff had still not come to help. In an interview on 05/31/23 at 3:16 PM, Resident #1 stated she made a bowel movement and needed help wiping herself. She stated she was sometimes incontinent with her bowels and had accidents, but she made it to the toilet this time. Resident #1 stated she was unable to reach her bottom to clean herself after a bowel movement due to some of her medical conditions. She stated she pressed the call light for help, but she believed it stopped working. She stated the facility had fixed it yesterday (05/30/23) and it worked earlier in the morning but must have stopped. She stated she was screaming for help for about 30-40 minutes. In a record review and interview on 06/01/23 at 12:24, the DON, she stated was aware of the incident on 05/01/23 with Resident #1. She stated since the call lights were out, the residents were given bells to call for help and the staff were doing rounds every 15 minutes. She stated Resident #1 and Resident #2 did tell her that Resident #1 was in the bathroom for about 30 minutes and staff had not come in to help. The DON stated she did speak to the nurse, who answered the first phone call made by Resident #2, but she couldn't recall which nurse it was, but the nurse told her she was in the middle of working with another resident and was checking their chart, when Resident #2 called. The DON stated the nurse advised her that when Resident #2 called she said Resident #1 needed help in the bathroom. She stated the nurse said she did not tell her it was emergency and she assumed she needed help with toileting. The DON stated nurse told her there was no one in the halls to ask them to check on Resident #1, so she went to finish up with her current situation and then was going to check on Resident #1. She stated when Resident #2 called the second time and spoke to LVN B and said Resident #1 was having a stroke in the bathroom, LVN B went to the room right away. The DON stated if staff would have been completing rounds every 15 minutes on 05/01/23 this would not have happened. She stated she in-serviced all direct care staff that had to do 15-minute rounds the following day. The DON stated she was made aware of the incident with Resident #1 not receiving help with toileting. She stated her expectations was for all CMAs, CNAs, and nurses to help with toileting and incontinence care. The DON stated she also in-serviced staff to continue with doing rounds every 15 minutes due to issues with call lights. She stated incontinence care was not a job only for CNAs. She stated she answered call lights to provide incontinence care and had wiped resident's bottoms, so her expectation was for all other staff to do the same. The DON provided an in-service titled Incontinence Care dated 05/31/23 and stated she started in-servicing yesterday (05/31/23) by going to each direct care staff personally and explaining her expectations regarding incontinence care. She stated she was still meeting individually with staff who did not work yesterday. In an interview on 06/16/23 at 12:28 PM, CNA C stated she was covering Resident #1's hall the day she was sent out to the hospital. She stated did not know exactly what happened to Resident #1, but what she recalled was her coming out of another resident's room and saw the paramedics taking Resident #1 out on a stretcher. CNA C stated she was giving showers to the residents during the time of the incident. She stated the call light system was not working so residents were given bells and they were doing 15-minute rounds. CNA C stated showers took longer than 15 minutes, so she let the nurse know when she was giving showers, so they could do the rounds. She stated even though showers take longer than 15 minutes, she would still complete rounds. CNA C stated once she is done with a resident's shower, she would do a round and then get started on the next shower. In an interview on 06/16/23 at 11:18 PM, the DON stated Resident #1 was alert and oriented, so she advised her to take her phone with her to the bathroom and provided her personal cell phone number to call if she needed help and was unable to get anyone. She stated the 15-minute rounds meant the CNAs were going up and down the hall listening for bells or anyone calling for help. She stated it did not mean they were going to each resident rooms because they were not able to complete that. She stated staff who were assigned to the hall could have been helping a resident, which could take over 15 minutes. The DON stated the expectation was once staff were finished with the resident if it took over 15 minutes, they should do rounds before moving on to the next task. The DON stated their corporate approved 1 additional staff per shift to help with the rounds. She stated the corporate would not approve any additional people, due to budget constraints. The DON stated staff were documenting the rounds and she was responsible for monitoring. She stated she checked the sheets three times per week. A record review of the facility document titled Q 15- Minute Checks- 600 (hall) PM Shift, dated 05/01/23, revealed from the timeframes of 6:00 PM to 4:45 AM, 15-minute checks were completed and checked off. The document did not have a staff signature on it, just a check mark. A record review of the facility's policy titled Statement of Resident Rights, undated, revealed You, the resident, do not give up any rights when you enter a nursing facility. The Facility must encourage and assist you to fully exercise your rights . You have a right to: 1. All care necessary for you to have the highest possible level of health; 2. Safe, decent, and clean conditions; 4. Be treated with courtesy, consideration, and respect . A record review of the facility policy titled Emergency Disaster and Life Safety Policies and Procedures, dated 02/01/20, revealed 4. Nursing personnel: D. Will establish and maintain a medical communication system to all areas not equipped with patent/resident call lights. This may include but is not limited to: 1. Use of bells or other devices 2. Runners to convey information 3. Periodic or routine rounds . This failure resulted in an identification of an Immediate Jeopardy on 06/16/2023 at 4:45 PM. The Administrator was informed and provided the IJ template on 06/16/2023 at 4:49 PM and a Plan of Removal (POR) was requested. The Plan of Removal reflected: F558 - Reasonable accommodations of needs/preferences Resident identified with no negative outcomes Call light system failure identified on 4/6/23. Diversify notified immediately for request a quote for repair of the call light system Repair quote for call light system repair from Diversify received on 4/11/23 Diversify returned on 5/24/23 after receiving the needed part for repair of the call light system. Once there, Diversify identified a more complex issue and were required to involve additional technicians and additional electrical repair 6/2/23 Diversify returned to continue repairs 6/9/23 Diversify returned and were able to partially repair the call light system 6/12/23 Diversify returned and completely repaired the call light system Residents who reside in the facility have the potential to be affected by this alleged deficient practice. In the event of call light system failure 15-minute checks will be initiated to monitor residents for needs and will continue until the call light system has been repaired. A monitoring tool will be used to document the 15-minute checks and will be used until call light system is repaired In the event the call light system fails affected residents will be provided bells. In the event of call light system failure, a resident council meeting will be held to inform residents of plan for alerting staff for assistance and the plan for the repair of the call light system In the event of call light system failure, the administrator will contact companies to obtain quotes for repairs of the call light system Facility employees will be educated on the plan that was initiated: Immediate notification to administrator of call light failure residents will have handheld call bells to alert the nursing staff for assistance in the event of call light failure An assignment will be made by the administrator and/or Director of Nursing for 15-minute checks on residents to monitor for residents needs in the event of call light failure Any employee not receiving this education by 6/16/23 will receive before their next scheduled shift. This will include any agency personnel and new hire orientation. Maintenance Director will perform weekly preventive maintenance to validate the call light system is functioning properly for 4 weeks, then monthly. Regional Maintenance Director will validate monthly preventive maintenance completed. Director of Nursing and Administrator will make rounds throughout the day to validate that the call light system is functioning properly, and resident needs are being met. In the event of call light system failure, Clinical Consultant will validate 15-minute checks completed weekly. Any concerns will be addressed at time of discovery. The medical director was informed of the Immediate Jeopardy and the contents of this plan on 6/16/23. An ad hoc Quality Assurance Performance Improvement meeting will be held on 6/16/23. The Plan of Removal was accepted on 06/16/23 at 6:12 PM. Monitoring of the plan of removal included: Observations and interviews were conducted on 06/16/23 from 1:45 PM to 3:05 PM on various rooms and revealed Rooms 401, 405, 406, 408, 413, 418, 419, 503, 506, 510, 511, 517, 518, 521, 522, 603, 604, and 608 call lights were working. Interviews with the residents of these rooms revealed the call lights had been working for approximately one week and staff were responding. Interviews with the 2 RNs, 1 LVN, 2 CMAs, 5 CNAs, who worked multiple shifts, revealed the call lights had been working for approximately one week and they knew the protocols should the call lights go out, which included residents would be provided bells and they were required to complete 15-minutes rounds. A record review on 06/16/23 of a memo from the tech company who fixed the call light system, dated 06/16/23, reflected the following To Whom It May Concern: As of June 12, 2023, our technicians have completed work to make sure that all devices on 400, 500, and 600 halls are operating for nurse call emergency calls for the rooms. By Friday, June 9 we were able to have most of the rooms up with the exceptions of a few devices needed to be ordered. In an observation and interview on 06/16/23 at 6:17 PM, the DON was observed providing in-services on expectations (report to DON/Administrator, bells, 15-minute checks) should call light system go out to 3 nurses and 4 CNAs. The DON stated she would continue to in-service the night and weekend staff. She stated all staff would be required to complete in-service, prior to starting their shift. The DON stated she would be responsible for doing rounds to ensure the call light system was working and were being answered. The Administrator were informed the Immediate Jeopardy was removed on 06/16/23 at 6:20 PM. The facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm and a scope of isolated, due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain grooming, and personal hygiene for 1 of 5 residents (Resident #1) reviewed for ADLs. The facility failed to ensure Resident #1 received help with toileting, even after MA A was notified that Resident #1 needed help. This failure could put residents at risk of poor personal hygiene, impaired skin integrity, and decreased feelings of self-worth and dignity. Findings Include: Record review of Resident #1's electronic Face Sheet, dated 05/31/23, revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #1 had diagnoses which included the following: epilepsy (a disorder of the brain characterized by repeated seizures), transient cerebral ischemic attack (a stroke that lasts only a few minutes), lack of coordination, systemic lupus erythematosus (autoimmune disease in which the immune system attacks its own tissues), muscle weakness, schizophrenia, diabetes mellitus, hemiplegia (a one-sided muscle paralysis or weakness), hypertension, multiple sclerosis (a potentially disabling disease of the brain and spinal cord), and difficulty walking. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS score of 15, which indicated Resident #1's cognition was intact. Further review revealed Resident #1 was occasionally incontinent of urine, and frequently incontinent of bowel and needed partial/moderate assistance for toileting hygiene. Record review of Resident #1's care plan, last revised on 04/03/23, revealed Resident #1 required ADL assistance with toileting and intervention included one person assistance. Further review revealed a problem of bowel/bladder incontinence, and interventions included adult briefs to enhance dignity and skin barrier cream after incontinent episodes. Record review of Resident #2's electronic Face Sheet, dated 05/31/23, revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #2 had diagnoses which included the following: paraplegia (the inability to voluntarily move the lower parts of the body), heart disease, muscle weakness, lack of coordination and muscle wasting atrophy (the decrease in size and wasting of muscle tissue). Record review of Resident #2's Quarterly MDS, dated [DATE], revealed a BIMS score of 15, which indicated Resident #2's cognition was intact. Record review of Resident #2's care plan, last revised 04/17/23, revealed Resident #2 required ADL assistance with toileting and intervention included 2 people were to assist. Further review revealed a problem of bowel/bladder incontinence, and the interventions use to adult briefs to enhance dignity and use skin barrier after incontinent episodes. An observation and interview on 05/31/23 at 2:43 PM, revealed as the State Surveyor approached Resident #1's room, Resident #1 was screaming from the bathroom, I need help. MA A was observed standing behind the medication cart in front of the room next to Resident # 1's room. Resident #2 was observed lying in bed. Resident #2 stated she had been in the bathroom screaming for help for about 30 minutes. Resident #2 stated the call light was working earlier that morning, but she believed it had stopped working again. Resident #1 was asked, while she was in the bathroom, if she pressed the call light and she stated yes but she believed it was not working again. The State Surveyor went into the hall and advised MA A that Resident #1 was in the bathroom screaming for help. MA A stated she would get a CNA to help. MA A was observed to continue standing at the medication cart. The State Surveyor went on the adjacent halls to look for help but was unable to find anyone to come help. When the State Surveyor returned to Resident #1's hall, MA A was observed standing in the same spot. State Surveyor then asked Resident #2 if anyone was in the bathroom with Resident #1, she stated no, and staff had still not come to help. In an interview on 05/31/23 at 3:16 PM, Resident #1 stated she had bowel movement and needed help wiping herself. She stated she was sometimes incontinent of bowel and had accidents but said made it to the toilet this time. Resident #1 stated she was unable to reach her bottom to clean herself after a bowel movement due to some of her medical conditions. She stated she pressed the call light for help, but she believed it stopped working. She stated the facility had fixed it yesterday (05/30/23) and it worked earlier in the morning but must had stopped. She stated she was screaming for help for about 30-40 minutes. In an interview on 06/01/23 at 2:03 PM, MA A stated even though she was in front of the room next to Resident # 1's room, she could not hear her screaming for help. MA A stated she messed up and should have helped Resident #1. She stated she was not in the middle of an emergency when Resident #1 needed help on 05/31/23 but she was running late for work on 05/31/23 and was trying to focus on what medications needed to be passed. She stated she should have stopped to help Resident #1. MA A stated she had the credentials to help Resident #1 because she was a CNA and MA. MA A stated it was not just the CNA's responsibility to help residents with toileting. MA A stated even if Resident #1 needed something she was not capable of doing, then she should have gone to get a nurse. MA A stated she had been in-serviced about this issue. In a record review and interview on 06/01/23 at 12:24 PM, the DON stated she was made aware of the incident with Resident #1 not receiving help with toileting. She stated her expectations was for all MAs, CNAs, and nurses to help with toileting and incontinence care. The DON stated she also in-serviced staff to continue with doing rounds every 15 minutes due to issues with call lights. She stated incontinence care was not a job only for CNAs. She stated she answered call lights to provide incontinence care and had wiped resident's bottoms, so her expectation was for all other staff to do the same. The DON provided an in-service titled Incontinence Care dated 05/31/23 and stated she started in-servicing yesterday (05/31/23) by going to each direct care staff personally and explaining her expectations regarding incontinence care. She stated she was still meeting individually with staff who did not work yesterday. A record review of the facility's policy titled Activities of Daily Living, Optimal Function, dated 05/02/23, revealed Policy: The facility provides care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. The facility provides necessary care to all residents that are unable to carry out activities of daily on their own to ensure they maintain proper nutrition, grooming and hygiene.

Based on observation, interview, and record review, the facility failed to allow residents to call for staff assistance through a communication system that relays the call directly to a staff member or to a centralized staff work area for two residents (Resident #1 and Resident #2) of 5 residents reviewed for the environment. The facility failed to ensure Resident #1 and Resident #2 had a communication system to call directly to the facility staff. This failure placed residents at risk of not being able to get staff assistance when they needed it. Findings included: An interview with the ADM on 04/26/23 at 9:23 am revealed the facility had reported to the State Agency on 04/06/23, the facility's call light system had been struck by lightning, resulting in the outage of the system. As of 04/26/23, the facility had some residents' rooms with a functioning call light system. The residents' rooms that were not working were identified by the Maintenance Director. The facility had identified 15 rooms in which the call light did not work. The rooms and residents with no working call light system were provided bells and more frequent rounding . The facility awaited to hear from the service company when they would make the repairs. Record review of Resident #1;s face sheet dated 04/05/23 revealed an [AGE] year-old- female. She was admitted to the facility on [DATE]. Her diagnoses included Acute Respiratory failure with hypoxia, Dementia and Increased secretion of gastrin. Review of Resident #1's MDS dated [DATE] revealed a BIMS revealed a score of 07, indicating severe cognition impairment. Resident #1 was not interviewable. Observation of room [ROOM NUMBER] on 04/26/23 at 11:42 am revealed Resident #1's call light was located on the floor behind the bedside table while Resident #1 laid in bed. An interview and observation with the ADON on 04/26/23 at 11:45 am in Resident #1's room revealed Resident #1 call light was placed behind the bedside table. The ADON pressed the call light and revealed the call light was not functioning. The ADON stated she was not aware of room [ROOM NUMBER] call light not working. Resident #1 did not have a call bell to request staff assistance in the room. The ADON tested Resident #2's call light, who also resided in room [ROOM NUMBER] and Resident #2's call light was also not working. There was no call bell in the room for Resident #2. Record review of a list of rooms with no working call light provided by the ADON on 11:54 am revealed room [ROOM NUMBER] was not listed as not working. Review of Resident #2's face sheet dated 04/27/23 revealed on [AGE] year- old- female. She was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included Cerebral infarction (Stroke), Depression and Dysphagia. Review of Resident #2 MDS dated [DATE] revealed a BIMS of 03, revealed severe cognitive impairment. Resident #2 was not intervewable. An interview with Resident #2 family member on 04/26/23 at 12:09 pm revealed Resident #2 had been in room [ROOM NUMBER] for a week. The family member revealed Resident #2 did not have a working call light system. Resident #2 had not received a call bell to request staff assistance. An interview with RN D on 04/26/23 at 1:02 pm revealed she was the assigned nurse for room [ROOM NUMBER]. Resident #1 and Resident #2 resided in the room. The list was kept behind the nursing station. She was not aware room [ROOM NUMBER] call light system was not working/functioning. The facility has provided a list of rooms that did not have a working call light system because of the storm that knocked the system offline. The resident room that did not have a working call light, was provided a bell and staff would round more often. Resident #1 and Resident #2 had not been provided a bell and more frequent rounding. An interview with the Maintenance Director on 04/26/23 at 1:34 pm via telephone revealed he was not aware of the room [ROOM NUMBER] call light system not functioning properly. The Maintenance Director stated it was likely a recent storm may have caused additional rooms to not function. The facility required a new electronic board for the call light system. He was not aware of the timetable for the call light system to be fixed. The Maintenance Director provided a list to the nurses after going around testing the call light system for the resdients. Afterwards he created a listed and placed the list at the nurse's station of the resident rooms not working . He stated was not aware of room [ROOM NUMBER] call light system not working . An additional interview with the ADM on 04/26/23 at 1:49 pm revealed she was not aware of the room [ROOM NUMBER] call light system not working. After the surveyor's inquiry, the facility completed a check of all call lights. Two additional rooms that were not originally listed were also not working. Those residents' rooms were added to the list, provided call bells, and staff were educated to round on those rooms more. Record review of the facility's Comprehensive Disaster Plan and Procedures' policy dated 09/29/21 revealed nursing personnel will establish a medical communication system for all areas not equipped with patient/resident call lights. May include but is not limited to 1. Use of bells or other devices 2. Runners to convey information 3. Periodic or routine rounds.

Based on interviews and record reviews the facility failed to ensure that residents receive adequate supervision and assistance devices to prevent accidents for one (Resident #1) of seven residents reviewed for falls. The facility failed to ensure NA B was trained to provide adequate assistance to prevent accidents for Resident #1 who was a two person assist with ADL care. As a result, the resident fell from the bed and was later taken to the hospital and found to have a femur fracture. The noncompliance was identified as PNC. The noncompliance began on 03/15/23 and ended on 03/16/23. The facility had corrected the noncompliance before the survey began. This failure could place the residents at risk for injury. Findings included: Review of Resident #1's undated face sheet reflected she was a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included multiple sclerosis, functional quadriplegia , and unspecified convulsions. Review of Resident #1's quarterly MDS Assessment, dated 01/13/23, reflected that a BIMS score should not be conducted but the staff assessment for mental status was completed. Review of Resident #1's functional status for bed mobility reflected she required extensive assistance and two or more persons for physical assistance. Further review of Resident #1's functional abilities and goals for rolling left and right reflected she was dependent to which the helper does all of the effort since the resident did none of the effort to complete the activity and that the assistance of two or more helpers is required for the resident to complete the activity. Resident #1's MDS assessment reflected she had not had any falls within the last month, within the last two to six months, or suffered a fracture related to a fall withing the last six months. Review of Resident #1's care plan, dated 03/17/23, reflected the following: - [Resident #1] is at increased risk for falling out of bed R/T cognition, total care, low air loss mattress, seizures, DX of MS. - [Resident #1] requires total assistance with ADL's and an approach of Bed mobility: assist of 2 persons, toileting: assist of 2 persons Review of an incident/accident report for Resident #1, dated 03/15/23, reflected under type of incident/accident fall witnessed was checked, under secondary injury no apparent injury was checked, and under describe exactly what happened was CNA called Nurse that resident was on floor on her buttock. CNA stated she was trying to reposition her and change her resident leg slide and fall. [sic]. The bottom of the report was signed off by RN L. Review of Resident #1's progress notes reflected the following: - .around 10:30 [Resident #1's RP] came she said resident need to go to hospital because she saw from camera she have seizure and need to do CT scan. When this nurse check no any sign of seizure she wants to call 911 after few minutes she said we have to wait some hours and after 30 minutes she said she may be she need to go hospital [NAME] transportation. notified [NP Z] and DON called transportation they are not available before 5 pm. notified [Resident #1] she said 5 pm to late call 911. called 911 resident transfer [hospital name] and she left in good condition no sign and symptoms of seizures noted . [sic] completed by RN H on 03/22/23. - Around 3:30 pm shift CNA come to nursing station that shift CNA said resident fell when this nurse went resident room found resident on the floor that time resident bed was low position when she fall. Resident was non verbal so this nurse asked CNA about fall she said while she was try to change resident and change resident position and in this between she sliding on the floor. Checked head to toe no any visible injuries noted this time. Continue neuro checked vitals. BP=1o5/75, p=77 r=17, T=97.7, Spo2 =98% without oxygen. Resident was alert with eye opening. Notified Dr, no any further ordered this time. Notified DON, Notified Administrator. Notified [Resident #1's RP] [sic]. Completed by RN L on 03/15/23. Review of Resident #1's hospital records, dated 03/23/23 , reflected the following: HPI: .Per ER documentation patient fell from bed during her bath a few days ago. Patient was not sent to hospital at that time .[Resident #1's RP] brought [Resident #1] to hospital and found to have femur fracture . Further review reflected: CT Abdomen Pelvis w Contrast .2. Fracture deformity through the proximal diaphysis of the right femur with adjacent edema . And Assessment and Plan .Principal Problem: closed displaced subtrochanteric fracture of right femur .Femur fracture, right sustaine a few days ago after a fall atNH . [sic]. Review of Resident #1's Neurological Evaluation Flow Sheet revealed neuro checks were completed from 03/15/23 to 03/17/23 and no change in condition was noted or any sign or symptom of pain was noted. Review of the facility's census dated 04/05/23 revealed Resident #1 was no longer at the facility. In an interview on 04/05/23 at 10:41 AM with CNA C revealed she knew to look in the resident's chart for their assistance level before providing care and to not provide care alone if the resident required two people. CNA C said she cared for Resident #1 after the fall on 03/15/23 and did not notice any change in condition in the resident or any signs/symptoms of pain or a fracture. In an interview on 04/05/23 at 11:36 AM with CNA D revealed she knew to look in the resident's chart for their assistance level before providing care and to not provide care alone if the resident required two people. In an interview on 04/05/23 at 11:46 AM with CNA E revealed she knew to look in the resident's chart for their assistance level before providing care and to not provide care alone if the resident required two people. In an interview on 04/05/23 at 11:56 AM with NA F revealed she was not certified yet and was still in training. NA F said she was only allowed to assist in providing care to residents when she was with a CNA or nurse. NA F said she understood she was not allowed to provide care to residents alone. NA F said she knew to look in the resident's chart for their assistance level before providing care and to not provide care alone if the resident required two people. In an interview on 04/05/23 at 12:25 PM with CNA G revealed she knew to look in the resident's chart for their assistance level before providing care and to not provide care alone if the resident required two people . CNA G said she cared for Resident #1 after the fall on 03/15/23 and did not notice any change in condition in the resident or any signs/symptoms of pain or a fracture. In an interview via phone on 04/05/23 at 12:46 PM with LVN A revealed she cared for and continued to monitor Resident #1 after her fall on 03/15/23 for any change in condition or delayed injuries, which Resident #1 had none . LVN A revealed she knew to look in the resident's chart for their assistance level before providing care and to not provide care alone if the resident required two people. In an interview on 04/05/23 at 1:11 PM with CNA J revealed she knew to look in the resident's chart for their assistance level before providing care and to not provide care alone if the resident required two people. In an interview via phone on 04/05/23 at 1:35 PM with RN H revealed she cared for and continued to monitor Resident #1 after her fall on 03/15/23 for any change in condition or delayed injuries, which Resident #1 had none. RN H revealed she knew to look in the resident's chart for their assistance level before providing care and to not provide care alone if the resident required two people. In an interview on 04/05/23 at 2:14 PM with CNA K revealed she knew to look in the resident's chart for their assistance level before providing care and to not provide care alone if the resident required two people. In an interview on 04/05/23 at 2:25 PM with NA B revealed she was not a certified nurse's aide as she was still considered a student in training. NA B said she took care of Resident #1 on 03/15/23 when the CNA for that hallway did not show up and she was asked to care for the residents until someone else came in to relieve her. NA B said she went to complete her rounds on each of the residents and did not check the resident's chart for their assistance level needs. NA B said she was never told or asked about Resident #1's assistance levels but that she needed to be changed . NA B said she knew Resident #1 needed to be changed because she was making her observation rounds NA B said she went in Resident #1's room to provide her incontinent care, and while rolling the resident to the other side to clean her up and she slipped off the bed and fell . NA B said she went to get the nurse to assess Resident #1 after the fall. NA B said at the time of the incident she had not been trained by the facility on how to provide incontinent care to residents. NA B said at the time of the incident she was not aware that Resident #1 was a fall risk. NA B said after the incident she was suspended and sent home for the day. NA B said she came back to the facility the next day, was written up and in-serviced. NA B said she received in-services regarding repositioning residents, looking at resident's charts for their plan of care, how to determine if a resident requires two persons to assist them or not. NA B said she was also instructed not to provide any care to residents until she was checked off for the skills related to the job. NA B said she had not been checked off for any job related skills yet. NA B said she understood she was not allowed to provide any care to any resident independently. NA B said she also knew to look in the resident's chart for their assistance level before providing care and to not provide care alone if the resident required two people. NA B said the purpose of checking for a resident's assistance level and abiding by that was to keep them safe. In an interview on 04/05/23 at 2:45 PM with RN L revealed NA B came to her at the nurse's station to tell her Resident #1 was on the floor on 03/15/23. RN L said when she went to the room Resident #1 was on the floor, so she completed an assessment and did not find any injuries or change in condition. RN L said NA B told her she had been trying to change Resident #1's brief on her own even though the resident required two people's assistance for care . RN L said Resident #1 did not have any function to her limbs or body which was why she needed two people to provide care for her to keep her safe. RN L said she continued to monitor Resident #1 for any delayed injuries and signs or symptoms of pain and nothing was found . RN L said she received a call from Resident #1's RP on 03/23/23 informing her that the hospital found a femur fracture which occurred after the fall on 03/15/23. RN L said she had completed a skin assessment on Resident #1 on 03/21/23 which did not show any signs there was an underlying fracture. In an interview on 04/05/23 at 3:00 PM with LVN M revealed she cared for and continued to monitor Resident #1 after her fall on 03/15/23 for any change in condition, delayed injuries, or signs and symptoms of pain, which Resident #1 had none. LVN A revealed she knew to look in the resident's chart for their assistance level before providing care and to not provide care alone if the resident required two people. In an interview on 04/05/23 at 3:15 PM with the DON revealed she was not in the building when Resident #1 had a fall on 03/15/23. The DON said she was not sure why NA B provided care in general to Resident #1 or by herself since NA B had not been checked off for any skills as of yet. The DON said she was not sure when the fracture occurred because it could have happened from the fall or any time before or after that. The DON said staff were in-serviced on checking for resident's assistance levels prior to providing care and not providing care to residents who require two people when the staff was alone. The DON said staff were also in-serviced that NA B and NA F were not allowed to provide care to residents alone and always had to be with a certified or licensed staff. The DON specified that NA B and NA F had been specifically instructed not to provide care until they had their skill check off's first . In an interview on 04/05/23 at 4:00 PM with the Administrator revealed she came in the building that day on 03/15/23 and was told that Resident #1 had a fall. The Administrator said she confirmed with staff that an assessment was completed and it was. The Administrator said she interviewed NA B and was told that she was providing peri-care alone and the resident had a fall. The Administrator said she suspended NA B until she could be educated and trained on providing care to residents, including Resident #1. The Administrator said NA B should not have been providing peri-care in general or to Resident #1. The Administrator said Resident #1 was non-verbal and not able to communicate so staff had been assessing her each day for any change in condition or delayed injury from the fall; which never occurred. The Administrator said she began in-services with the staff regarding checking resident care levels before providing care, providing care with two or more staff when indicated, falls/fall management, and abuse/neglect. The Administrator said she also instructed NA B and NA F that they could not provide care until they had their skill check off's first by the DON . The Administrator said the nurses and CNA's had been instructed that NA B and NA F were not allowed to provide care alone and had to have a licensed or certified person with them at all times. The Administrator said the purpose of providing care to residents based on their care levels was to keep them safe. Review of an in-service, dated 03/16/23, and titled CNA Class reflected: 1. Do not provide care alone- only with mentor (another certified aide or licensed nurse). 2. Always ask 'how many staff to provide care'. Review of associating sign-in sheet revealed multiple staff signed the sheet, including NA B and NA F. Review of an in-service, dated 03/16/23, and titled Nurse Assistant Program reflected: Nursing assistants are not to provide care for a skill they are not checked off on. Until further notice, the 2 students in the Nurse Aide Program will shadow another CNA and will not provide alone. [sic]. Review of associating sign-in sheet revealed multiple staff signed the sheet. Review of the facility's policy, dated 2022, and titled Fall Management reflected: 3. The facility provides assistive devices and/or therapies based on individual resident needs to facility mobility increase balance awareness, transfers, safe toileting, or other areas to assist the resident with fall prevention. [sic]. The noncompliance was identified as PNC. The noncompliance began on 03/15/23 and ended on 03/16/23. The facility had corrected the noncompliance before the survey began.

Based on interviews and record reviews, the facility failed to ensure residents were free of accident hazards as was possible for one of 8 (Resident #1) residents reviewed for Incidents and accidents. On 10/31/22, CNA A and CNA B failed to follow Resident #1's care plan for extensive 2 person assistance for bed mobility, transfers, dressing and total dependence with 2 person support for bathing, which resulted in Resident #1 rolling off the bed and transferred back onto her bed, prior to being assessed by LVN C, which resulted in Resident #1 being diagnosed with comminuted angulated intertrochanteric left femoral neck fracture (Thigh bone fracture) on 11/02/22. It was determined a Past Non-Compliance Immediate Jeopardy existed and Administrator F was notified on 12/01/22 at 12:06 PM. The Immediate Jeopardy was determined to have been removed on 11/02/22 due to the facility's implemented actions that corrected the non-compliance of suspending CNA A and CNA B on 11/02/22 and terminating them on 11/04/22, re-educating staff about following the resident's plan of care, fall prevention and what to do after a resident fell , and a Quality Assurance meeting to discuss fall interventions was completed The Staff were interviewed and it was determined the facility staff were adequately trained about fall prevention, following plan of care, and what to do after a resident fell . There were actions put into place which included continued monitoring of the facility's preventive measures and Inservice trainings prior to the beginning of the HHSC investigation on 11/28/22 These failures could place all residents at risk for accidents, falls and serious injury resulting in a decreased psycho-social well-being, physical decline or death. Findings included: Record review of Resident #1's Physician Order Report dated 10/26/22 -11/28/22 revealed a [AGE] year old female who admitted [DATE] with diagnoses COPD, fracture of unspecified part of neck of left femur, Acquired absence of right leg, above knee, Acquired absence of left leg, below knee, morbid obesity, hypertension, diabetes mellitus Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 (cognitively intact), extensive assistance with 2 person assistance for Bed Mobility, transfers, dressing .total dependence with 2 person support for bathing, unable to walk with no impairment of upper extremity and impairment on one side of lower extremity, use of a wheelchair and frequently incontinent to bowel and bladder functioning . Record review of Resident #1's Incident/Accident Report by LVN C dated 10/31/22 revealed, At 11:45 am in patient's room resident had a witness fall and slid to the floor from low air low mattress and sustained an abrasion of the Left distal amputated site. Resident was alert/oriented, no change in condition .paraplegia, COPD, DM, HTN and incontinent to bowel and bladder .CNA stated patient slid off bed holding on to bed holding on to siderail during care provided; patient made contact with floor however did not fall or hit head; explained to have been in standing like position on amputated sites bilateral lower extremities .Findings and analysis: Section was blank Follow up step to prevent reoccurrence : 2 person assist at all times with ADL's .Describe patient's health condition dated 11/04/22: Hospital Record review of Resident#1's Care Plan dated 10/31/22 by MDS revealed, Created 11/04/22 Falls - Abrasion to left above the knee amputation - will remain free from injury, monitor and treat abrasion, transfer and care of resident with 2 staff members .Edited 11/14/22 Pain - resident has acute and chronic pain - Resident will receive adequate fast and effective pain relief and maintain pain at 3/10 or less- give pain medication as ordered and reassess for effectiveness in 30 minutes .Edited 11/14/22 ADL function/Rehabilitation potential - resident require assistance with ADL's - resident will be assisted with all activities of daily living and be allowed to be as independent as possible - resident needs assist with bed mobility, personal hygiene, toilet use, with transfers with Hoyer lift Record review of Resident #1's Falls Investigations Worksheet dated 11/01/22 by DON revealed, 10/31/22 at 11:45 am, In resident's room getting a bed bath, yes the resident called for help .witnessed fall individual(s) witnessing fall: CNA A and CNA B, no injury, Doctor notified 10/31/22 at 12:15 pm Recommendations/Interventions: Resident remain 2 person assist with bed mobility and transfers. Record review of Resident #1's Nurses note Recorded as late entry 11/02/22 (6:07 PM) by LVN C revealed, On 10/31/22 at 3:00 PM, nurse called to patient room by CNA for report of patient sliding off of bed; upon entering room patient was lying in bed and had been assisted back by CNA via Hoyer lift; Assessment of patient completed by nurse at this time, vital signs normal .Pain 0/10, when questioned about what occurred patient stated: she was receiving care by CNA, when being turned lost balance at edge of bed grabbed a hold of the side rail to prevent falling, stated she held onto rail with upper torso and bottom torso slid off of the bed; this further explain by CNA present that patient did not hit her head nor lay flat on floor instead was in a standing like position holding onto to [sic] rail due to being paraplegic; skin assessment performed and small redness noted to (Left) distal amputation site; Appears as abrasion without w/o any bleeding noted; no other injury noted; patient denies pain; ROM assessed w/o issue; patient stated her upper half appeared to be weak as she noticed while holding rail during incident; X-ray suggested to patient to r/o any possible unseen injury r/t the incident despite stating she did not fall, patient claimed she did not want to have an X-ray completed; nurse informed patient it could be done within the facility and she would not have to go out for procedure; patient still refused; will continue to monitor for any s/s of significant change. Report to be given to oncoming nurse. Resident #1's Provider Investigative Report dated 11/02/22 by Former Administrator E revealed on 10/31/22 Resident #1 was getting a bed bath from CNA A and fell out of the bed and then CNA B helped CNA A get Resident #1 back into her bed with the use of a Hoyer lift before LVN C assessed Resident #1. LVN C assessed resident with a abrasion to the left stump. On 11/02/22, CNA A and CNA B listed as alleged perpetrators were interviewed and suspended and LVN C was put on the do not return list. And Inservice trainings with all staff regarding fall prevention and management, abuse and neglect and following the resident's plan of care were conducted and on 11/04/22 CNA A and CNA B were terminated. Findings: Confirmed. Record review of Resident #1's Hospital Record dated 11/02/22 revealed she was admitted for Chief Complaint: Fall with leg pain .diagnosed with comminuted angulated intertrochanteric left femoral neck fracture (thigh bone fracture), no dislocation Assessment and Plan: Fracture of femoral neck, left .CT Pelvis wo Contrast: Patient presents to the hospital after a fall at her nursing facility complaints of fall earlier this morning when and [sic] caretaker at rehab facility with assisting patient she fell from bed and landed on her bottom, has bilateral leg pain now Interview on 11/28/22 at 10:15 am, Resident #1 stated she had left leg pain because it was broken because a young lady, CNA A gave her a bed bath about three weeks ago and turned her to the side. Resident #1 told the aide she was sliding but she did not listen and next thing she knew she fell off to the right side of bed (closest to the bathroom). She said her left leg stump was what hit the floor then she started screaming to staff to get her off of the floor with her pain level at a 9 out of 10 [severe pain]. She stated her left leg stump hit the floor and bed side table, then CNA A got another aide CNA B to get the sling Hoyer lift to put her back into bed. She stated she did not really remember much after that then she was at the hospital and was told by the hospital Doctor she had a left femur that was broken. Resident #1 said she hated the fact of having to go through this and it made her feel like the aide really did not care about having a second person helping her with her bed bath. She stated after she fell , the second aide CNA B helped CNA A get her back into bed. Interview on 11/28/22 at 3:53 pm, Administrator F stated she started working at this facility on 11/15/22 and heard about Resident #1's incident was reported to HHSC. Interview on 11/28/22 at 11:21 am, the DON stated Resident #1 was a total care (required extensive staff assistance) resident who received bed baths and Hoyer lift transfers because of her weight and recently had an incident. The DON stated she fell based on an incident report on 10/31/22, and she said she asked CNA A what happened and was told Resident #1 was moved from the bed to the floor. Then CNA A said she went to get CNA B to help get Resident #1 back into the bed with the use of the Hoyer lift and Resident #1 was assessed She stated she found out from the hospital the resident had a left femur fracture on 11/01/22 then she informed the Former Administrator E about it. She stated Resident #1 was a 2-person staff assistance resident and if CNA A had someone with her she would not have encountered the resident falling. She stated CNA A did Resident #1's bed bath by herself and did not say why and stated CNA A and CNA B should have waited for the nurse to do the assessment before they transferred Resident #1 to bed. She stated LVN C said the resident was already in the bed when he went to assess her and asked CNA A and CNA B what happened. She stated CNA A and CNA B did not follow the facility's fall protocol and plan of care and they were suspended on 11/02/22 and a few days later terminated. She stated Resident #1 had no history of falls, was alert/oriented, was getting therapy and after she fell they updated her care plan and added falls to it and her plan of care remained 2 person staff assistance. She stated a day after Resident #1's fall incident on 11/01/22, she had LVN C return to the facility to do the Incident Report and complete the nurses documenting in the EMR about the incident. She said LVN C told her he did the nurses documentation on 10/31/22 but forgot to press the save button. Interview on 11/29/22 at 9:09 am, CNA B stated the afternoon of 10/31/22 she was not in the room when Resident #1 fell but walked into her room and saw the resident on the floor about 2 feet from her bed and she was crying in pain and wanted to get up. She stated she reported Resident #1's fall to LVN C who was sitting at the nurse's station, but he did not get up to assess Resident #1, so she went with CNA A to get the Hoyer lift and assisted with putting Resident #1 back to her bed. She stated she was told she should not have moved the resident because the nurse had not assessed her and said she lost her job behind it. She stated she came to work the next day 11/02/22 and was told Resident #1 was transferred to the hospital. She stated she worked Wednesday 11/02/22 then later in the day, Former Administrator E suspended her and then on Friday 11/04/22 she was terminated. She said she was a new CNA for 4 months and was trained on falls, assessments and she had a training for falls and assessment after this fall incident. She stated she knew Resident #1 was a 2 person assist but CNA A asked for her help, and she got fired for helping someone else and in hindsight she said she never would have walked into Resident #1's room to help CNA A and should have reported CNA A to the DON immediately. She stated she broke one rule, helping to pick Resident #1 up before the resident was assessed by the nurse. Interview on 11/29/22 at 10:10 am, CNA A stated she worked as a Medication Aide and at times filled in as a CNA and said Former Administrator E suspended her on 11/02/22 then Friday 11/04/22 they terminated her because of Resident #1's fall. She stated on Monday 10/31/22 around 10:00 AM she was giving Resident #1 a bed bath by herself, and the resident slid down the bed. She stated Resident #1 fell with her upper body up against the bed and her lower body of her leg stump was on the floor and the resident appeared to be in pain saying that her leg hurt. She stated she went to get someone to help her get Resident #1 off the floor and CNA B helped her get Resident #1 back into her bed. She stated that the DON told her she should have waited for the nurse to assess the resident then she and CNA B were fired. She said after Resident #1 was put to bed LVN C went to assess Resident #1 and gave her a pain pill but Resident #1 did not go to the hospital. She stated a day later, Tuesday 11/01/22, Resident #1 went to the hospital because she had a change in condition. She stated she worked at the facility on 11/01/22 and 11/02/22 and on 11/02/22 around 4:00 pm she was suspended because she did not call the nurse before getting the resident into bed. She stated she was sorry for Resident #1 falling onto the floor and that she had almost completed Resident #1's bed bath and was putting on her adult brief and the resident turned to her right side, and she fell with her leg stump hitting the floor. She stated she knew from trainings she was to let the charge nurse know when a resident fell and said she did not get a second staff to help her with Resident #1's bed bath because the other aide was by herself on another hall. She stated she thought she could do Resident #'1s bed bath by herself, because she had done it four other times and the resident was able to move and roll over. She stated she was new working at this facility and did not know Resident #1 was a 2- person assist and did not check the EMR to see if Resident #1 was a 2 person assist. She stated the last training she had on fall prevention was when she first started working at this facility but stated no one had told her where to look to determine if a resident was a 1 or 2 person assist. She stated in CNA school she was taught not to move a resident if they fell but that day, she asked CNA B to help her get Resident #1 into bed. She stated in hindsight she should have called the nurse first and learned her lesson from this definitely to wait for the nurse to come to assess the resident and stated she felt sorry for Resident #1 and needed to make sure she asked who was a 2 person assist and to look into the EMR for the resident's plan of care. She stated the DON told her she was wrong for moving Resident #1 before the nurse assessed her because it could have caused more of an injury. Interview on 11/29/22 at 1:40 pm, the DON stated the ADON assisted her with monitoring how the staff completed their ADL tasks with random observations of resident care and with how they navigated in the EMR system to get to the resident's care plan and with nursing documentation and communicating with the resident's doctors. She stated the facility also ensured the agency staff reviewed and understood all of what was on the Orientation Checklist for caring for the residents. She stated she reviewed all of what the facility had done with the Corporate Nurse Consultant, and she did not have any further suggestions but to continue in service trainings and monitoring the staff. She stated she and the ADON would continue to do random observations of the staff twice weekly and continue to discuss the effectiveness of their trainings and monitoring in their Quality Assurance Meetings. Interview on 11/30/22 at 8:13 am, the Former Administrator E stated she was the interim Administrator from 11/02/22 to 11/18/22. She stated Resident #1's incident occurred on 10/31/22 and the DON notified her on 11/02/22 about Resident #1 falling and was at the hospital with a left femur fracture. She stated she started asking did Resident #1 fall at this facility and asked the DON what happened and was told Resident #1 fell during the 2:00 pm 10:00 pm shift on 10/31/22. She stated she was not able to determine when LVN C assessed Resident #1, but it was at some point with the resident already back in bed and the resident had no signs or symptoms of pain. Then on 11/01/22 Resident #1 was sent to the hospital and the hospital diagnosed her with a left femur fracture and on 11/02/22 around 2:00 pm, the DON notified her about the resident's femur fracture. She asked CNA A why she was giving Resident #1 assistance alone and she did not give her a clear explanation because Resident #1 was a 2 person assist and the second problem was Resident #1 should not have been moved until the nurse assessed her. She stated CNA A said Resident #1 pleaded to please get her up and so CNA A said she did. She stated CNA B helped CNA A move Resident #1 to her bed and both CNA A and CNA B were suspended on 11/02/22. She stated CNA B kept saying Resident #1 was not her patient but told CNA B she had a role and responsibility not to move the resident because it could have potentially caused the resident more injury. She stated after Resident #1 fell , they did Inservice trainings on plan of care, , fall prevention protocol, and what happens after a resident fell . She stated the staff were trained on how to review a point of care document and what a 2 person assist meant, She stated Resident #1 returned to this facility 11/10/22 and added her expectation for resident care was for the resident's plan of care to be reviewed prior to caring for the resident to know how to take care of the patient before providing any ADL assistance, with everything they should do for feeding bathing, positioning. She stated they in serviced the staff to follow the plan of care and if they had any questions to ask the nurse, they did check offs with return demonstration of transfers with therapy and MDS Coordinator and she spoke to the Medical Director and had a Quality Assurance meeting to further discuss Resident #1's incident and other fall incidents to determine if this incident was systemic or isolated. She stated after review, Resident #1's incident appeared to be isolated but stated CNA A was a Medication Aide and still no excuse, she should have known better. Interview on 11/30/22 at 10:31 am, the DON stated the ADON, and staffing coordinator assisted her with in servicing all staff including the Medication Aides and one Restorative Aide. She stated Resident #1 had an order for Hydrocodone PRN since 02/05/22 and had taken it once or twice since her fall 10/31/22 because she did not have regular pain issues. She stated after Resident #1's fall on 10/31/22, she was assessed without injury and there was not a need to notify Former Executive Director D of on 10/31/22 because it was a normal fall and was no cause for alarm. She said initially she was not aware Resident #1 had a bed bath by only one CNA before she fell . Interview on 11/30/22 at 3:05 pm, the facility's Medical Director stated the DON and Administrator F talked to him about Resident #1 having a guided fall but because she was so heavy and unable to move her lower extremity, she fell to the floor. She was hospitalized for another reason, but the hospital found she had a fractured femur, he said he was aware there was one person assisting Resident #1 with bed bath when there should have been two staff. He stated 2 staff were needed especially because Resident #1 was overweight and unable to stand. He stated telling the administrator and DON to ensure that the appropriate help was provided and said it was common sense for a two person assist resident to get proper care. He stated it was about education and would think the CNA's received training on plan or care and with not moving a resident who had fallen. Interview on 11/30/22 at 3:55 pm, the Former Executive Director D stated she was the interim ED from 10/31/22-11/01/22 and Resident #1 was getting a bed bath on 10/31/22 and the two aides lowered her to the floor. She stated it was reported Resident #1 was assessed by the nurse without any pain or injury noted then 11/01/22 the DON told her the hospital reported Resident #1 sustained a leg fracture. She stated when there was a normal fall with no injury or pain the common practice was to have a discussion about it in their standup meeting for interventions. Interview on 11/30/22 at 5:02 pm, the Administrator F stated they terminated CNA A and CNA B and placed LVN C on the do not return status based on the information gathered and they felt like there was too many things that were wrong once it was discovered why Resident #1 fell . She stated when this incident was brought to the DON all the facts were not present because the DON thought it was 2 aides providing Resident #1 care. She stated when Resident #1 had a change in condition with her cognition she was sent to the hospital but anytime there was a fall they have to X-ray and had that been done they would have known about the leg fracture sooner. She stated her expectations with following the care plan was to ensure the staff rounded with each other and between shift changes and to pay attention and review the EMR kiosk to give the residents individualized care. She stated the whole point of the plan of care was for the resident not to get the same care and was the staff's responsibility to report any changes of the resident to the nurse immediately. She stated the DON and ADON were responsible for ensuring the resident's plan of care was followed. Interview on 12/01/22 at 11:28 am, the DON stated after Resident #1 fell on [DATE], she was coming down the hallway and LVN C asked was Resident #1's incident considered a fall and that two CNA's moved resident to the bed then asked LVN C how she got into bed he said she was given a bed bath and the resident fell out of bed. She stated she spoke to Resident #1 and CNA A and CNA B about how they got the resident up and said she did not know LVN C was not in the room when Resident #1 was put to bed. She stated CNA A and CNA B said they used the Hoyer lift to get Resident #1 to her bed. She stated the only policy not followed was with two CNA's and one LVN not following proper protocol. Record review of the facility's Inservice trainings from 11/02/22 to 11/09/22 revealed the staff were trained on Fall Prevention management and steps to take after a resident falls, and with following the resident's plan of care. Interview on 11/30/22 at 8:13 am revealed the Former Administrator E stated they had a Quality Assurance meeting with the Medical Director and other department heads to address Resident #1's fall. Interviews from 11/29/22 at 9:09 am to 12/01/22 at 12:51 pm with the staff revealed they were adequately educated about fall prevention and management, knowing where to find the resident's plan of care and what to do and not do after a resident fell . Record review of the facility's Accident/Incident Reporting - Patient/Resident policy dated 11/01/2017 revealed, Policy: The facility's leadership will follow the established guidelines for the reporting of accidents and incidents.6. The Director of Nursing designates the responsible party to complete the follow-up. The designee conducts a complete investigation of all accidents and incidents and documents the findings on the second page of the worksheet (Fall investigation worksheet) . Accidents or incidents involving a patient/resident that result in an injury are immediately reported to his/her physician promptly reported .8. For 3 days following an incident/accident the nurse documents the condition of the patient/resident in the medical record every shift Record review of the facility's Fall Management Policy dated 09/18/2017 revealed, Policy: Facility staff will identify each patient/resident who is at risk for falls and develop a resident-centered and individualized plan of care to reduce fall risk. Definitions: Fall refers to the unintentional coming to rest on the ground, floor or other lower level . a fall without injury is still defined as a fall 5. If a fall occurs, qualified staff completes a root cause analysis of the patient/resident for injury from the fall and determines what may have caused or contributed to the fall .addresses the risk factors for the fall such as the resident's medical condition, facility environment issues, or staffing issues, and determines appropriate interventions to prevent future falls It was determined a Past Non-Compliance Immediate Jeopardy existed and Administrator F was notified on 12/01/22 at 12:06 PM. The Immediate Jeopardy was determined to have been removed on 11/02/22 due to the facility's implemented actions that corrected the non-compliance of suspending CNA A and CNA B on 11/02/22 and terminating them on 11/04/22, re-educating staff about following the resident's plan of care, fall prevention and what to do after a resident fell , and a Quality Assurance meeting to discuss fall interventions was completed The Staff were interviewed and it was determined the facility staff were adequately trained about fall prevention, following plan of care, and what to do after a resident fell . There were actions put into place which included continued monitoring of the facility's preventive measures and Inservice trainings prior to the beginning of the HHSC investigation on 11/28/22

Based on interview and record review, the facility failed to ensure personnel provided basic life support, including Cardiopulmonary Resuscitation (CPR), prior to the arrival of emergency medical personnel in accordance with the resident's advance directive and professional standards of practice for one (Resident #19) of two residents reviewed for CPR. LVN A and RN B failed to perform CPR and call 911 to request emergency medical personnel when Resident #19, who was a full code, was found unresponsive by staff on [DATE] at 9:35 PM. As a result, Resident #19 expired in the facility on [DATE]. This was determined to be past non-compliance due to the facility having implemented actions that corrected the noncompliance prior to the beginning of the investigation. This failure placed residents at risk of not receiving necessary and timely treatment and interventions, which could result in a decline in health, serious impairment, or death. Findings included: Review of Resident #19's face sheet, dated [DATE], reflected Resident #19 was an [AGE] year-old female with a primary [DIAGNOSES REDACTED]. Review of Resident #19's Admission Minimum Data Set (MDS) assessment, dated [DATE], reflected she admitted to the facility on [DATE] with a brief interview for mental status score (BIMS) of 13 showing little to no cognitive impairment. Resident #19 had [DIAGNOSES REDACTED]. Review of Resident #19's physician orders, start date [DATE], reflected an order for [REDACTED].>Review of Resident #19's clinical record revealed no documentation pertaining to a desire for a Do Not Resuscitate status, or any documentation that a Do Not Resuscitate order had been obtained for the resident. Review of facility progress note for Resident #19, dated [DATE] at 9:35 PM, reflected, Daughter complains of (c/o) to Nurse @ (at 8:00 PM) 2000 that patient was nauseating s/c, Patient was assessed and patient verbalized she does not need nausea medication, Patient was rechecked @ (at 9:20 PM) 2120 Patient was laying bed with eyes opened with no signs of distress noted Patient verbalized am ok I do not need anything. CNA @ (at 9:35 PM) 2135 went to Patient room to change her brief and found that patient unresponsive, this Nurse was called and immediately went to the room with crash cart, Patient was assessed unresponsive and pale vital signs was checked unable to reading s/c value, no pulse, no breathing. MD was notified, Daughter was notified, DON was also notified. RN in the building pronounced death @ (at 9:40 PM) 2140. Daughter is now @ the bed side. This note was created by LVN [NAME] In an interview on [DATE] at 9:05 AM LVN A revealed she was assigned to Resident #19 on [DATE]. LVN A stated on [DATE] around 9:10 PM she visited with Resident #19 who was not showing any signs or symptoms of distress and when she asked the resident if she was okay the resident response she was fine. LVN A stated on [DATE] between 9:35 PM and 9:37 PM an aide ran to the nursing station calling for help with Resident #19. LVN A stated she and RN B ran to Resident #19's room and found her unresponsive. LVN A stated both her and RN B checked Resident #19 who did not have a pulse and was not breathing because there was no visible rise and fall of her chest. LVN A stated she ran to the nursing station and verified Resident #19 was a full code. She and RN B returned to the resident's room with the crash cart. LVN A stated she asked RN B to call 911 to which RN B responded there was no need to call 911 or do cardiopulmonary resuscitation (CPR) because the resident was already gone. LVN A stated she did not perform CPR at any time because RN B told her the patient was already gone. LVN A stated she acted on RN B's instructions because RN B was her supervisor at the time. LVN A stated she should have performed CPR and called 911. LVN A stated RN B pronounced Resident #19 deceased at 9:40 PM on [DATE]. LVN A stated she did not see 911 respond to the building at any time. LVN A stated she did not observe RN B perform any chest compressions while in the resident's room. In an interview on [DATE] at 3:06 PM CNA G revealed he cared for Resident # 19 on [DATE]. CNA G stated on [DATE] around 9:00 PM he went to Resident #19's room and spoke with the resident who showed no signs of distress. CNA G stated he rounded on Resident # 19 again around 9:40 PM prior to his shift change. CNA G stated at 9:40 PM Resident # 19 was unresponsive to him calling her name, not blinking, and she was not moving at all. CNA G stated he immediately left the room and went to the nursing station to notify RN B and LVN A of the resident's condition. CNA G stated both nurses responded immediately by going to the resident's room. CNA G stated while in the room with both nurses he saw RN B and LVN A check the resident's pulse. CNA G stated both nurses then pulled the privacy curtain, and he left the resident's room. CNA G stated he returned to the nursing station to chart and saw RN B come out of Resident #19's room to obtain the crash cart. CNA G stated he heard RN B tell LVN A who was also at the nursing station to call the resident's daughter, DON, and Administrator immediately. CNA G stated LVN A grabbed the numbers and called the family, Administrator and DON. CNA G stated he did not hear either of the nurses call 911. In an interview on [DATE] at 11:12 AM RN B, nurse supervisor for the shift, revealed she was working the evening of [DATE] but was not assigned to Resident #19. She stated on [DATE], LVN A called her to the nursing station and informed her Resident #19 was unresponsive RN B stated she could not remember the exact time this occurred. RN B stated she and LVN A ran to Resident #19's room and she found the resident unresponsive. RN B stated she went to get the facility crash cart and asked LVN A to check the resident's code status. RN B stated she heard someone state Resident #19 was a full code but could not remember who. RN B stated she called for someone to call 911. RN B stated she did not know if someone called 911 but emergency personnel never responded to the facility. She believed LVN A called 911 as she went to the resident's room. RN B stated she returned to Resident #19's room alone and started CPR. RN B stated she tried to assess the resident and realized the resident was not responding with any signs of a pulse, so she stopped CPR. RN B stated she could not remember how long she was in the room before she stopped CPR on the resident. RN B revealed if CPR was initiated, she was supposed to continue until there was relief. RN B stated she did not resume CPR or call 911 because when she left Resident #19's room, the resident showed no signs of clinical irreversible signs of death. RN B revealed Resident # 19's responsible party did respond to the facility but she could not recall what time. RN B stated she pronounced Resident #19 dead. RN B stated she did not speak with the resident's responsible party. In an interview on [DATE] at 10:55 AM Resident #19's physician revealed Resident #19 did not possess a do not resuscitate (DNR) order while at the facility. The physician stated the last time he visited with Resident #19 was on [DATE] and she was stable. The physician stated there was a full code order in the facility system for the resident. The physician stated if a resident was found unresponsive and they were a full code, the staff should start CPR and call 911. He stated Resident #19 should have had CPR and 911 should have been called. He stated in Resident #19's case, staff should have attempted CPR and 911 should have been called. He stated 911 should always be called because they have more expertise and could help with CPR. The physician revealed if Resident #19 was found unresponsive at 9:35 PM and pronounced deceased at 9:40 PM, that was too soon and CPR should have been continued. In an interview on [DATE] at 1:28 PM RN C revealed she was the Director of Nurses on [DATE]. RN C revealed the life saving measures expected for full code residents who did not have a pulse and were not breathing included: call Emergency Management Services (EMS) by dialing 911, initiate CPR and continue it until 911 arrived and took over. RN C stated staff would notify the physician on record, and if they were not available the medical director, responsible party, Administrator, and DON. RN C stated the incident involving Resident #19 was based upon RN B's assessment of the situation involving Resident #19. RN C stated either LVN A or RN B could have called 911 and initiated CPR. RN C stated she received a missed call from the facility on [DATE] around 9:30 PM. RN C Stated she called the facility back around 9:45 PM and spoke with RN B about the incident involving Resident # 19. RN C revealed being told by RN B she grabbed the crash cart and went down the hall to the resident's room; RN B sated when she went in the room the resident was cold, pale, was not breathing, and was stiff. RN C stated RN B revealed the resident was cold to touch, there was not any rise and fall of the resident's chest, and there were no obtainable blood pressure or vitals from the resident. RN C stated RN B revealed she did not initiate CPR, when RN C asked why RN B said based on her assessment of Resident # 19 with no vitals, her body cold and stiff she did not perform CPR. RN C stated being told by RN B at 9:45PM Resident #19's responsible party had arrived to the facility and did not want CPR for Resident #19. In an interview on [DATE] at 11:35 AM the DON revealed she was not the DON at the time of the incident involving Resident #19 on [DATE]. The DON revealed if staff determined a resident to be full code emergency response system should be activated to include, placing an AED on the resident, performing CPR, calling 911 and continuing CPR until emergency management services responded to the facility. She stated she also expected staff to notify the physician, carry out any order provided, and notify the family. In an interview on [DATE] at 12:25 PM the Administrator revealed based on the facility's investigation of the incident involving Resident #19, she determined on [DATE] around 9:35 PM LVN A and RN B were alerted the resident was unresponsive. She stated both LVN A and RN B communicated to her that within 5 to 10 minutes of being in the resident's room, they determined the resident was deceased . The Administrator revealed both nurses should have called 911 and each nurse stated because the resident was already gone they did not call 911. The Administrator revealed the facility policy reflected CPR should be provided to residents that were full code and in if CPR is staff should also notify 911. The Administrator revealed 911 was not called in the incident involving Resident #19 and that is why she reported the incident to Health and Human Services. In an interview on [DATE] at 4:01 PM Resident # 19's daughter stated she was contacted by a nurse at the facility her mother was not doing well on [DATE] at 9:45 PM. She stated as she arrived to the facility being told by a nurse her mother had passed away. The Administrator stated in response to the incident, the facility took immediate corrective action by: suspending both LVN A and RN B on [DATE] pending the provider investigation, notified the medical director of the incident and determined the root cause of the incident, initiated mock code blue drills on [DATE], ensured all staff were in-serviced on determining code status of residents, verified all resident code statuses, ensured all nurses were trained on CPR and the facility policy on Cardiopulmonary Resuscitation Emergency Code Blue. The Administrator stated the facility continued to monitor staff compliance with facility policy by performing ongoing training with competency testing of all staff, performing weekly random mock code blue drills throughout all shifts, verifying the credentials of agency staff and ensure they have code status training, and providing orientation training for agency staff. The Administrator stated they were holding monthly Quality Assurance Performance Improvement committee meetings with the facility medical director to identify root causes in the incident involving Resident #19, discuss/review current report of incidents accidents to determine causative factors, and develop procedures and interventions within the facility to mitigate potential future risks. She also revealed RN B was terminated from employment for not following policy on code status and not performing CPR. She stated LVN A, an agency nurse, was barred from returning to the facility and her agency was notified of the incident. The Administrator also stated both LVN A and RN B licenses were referred to the Board of Nursing for failure to follow policy on code status and not providing CPR. Review of facility Provider Investigation Report investigation summary dated [DATE], reflected all direct witnesses to the event involving Resident # 19 were interviewed, RN B and LVN A were suspended pending the investigation, the facility medical director was notified of the incident, and investigation initiated. Based upon the investigation it was determined LVN A and RN B failed to follow the facility policy on code status by not performing CPR. The investigation indicated RN B and LVN A did not administer CPR to Resident # 19 based upon their clinical judgement that the resident had been deceased too long. Facility actions for LVN A and RN B not following facility policy on code status were RN B was terminated from employment and LVN A an agency nurse was red flagged with her agency and not allowed to return to the facility. The facility referred both LVN A and RN B licenses to the Board of Nursing. The facility performed mock code blues with licensed nursing staff on all shifts before they were allowed to return to work at the facility, resident code statuses verified, and in servicing conducted with all staff as to how to determine resident code status and actions to take for full code residents. Review of LVN A's personnel file included a CPR certification issued on [DATE] with a renewal date of (MONTH) 2021. Review of RN B's personnel file included a CPR certification issued on [DATE] with a renewal date of (MONTH) 2020. Review of the facility policy dated [DATE], titled Cardiopulmonary Resuscitation, Emergency Code Blue reflected: .3. [NAME] Staff are directed to initiate CPR when cardiac or respiratory arrest occurs for residents who do not show obvious clinical signs of irreversible death and; 1) who have requested CPR in the advance directives, or 2) who have not formulated an advance directive, or 3) who do not have a valid DNR order . Procedures: 1. Follow practice guidelines for CPR by initiating resuscitation with and without Automatic External Defibrillator (AED) as appropriate, etc. in accordance with patient/resident Advanced Directive. 2. Page overhead code Blue (room and unit) repeat two times .3. Call 911 for emergency transfer to an acute care center, unless the patient/resident is coding, and staff has determined that the patient/resident is a DNR. 4. Contact patient's/resident's physician for further orders. 5. Contact patient's/resident's responsible party to inform him/her of change in condition. 6. Continue CPR efforts as appropriate, etc. in accordance with patient/resident Advance Directives, until advance rescue team arrives or until spontaneous respiration's, pule, and blood pressure return. Review of facility policy dated [DATE], titled Pronouncement of death- For Texas SNFs only Procedures: reflected: 1. Patients with Valid DNR. [NAME] Registered Nurse (RN): When a patient/resident is found to be without heartbeat or respiration the registered nurse on duty: 1) makes an immediate assessment 2) determines signs and symptoms of an apparent death of patient/resident as evidenced by, at minimum: a) absence of audible/palpable pulse b. absence of discernible blood pressure c. absence of evidence of respirations d. absence of evidence of heartbeat e. absence of papillary response to light f. general observations such as degree of cyanosis or pallor, skin temp (warm or cool) 3) verifies the no code order by the physician in the medical record. 4) If all the above signs and symptoms are present, the RN may pronounce death . 2. Patients/Resident Without Valid DNR/Advanced Directives: [NAME] When a patient is found to be without heartbeat or respirations, the RN and LVN shall make an immediate patient/resident assessment and begin emergency measure, including CPR. The nurse must initiate CPR and promptly notify the patient's/resident's physician. Note: in the case of a patient/resident arrest without DNR orders, a nurse's failure to initiate CPR may constitute failure to comply with the standards of nursing care. C. The physician may pronounce the patient's/resident's death via the telephone. D. Documentation by the RN and LVN should include that the physician pronounced the patient's/resident's death via telephone, the name of the physician and the time. Review of the American Heart association's guidelines for CPR reflected, . Cardiac Chain of Survival . To have the best chance of recovering from a [MEDICAL CONDITION] the ARC (American Red Cross) advises that individuals should follow the Cardiac Chain of Survival. The chain starts with early recognition of [MEDICAL CONDITION] and immediately upon recognition activation of Emergency Medical Services with a rapid response from them. The second link in the chain is CPR provided by those on scene with the victim immediately at the time of collapse. The third link is early defibrillation, when appropriate, by quick use of an AED by bystanders. The final link is early advanced care as provided by Emergency Medical Services and then a hospital with the capability of correcting the problem which led to the [MEDICAL CONDITION] . (retrieved on [DATE] from https://www.cprcertificationonlinehq.com/american-red-cross-official-guidelines-cpr-2014/-) Review of the Texas Board of Nursing Standards of Nursing Practice, reflected a nurse must, .(M) Institute appropriate nursing interventions that might be required to stabilize a client's condition and/or prevent complications . (retrieved on [DATE] from http://www.bon.texas.gov/rr_current/,[DATE].asp) Review of the facility Mitigation Plan, dated [DATE], concerning the incident involving Resident # 19 reflected: Mock codes were conducted [DATE], [DATE], [DATE], [DATE], [DATE], then weekly on random shifts. Corrective action will be monitored to ensure the deficient practice will not recur. Nursing staff has been re-educated on the Cardiopulmonary Resuscitation Policy and process to include the following: Resuscitation Equipment will be maintained in designated crash carts in general nursing areas. Person finding resident unresponsive will not leave the resident unattended but will call for help immediately. Licensed nurses will respond immediately to the emergency and evaluate resident and begin resuscitation effort if indicated. Nurse will direct nursing staff, either nurse or Certified Nursing Assistant to check the resident's code status found in the Resident Profile by the resident's name. DNR in Red and Full Code in Green. Nurse will direct Certified Nursing Assistants or other staff to gather equipment (crash cart) and bring to the resident's room. Staff will call 911 and offer assistance to the nurse. Once resuscitation is initiated it must continue until Emergency Medical Services arrives and takes over, or resident's spontaneous efforts have returned and are adequate. This reeducation was completed by [DATE] for all facility staff, is presented in new hire orientation, and will be presented in the Agency Orientation Binder. Any staff who did not receive this education will be re-educated before their next shift to work by the administrator, Director of Nursing or designee. Licensed nurses will be interviewed daily for 5 days on each shift then weekly for 2 weeks by members of nursing management to validate that the transfer of learning regarding the expectation that a resident found unresponsive that is a full code has CPR and not stopped by facility nurses. The DON/ADON will randomly interview licensed nurses weekly for 3 months to validate that nurses understand the expectation that Cardiopulmonary Resuscitation is to be initiated on a resident found unresponsive that is a full code and not stopped by facility nursing staff. Certified Nursing Assistants will be interviewed weekly by nursing administration for 4 weeks, then monthly for 3 months to ensure the education was understood. Quality Assurance program put into place: The Medical Director was notified of this on [DATE]. A Quality Assurance Performance Improvement (QAPI) meeting was held on [DATE] regarding the contents of this plan. The data received will be reviewed in the QAPI meeting monthly for 3 months for determination of compliance and further actions. Any concerns identified will be addressed at time of discovery. On [DATE] separate interviews were conducted with LPN D at 2:58 PM (works 6a-2pm shift), LVN [NAME] at 3:08 PM (works 2pm-10pm shift), and LVN F (agency nurse works various shifts) at 3:17 PM. Each nurse responded correctly to the following questions: 1. How do you respond to finding a resident in cardiopulmonary arrest, unresponsive and not breathing? Call for assistance, stay with the resident, ask staff to check the resident's code status and notify staff to call 911, if resident was a full code, initiate CPR while staff obtained the crash cart, AED, and called 911. Continue CPR until spontaneous blood pressure, pulse and breathing returned or 911 arrived to relieve me of CPR. 2. How does someone know or find a resident's code status? There is a book at the nurse's station with all resident's code status, and code status is indicated in the computer for each resident. Full Code resident's in the computer system are indicated in green and DNR code status in red. 3. Who should be notified in the event of a resident coding? The physician, DON, Administrator, ADON, Supervisor on Staff, and the resident's responsible party. 4. Reviewed Record of facility in services subject, Code status for dates [DATE], [DATE], [DATE], [DATE] with signatures of all staff trained on mock code blue rapid response drills which included topics: verification of resident code status, AED, activation of EMS calling 911, notification of physician and responsible party, transfer of resident as appropriate and documentation, full code residents-CPR initiated and continued until EMS arrival. Reviewed staff competency testing on Cardiopulmonary Resuscitation for all nursing staff conducted between [DATE] and [DATE]. Reviewed agency nurse training binder in which it indicated how to determine resident code status, how to respond to a resident in cardiopulmonary arrest, location of crash cart, who is required to be notified of resident change in condition.

Based on observation, interview, and record review the facility failed to ensure appropriate treatment and care was provided in accordance with professional standards, comprehensive person-centered care plan and resident choices for 1 of 18 residents reviewed for quality of care. (Resident #3) The facility did not ensure staff identified and addressed Resident #3's change of condition. LVN G did not conduct an in-depth assessment and follow-up when Resident #3 was noted to have a large discoloration/DTI to her lower left extremity. Eight days later, Resident #3 was found to have a [MEDICAL CONDITION] proximal tibia with mild displacement. This failure could place residents at risk of complications and delayed treatment resulting from inadequate assessments. Findings included: 1.Physician order [REDACTED].#3 admitted [DATE] on hospice, was a [AGE] year-old female with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #3 was cognitively severely impaired and totally dependent on staff for transfers. A care plan dated initiated 6/28/19 and revised on 7/31/19 indicated Resident #3 had an impact fracture of tibia/fibula and required a mechanical lift with two person assist. A nursing note dated 7/15/19 at 2:00p.m. indicated LVN G notified a hospice nurse that Resident #3 had a large discoloration/deep tissue injury to left shin. The resident was not capable of explaining the injury. The note indicated staff should continue to monitor the resident and injury. A nursing note dated 7/22/19 at 8:07a.m. indicated CNA D showed the nurse Resident #3's left knee was swollen, and the resident appeared to be in pain. The note indicated the skilled nurse elevated the resident's leg and placed a pillow underneath the leg to reduce [MEDICAL CONDITION] and promote venous circulations. Tylenol 325mg 2 tabs was given for pain. The oncoming nurse was notified for further follow up. A nursing note dated 7/23/19 at 9:21p.m indicated at 8:00 p.m., an x-ray was obtained of Resident #3's left leg. Routine pain medication was administered, and the resident's legs were elevated pending X-ray results. A nursing note dated 7/24/19 at 4:06 a.m. indicated Resident #3's x-ray results indicated a recent impacted [MEDICAL CONDITION] leg, and the knee and ankle joints were intact with mild displacement. The physician was notified. An x-ray report dated 7/23/19 at 4:06 a.m. indicated Resident #3 had a recent impacted [MEDICAL CONDITION] leg with mild displacement. During an interview on 10/30/19 at 9:43 a.m., the administrator said she did not know about the discoloration/DTI to Resident #3's leg until 7/22/19. She said she spoke to the DON and she said she was not made aware of the incident until 7/22/19. She said the DON informed her she should have been notified immediately of the discoloration/DTI to Resident #3's leg. She said the DON who worked at the facility at the time the incident was first identified, on 7/15/19, was no longer employed at the facility. She said the facility physician was not notified until 7/22/19. She said there was no documentation of any assessments completed on Resident #3 after 7/15/19 when LVN G noted the discoloration/DTI to Resident #3's left leg. The Administrator said she did not know why an assessment was not done. She said there was no follow up after Resident #3 was noted to have the discoloration/DTI. She said a complete assessment and a follow up should have been done after Resident #3 was noted to have a discoloration/DTI to her left lower leg. She said the facility physician assessed the resident on 7/31/19. The Administrator said LVN G should have informed the family, the physician, and herself immediately after it was noted. During an interview on 10/30/19 at 10:38 a.m., Resident #3's daughter said she could not remember when she was notified of the discoloration/DTI to her mother's leg. She said she knows the physician did not see her mother until after the x-rays were done on 7/23/19. She said she does not think the facility took adequate care of her mother. She said the staff seemed to think since her mother was on hospice that they did not have to provide care to her. During an interview on 10/30/19 at 11:14 a.m., LVN C said she remembered LVN G saying she notified the hospice nurse about Resident #3's leg on 7/15/19, but the hospice nurse did not come to the facility to assess Resident #3. She said it was a week later when CNA D noticed the discoloration to Resident #3's leg and reported it to LVN [NAME] LVN C stated LVN G should have completed a head to toe assessment as soon as she noted the discoloration/DTI to Resident #3's leg. During an interview on 10/30/19 at 11:36 a.m., CNA D said she reported the discoloration to Resident #3's leg as soon as she noticed it. She said she could not remember the exact date, but she thought it was in the later part of July. She said she did not notice it before then because the hospice aid was the one who usually provided care for Resident #3. CNA D said she assisted the hospice aid with the hoyer lift to get Resident #3 up on 7/22/19 and that is when she noticed the discoloration to Resident #3's leg. During an interview on 10/30/19 at 1:00 p.m., the hospice nurse said he did not know about the discoloration/DTI to Resident #3's leg until 7/22/19. He said he visited the facility and assessed the resident that same day. He said Resident #3 was noted to have bruising and [MEDICAL CONDITION] to her left lower extremity. He said he ordered an x-ray and the results indicated Resident #3 had a [MEDICAL CONDITION] proximal tibia with mild displacement. During the exit on 10/31/19 at 6:15 p.m. the facility was asked for additional information related to the findings. No additional information was provided.