Every finding on record at Las Colinas of Westover

Based on interviews, observation, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that include measurable objectives and time frames to meet residents' mental, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and to ensure that the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including the right to refuse treatment for 2 of 9 residents (Residents #1 and #2) reviewed for care plans. Residents #1 and #2's care plans reflected contractures. This failure could place residents at risk by not having their needs met and not receiving appropriate care. The findings included:Record Review of Resident #1's admission Record, dated 09/16/2025, reflected he was a [AGE] year-old with admission date 05/10/2025, discharge date [DATE], and diagnoses to include age-related cognitive decline. Record Review of Resident #1's Care Plan, closed date 07/07/2025, did not reflect contractures. Record Review of Resident #1's admission MDS assessment, dated 05/23/2025, reflected a BIMS score of 14 out of 15, indicating intact cognition. It further reflected Resident #1 had impairment on both sides of his lower extremity and his upper extremity. Record Review of Resident #1's order summary report, dated 09/16/2025, reflected May wear bilateral hand contracture cushion as tolerated Record Review of Resident #1's OT Evaluation & Plan of Treatment, dated 05/23/2025 to 06/21/2025, reflected during Musculoskeletal System Assessment, Resident #1 had functional limitations present due to contractures. Record Review of Resident #2's admission Record, dated 09/18/2025, reflected he was a [AGE] year-old with initial admission date 06/01/2024, re-admission date 04/24/2025, and diagnoses to include lack of coordination, muscle wasting and atrophy, and age-related physical debility. Record Review of Resident #2's Care Plan, closed date 07/07/2025, did not reflect any mention of contractures. Record Review of Resident #2's admission MDS assessment, dated 05/23/2025, reflected a BIMS score of 12 out of 15, indicating intact cognition. It further reflected Resident #2 had impairment on one side of his upper extremity and impairment on both sides of his lower extremity. Interview on 09/17/2025 at 02:47 PM, CNA A revealed Resident #1 did need help eating sometimes due to trouble using his hands. Interview on 09/18/2025 at 02:11 PM, the DOR revealed Resident #1 was being seen by therapy to help with his contractures. He revealed they had ordered splints to help improve his strength. Interview and observation on 09/18/2025 at 02:51 PM, Resident #2 had a contracture to his left hand. He revealed the facility was aware of his left hand as they would help him when he needed, like strengthening exercises due to his contracture. Interview on 09/18/2025 at 03:30 PM, the MDS nurse revealed there were no contractures in the care plan. She mentioned when a resident had a contracture this would mean no mobility for the joint. She further revealed because Resident #1 was able to utilize the urinal and feed himself with plasticware, he was not contracted. She further revealed it was important to update care plans to give the best care possible to residents. She further revealed she oversaw that care plans were up to date, and she tried to update as best as she could for the residents in the facility. Interview on 09/18/25 at 04:15 PM, ADON B and ADON C revealed Resident #1 had a contracture. Interview on 09/18/2025 at 04:55 PM, the DON revealed Resident #1 had a contracture and therapy worked with him. She revealed Resident #1 had splints for his contractures. She further revealed she could not find contractures mentioned on Resident #1's care plan. She revealed it was important to have this on the care plan, so the team knew how to provide care to the residents. Interview on 09/18/2025 at 06:36 PM, ADON B and ADON C revealed Resident #2 had a contracture on his left hand and the facility would adjust his care accordingly. They revealed it should be care planned if a resident had a contracture. Interview on 09/18/2025 at 06:49 PM, the MDS nurse revealed Resident #2 did not have contractures in his care plan. Record Review of facility's policy, undated, Resident Mobility and Range of Motion, reflected 5. The care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion including contractures. Record Review of facility's policy, revised December 2016, Care Plans, Comprehensive Person-Centered reflected 8. The comprehensive, person-centered care plan will: b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on interviews and record reviews, the facility failed to accurately reflect the residents' status for 4 residents (Residents #43, # 62, 75 and #106) of 32 residents reviewed for MDS assessments. Resident #43's quarterly MDS assessment dated [DATE] inaccurately reflected that she took an anticoagulant and did not reflect that she took an antiplatelet medication. 2. Resident #62's psychoactive and antiplatelet medications were not reflected on her quarterly MDS assessment dated [DATE]. 3. Resident #75's fall on 05/22/2025 was not reflected on her annual MDS assessment dated [DATE]. 4. The facility failed to ensure Resident #106's planned discharge was coded accurately. These facility failures affect residents who receive care and could result in missed or inappropriate care. The findings included: 1. Record review of Resident #43's electronic face sheet dated 09/30/2025 reflected she was a [AGE] year-old female who was readmitted to the facility on [DATE]. Her diagnoses included: chronic obstructive pulmonary disease (a group of lung diseases that cause ongoing inflammation and narrowing of the airways, making it difficult to breathe), type II diabetes mellitus (chronic condition where the body does not use insulin effectively or does not produce enough insulin to regulate blood sugar levels), dysphagia (difficulty or discomfort in swallowing), dementia (condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), depression (common mental health condition characterized by persistent feelings of sadness hopelessness, and loss of interest or pleasure in activities), and cognitive communication deficit (condition that affects the brain's ability to perform mental processes, such as attention, memory, reasoning and problem-solving, which impairs ability to communicate effectively). Record review of Resident #43's Active Orders as of: 09/30/2025 reflected she was not ordered an anticoagulant (prevents the liver from producing vitamin K-dependent clotting factors). She had ordered Aspirin on 02/24/2025, which was classified as an antiplatelet (medication that prevented platelets from sticking together and forming blood clots). Record review of Resident #43's quarterly MDS assessment with an ARD of 09/12/2025 reflected she sometimes understood and could sometimes understand. She scored a 00 of 15 on her BIMS which indicated her cognitive status was severely impaired. She was dependent on most of her ADLs. Her MDS assessment reflected she took an anticoagulant and did not reflect that she took an antiplatelet. Record review of Resident #43's comprehensive care plan dated 02/26/2025 did not reflect that she took an anticoagulant or an antiplatelet . 2. Record review of Resident #62's electronic face sheet dated 09/30/2025 reflected she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included: chronic obstructive pulmonary disease (a group of lung diseases that cause ongoing inflammation and narrowing of the airways, making it difficult to breathe), dementia (condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), type II diabetes mellitus (chronic condition where the body does not use insulin effectively or does not produce enough insulin to regulate blood sugar levels), major depressive disorder (common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities) and bipolar disorder (chronic mental health condition characterized by extreme mood swings between mania (high energy, euphoria, and impulsivity), hypothyroidism (when the thyroid gland does not make and release enough hormone into the bloodstream which can cause fatigue and weight gain) and depression (low mood, fatigue, and hopelessness). Record review of Resident #62's comprehensive care plan dated 09/21/2025 did not reflect that she took an antiplatelet. Resident #62's care plan dated 06/02/2025 reflected Focus, resident has an alteration in neurological status r/t bipolar disorder, Interventions: assess for effects of psychotropic meds, and give medications as ordered. Record review of Resident #62's quarterly MDS assessment with an ARD of 09/24/2025 reflected she usually understood and could usually understand. She scored an 8 of 15 on her BIMS which signified her cognitive status was moderately impaired. She required substantial assistance with most of her ADLs. She was not coded for taking an antipsychotic. Review of the section N040 Antipsychotic Medication Review, did the resident receive antipsychotic medications since admission/entry or reentry or prior OBRA assessment, whichever is more recent? 0 which indicated No was coded. The antiplatelet was not check marked. Record review of Resident #62's Active Orders as of: 09/30/2025 reflected she took Risperidone (antipsychotic medication) one tablet twice a day for antipsychotic purposes since 05/21/2025. Resident #62's orders reflected she took Aspirin EC Low Dose 81 mg, one tablet po each day since 05/23/2025. 3. Record review of Resident #75's electronic face sheet dated 09/30/2025 reflected she was an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included: Alzheimer's disease (progressive brain disorder that causes memory loss, confusion, and other cognitive decline), dysphagia (difficulty swallowing foods and liquids), anxiety disorder (mental health condition characterized by excessive worry, fear, and nervousness that can interfere with daily life) , repeated falls (two or more falls occurring within a specific timeframe, most commonly defined as a 12-month period but sometimes also using a 6-month period), dementia (general term for a group of brain disorders that cause a progressive decline in cognitive abilities, such as: memory, thinking, language, judgment, problem-solving, and behavior), bipolar disorder (a chronic mental health condition characterized by extreme mood swings between periods of mania (elevated mood) and depression) and psychosis (mental health condition characterized by a loss of touch with reality). Record review of Resident #75's incident report dated 06/11/2025 reflected she had a fall and was found lying on the fall mat on the floor.' Record review of Resident #75's annual MDS assessment with an ARD of 08/21/2025 reflected she was usually understood and sometimes understands. She scored 3 of 15 on her BIMS which indicated her cognitive status was severely impaired. She was dependent on her ADLs. Review of section J1800 Any Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), reflected a 0 which indicated No. Her previous quarterly MDS assessment was completed on 05/22/2025. Record review of Resident #75's comprehensive care plan dated 06/11/2025 reflected Focus, resident is high risk for falls r/t resident has no safety awareness, 06/11/2025-Found sitting on fall mat in room, Interventions, bed in lowest position, fall mats on floor. During an interview on 10/03/2025 at 07:41 am with LVN E revealed she had miscoded Resident #45's quarterly MDS assessment because aspirin was not considered an anticoagulant. She stated she should have checked off antiplatelet. She stated that an inaccurate MDS assessment did not reflect the residents and could affect the care of the residents with misinformation. She stated she did not know why she coded Resident #43's MDS to show she took an anticoagulant and did not code antiplatelet. She stated Resident #62's quarterly MDS dated [DATE] did not reflect she took an antipsychotic medication or an antiplatelet when she took Risperidone and Aspirin daily. LVN E stated Resident #62's fall in on 06/11/2025 was between assessment periods and her annual MDS assessment dated [DATE] should have reflected the fall. During an interview on 10/03/2025 at 08:56 am, the DON stated it was important to have the correct information to accurately reflect the resident's condition on the MDS. She stated care could be missed or the residents might receive inappropriate care because the MDS information was transferred to the comprehensive care plan. She stated Resident #43 was prescribed an antiplatelet and not an anticoagulant and that it needed to be coded accurately on the MDS and care planned because the two medications worked differently. She stated Resident #62's Risperidone and Aspirin needed to be coded on her MDS and Resident #75's fall needed to be reflected. During an interview on 10/03/2025 at 09:30 am, the ADM stated the MDS was important, and he was accountable for some of the MDS. He stated the information from the MDS assessments is transferred to the care plan and if the MDS was inaccurate, the care plan could be, and care could be missed for a resident. 4. Record review of Resident #106's face sheet dated 10/01/2025, revealed Resident #25 was admitted to the facility on [DATE], readmitted on [DATE] with diagnoses that included: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, hypertension (high blood pressure), hypothyroidism (thyroid gland doesn't make and release enough hormone into the bloodstream), and atherosclerotic heart disease of native coronary artery without angina pectoris (heart tissue isn't receiving enough oxygen-rich blood due to narrowed or blocked arteries). Record review of Resident #106's progress note revealed a progress note dated 07/26/2025 that reflected [ambulance company name] here to pick up resident and take her home, belongings/medications signed by EMS driver, all belongings taken with resident, resident left facility by stretcher,. Resident #106's progress notes further revealed a note dated 07/17/2025 that reflected, Respite day 3/11. Resident will be private pay the 20th-25th. Patient adjusting well, good appetite with no signs of pain or distress this shift. Record review of Resident #106's physician order summary dated, 10/01/2025, reflected admit to respite for care giver relief for 5 days from 07/15/25 - 07/20/25, will remain at [facility name] from 07/20/25 - 07/25/25 private pay. Record review of Resident #106's Discharge MDS assessment, dated 07/26/2025 revealed Section A0310 F of discharge assessment - return not anticipated. Section A0310 G further revealed the type of discharge code as a 2 for unplanned. During an interview on 10/01/2025 at 3:34 p.m. the MDS coordinator stated the Discharge MDS Assessment was miscoded, and it was just an error. The MDS coordinator further stated the Discharge MDS assessment should have been coded 1 for planned discharge after having reviewed Resident #106's orders and electronic medical record. The MDS coordinator stated she was responsible for the coding of the MDS and for the accuracy of the MDS assessments. During an interview on 10/03/2025 at 1:55 p.m. the ADM stated the MDS coordinator was responsible for the MDS assessment accuracy and there was an offsite consultant that also oversaw the MDS coordinator. The ADM stated by miscoding MDS assessment could have caused issues with the payment of a resident's care. Record review of the CMS RAI Version MDS 3.0 Manual dated October 2025 revealed in part, .The OBRA regulations require nursing homes that are Medicare certified, Medicaid certified or both, to conduct initial and periodic assessments for all their residents. The Resident Assessment Instrument (RAI) process is the basis for the accurate assessment of each resident. Section A: Identification Information Intent: The intent of this section is to obtain the reasons for assessment, administrative information, and key demographic information to uniquely identify each resident.Coding instructions for A0310G, type of discharge (complete only if A030F =10 or 11). Enter the number corresponding to the type of discharge. Code 1: if type of discharge is a planned discharge. Code 2: if type of discharge is an unplanned discharge. Record review of the facility policy and procedure titled Resident Assessment Instrument (undated) reflected The purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity, information derived from the comprehensive assessment helps the staff to plan care that allows the resident to reach his/her highest practicable level of functioning. Record review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.20.1, October 2025 reflected The RAI process has multiple regulatory requirements . (1) the assessment accurately reflects the resident's status.

Based on observations, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 3 residents (Resident #37, #62 and #75) of 32 residents reviewed for care plans. 1. Resident #37's comprehensive care plan did not reflect that she required a leg strap to hold her indwelling catheter tubing in place. 2. Resident #62's comprehensive care plan did not reflect she had hypothyroidism as an active diagnosis or her use of an antiplatelet medication. 3. Resident 75's comprehensive care plan did not reflect that she had electronic monitoring in her room. This facility failure affects residents at the facility and could result in missed or inaccurate care provided. Findings included:1.Record review of Resident #37's electronic face sheet dated 10/02/2025 reflected she was a [AGE] year-old female who was readmitted to the facility on [DATE]. Her diagnoses included fracture of unspecified part of neck of left femur (a break in the neck of the thigh bone), chronic obstructive pulmonary disease (lung disease characterized by ongoing inflammation and narrowing of the airways, leading to airflow obstruction and breathing difficulties), permanent atrial fibrillation (condition where the heart's upper chambers beat irregularly and rapidly for an extended period, and it is not possible to restore a normal heart rhythm through treatment), and retention of urine (inability to empty the bladder completely). Record review of Resident #37's annual MDS assessment with an ARD of 07/24/2025 reflected that she could understand and be understood. She scored a 10 of 15 on her BIMS which indicated her cognitive status was moderately impaired. She had an indwelling urinary catheter. She required partial assistance with her ADLs. Record review of Resident #37's Active Orders as of: 10/02/2025 reflected Foley leg strap/tubing: secure tubing with leg strap in place at all times to prevent pulling, start date 08/14/2024. Record review of Resident #37's comprehensive care plan dated 04/04/2025 reflected Focus, has an indwelling catheter, interventions, check tubing for kinks each shift. Resident #37's need for a urinary catheter leg strap was not reflected. 2. Record review of Resident #62's electronic face sheet dated 09/30/2025 reflected she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included: chronic obstructive pulmonary disease (a group of lung diseases that cause ongoing inflammation and narrowing of the airways, making it difficult to breathe), dementia (condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), type II diabetes mellitus (chronic condition where the body does not use insulin effectively or does not produce enough insulin to regulate blood sugar levels), major depressive disorder (common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities) and bipolar disorder (chronic mental health condition characterized by extreme mood swings between mania (high energy, euphoria, and impulsivity), hypothyroidism (when the thyroid gland does not make and release enough hormone into the bloodstream which can cause fatigue and weight gain) and depression (low mood, fatigue, and hopelessness). Record review of Resident #62's quarterly MDS assessment with an ARD of 09/24/2025 reflected she usually understood and could usually understand. She scored an 8 of 15 on her BIMS which signified her cognitive status was moderately impaired. She required substantial assistance with most of her ADLs. She was coded to have an active diagnosis of hypothyroidism. Record review of Resident #62's Active Orders as of: 09/30/2025 reflected she took Levothyroxine Sodium, one tablet each day for hypothyroidism since 05/21/2025. Resident #62's orders reflected she took Aspirin EC Low Dose 81 mg, one tablet po each day since 05/23/2025. Record review of Resident #62's comprehensive care plan dated 09/21/2025 did not reflect she was treated for hypothyroidism, or she took an antiplatelet. 3.Record review of Resident #75's electronic face sheet dated 09/30/2025 reflected she was an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included: Alzheimer's disease (progressive brain disorder that causes memory loss, confusion, and other cognitive decline), dysphagia (difficulty swallowing foods and liquids), anxiety disorder (mental health condition characterized by excessive worry, fear, and nervousness that can interfere with daily life) , repeated falls (two or more falls occurring within a specific timeframe, most commonly defined as a 12-month period but sometimes also using a 6-month period), dementia (general term for a group of brain disorders that cause a progressive decline in cognitive abilities, such as: memory, thinking, language, judgment, problem-solving, and behavior), bipolar disorder (a chronic mental health condition characterized by extreme mood swings between periods of mania (elevated mood) and depression) and psychosis (mental health condition characterized by a loss of touch with reality). Record review of Resident #75's annual MDS assessment with an ARD of 08/21/2025 reflected she was usually understood and sometimes understands. She scored 3 of 15 on her BIMS which indicated her cognitive status was severely impaired. She was dependent on her ADLs. Observation on 09/30/2025 at 09:40 am revealed signage on Resident #75's room which indicated Electronic Monitoring was used in the room. A camera could be seen in the room from the doorway which triggered with motion. Record review of a consent dated 07/05/2025 reflected Resident #75's family member who was her RP had consented to electronic monitoring. Record review of Resident #75's comprehensive care plan dated 06/11/2025 did not reflect that she had electronic monitoring in her room. During an interview on 10/03/2025 at 07:41 am with LVN E revealed that the care plan was part of the IDT development. She stated Resident #37's leg strap needed to be care planned because it was a specific part of her care. She stated Resident #62's antiplatelet, and hypothyroidism needed to be care planned and did not know how they were missed. She said the care plan tells others what care the resident required specific to that resident. She stated Resident #75's electronic monitoring was a preference which needed to be care planned to let others know her family wanted the monitoring in place to observe her care and condition and that was their right. During an interview on 10/03/2025 at 08:56 am, the DON stated it was important for the care plan to be accurate because it communicated to others the residents care requirements or preferences. She stated Resident #37's catheter leg strap needed to be care planned, Resident #62's hypothyroidism and antiplatelet, and Resident #45's electronic monitoring needed to be care planned because care could be missed without the information being transferred to the Kardex (care form for CNA's) about the resident. During an interview on 10/03/2025 at 09:30 am, the ADM stated information from the MDS assessments is transferred to the care plan and if the MDS was inaccurate, the care plan could be, and care could be missed for a resident. Record review of the facility policy and procedure titled Comprehensive Assessment and the Care Delivery Process (undated) reflected Comprehensive assessments, care planning and the care delivery process involve collecting and analyzing information, choosing and initiating interventions, and then monitoring results and adjusting interventions. Record review of the facility policy and procedure titled Care Plans, Comprehensive Person-Centered dated December 2016 reflected The IDT, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident, the comprehensive, person-centered care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychological well-being.

Based on observations, interviews and records reviews the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preference for 4 residents (Resident #35, Resident #43, Resident #45, and Resident #62) of 4 residents observed for oxygen therapy.1. The Facility failed to ensure Resident #35 had an order for the use of oxygen with the liters per minute to be used.2. Resident #43 was observed in the dining room with a portable oxygen tank set on 2L/min via NC and the pressure gauge needle was in the red zone (which indicated near empty or empty and requires immediate attention).3. Resident #62 was sitting in a common area prior to lunch near the 200 Hall nurses' station at a table with a portable oxygen tank set on 2L/min via NC and the pressure gauge needle was in the red zone.This facility failure affects residents who receive oxygen therapy and could result in hypoxia (low oxygen in blood) or respiratory distress.The findings included:1. Record review of Resident #35's face sheet, dated 10/01/2025, revealed Resident #35 was admitted on [DATE] with diagnoses which included: obesity, class 3 (a complex chronic disease in which you have a body mass index (BMI) of 40 or higher), pulmonary hypertension (high blood pressure that affects the arteries in the lungs and the right side of the heart), unspecified, (congestive) heart failure, pleural effusion (collection of fluid around your lungs), not elsewhere classified, and fluid overload, unspecified. Record review of Resident #35's admission assessment, dated 09/19/2025, revealed Resident #35's BIMs score was 14 noting intact cognition. The admission assessment further revealed Resident #35 receiving oxygen therapy while a resident. Record review of Resident #35's care plan with an initiated date of 09/21/2025, revealed Resident #35 had a Focus: The resident has Oxygen Therapy r/t ineffective gas exchange. Record review of Resident #35's physician's order summary report, dated 10/01/2025, revealed there were not any orders for Resident #35 to receive oxygen and did not have orders for number of liters per minute. Observation on 09/30/2025 at 10:02 a.m. revealed an EBP (Enhanced Barrier Precaution) sign to Resident #35's room door with supplies present outside of the room and an oxygen in use sign present. Resident #35 was observed to be lying in his bed wearing oxygen with it set at 2.5 liters. During interview and observation on 10/01/2025 at 3:09 p.m. Resident #35 stated he used his oxygen pretty much all the time and took a portable tank with him when going to dialysis. Resident #35 further stated his oxygen was usually set at 2 or 3 liters when using it. Resident #35 was observed wearing oxygen during the interview. During an interview and observation on 10/01/2025 at 3:25 p.m. LVN H stated Resident #35 preferred to wear his oxygen continuously. LVN H stated she believed Resident #35 was supposed to have his oxygen set at 3 liters. LVN H reviewed Resident #35's physician's orders and stated she did not see an order. LVN H stated there should have been an order for oxygen. LVN H stated usually the use of oxygen was verified by the physician when reviewing admission orders with them. LVN H further stated Resident #35 was alert and oriented times 4 and was able to tell her what his oxygen was supposed to be set at. LVN H stated they needed an order for everything. During an interview on 10/01/2025 at 3:41 p.m. the DON stated the use of oxygen once would have been considered a nursing judgment, but the nurse needed to put an order in. The DON stated orders informed the staff if the oxygen was to be used PRN or continuously, if the resident had respiratory problems and it would tell them how many liters were supposed to be used. The DON further stated the ADON would do chart audits and was not sure why Resident #35 did not have the lack of an order was not caught. The DON stated it was the nurse's responsibility to get the order for oxygen use and how much to give. The DON stated he came with an order for PRN oxygen use after having reviewed Resident #35's clinical records sent with him. During an interview on 10/03/2025 at 1:59 p.m. the ADM stated Resident #35 should have had orders for oxygen use due to having to have an order for any care provided. The ADM stated the nursing staff were responsible for ensuring orders were written. 2. Record review of Resident #43's electronic face sheet dated 09/30/2025 reflected she was a [AGE] year-old female who was readmitted to the facility on [DATE]. Her diagnoses included: chronic obstructive pulmonary disease (a group of lung diseases that cause ongoing inflammation and narrowing of the airways, making it difficult to breathe), type II diabetes mellitus (chronic condition where the body does not use insulin effectively or does not produce enough insulin to regulate blood sugar levels), dysphagia (difficulty or discomfort in swallowing), dementia (condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), depression (common mental health condition characterized by persistent feelings of sadness hopelessness, and loss of interest or pleasure in activities), and cognitive communication deficit (condition that affects the brain's ability to perform mental processes, such as attention, memory, reasoning and problem-solving, which impairs ability to communicate effectively). Record review of Resident #43's quarterly MDS assessment with an ARD of 09/12/2025 reflected she sometimes understood and could sometimes understand. She scored a 00 of 15 on her BIMS which indicated her cognitive status was severely impaired. She was dependent on most of her ADLs. She received therapeutic oxygen while she was a resident. Record review of Resident #43's comprehensive care plan dated 03/18/2025 reflected Focus, has oxygen therapy, interventions, for residents who should be ambulatory, provide extension tubing or portable oxygen, if a resident is allowed to eat, oxygen still must be given to the resident. Record review of Resident #43's Active Orders as of: 09/01/2025 reflected Oxygen at 2-4 L/Min via NC, on continuous every shift for shortness of breath, start date 06/04/2025. Observation on 09/30/2025 at 11:40 pm of Resident #43 in the dining room sitting at a table waiting for lunch to be served revealed she had oxygen via a portable tank set at 2L/Min, and the pressure gauge was in the red zone. She did not appear in respiratory distress. Observation on 09/30/2025 at 12:15 pm with the DON revealed Resident #43 in the dining room and her portable oxygen tank gauge was in the red zone. She did not appear in respiratory distress or have signs of difficulty breathing. Interview on 10/01/2025 at 07:30 am, LVN A who was Resident #43's nurse on 09/30/2025, stated an E tank lasted about 4 hours and the pressure gauge should not get into the red zone because it indicated oxygen pressure was low or gone. She stated she was busy and did not think to check Resident #43's oxygen tank until the DON directed her to it. She stated Resident #43 had no signs of respiratory distress or shortness of breath. She stated she was trained to change out the portable oxygen tank when the pressure gauge was near or in the red zone. 3. Record review of Resident #62's electronic face sheet dated 09/30/2025 reflected she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included: chronic obstructive pulmonary disease (a group of lung diseases that cause ongoing inflammation and narrowing of the airways, making it difficult to breathe), dementia (condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), type II diabetes mellitus (chronic condition where the body does not use insulin effectively or does not produce enough insulin to regulate blood sugar levels), major depressive disorder (common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities) and bipolar disorder (chronic mental health condition characterized by extreme mood swings between mania (high energy, euphoria, and impulsivity), hypothyroidism (when the thyroid gland does not make and release enough hormone into the bloodstream which can cause fatigue and weight gain) and depression (low mood, fatigue, and hopelessness). Record review of Resident #62's quarterly MDS assessment with an ARD of 09/24/2025 reflected she usually understood and could usually understand. She scored an 8 of 15 on her BIMS which signified her cognitive status was moderately impaired. She required substantial assistance with most of her ADLs. She received therapeutic oxygen while a resident. Record review of Resident #62's comprehensive care plan dated 07/22/2025 reflected Focus, has oxygen therapy r/t COPD, interventions, for residents who should be ambulatory, provide extension tubing or portable oxygen, if the resident is allowed to eat, oxygen still must be given. Observation on 09/30/2025 at 11:20 pm of Resident #62 sitting at a table near the nurses' station on 200 Hall revealed she had a portable oxygen tank set at 2L/Min via NC and her oxygen pressure gauge was in the red zone. She did not appear to be in respiratory distress. Observation on 09/30/2025 at 12:00 pm of Resident #62 with the DON revealed she was sitting at a table near the nurses' station on 200 Hall and had a portable oxygen tank and the oxygen pressure gauge was in the red zone. Interview at 10/01/2025 at 7:15 am, RN F who was Resident #62's nurse on 09/30/2025 stated Resident #62 got up out of bed at 07:00 am and he had equipped her with a full oxygen tank. He stated a portable oxygen E tank at 2L/Min last 4 hours and needed to be changed. He stated the tank gauge should not be in the red and he should have checked the tank and did not think about it. He stated he checked the resident, and she did not appear to be in respiratory distress or having difficulty breathing. He stated he felt air flow coming through the tubing when he changed the tank. He stated he was trained to change out a portable oxygen tank when the pressure indicator was low or near the red zone. During an interview on 10/03/2025 at 08:56 am, the DON stated she was accountable for the nursing care in the facility and the nurses needed to check the portable oxygen tanks. She stated the tank pressure gauges should never get into the red zone. She stated when a tank is near empty moisture can get into the tank due to the low pressure and can damage the integrity of the tank which can cause rust on the inside. She stated the oxygen pressure gauge needed to be checked frequently and nurses needed to make sure residents received their adequate oxygen flow to prevent respiratory distress. Record review of the facility's policy titled Safety and Supervision of Residents Oxygen, effective date, 11/28/2020, revealed Objective: To ensure sanitary, appropriate use and storage of oxygen cylinders for safety of all residents. Policy: Facility must ensure use of oxygen safely maintain or improve respiratory status by 1. ensuring complete physician order for device including administration rate and time. Record review of the facility's policy titled Oxygen Administration, revised date, November 2011, revealed Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen administration.

Based on interview and record review, the facility failed to develop, implement, and maintain an effective training program for all new and existing staff for 19 of 24 (Administrator, DON, Dietary Manager, Activity Director, Social Worker, LVN G, LVN L, CNA M, CNA N, CNA O, Restorative Aide P, CNA Q, CNA R, CNA S, CNA T, RN U, RN V, LVN W, and ADON X) employees reviewed for training requirements. The facility failed to implement and maintain a training program that ensured Social Worker, Dietary Manager and Restorative Aide P received required trainings upon hire. The facility failed to implement and maintain a training program that ensured Administrator, DON, Activity Director, LVN G, LVN L, CNA M, CNA N, CNA O, CNA Q, CNA R, CNA S, CNA T, RN U, RN V, LVN W, and ADON X received required training annually. This failure could place residents at risk of being cared for by staff who have been insufficiently trained. The findings were: Record review of personnel record for Administrator revealed hire date of 02/08/2021. Review of the training log for the previous 12 months provided by human resources revealed no evidence that the Administrator completed the required annual training. Record review of personnel record for DON revealed hire date of 11/21/2022. Review of training log for the previous 12 months provided by human resources revealed no evidence that DON completed the required annual training. Record review of personnel record for Dietary Manager revealed hire date of 09/02/2025. Review of the training log provided by human resources revealed the Dietary Manager did not complete the required training upon hire. Record review of personnel record for Activity Director revealed hire date of 01/05/2021. Review of the training log for the previous 12 months provided by human resources revealed no evidence that the Activity Director completed the required annual training. Record review of personnel record for Social Worker revealed hire date of 09/02/2025. Review of training log provided by human resources revealed the Social Worker did not complete the required training upon hire. Record review of personnel record for LVN G revealed hire date of 02/10/2021. Review of the training log for the previous 12 months provided by human resources revealed no evidence that LVN G completed the required annual training. Record review of personnel record for LVN L revealed hire date of 06/24/2022. Review of the training log for the previous 12 months provided by human resources revealed no evidence that LVN L completed the required annual training. Record review of personnel record for CNA M revealed hire date of 08/02/2024. Review of the training log for the previous 12 months provided by human resources revealed no evidence that CNA M completed the required annual training. Record review of personnel record for CNA N revealed hire date of 12/20/2023. Review of training log for the previous 12 months provided by human resources revealed no evidence that CNA N completed the required annual training. Record review of personnel record for CNA O revealed hire date of 11/08/2023. Review of the training log for the previous 12 months provided by human resources revealed no evidence that CNA O completed the required annual training. Record review of personnel record for Restorative Aide P revealed hire date of 08/26/2025. Review of training log provided by human resources revealed Restorative Aide P did not complete the required training upon hire. Record review of personnel record for CNA Q revealed hire date of 01/23/2023. Review of the training log for the previous 12 months provided by human resources revealed no evidence that CNA Q completed the required annual training. Record review of personnel record for CNA R revealed hire date of 02/10/2021. Review of the training log for the previous 12 months provided by human resources revealed no evidence that CNA R completed the required annual training. Record review of personnel record for CNA S revealed hire date of 01/23/2022. Review of the training log for the previous 12 months provided by human resources revealed no evidence that CNA S completed the required annual training. Record review of personnel record for CNA T revealed hire date of 06/06/2024. Review of the training log for the previous 12 months provided by human resources revealed no evidence that CNA T completed the required annual training. Record review of personnel record for RN U revealed hire date of 09/21/2022. Review of the training log for the previous 12 months provided by human resources revealed no evidence that RN U completed the required annual training. Record review of personnel record for RN V revealed hire date of 03/07/2024. Review of training log for the previous 12 months provided by human resources revealed no evidence that RN V completed the required annual training. Record review of personnel record for LVN W revealed hire date of 01/13/2023. Review of the training log for the previous 12 months provided by human resources revealed no evidence that LVN W completed the required annual training. Record review of personnel record for ADON X revealed hire date of 08/18/2018. Review of the training log for the previous 12 months provided by human resources revealed no evidence that ADON X completed the required annual training. Interview with HR on 10/03/2025 at 2:01 PM revealed the facility had a training packet that staff were to complete upon hire and then again annually. HR stated the training packet did not include communication training, QAPI training, or ethics training. HR stated it was the responsibility of HR and ADON to ensure staff complete the training packet upon hire and annually. HR stated by not ensuring staff completed all required training upon hire and again annually could lead to mistreatment or neglect of the residents. Interview with ADON X on 10/03/2025 at 2:10 PM revealed she and HR were responsible for ensuring staff complete their initial training upon hire and again annually. ADON X stated there was a training packet that she used to train the staff. ADON X stated she was unaware that communication training, QAPI training and ethics training were not in the packet. ADON X stated it was important to completely train staff to ensure residents received good care. Interview with DON on 10/03/2025 at 2:32 PM revealed she supervised the ADON who was responsible for ensuring staff receive training upon hire and annually. DON stated she was not aware that communication training, QAPI training and ethics training were not included in the training. DON stated by not ensuring staff completed all required training upon hire and again annually could lead to mistreatment or neglect of the residents. Interview with the Administrator on 10/03/2025 at 2:37 PM revealed he was ultimately responsible for ensuring staff received the required training upon hire and annually since he supervised HR and ADON X. The Administrator stated he was unaware that the training packet did not include communication training, QAPI training, or ethics training. The Administrator stated it was important that staff received the required training to ensure residents received good quality care. A policy identifying required training topics and frequency of training was requested on 10/03/2025 at 2:01 PM from HR and again from the Administrator on 10/03/2025 at 2:37 PM but was not provided prior to exit.

Based on interview and record review, the facility failed to ensure QAPI training was completed by new and existing staff for 19 of 24 (Administrator, DON, Dietary Manager, Activity Director, Social Worker, LVN G, LVN L, CNA M, CNA N, CNA O, Restorative Aide P, CNA Q, CNA R, CNA S, CNA T, RN U, RN V, LVN W, and ADON X) employees reviewed for training requirements. The facility failed to provide QAPI training was completed by Social Worker, Dietary Manager and Restorative Aide P upon hire. The facility failed to provide QAPI training was completed by Administrator, DON, Activity Director, LVN G, LVN L, CNA M, CNA N, CNA O, CNA Q, CNA R, CNA S, CNA T, RN U, RN V, LVN W, and ADON X annually. This failure could place residents at risk of being cared for by staff who have been insufficiently trained.The findings were: Record review of personnel record for Administrator revealed hire date of 02/08/2021. Review of the training log for the previous 12 months provided by human resources revealed no evidence that the Administrator completed QAPI training annually. Record review of personnel record for DON revealed hire date of 11/21/2022. Review of training log for the previous 12 months provided by human resources revealed no evidence that DON completed QAPI training annually. Record review of personnel record for Dietary Manager revealed hire date of 09/02/2025. Review of the training log provided by human resources revealed the Dietary Manager did not complete QAPI training upon hire. Record review of personnel record for Activity Director revealed hire date of 01/05/2021. Review of the training log for the previous 12 months provided by human resources revealed no evidence that the Activity Director completed QAPI training annually. Record review of personnel record for Social Worker revealed hire date of 09/02/2025. Review of training log provided by human resources revealed the Social Worker did not complete QAPI training upon hire. Record review of personnel record for LVN G revealed hire date of 02/10/2021. Review of the training log for the previous 12 months provided by human resources revealed no evidence that LVN G completed QAPI training annually. Record review of personnel record for LVN L revealed hire date of 06/24/2022. Review of the training log for the previous 12 months provided by human resources revealed no evidence that LVN L completed QAPI training annually. Record review of personnel record for CNA M revealed hire date of 08/02/2024. Review of the training log for the previous 12 months provided by human resources revealed no evidence that CNA M completed QAPI training annually. Record review of personnel record for CNA N revealed hire date of 12/20/2023. Review of training log for the previous 12 months provided by human resources revealed no evidence that CNA N completed QAPI training annually. Record review of personnel record for CNA O revealed hire date of 11/08/2023. Review of the training log for the previous 12 months provided by human resources revealed no evidence that CNA O completed QAPI training annually. Record review of personnel record for Restorative Aide P revealed hire date of 08/26/2025. Review of training log provided by human resources revealed Restorative Aide P did not complete the QAPI training upon hire. Record review of personnel record for CNA Q revealed hire date of 01/23/2023. Review of the training log for the previous 12 months provided by human resources revealed no evidence that CNA Q completed QAPI training annually. Record review of personnel record for CNA R revealed hire date of 02/10/2021. Review of the training log for the previous 12 months provided by human resources revealed no evidence that CNA R completed QAPI training annually. Record review of personnel record for CNA S revealed hire date of 01/23/2022. Review of the training log for the previous 12 months provided by human resources revealed no evidence that CNA S completed QAPI training annually. Record review of personnel record for CNA T revealed hire date of 06/06/2024. Review of the training log for the previous 12 months provided by human resources revealed no evidence that CNA T completed QAPI training annually. Record review of personnel record for RN U revealed hire date of 09/21/2022. Review of the training log for the previous 12 months provided by human resources revealed no evidence that RN U completed QAPI training annually. Record review of personnel record for RN V revealed hire date of 03/07/2024. Review of training log for the previous 12 months provided by human resources revealed no evidence that RN V completed QAPI training annually. Record review of personnel record for LVN W revealed hire date of 01/13/2023. Review of the training log for the previous 12 months provided by human resources revealed no evidence that LVN W completed QAPI training annually. Record review of personnel record for ADON X revealed hire date of 08/18/2018. Review of the training log for the previous 12 months provided by human resources revealed no evidence that RN X completed QAPI training annually. Interview with HR on 10/03/2025 at 2:01 PM revealed the facility had a training packet that staff were to complete upon hire and then again annually. HR stated the training packet does not include QAPI training. HR stated it was the responsibility of HR and ADON to ensure staff complete the training packet upon hire and annually. HR stated by not ensuring staff completed all required training upon hire and again annually could lead to mistreatment or neglect of the residents. Interview with ADON X on 10/03/2025 at 2:10 PM revealed she and HR were responsible for ensuring staff complete their initial training upon hire and again annually. ADON X stated there was a training packet that she used to train the staff. ADON X stated she was unaware that QAPI training was not in the packet. ADON X stated it was important to completely train staff to ensure residents received good care. Interview with DON on 10/03/2025 at 2:32 PM revealed she supervised the ADON who was responsible for ensuring staff receive training upon hire and annually. DON stated she was not aware that QAPI training was not included in the training. DON stated by not ensuring staff completed all required training upon hire and again annually could lead to mistreatment or neglect of the residents. Interview with the Administrator on 10/03/2025 at 2:37 PM revealed he was ultimately responsible for ensuring staff received the required training upon hire and annually since he supervised HR and ADON X. The Administrator stated he was unaware that the training packet does not include QAPI training. The Administrator stated it was important that staff received the required training to ensure residents received good quality care. A policy identifying required training topics and frequency of training was requested on 10/03/2025 at 2:01 PM from HR and again from the Administrator on 10/03/2025 at 2:37 PM but was not provided prior to exit.

Based on interview and record review, the facility failed to ensure ethics training was completed by new and existing staff for 19 of 24 (Administrator, DON, Dietary Manager, Activity Director, Social Worker, LVN G, LVN L, CNA M, CNA N, CNA O, Restorative Aide P, CNA Q, CNA R, CNA S, CNA T, RN U, RN V, LVN W, and ADON X) employees reviewed for training requirements. The facility failed to ensure ethics training was completed by Social Worker, Dietary Manager and Restorative Aide P upon hire. The facility failed to ensure ethics training was completed by Administrator, DON, Activity Director, LVN G, LVN L, CNA M, CNA N, CNA O, CNA Q, CNA R, CNA S, CNA T, RN U, RN V, LVN W, and ADON X annually. This failure could place residents at risk of being cared for by staff who have been insufficiently trained. The findings were: Record review of personnel record for Administrator revealed hire date of 02/08/2021. Review of the training log for the previous 12 months provided by human resources revealed no evidence that the Administrator completed ethics training annually. Record review of personnel record for DON revealed hire date of 11/21/2022. Review of training log for the previous 12 months provided by human resources revealed no evidence that DON completed ethics training annually. Record review of personnel record for Dietary Manager revealed hire date of 09/02/2025. Review of the training log provided by human resources revealed the Dietary Manager did not complete ethics training upon hire. Record review of personnel record for Activity Director revealed hire date of 01/05/2021. Review of the training log for the previous 12 months provided by human resources revealed no evidence that the Activity Director completed ethics training annually. Record review of personnel record for Social Worker revealed hire date of 09/02/2025. Review of training log provided by human resources revealed the Social Worker did not complete ethics training upon hire. Record review of personnel record for LVN G revealed hire date of 02/10/2021. Review of the training log for the previous 12 months provided by human resources revealed no evidence that LVN G completed ethics training annually. Record review of personnel record for LVN L revealed hire date of 06/24/2022. Review of the training log for the previous 12 months provided by human resources revealed no evidence that LVN L completed ethics training annually. Record review of personnel record for CNA M revealed hire date of 08/02/2024. Review of the training log for the previous 12 months provided by human resources revealed no evidence that CNA M completed ethics training annually. Record review of personnel record for CNA N revealed hire date of 12/20/2023. Review of training log for the previous 12 months provided by human resources revealed no evidence that CNA N completed ethics training annually. Record review of personnel record for CNA O revealed hire date of 11/08/2023. Review of the training log for the previous 12 months provided by human resources revealed no evidence that CNA O completed ethics training annually. Record review of personnel record for Restorative Aide P revealed hire date of 08/26/2025. Review of training log provided by human resources revealed Restorative Aide P did not complete the ethics training upon hire. Record review of personnel record for CNA Q revealed hire date of 01/23/2023. Review of the training log for the previous 12 months provided by human resources revealed no evidence that CNA Q completed ethics training annually. Record review of personnel record for CNA R revealed hire date of 02/10/2021. Review of the training log for the previous 12 months provided by human resources revealed no evidence that CNA R completed ethics training annually. Record review of personnel record for CNA S revealed hire date of 01/23/2022. Review of the training log for the previous 12 months provided by human resources revealed no evidence that CNA S completed ethics training annually. Record review of personnel record for CNA T revealed hire date of 06/06/2024. Review of the training log for the previous 12 months provided by human resources revealed no evidence that CNA T completed ethics training annually. Record review of personnel record for RN U revealed hire date of 09/21/2022. Review of the training log for the previous 12 months provided by human resources revealed no evidence that RN U completed ethics training annually. Record review of personnel record for RN V revealed hire date of 03/07/2024. Review of training log for the previous 12 months provided by human resources revealed no evidence that RN V completed ethics training annually. Record review of personnel record for LVN W revealed hire date of 01/13/2023. Review of the training log for the previous 12 months provided by human resources revealed no evidence that LVN W completed ethics training annually. Record review of personnel record for ADON X revealed hire date of 08/18/2018. Review of the training log for the previous 12 months provided by human resources revealed no evidence that ADON X completed ethics training annually. Interview with HR on 10/03/2025 at 2:01 PM revealed the facility had a training packet that staff were to complete upon hire and then again annually. HR stated the training packet does not include ethics training. HR stated it was the responsibility of HR and ADON to ensure staff complete the training packet upon hire and annually. HR stated by not ensuring staff completed all required training upon hire and again annually could lead to mistreatment or neglect of the residents. Interview with ADON X on 10/03/2025 at 2:10 PM revealed she and HR were responsible for ensuring staff complete their initial training upon hire and again annually. ADON X stated there was a training packet that she used to train the staff. ADON X stated she was unaware that ethics training was not in the packet. ADON X stated it was important to completely train staff to ensure residents received good care. Interview with DON on 10/03/2025 at 2:32 PM revealed she supervised the ADON who was responsible for ensuring staff receive training upon hire and annually. DON stated she was not aware that ethics training was not included in the training. DON stated by not ensuring staff completed all required training upon hire and again annually could lead to mistreatment or neglect of the residents. Interview with the Administrator on 10/03/2025 at 2:37 PM revealed he was ultimately responsible for ensuring staff received the required training upon hire and annually since he supervised HR and ADON X. The Administrator stated he was unaware that the training packet does not include ethics training. The Administrator stated it was important that staff received the required training to ensure residents received good quality care. A policy identifying required training topics and frequency of training was requested on 10/03/2025 at 2:01 PM from HR and again from the Administrator on 10/03/2025 at 2:37 PM but was not provided prior to exit.

Based on interview and record review, the facility failed to ensure CNAs received the required minimum 12 hours annual in-services for 7 of 7 (CNA M, CNA N, CNA O, CNA Q, CNA R, CNA S, CNA T) CNAs reviewed for trainings requirements. The facility failed to provide the required 12 hours of annual training to CNA M, CNA N, CNA O, CNA Q, CNA R, CNA S, CNA T. This failure could place residents at risk of being cared for by staff who have been insufficiently trained.The findings were: Record review of personnel record for CNA M revealed hire date of 08/02/2024. Review of training log for the previous 12 months provided by human resources revealed evidence of less than 12 hours per year of required in-service training being provided annually. Record review of personnel record for CNA N revealed hire date of 12/20/2023. Review of training log for the previous 12 months provided by human resources revealed evidence of less than 12 hours per year of required in-service training being provided annually. Record review of personnel record for CNA O revealed hire date of 11/08/2023. Review of training log for the previous 12 months provided by human resources revealed evidence of less than 12 hours per year of required in-service training being provided annually. Record review of personnel record for CNA Q revealed hire date of 01/23/2023. Review of training log for the previous 12 months provided by human resources revealed evidence of less than 12 hours per year of required in-service training being provided annually. Record review of personnel record for CNA R revealed hire date of 02/10/2021. Review of training log for the previous 12 months provided by human resources revealed evidence of less than 12 hours per year of required in-service training being provided annually. Record review of personnel record for CNA S revealed hire date of 01/23/2022. Review of training log for the previous 12 months provided by human resources revealed evidence of less than 12 hours per year of required in-service training being provided annually. Record review of personnel record for CNA T revealed hire date of 06/06/2024. Review of training log for the previous 12 months provided by human resources revealed evidence of less than 12 hours per year of required in-service training being provided annually. Interview with HR on 10/03/2025 at 2:01 PM revealed the facility had a training packet that staff were to complete upon hire and then again annually. HR stated the training packet does not include communication training, QAPI training, or ethics training. HR stated it was the responsibility of HR and ADON to ensure staff complete the training packet upon hire and annually. HR stated by not ensuring staff completed all required training upon hire and again annually could lead to mistreatment or neglect of the residents. Interview with ADON X on 10/03/2025 at 2:10 PM revealed she and HR were responsible for ensuring staff complete their initial training upon hire and again annually. ADON X stated there was a training packet that she used to train the staff. ADON X stated she was unaware that communication training, QAPI training and ethics training was not in the packet. ADON X stated it was important to completely train staff to ensure residents received good care. Interview with DON on 10/03/2025 at 2:32 PM revealed she supervised the ADON who was responsible for ensuring staff receive training upon hire and annually. DON stated she was not aware that communication training, QAPI training and ethics training were not included in the training. DON stated by not ensuring staff completed all required training upon hire and again annually could lead to mistreatment or neglect of the residents. Interview with the Administrator on 10/03/2025 at 2:37 PM revealed he was ultimately responsible for ensuring staff received the required training upon hire and annually since he supervised HR and ADON X. The Administrator stated he was unaware that the training packet does not include communication training, QAPI training, or ethics training. The Administrator stated it was important that staff received the required training to ensure residents received good quality care. A policy identifying required training topics and frequency of training was requested on 10/03/2025 at 2:01 PM from HR and again from the Administrator on 10/03/2025 at 2:37 PM but was not provided prior to exit.

Based on observations, interviews and record reviews, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 resident (Resident #37) of 3 residents observed with indwelling urinary catheter care. The facility failed to ensure Resident #37 had an indwelling urinary catheter leg strap. This facility failure affects residents with indwelling urinary catheter's and could result in pain, inflammation, dislodgement, and urinary tract infections. The findings included:Record review of Resident #37's electronic face sheet dated 10/02/2025 reflected she was a [AGE] year-old female who was readmitted to the facility on [DATE]. Her diagnoses included fracture of unspecified part of neck of left femur (a break in the neck of the thigh bone), chronic obstructive pulmonary disease (lung disease characterized by ongoing inflammation and narrowing of the airways, leading to airflow obstruction and breathing difficulties), permanent atrial fibrillation (condition where the heart's upper chambers beat irregularly and rapidly for an extended period, and it is not possible to restore a normal heart rhythm through treatment), and retention of urine (inability to empty the bladder completely). Record review of Resident #37's annual MDS assessment with an ARD of 07/24/2025 reflected that she could understand and be understood. She scored a 10 of 15 on her BIMS which indicated her cognitive status was moderately impaired. She had an indwelling urinary catheter. She required partial assistance with her ADLs. Record review of Resident #37's comprehensive care plan dated 04/04/2025 reflected Focus, has an indwelling catheter, interventions, check tubing for kinks each shift. Resident #37's need for a urinary catheter leg strap was not reflected. Record review of Resident #37's Active Orders as of: 10/02/2025 reflected Foley leg strap/tubing: secure tubing with leg strap in place at all times to prevent pulling, start date 08/14/2024.Observation on 10/02/2025 at 08:55 am revealed CNA C performed catheter care for Resident #37, Resident #37 did not have a leg strap. Interview on 10/02/2025 at 09:99 am, CNA C stated Resident #37 usually had a leg strap for her catheter to keep the catheter tubing from pulling and causing discomfort. She stated the nurses monitored the catheter tubing and leg strap. Observation on 10/03/2025 at 07:34 am of Resident #37 revealed she was sitting on the side of her bed in her room and did not have a catheter leg strap in place. Interview on 10/03/2025 at 07:35 am, Resident #37 stated she preferred having a catheter leg strap in place because when the catheter tubing pulled, she felt discomfort. During an interview on 10/03/2025 at 08:56 am, the DON stated it was important for the care plan to be accurate because it communicated to others the residents care requirements or preferences. She stated Resident #37 wanted a urinary catheter leg strap to keep the tubing from pulling or dislodging the bulb that held it in place. She stated trauma to the neck of the bladder could occur and the potential for infections. She stated she was accountable for nursing care in the facility. She stated the leg strap may have gotten wet in the shower and was never replaced. She stated unless a resident refused a leg band it was a standard of care for indwelling urinary catheters. Record review of the facility policy and procedure titled Catheter Care, Urinary, dated September 2014 reflected secure catheter utilizing a leg band.

Based on observation, interview and record review, the facility failed to store medications under appropriate conditions of sanitation, temperature, light, moisture, ventilation, segregation, and security for 1 (200-A unit) of 4 medication carts reviewed for storage.In 200-A unit nursing cart, Resident #47's brand-new eye drop (Latanoprost) was stored at the room temperature on [DATE], but per the label of the eye drop indicated refrigerate. This failure could place residents at risk of not receiving therapeutic effects by using medications that were not refrigerated. The findings included: Record review of Resident #47's face sheet, dated [DATE], revealed the resident was 54-years-old female and admitted to the facility on [DATE] with diagnoses of diffuse traumatic brain injury (tearing of the brain's long connecting nerve fibers that happens when the brain is injured), ataxic gait (poor muscle control that causes clumsy movements), hemiplegia (paralysis of one side of the body), other seasonal allergic rhinitis (runny nose and itch eyes), and dysphagia (difficulty swallowing). Record review of Resident #47's quarterly MDS assessment, dated [DATE], revealed the resident's BIMS was 9 out of 15 indicating the resident had moderate cognitive impairment. Record review of Resident #47's physician's order, dated [DATE], revealed the resident had the order of Latanoprost Ophthalmic Solution 0.005 % (Latanoprost), Instill 1 drop in both eyes every evening shift for eyes. Observation on [DATE] at 2:11 p.m. revealed Resident #47's brand-new eye drops (Latanoprost) were stored at room temperature in the 200-A unit nursing cart. Further observation revealed the resident's brand-new eye drops were labeled Refrigerate on the box. During an interview on [DATE] at 2:17 p.m. LVN-I stated Resident #47's brand-new eye drops (Latanoprost) were stored at room temperature in the 200-A unit nursing cart, but the resident's brand-new eye drops were labeled Refrigerate on the box. Further interview with LVN-I revealed the facility nurses should have stored Resident #47's brand-new eye drops (Latanoprost) in a refrigerator because the label said, Refrigerate. LVN-I said she saw the medication was stored inside the 200-A unit nursing cart since [DATE], but he did not know how long or the reason why the eye drops were stored on the cart instead of the refrigerator. During an interview on [DATE] at 2:17 p.m. the DON stated Resident #47's brand-new eye drops (Latanoprost) would not reach therapeutic effects. Record review of the facility policy, titled Storage of Medications, undated, revealed . 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed, and for storage and expiration - diabetes injections. For Humalog vial (Insulin lispro) and Novolog vial (Insulin aspart), expired 28 days after opening.

Based on observation, interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 32 residents (Resident #75) reviewed for accuracy of medical records. The facility failed to ensure Resident #75's oxygen therapy was documented on her MAR. This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care and treatment. The findings included: Record review of Resident #75's electronic face sheet dated 09/30/2025 reflected she was an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included: Alzheimer's disease (progressive brain disorder that causes memory loss, confusion, and other cognitive decline), dysphagia (difficulty swallowing foods and liquids), anxiety disorder (mental health condition characterized by excessive worry, fear, and nervousness that can interfere with daily life) , repeated falls (two or more falls occurring within a specific timeframe, most commonly defined as a 12-month period but sometimes also using a 6-month period), dementia (general term for a group of brain disorders that cause a progressive decline in cognitive abilities, such as: memory, thinking, language, judgment, problem-solving, and behavior), bipolar disorder (a chronic mental health condition characterized by extreme mood swings between periods of mania (elevated mood) and depression) and psychosis (mental health condition characterized by a loss of touch with reality). Record review of Resident #75's annual MDS assessment with an ARD of 08/21/2025 reflected she was usually understood and sometimes understands. She scored 3 of 15 on her BIMS which indicated her cognitive status was severely impaired. She was dependent on her ADLs. She did not have oxygen therapy. Record review of Resident #75's comprehensive care plan dated 09/09/2025 reflected Focus, treated for URI and had experienced SOB with exertion, interventions, administer oxygen as directed by physician. Record review of Resident #75's Active Orders as of: 09/30/2025 reflected Oxygen at 2-5 L/Min via NC as needed for SOB, maintain O2 saturations greater than 92% as needed, start date 09/22/25. Record review of Resident #75's progress notes written by LVN A for 09/22/2025, 09/23/2025 and 09/24/2025 reflected Resident #75 received oxygen at 2L/Min via NC for SOB. Record review of Resident #75's O2 Saturation Summary (undated) reflected she received oxygen via NC on 09/22/2025, 09/23/2025 and 09/24/2025. Record review of Resident #75's MAR dated September 01-September 30 reflected no initials were present for her PRN oxygen for 09/22/2025, 09/23/2025 and 09/24/2025. Observation on 09/30/2025 at 09:40 am of Resident #75's room revealed an oxygen concentrator with oxygen tubing with NC unbagged and draped over the machine. Interview on 10/01/2025 at 07:30 am, LVN A stated Resident #75's oxygen order was a new order, and she did not think it was on the MAR. She stated she did not look for it on the MAR, checked the resident's saturations and provided the oxygen as ordered. She stated care documentation is a professional standard, and she should have checked and initialed Resident #75's MAR. During an interview on 10/03/2025 at 08:56 am, the DON, stated documentation of nursing care is a professional expectation, and she did not know why it was not done. She stated if it was not documented, it was not done. She stated the MAR was an official part of the resident's clinical record and needed to be completed. She stated she was accountable for the nursing care at the facility, and nurses are trained from school on how and what to document. Record review of the facility policy and procedure titled Safety and Supervision of Residents Oxygen dated 11/28/24 reflected under documentation the date and time the procedure was performed, and the name and title of the individual who performed the procedure.

Based on observations, interviews and record reviews, 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 residents (Resident #57 and #88) of 32 residents observed for infection control. 1. CNA D failed to change her gloves and sanitize her hands between soiled and clean items when she performed incontinent care for Resident #57. 2. CNA C failed to change her gloves and sanitize her hands between soiled and clean items when she and CNA B performed incontinent care for Resident #88. These failures could affect residents and place them at risk for infection. The findings included:1.Record review of Resident #57's electronic face sheet dated 10/02/2025 reflected she was a [AGE] year-old female who was readmitted to the facility on [DATE]. Her diagnoses included: senile degeneration of brain (progressive deterioration of brain tissue and function), anxiety disorder (a feeling of worry, nervousness, or unease), dysphagia (difficulty swallowing) and schizophrenia (a serious mental health condition that affects how people think, feel, and behave). Record review of Resident #57's quarterly MDS assessment with an ARD of 08/15/2025 reflected that she could usually understand and be understood. She scored an 8 of 15 on her BIMS which indicated her cognitive status was moderately impaired. She required moderate to extensive assistance with her ADLs. She was frequently incontinent with bowel and bladder. Record review of Resident #57's comprehensive care plan dated 04/15/2025 reflected Focus, resident is at risk for bowel and bladder incontinence, intervention and goal, keep resident clean, dry and odor free. Observation on 10/01/2025 at 4:09 pm of CNA D performing incontinent care for Resident #57 revealed she cleaned the labia and perineal area (thin layer of skin between the anus and the genitals), took her soiled gloves off, sanitized her hands, put on clean gloves, then cleaned the backside of the resident. CNA D went to clean her hands and put on clean gloves, returned to the bed, and took the clean brief and placed it under Resident #57. She then pulled up the soiled brief from beneath the resident and discarded it. CNA D did not clean hands or change her gloves and continued to complete care after working with the soiled brief. CNA D finished closing the clean brief and straightening out the resident's bedding. During an interview on 10/01/2025 with CNA D, she stated that she forgot to clean her hands again and to put clean gloves on after she took off the residents soiled brief. She stated that cross contamination could occur and cause an infection. She stated she was trained to keep clean and soiled apart from each other. 2.Record review of Resident #88's electronic face sheet reflected he was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included: atherosclerotic heart disease (hardening of the arteries from plaque buildup inside them which limits the flow of blood to the brain and heart), type II diabetes mellitus (a condition that affects how the body uses insulin and sugar), dementia (group of symptoms affecting memory, thinking and social abilities), major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest) and peripheral vascular disease (disorder of the blood vessels outside the heart, and can affect the legs, feet, brain and other organs). Record review of Resident #88's quarterly MDS assessment with an ARD of 07/04/2025 reflected he could understand and be understood. He scored 12 of 15 on his BIMS which indicated his cognitive status was moderately impaired. He was dependent on most of his ADLs. He was always incontinent of bowel and bladder. Record review of Resident #88's comprehensive care plan dated 04/07/2025 reflected Focus, incontinent of bowel and bladder, interventions/goals, keep clean and dry. Observation on 10/02/2025 at 3:30 pm of CNA C and CNA B performing incontinent care for Resident #88 revealed CNA C sanitized her hands and put on clean gloves. She cleaned Resident #88's penis, scrotal area and backside. She then was reminded by CNA B to change the draw sheet which was underneath the resident. CNA C grabbed the clean brief and placed it under the resident with her soiled gloves. She then proceeded to finish pulling through the soiled drawsheet and then picked up the clean brief with her soiled gloves and put it back on her clean area. She then took off her soiled gloves and sanitized her hands and put on clean gloves and grabbed the same brief off the bedside table and reapplied the brief to the resident. During an interview on 10/02/2025 at 3:55 pm with CNA C, she stated she should have gotten a clean brief instead of using the one she had touched with the soiled gloves. She stated cross contamination could occur and cause infections for the residents. She stated she was trained not to mix clean linens with soiled items. During an interview on 10/03/2025 at 08:56 am, the DON stated that she was accountable for the nursing care in the facility. She stated that not sanitizing hands and changing gloves when performing peri care could result in cross contamination, spread of bacteria and lead to urinary tract infections. She stated oxygen tubing when not in use needed to be bagged to prevent particles in the air to get into the equipment. Record review of Clinical Competency Validation, Perineal Care for CNA C and CNA D dated 07/22/25 reflected Cleans hands, puts on gloves, after cleaning soiled areas, wash hands and applies clean gloves. Record review of the facility policy and procedure titled Perineal Care dated February 2018 reflected discard disposable items into designated containers, remove gloves and discard into designated container, wash and dry hands thoroughly, reposition the resident's bed covers.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, and sanitary environment for 2 (Resident #37's room and Resident #8's room) out of 8 Residents' rooms reviewed, in that: 1. In Resident #37's restroom, the floor of the shower area was wet because the shower head was leaking water. 2. In Resident #8's restroom, there were human feces on the floor of the restroom. This deficient practice could result in residents living, staff working, and families visiting in an unsafe, unclean, and unpleasant environment. The findings were: 1. Record review of Resident #37's face sheet, dated 10/03/2025, revealed the resident was a [AGE] year-old female, originally admitted on [DATE], and readmitted to the facility on [DATE] with diagnoses of fracture of unspecified part of neck of left femur Chronic obstructive pulmonary disease (common lung disease causing restricted airflow and breathing problems), muscle weakness, and obstructive and reflux uropathy (condition in which the flow of urine is blocked). Record review of Resident #37's annual MDS assessment, dated 07/24/2025, revealed the resident's BIMS score was 10 out of 15 indicating the resident had moderate cognitive impairment and was Independent (Resident completes the activity by themself with no assistance from a helper) to sit to stand, chair to bed, toilet transfer, and walk with a walker. Record review of Resident #37's comprehensive care plan, dated 08/05/2025, revealed Risk for falls characterized by history of falls/ injury, multiple risk factors related to: impaired balance. For intervention - Ensure environment is free of clutter. Observation on 09/30/2025 at 9:50 a.m. revealed there was a restroom in Resident #37's room, and the restroom had toilet area and shower area without divider. The floor of the shower area was wet with water because the shower head was leaking water. During an interview on 09/30/2025 at 2:28 p.m. with Resident #37 she stated she could use her restroom by herself for showers and toileting, and she did not know the floor of the resident's shower area was wet because the shower head was leaking water. Further interview with Resident #37 revealed she did not have any problem when using her restroom regarding falls, and the facility cleaned her restroom every day. During an interview on 09/30/2025 at 10:54 a.m. RN-K stated in Resident #37's restroom, the floor of the shower area was wet because the shower head was leaking water. RN-K said he worked on 09/29/2025 and did not see any leaking water, so leaking water from the shower head in Resident #37's restroom started on 09/30/2025, and it should have been fixed immediately to prevent possible falls. During an interview on 10/03/2025 at 9:13 a.m. Maintenance stated RN-K reported that the floor of the shower area in Resident #37's restroom was wet because the shower head was leaking water, so the Maintenance fixed it immediately to prevent possible falls, and there was not any other leaking water in the facility. 2. Record review of Resident #8's face sheet, dated 10/03/2025, revealed the resident was 83-years-old female, originally admitted on [DATE], and readmitted to the facility on [DATE] with diagnoses of senile degeneration of brain (a decline in an individual's memory, behavior, and cognitive abilities), Alzheimer's disease (progressive disease that destroy memories and other important mental functions), muscle wasting and atrophy (loss of skeletal muscle mass), and chronic kidney disease stage 1 (mild damage to the kidneys). Record review of Resident #8's quarterly MDS assessment, dated 08/24/2025, revealed the resident's BIMS score was 0 out of 15 indicating the resident had severe cognitive impairment, required Partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) to chair to bed, toilet transfer, and walk, and had frequent urinary incontinence and occasional bowel incontinence. Record review of Resident #8's comprehensive care plan, dated 07/15/2025, revealed The resident is high risk for falls related to resident has no safety awareness confusion, Gait/balance problems, unaware of safety needs, and wandering. For intervention - Ensure environment is free of clutter-humidifier removed. Observation on 09/30/2025 at 10:19 a.m. revealed there was a small lump with brown color on the floor at the left side of toilet inside Resident #8's restroom, and the small lump was old and looked like human feces. An interview was attempted on 09/30/2025 at 10:20 a.m. with Resident #8, but the resident was not able to interview due to impaired cognitive functions. During an interview on 09/30/2025 at 10:35 a.m. LVN-L stated she saw a small lump with brown color on the floor at the left side of toilet inside Resident #8's restroom at the same time as this surveyor and said it was human feces. LVN-L said she did not know what reason the feces were on the floor in Resident #8's restroom because housekeepers cleaned the room every day, and it was not fresh but old. LVN-L said Resident #8's restroom should have been clean always to prevent possible fall and for the resident's quality of life. During an interview on 10/03/2025 at 9:30 a.m. Housekeeping Director stated housekeepers cleaned each resident's room and restroom every day for safety and quality of life, and the Housekeeping Director thought that CNAs working overnight might not clean because the feces found in Resident #8's restroom was old. During an interview on 10/03/2025 at 9:36 a.m. DON said Resident #37 and #8's restrooms should have been clean to prevent possible falls. Record review of the facility policy, titled Quality of Life - Homelike Environment, undated revealed . 2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Clean, sanitary and orderly environment.

Based on observation, interview, and record review, the facility failed to ensure the residents' right to a safe, clean, comfortable and homelike environment for 1 of 1 Beauty Shop, in that:The facility Beauty Shop was found unlocked on 11/25/25 and contained potentially harmful items.This deficient practice could result in residents living in an unsafe environment.The findings were:Observation on 11/25/2025 at 10:32 a.m., revealed the facility Beauty Shop was unlocked and unoccupied, and contained containers of potentially harmful materials including: hairspray labeled flammable, hair dye labeled can cause allergic reaction and may cause skin irritation, sanitizing wipes labeled flammable and avoid contact with eyes, hair setting solution labeled keep out of reach of children', and nail dryer labeled flammable.During an interview with the Administrator on 11/25/2025 at 10:40 a.m., the Administrator confirmed the Beauty Shop should have been secured so that residents would not come into contact with potentially harmful materials. He stated the shop was usually secure and the door must have been left unlocked accidentally. He stated it was the responsibility of all staff who utilize the Beauty Shop to ensure it remained locked when not in use.Record review of the facility policy, Quality of Life, Homelike Environment, undated, revealed, Residents are provided with a safe, clean, comfortable, and homelike environment.

Based on interview and record review, the facility failed to maintain medical records that were complete and accurately documented for 1 of 15 (Resident #1) residents reviewed, in that: Resident #1's diagnoses of Primary Osteoarthritis Left Shoulder, Primary Osteoarthritis Right Shoulder, and Polyneuropathy Unspecified were not listed on his face sheet. This failure could result in inadequate care due to incomplete and inaccurate medical records. The findings were:Record review of Resident #1's face sheet, dated 11/25/2025, revealed he was admitted on [DATE] with diagnoses including: Chronic Respiratory Failure with Hypoxia, Unspecified Protein-Calorie Malnutrition, and Unspecified Combined Systolic (Congestive) and Diastolic (Congestive) Heart Failure. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS score of 15 which indicated intact cognition. Record review of Resident #1's care plan, dated 09/21/2025, revealed Pain related to Immobility. Record review of a provider note from Resident #1's Nurse Practitioner, dated 11/20/2025, revealed a list of diagnoses which included Primary Osteoarthritis Left Shoulder, Primary Osteoarthritis Right Shoulder, and Polyneuropathy Unspecified. Further review of Resident #1's face sheet revealed the diagnoses Primary Osteoarthritis Left Shoulder, Primary Osteoarthritis Right Shoulder, and Polyneuropathy Unspecified were not listed. During an interview with the DON on 11/25/2025 at 12:02 p.m., the DON confirmed that it was important to have all diagnoses listed on the residents' face sheets since it was the primary method of communication to outside providers, including hospitals, of a resident's health status. The DON stated that the Nurse Practitioner had not informed the facility of these diagnoses and that she would address the issue with him to ensure improved communication in the future. Record review of the facility policy, Documentation in Medical Record, 06/06/2025, revealed, Each resident's medical record shall contain an accurate representation of the actual experience of the resident.through complete, accurate, and timely documentation.

Based on observation, interview and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes enhancement of his or her quality of life, recognizing each resident's individuality for 3 of 7 Residents (Resident #71, Resident #101 and Resident #64) who were observed for ADL care. 1. LVN A stood while feeding Resident #71 her lunch meal on 9/24/24 and on 9/25/24. 2. LVN A stood while feeding Resident #101 her lunch meal on 9/25/24. 3. LVN B held the door open while a CNA was talking to him about Resident #64 exposing him to anyone walking down the hallway on 9/26/24. These deficient practices could affect dependent residents and contribute to feelings of shame or feeling uncomfortable. The findings were: 1. Review of Resident #71's face sheet, dated 9/27/24, revealed she was admitted to the facility on [DATE] with diagnosis including Dementia, Schizoaffective Disorder and Major Depressive Disorder, all dated 4/17/23. Review of Resident #71's quarterly MDS assessment, dated 07/25/24, revealed her BIMS was 0 meaning she was unable to complete the Brief Interview for Mental Status. Further review revealed she had a diagnosis of Depression and Schizophrenia and required supervision or touching assistance with eating. Review of Resident #71's Care Plan, revised 04/24/23, , revealed she had a nutritional problem or potential nutritional problem and staff was to encourage meal intake and provide and serve diet as ordered. Further review revealed there was no mention of whether Resident #71 required assistance with feeding. Observation on 09/24/24 at 12:00 to 12:13 PM revealed LVN A standing while feeding Resident #71. Resident #71 was eating her meal while periodically looking up at LVN A. Observation on 09/25/24 from 12:01 PM revealed LVN A feeding Resident #71 while standing up. Resident #71 was eating all of her food while periodically looking up at LVN A. 2. Review of Resident #101's face sheet, dated 9/27/24, revealed she was admitted to the facility on [DATE] with diagnoses including Dementia and Major Depressive Disorder. Review of Resident #101's quarterly MDS assessment, dated 08/16/24, revealed her BIMS was 0 meaning she was unable to complete the Brief Interview for Mental Status. Further review revealed she required partial or moderate assistance with eating. Review of Resident #71's Care Plan, revised 04/24/23, , revealed she had State of nourishment; less than body requirement characterized by weight Loss, inadequate intake, decreased appetite related to: Cognitive Impairment and staff was to Serve large protein portions with all meals. However, there was no mention of whether or not she required assistance with feeding. Observation on 09/25/24 at 12:10 PM revealed LVN A feeding Resident #101 while standing up. Resident #101 was eating her food; constantly talking and grabbing at the spoon. Resident #101 was looking up at LVN A. LVN A sat the lunch tray on a bedside table away from Resident #101. Interview on 09/27/24 at 12:08 PM with LVN A revealed she usually stood while she fed the Residents because she would move from Resident to Resident and sometimes had to intervene related to behaviors. LVN A stated she had to be ready in case anything happened but stated she understood it was a dignity issue because she did not sit at the Resident's eye level and she looked down at them while feeding the Resident's. This caused the Resident's to look up at her. LVN A stated she had not received any formal training for feeding Residents but stated it made sense that she should sit so it allowed for a comfortable experience. 3. Review of Resident #64's face sheet, dated 09/27/24, revealed he was admitted to the facility on [DATE] with diagnoses including Parkinson's with Dyskinesia, with fluctuations and generalized muscle weakness. Review of Resident #64's annual MDS assessment, dated 9/14/24, revealed his BIMS was 4 indicating severe cognitive impairment. Further review revealed Resident #64 was dependent on staff for all ADL's. Review of Resident #64's Care Plan, dated 10/23/23, revealed, The resident has impaired cognitive function/impaired thought processes r/t Parkinson's, aging and The resident requires approaches that maximize involvement in daily decision making and activity. Observation and interview on 09/26/24 at 03:51 PM revealed LVN B at Resident #64's doorway holding the door open. There was a female staff member standing at Resident #64's bedside talking with LVN B. Resident #64 was turned on his right side. The linens were turned down and Resident #64 was lying in his brief exposed to anyone walking down the hallway. Further observation revealed the privacy curtain was not drawn around the bed exposing Resident #64. Interview with LVN B revealed the CNA was talking to him about Resident #64. He stated he did not completely close the door and the CNA had not drawn the privacy curtain. LVN B stated they should provide Resident #64 with privacy and dignity during care. Interview on 09/27/24 at 04:20 PM with the DON revealed staff should pull privacy curtain and close the door during Resident care. If staff were having a discussion, then they should either come out into the hallway or stay in the room and have their discussion without exposing the Resident and violating his dignity. Review of a facility policy, Quality of Life--Dignity, revised February 2020) read: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self -worth and self-esteem. 1. Residents are treated with dignity and respect at all times.

Based on observation, interview and record review the facility failed to post a notice of the availability of such reports (surveys, certifications, and complaint investigations) in areas of the facility that are prominent and accessible to the public for 3 of 4 days observed for required postings. The facility did not post a sign providing the location of the survey results binder. This deficient practice could affect any resident and result in residents not being informed of the survey results. The findings were: Interview with 8 residents during a group meeting on 09/26/24 at 01:37 PM revealed they were not familiar with the survey results and where they were stored. All 8 residents stated they had not seen a sign or a binder labeled survey results. Observation on 09/26/24 at 02:18 PM in the facility lobby area revealed a group of binders on the shelf on the right-hand side. Amongst the binders there was 1 binder labeled Survey Results; it was not easily visible. Further observation revealed there was not a sign letting the residents and the public know of the location of the survey results binder. Interview on 09/26/24 at 03:06 PM with the AD revealed she had not shared the location of the survey results binder with the resident's. She stated she thought it was up front in the lobby area. Observation and interview on 09/26/24 at 03:23 PM with the ADM revealed the survey binder was available with last survey results. The ADM stated he did not know he needed to post sign providing the locations of the survey result. He stated there was not a sign posted.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for 1 of 1 kitchen observed for food service. The facility failed to ensure that items stored in the walk-in in refrigerator were labeled. The Dietary Manager and Dietary Aide failed to wear beard restraints while working in the kitchen. Cook and Dietary Aide did not properly wear hair restraints in a way that covered all their hair. This failure could place residents who receive food prepared in the facility's only kitchen by placing them at risk for food-borne illness and food contamination. The findings were: Observation of the facility's kitchen on [DATE] at 8:40 AM revealed Dietary Manager not wearing beard restraint over his facial hair while in the kitchen. Observation of the walk-in refrigerator on [DATE] at 8:44 AM revealed 13 trays of pre-portioned drinks, cakes, and bowls of cereal and unlabeled. Observation of the facility kitchen on [DATE] at 10:24 AM revealed Cook's hair restraint not covering all her hair while preparing pureed foods for lunch. Further observation revealed the Dietary Aide's hair restraint not covering all his hair while doing dishes. Interview with [NAME] on [DATE] at 10:52 AM revealed the [NAME] received training from the dietary manager on appropriate hygiene when first hired. The [NAME] stated hair restraints are to cover all hair to prevent hair from falling into food. The [NAME] stated that hair falling into food could cause foodborne illness in the residents. The [NAME] stated all open food in the walk-in refrigerator needed to be labeled with the date open. The [NAME] also stated that it was the responsibility of whoever was putting open items in the walk-in to label it. Interview with Dietary Aide on [DATE] at 10:54 AM revealed he had worked at the facility since January of 2024 and received training on appropriate hygiene when he started. The Dietary Aide stated hair restraints should cover all hair on top the head. Dietary Aide stated any hair not in the hair restraint could fall into the food and cause foodborne illness in those who ate food from the kitchen. Dietary Aide stated food stored in the walk-in refrigerator was to be labeled with the date opened. Dietary Aide stated any staff placing open items in the walk-in refrigerator was responsible to label it. Interview with Dietary Manager on [DATE] at 10:58 AM revealed staff are trained on appropriate hygiene when they start and all hair, including facial hair, was to be in a hair restraint when in the kitchen. Dietary manager stated hair that was not in a hair restraint could fall into food being prepared causing it to be contaminated. Dietary Manager stated contaminated food could cause foodborne illness in the residents. Dietary Manager stated all staff are responsible for labeling open items being placed in the walk-in refrigerator. Dietary Manager stated he checks the walk-in daily before the end of his shift to ensure all items are labeled. Dietary manager stated by not labeling items in the walk-in refrigerator there is potential to serve expired foods to residents causing foodborne illness. Record review of the facility policy named Preventing Foodborne Illness-Employee Hygiene and Sanitary Practice, not dated, revealed 11. Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linens. Record review of the facility policy named Receiving, not dated, revealed 6. All food items will be appropriately labeled and dated either through manufacturer packaging or staff notation. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022 states Except as provided in, (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed ,d+[DATE].17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) -(G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (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.

42031 Based on observations, interviews, and record reviews, the facility failed to 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 5 residents (Residents #69, #90) and 1 of 1 rooms (room [ROOM NUMBER]), reviewed for infection control. 1. Resident #69 was provided wound care without EBP being used 2. Resident #90 was provided wound care from supplies that were open and kept in the same baggie, the staff made direct contact with the and gloves were not changed after, and the padding in the soiled brief contacted the wound when applying the dressing, and after the wound care was completed, the wound dressing was covered with the soiled brief while turning the resident. 3. Nursing staff failed to ensure the shower chair in room [ROOM NUMBER] was cleaned and sanitized when soiled with feces. These failures could place residents at risk of cross contamination, infection, and illness. The findings were: 1. Record review of Resident #69's face sheet dated 9/27/24 revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with readmission on 10/14/22. Her diagnoses included Parkinson's disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), and muscle wasting, and atrophy not elsewhere classified multiple sites (wasting or loss of muscle tissue). Record review of Resident #69's quarterly MDS assessment dated [DATE] indicated the resident rarely or never understands or was understood and had a BIMS score of 0 indicating the resident was severely cognitively impaired. The resident required Substantial/maximal assistance or was dependent for mobility. The resident was always incontinent of bowel and bladder and had no wounds. Record review of Resident #69's care plan last reviewed 7/19/24 revealed a focus initiated on 9/2/24 and revised on 9/18/24 for pressure ulcer to coccyx that was unstageable. Interventions included to administer treatments as ordered and to follow facility policies/protocols for the treatment of skin breakdown. Record review of Resident #69's Physician's orders revealed an order with a start date of 1/4/23 for hospice services. Record review of Resident #69's Physician's orders revealed an order with a start date of 9/18/24 for Coccyx Unstageable Pressure Injury: cleanse with NS (Normal Saline) or wound cleanser, pat dry with 4x4 gauze, apply Medi honey and calcium alginate, and cover with bordered foam dressing daily and PRN every day shift for wound care. In an observation on 9/27/24 at 9:50 a.m. Resident #69 was provided wound care by RN C and was assisted by ADON D. An EBP (Enhanced Barrier Precautions) sign was on the resident's room door. RN C and ADON D completed the resident's wound care as ordered but did not utilize EBP by using PPE (Personal Protective Equipment) during the wound care. In an interview on 9/27/24 at 10:00 a.m. RN C and ADON D stated PPE for EBP should have been utilized. RN C stated not using EBP could cause cross contamination and infection control issues. 2. Record review of Resident # 90's face sheet dated 9/27/24 revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included paraplegia (Severe or complete loss of motor function in the lower extremities and lower portions of the trunk), and pressure ulcer of the sacral region unspecified stage (pressure ulcer is a localized injury to the skin or underlying tissue, usually over a bony prominence, as a result of unrelieved pressure). Record review of Resident # 90's quarterly MDS assessment dated [DATE] indicated the resident had a BIMS score of 15 of 15 indicating the resident was cognitively intact. The resident had one stage 4 pressure ulcer. Record review of Resident # 90's care plan last reviewed on 7/30/24 revealed a focus revised on 1/2/24 for multiple pressure ulcers with a goal revised on 7/30/24 to be free from infection with a target date of 10/25/24. Interventions included to administer treatments as ordered. Record review of Resident # 90's Physician orders revealed an order with a start date of 8/29/24 for Left lateral buttocks stage 4 pressure injury: cleanse wound with NS, pat dry with 4x4 gauze, apply Santyl to wound bed, and calcium alginate, apply zinc to peri wound, and cover with bordered dressing daily and PRN. The wound care orders were for the Coccyx wound. In an observation on 9/27/24 at 9:10 a.m. RN C was prepping her supplies wound care and pulled a plastic baggie out of the treatment cart. Inside the plastic zip-loc bag was: * calcium alginate that was open and had been cut in to smaller pieces, *A previously opened and used tube of Santyl ointment inside the original box, and *a tube of zinc oxide ointment that had previously been opened. RN C pulled the items out one at a time with her bare hands and placed them back in the baggie when she was finished dispensing a certain amount of the ointments into clear plastic medicine cups. Further observation revealed during the wound care to the Resident #90's sacral region, RN C pushed the calcium alginate in and around the wound with her gloved finger then without changing gloves put her finger in the zinc oxide ointment and applied it around the wound edge. The smaller dressing to buttock was applied and overlapped the sacral wound slightly and did not stick due to the tape being applied over the zinc oxide. There was a pad inside a brief and the pad was slightly under the sacral dressing when applied and RN C had to pull the brief down slightly to free the brief. The pad inside the brief was observed to be slightly damp with urine and the resident wanted to turn prior changing his brief. The nurse then covered the dressings with the damp brief and pad and the resident and was then changed. In an interview on 9/27/24 at 9:35 a.m. RN C stated she should have changed gloves after putting her finger in the wound and prior to putting her glove inside the plastic cup. RN C stated the resident wanted to keep his brief and pad on and turn then staff could provide incontinent care. RN C stated the issues with wound care observations could cause infection control and cross contamination. In an interview on 9/27/24 at 3:20 p.m. the DON stated EBP should have been used for wound care and not using EBP could cause infection by way of cross contamination. The DON further stated the calcium alginate and creams should be in separate bags to prevent cross contamination, the soiled brief should have been changed prior to wound care and or not replaced over the clean wound dressings. 3. Observation on 09/24/24 at 10:41 AM in room [ROOM NUMBER] in the memory care unit revealed a shower chair beside the sink. There was dried brown substance on the seat. Observation and interview on 09/24/24 at 10:50 AM with LVN A revealed she walked in to the room and stated she was making sure no one was in the room. LVN A looked at the shower chair and stated the brown substance was BM, bowel movement. She stated the CNAs should be wiping down, cleaning the resident's equipment; shower chair after each shower, with disinfectant wipes. Interview on 9/27/24 at 12:08 PM with LVN A revealed both Residents in room [ROOM NUMBER] were cognitively impaired; anxious, would become easily agitated and wandered. She stated it was important for nursing staff to keep resident equipment clean to maintain good sanitation and infection control. LVN A stated she made rounds throughout the shift; however, on 09/24/2024, she did not go into the bathroom in room [ROOM NUMBER]. Review of the facility policy for wound care revised October 2010 indicated . The following equipment and supplies will be necessary when performing this procedure. 4. Personal protective equipment (eg., gowns, gloves, mask, etc., as needed).

Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility is free of pests for 1 of 1 facility reviewed for physical environment. Multiple gnats were observed on resident food containers and flying around the facility. This failure places residents at risk of frustration, anxiety, and could result in the resident's not having a safe, sanitary environment. The findings were: In an observation of room [ROOM NUMBER] A on 9/24/24 at 9:45 a.m. on a bedside table next to bed held a tumbler and on top of the tumbler was a small snack sized Styrofoam bowl of fruit, possibly diced pears or peaches sealed with plastic wrap. On top of the plastic wrap was 8 to 10 gnats, and multiple flying around the tumbler and around surveyor's head at doorway. There was no loose food or open containers were observed. In an observation of room [ROOM NUMBER] A on 9/24/24 at 9:25 a.m. revealed a sticky fly trap tape hanging from the light above the bed on each side of the bed hanging down approximately 2.5 feet on each side. Approximately 7 gnats/fruit flies observed stuck to each tape. In an observation on 9/27/24 at 9:10 a.m. gnats were flying near a wound care treatment cart on 100 hall as the nurse was preparing supplies. In a group resident council meeting during the survey, the residents stated there was a pest control problem at the facility to include gnats and roaches. In an interview on 9/27/24 at 10:15 a.m. a resident expressed concerns about roaches, gnats, and flies in his room periodically throughout his stay at the facility. The resident stated he had seen the exterminator one time and the pest control man was not intending on spraying his room until the resident intervened. The resident stated he had told the previous SW and the Administrator but continued to have problems about the following areas: roaches, gnats and flies in his room periodically throughout his stay at the NF. In an interview on 9/27/24 at 3:10 p.m. the DON stated there was a gnat problem at times and the pest control comes. In an interview on 9/27/24 at 3:45 p.m. the Administrator stated pest control has treated for gnats and treats regularly. The Administrator stated that some residents hoard food and leftovers in their rooms and even in drawers but the facility continues to encourage the residents not to hoard food and leftovers in their rooms. He further stated that a resident had complained about gnats today and he had already contacted the pest control company and they will be coming to treat his room. Review of facility pest prevention service reports are as follows: *7 /26/24 room [ROOM NUMBER] for drain flies in bathroom, *8/5/24 inspected and treated all common areas and rooms 215, and 212. Target pests roaches, ants, crickets, and rodent, *8/30/24 inspected and treated all common areas and rooms 101, 110, 310, 200 for target pests ants, wasps, roaches, crickets, *9/3/24 all common areas and target pests roaches and rodent, and *9/19/24 all common areas and room [ROOM NUMBER]. Review of facility pest control service log indicated the facility had pest control visits on the following dates: * 7/26/24 for gnats, *8/5/24 for roaches and general pests, *8/21/24 general and roaches in 100, 200, 300. * 8/27/24, general pests. *8/30/24 general pests. *9/3/24 general pests, and *9/19/24 general pests. Review of facility pest control policy revised August 2008 indicated Our facility shall maintain an effective pest control program. 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.

Based on interviews, and record reviews,the facility failed to provide pharmaceutical services including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of 1 of 2 residents (Resident #1). The facility failed to prevent Resident #1 from having a methadone overdose due to receiving incorrect medications. An IJ was identified on 8/4/2024. The IJ template was presented to the facility on [DATE] at 7:02 PM. While the IJ was removed on 8/6/2024 at 8:03 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm due to the facilities need to continue to monitor the effectiveness of their plan. This deficient practice could place residents at risk of receiving incorrect medications resulting in hospitalization or death. The findings included: Record review of Resident #1's eMAR (electronic Medication Administration Record) revealed an admitted [DATE] with diagnoses that included: coronary artery disease, heart failure, Parkinson's, and dementia with behaviors. Resident #1 had a BIMS score of 3. Record review of Resident #1's physician orders and MARS revealed no order for Methadone. Record reviews of facility physician orders revealed the only resident in the facility receiving Methadone was Resident #2, who resided across the hall from Resident #1. Record review Resident #2's eMar revealed LVN F (4:00 PM); Med Aide B1 (10:00 PM), and Med Aide A1 (10:00 AM) administered Methadone to resident on 8/2/2024. During an interview on 8/4/2024 at 12:28 PM, LVN A stated Resident #1 on 8/3/2024 at 2:53 PM was becoming less active and falling asleep and not his normal behavior. LVN A stated she took his vitals and his O2 saturation was low at 87%-91%. She stated she gave him oxygen and put him back to bed, called the NP, and got the order to send him to the hospital. During an interview on 8/4/2024 1:10 PM, the RN at a local hospital stated Resident #1 displayed all the signs of drug overdose. The hospital RN stated he was blue and had 3 breaths per minute (agonal breaths). She stated he received Narcan and tested positive for Methadone overdose. She stated after he received the Narcan, he woke up but needed another dose of Narcan. She stated she Resident #1 eventually admitted to ICU and he woke up again. During an interview on 8/4/2024 at 6:30 PM, the DON stated Resident #1 could have received the Methadone because someone pre-pulled the medication that caused a medication error because they did not remember what pills belonged to which resident. She stated medications are to be pulled using the 5 rights of medication administration. The individual administering the medication checks the label 3 times the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication to the resident. During an interview 8/5/2024 at 4:35 PM, the Pharmacist that was contracted with the facility stated the effects of methadone overdose was confusion, disorientation, fatigue, and sleepiness. She stated the dosage that would cause an overdose would depend on the dosage and depend on how fast they metabolized it. Record Review of the facility's policy titled Administering Medications dated April 2019 stated in part; Medications are administered in a safe and timely manner, and as prescribed. (9). The individual administering medications verifies the resident's identity before giving the resident medication. Methods of identifying the resident include checking identification band, photograph attached to medical record, and if necessary, verify resident identification with other facility personnel.(10). The individual administering the medication checks the label 3 times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. On on 8/4/2024 at 7:02 PM, an Immediate Jeopardy (IJ) was identified. The Administrator and the DON were notified. The Administrator and the DON was provided with the IJ template, and a Plan of Removal (POR) was requested at that time. The POR was accepted on 8/5/2024 and verification began on 8/6/2024: IJ Component: F 755 Pharmaceutical Services Facility failed to ensure resident was receiving the appropriate medication. Immediate Actions: 1. DON/designee reviewed all resident narcotic administration records to ensure residents are receiving the correct medication as ordered by the physician. All counts were correct. Initiated on 8/4/2024. Completed 8/5/2024 2. DON/designee moved all scheduled and PRN narcotic medications from the certified medication aide cart to the licensed nurse medication cart-this will be permanent. Only Licensed Nurses will be administering routine ordered and PRN ordered narcotics. The CMA's will not have access or keys to the Nurses medication carts. Initiated on 8/4/2024. Completed 8/4/2024 Facility Plan to ensure compliance: 1. DON/designee to re-educate licensed nurses and certified medication aides in the process of medication administration with an emphasis of verifying the resident's identity before giving the resident his/her medications and adverse consequences of medication errors. The Regional Nurse Consultant and [NAME] President of Operations provided in-service to DON and administrator on 8/4/2024. Staff that are on leave from the facility, as well as newly hired staff in the future will be given medication administration education by the same individuals noted above before starting their next shift. This facility does not employ the use of agency personnel. Initiated on 8/4/2024. Completed 8/5/2024. 2. DON/designee to educate licensed nurses that all narcotics given will require 2 licensed nurses to initial administration to ensure administration of medication to the correct resident. The Regional Nurse Consultant and [NAME] President of Operations provided in-service to DON and administrator on 8/4/2024. Staff that are on leave from the facility, as well as newly hired staff will be given medication administration education by the same individuals noted above before starting their next shift. This facility does not employ the use of agency personnel. This training will be on an ongoing basis for all new hires. Initiated on 8/4/2024. Completed 8/5/2024. 3. The Medical Director was notified by the Administrator on 8/4/2024 at 7:20 pm on the immediate jeopardy citation. 4. An Ad-hoc QAPI meeting was held on 8/4/2024 by the interdisciplinary team to discuss the immediate jeopardies and review the plan of removal. Monitoring 1. DON/designee will perform medication administration observations on the licensed nurses and certified medication aides twice a week beginning 8/4/2024 and ongoing to ensure medications are administered to the correct resident. A medication observation tool will be used to document compliance with the medication administration beginning 8/4/2024 for 60 days. The pharmacy consultant will perform medication observation monthly during her routine monthly visit on an ongoing basis. 2. The above will be reviewed in the monthly facility QAPI meeting for no less than 60 days or until the Administrator determines substantial compliance has been achieved and maintained. Monitoring of the Plan of Removal from 8/6/2024 to 8/6/2024 included the following: Interviews with 27 out of 28 were done with 27 nurses and 2 Medication Aides were done (one terminated). 4 nurses for day and evening; 5 nurses for day shift; 7 nurses and 1 Medication Aide for evening; 4 nurses for all shifts (PRN); 4 nurses for overnight; and 3 RN Managers. The one nurse that was PRN (as needed) would receive the in-service before she can start her shift. All that received the in-service stated the carts were audited and the narcotics were only on the nurses' carts, not to be administered by Medication Aides any longer. They were in-serviced on medication rights of administration: right resident, right time, right dose, and right route and right documentation. During an interview on 8/6/2024 at 9:38 AM LVN A who worked day shift stated she had been a nurse 5 years. She stated she had in-service on passing medication. She stated she was told that they had to have another person to witness narcotics being passed for at least 60 days. She stated they would be checked weekly on medication passed and it was done yesterday. She stated Med Aides no longer have access to narcotics and only nurses would administer as needed narcotics and scheduled narcotics. She stated they went over the 5 rights of administering medication; nursing assessment and when medication should be held and call doctor to inform of reason of holding medication and document. She stated before passing medication they did a count of the narcotics with the previous shift nurse or Med Aide. She stated if there was an error with the narcotics, she would not take the keys and immediately inform the DON. She stated she would take vitals on her residents when needed before administering her medications. She stated pre-pulling medications could cause confusion and it would be better to do the medications one resident at a time. During an interview on 8/6/2024 at 9:50 AM LVN U who worked day shift stated he had in-service on narcotics administration that now needed 2 signatures as a witness. He stated he did not pre-pull medication, take vitals, assessment for pain and makes sure he does the 5 rights order, patient, time, dose, and medication. He stated that there was no Med Aide on the unit he worked and was not aware there would be random medication observations. During an interview on 8/6/2024 at 9:58 AM LVN C who worked day shift stated she had the in-service on nurses passed narcotics for scheduled and as needed and 2 nurses had to sign off on the narcotics. She stated DON audited her narcotics on her cart and moved all narcotics to her cart. She stated she did not pre-pull her medications because it would be easy to make a mistake with administering medication. She stated she did one resident at a time, even if it was over the counter medications. She stated that administering someone the wrong medication may have an allergic reaction. She stated she would check MAR, resident, blood pressure and document, check name of medication, dose, frequency, time and day using 5 rights of medication administration. She stated when there had been times, she found medications on the cart that had been pre-pulled she would notify the ADON and they would discard the medications. During an interview on 8/6/2024 at 10:16 AM Med Aide A1 stated she had the in-service on medication pass. She stated she was taught the 5 rights of medication pass and taking vitals. She stated she was told to pass medication one resident at a time. She stated it was important not to pre-pull medication because a mistake could happen, giving the wrong medication to a resident. She stated she pre-pulled today and was terminated. She stated the last time she gave Resident #1 was Friday at 10 or 11 in the morning. She stated she would have to buy him a cupcake or a soda for him to take his medications. She stated he would agree to take it after an hour or so without buying him anything. She stated she had not seen anyone else pre-pull medications. During an interview on 8/6/2024 at 10:41 AM LVN D who worked day shift stated she had in-service on medication pass. She stated she was informed not to pre-pull, medication rights. She stated only the nurses would pass out medication with 2 nurses' signatures. She stated pre-pulling medication could cause a medication error. She stated her cart was audited by the DON and all the narcotic sheets and keys were now on her cart and not the Med Aide's cart. She stated she had not seen anyone pre-pull medications but if she had seen it, she would report it to the DON. During an interview on 8/6/2024 at 10:53 AM LVN E who worked day shift new hired nurse and had been a nurse since 2004. She stated she had an in-service on Monday. She stated she was off on the weekend and the training was about the rights of the resident with medication pass. She stated she always kept the rights on her. She stated she did not pre-pull because it could cause confusion and med pass error. She stated it should be done one resident at a time. She stated she had not seen anyone pre- pulling medication but if she had seen it, she would inform them of the issues with doing that and then notify the DON. She stated only the nurses passed the narcotics with 2 signatures each time a narcotic was pulled. She stated she did not know how long the 2-signature process would last. During an interview on 8/6/2024 at 11:48 AM LVN G who worked overnight shift stated the in-service was about medication pass and narcotics. He stated it was about the 6 rights, counting and documentation: not giving unprescribed medications. He stated only nurses were to administer narcotics. He stated he had not seen anyone pre-pull medication. He stated pre-pull medication can be a safety hazard, it would be loose medication in the cart. He stated pre-pulled medication could cause a medication error. He stated 2 nurses were to sign out narcotics. During an interview on 8/6/2024 at 12:20 PM LVN K who worked evening shift stated she had been at the facility for 4 days. She was called to the DON's office to discuss medication administration with the 5 rights and another nurse to sign off for narcotics. She stated only the nurses were allowed to pass narcotics. She stated she was in the Memory Care Unit and she did not have a MA. She stated pre-pulling medications can cause medication error and she would only do one resident at a time. She stated she was unaware if the cart was audited because yesterday was her first day working alone. She stated there was no issue with the narcotic count and when she ended her shift, she and the other nurse both signed out. She stated if there was an issue with the narcotic count, she would not accept the keys and inform the DON. She stated if she saw if someone pre-pulled medication, she would inform a supervisor. During an interview on 8/6/2024 at 12:35 PM RN Weekend Supervisor (P) she stated that 2 nurses were to sign off on narcotics. She stated as the supervisor to enforce the new policy, she would do a medication pass audit/in-service because she only worked on the weekend. She stated she would be more adamant about checking carts for pre-pulled medications on each shift. Most times there were shift changes but most of them worked doubles. During an interview on 8/6/2024 at 12:44 PM LVN W who worked day and evening shifts stated she had the in-service Sunday about medication pass, and verifying with the 5 rights of medication pass. She stated she would not pre-pull medication because it could cause medication error and she only does one medication at time. She stated she had not seen anyone pre-pull medication. She stated she would report it to a supervisor. She stated the narcotics were the only one to give out narcotics and the process is for 2 nurses to verify and sign. She stated she would not give medications to a resident that was drowsy. She would take vitals, check medications given previously, and call the doctor. During an interview on 8/6/2024 at 12:57 PM LVN L who worked day and evening shifts stated she had the in-service and were told Med Aides were not allowed to pass the narcotics and 2 nurses were to verify and sign out narcotics. She stated she noticed that all of the narcotics and the keys were on her cart. She stated pre-pulling medications were not allowed and medications were not allowed to be administered before the scheduled time. She stated pre-pulling medication could cause medication error. She stated she used the 6 rights of the residents to pass her medication. She stated she had not seen anyone pre-pulled medication and if she had seen it, she would notify the supervisor. She stated she would not allow the medication to be passed and immediately call a supervisor. She stated if she observed someone drowsy, she would take vitals and call the doctor to get an order to hold a medication that may cause drowsiness she would also notify a supervisor. She states she only worked on the weekends. During an interview on 8/6/2024 at 1:05 PM RN X who worked evening shift stated she had an in-service on Sunday about medication pass and the 5 rights of medication pass. She stated the narcotics were not to be administered by Medication Aides and all the narcotics were moved to her cart with the keys given to her. She stated 2 nurses now need to verify and sign for narcotic administration. She stated she did not pre pull her medications because it could cause medication error- giving the wrong medication to a resident, confusing medications. If she saw someone drowsy, she would take vitals and call the physician to hold the medication, or any other orders given. She stated if she saw someone had pre pulled medication she would notify the supervisor. During an interview on 8/6/2024 at 1:40 PM LVN O who worked day and evening shifts worked on the weekends. He stated he had the in-service on the 5 rights of medication administration and was also observed doing a medication pass. He stated all the narcotics were on the nurses' carts and no longer on the Med Aide's carts. He stated he was informed that the narcotics were to be signed by 2 nurses for verification. He stated medications should not be pre pulled because the medication could be given to the wrong resident. He stated he was newly hired at the facility and had not seen anyone pre pull medication. If he were to see it, he would notify the supervisor. He stated he had been observed by the DON doing medication pass. During an interview on 8/6/2024 at 1:49 PM LVN I who worked overnight shift stated she had an in-service this morning about medication administration and the 5 rights. She stated 2 nurses needed to confirm and sign for narcotics. She stated the med aides would not be passing narcotics any longer. She stated she had not seen any pre pulled medications. She stated she would ask about the medication if it was left in the cart and she would call the supervisor. She stated pre pulled medications could result in a medication error. During an interview on 8/6/2024 at 2:00 PM LVN H who worked overnight shift stated he had received the in-services about drug administration and the 5 rights. He stated he did not pre-pull medication because it could result in a medication error. He stated he had not seen any pre pulled medications in the cart and if he had seen it, he would report it to the DON. He stated 2 nurses needed to verify and sign off for the administration of narcotics. He was informed that med aides would not be allowed to pass narcotics. He stated if he saw someone very drowsy, he would take a set of vitals, notify the doctor, and hold the medication until he spoke with the doctor. During an interview on 8/6/2024 at 2:06 PM LVN N who worked as needed and weekends stated she had the in-service and was informed only nurses would administer narcotics, all the narcotics were removed from the med aides' carts, and 2 nurses would be needed to administer the narcotics to verify and sign. She stated it was important to not pre pull medications because it would be easy to make a medication error giving the medication to the wrong resident. She stated they also discussed the 5 rights of medication administration. She stated if she saw pre pulled medication on the cart, she would report it to the DON or ADON. During an interview on 8/6/2024 at 2:07 PM LVN M who worked evening shift stated she had the in-service yesterday and was told the nurses would administer the narcotic. She stated she was told to use the 5 rights to administer medications. She stated that 2 nurses needed to sign out narcotics to verify the correct medication was administered. She stated all the narcotics and the books with the sheets were put into the nurses' carts. She stated it was important not to pre pull medications because it could cause a medication error- by forgetting who the medication belonged to. She stated she had not seen medication pre pulled on a cart. She stated she would question who or what the medication was for, she would discard it and inform the supervisor. She stated if she saw a resident groggy, she would do an assessment, take vitals, notify the supervisor, notify the physician, and hold the medication until further orders from the doctor. During an interview on 8/6/2024 at 2:16 PM Med Aide B1 who worked evening shift stated she had the in service about medication process using 5 rights and not to pre pull medications. She stated narcotics were removed from her cart and would be administer by the nurses only to prevent too many people handling the narcotics. She stated it was important not to pre pull medication to prevent medication error. She stated she had not seen anyone pre pulling medications. She stated if she had seen it, she would report it to the charge nurse and if nothing was done about it, she would report it to the DON. She stated there had been times that Resident #2 had been very drowsy and she reported it the nurse and she did not give the medication to him. During an interview on 8/6/2024 at 2:29 PM RN R who worked evening shift stated she had the in-service of medication administration and the 5 rights of medication administration. She stated there would need to be 2 nurses to sign for a delivery of a narcotic and to administer to a resident. She stated it was important not to pre pull to prevent medication error- wrong time, wrong med, wrong resident. She stated she had seen medication pre pulled medication and she informed the person that did it not to do it and she told the ADON about it. She stated if she saw that a resident was very drowsy, she would do an assessment with a set of vitals, hold the medication, notify the doctor, the DON, family, and wait for further orders from the doctor. During an interview on 8/6/2024 at 2:49PM RN J worked all shifts stated she had the in service yesterday. She stated they discussed 5 rights of medication administration. 2 nurses were needed to administer narcotics. She stated the carts were audited and is aware Med Aides were no longer able to pass narcotics. She stated she had not seen anyone pre pull medications. She stated pre pulled medications could cause medication error. She stated if she had seen someone who pre pulled, she would stop the administration first and notify a supervisor immediately. During an interview on 8/6/2024 at 2:58 PM RN V who worked evening shift stated she had the in-service on medication administration on the 7 rights of administration. She stated that narcotics required 2 nurses to verify and sign. She stated pre pulled medications-ask the resident first if it was needed before pulling a narcotic. She stated pre pulled medications could result in medication error that could have dangerous results. She stated Med Aides were no longer allowed to administer narcotics. She stated she had not seen anyone pre pull medications and she had only been employed with the facility for 2 months. She stated if she saw someone pre pulled medications, she would inquire to the person who had done it, she stated it would be best to report it to the supervisor. She stated if she saw someone groggy, she would not administer a narcotic and do an assessment with vitals, report it to the doctor, the supervisor, and the family await further instructions from the doctor. During an interview on 8/6/2024 at 3:06 PM LVN Y who worked overnight shift stated she had the in-service this morning about resident 7 rights of medication administration. She stated she was informed that 2 nurses would need to sign out narcotics to verify. She stated the cart and narcotic book was audited. She stated she was informed that the Med Aides were not allowed to pass narcotics. She stated she had not seen anyone pre pull medications, and pre pulled med errors could cause a medication error. She stated she would do an assessment with vital signs, hold the medication, and notify the doctor. She stated if she would see someone with pre pulled medications, she would advise them to discard the medications and assist them if needed. She stated if the person were to do it more than once, she would then go to the DON. During an interview on 8/6/2024 at 3:21 PM LVN T who worked overnight shift stated she had the in- service about medication administration that now required 2 nurses to sign for verification. She stated that medications should not be pre pulled and use the 7 rights of medication administration. She stated it was important not to pre pull to prevent medication error. She stated she had not seen anyone pre pull medications, but had she seen it, she would inform the person not to do that and then report. She stated if she saw someone drowsy, she would not administer a narcotic because it could mask another problem. She stated she would call the supervisor, the doctor, and the family and wait for further orders from the doctor. During an observation on 8/6/2024 at 3:50 PM, the medication carts on the 100-hall unit had all the narcotics on the nurses' carts and no narcotics on the Medication Aide's cart. Observed LVN F on 100 hall passed medication and LVN F verified a narcotic he pulled with RN V. During an interview on 8/6/2024 at 10:10 AM, the DON stated she did not want staff to know she would do random medication observations because she wanted to ensure they were doing the medication pass per facility policy. She stated she did an in-service with Med Aide A1 that morning and she was informed not to pre-pull medication. She stated she allowed her to prepare for medication pass and decided to do a random observation with her. She stated she found that the Med Aide A1 was about to enter a residents' room with 2 cups of medication- one cup for each resident. The Med Aide was terminated. During an interview on 8/6/2024 at 1:40 PM LVN O who worked day and evening shifts worked on the weekends. He stated he had the in-service on the 5 rights of medication administration and was also observed doing a medication pass. He stated all the narcotics were on the nurses' carts and no longer on the Med Aide's carts. He stated he was informed that the narcotics were to be signed by 2 nurses for verification. He stated medications should not be pre pulled because the medication could be given to the wrong resident. He stated he was newly hired at the facility and had not seen anyone pre pull medication. If he were to see it, he would notify the supervisor. He stated he had been observed by the DON doing medication pass. Record review of QAPI signature page dated 8/4/2024 revealed the Medical Director gave verbal approval over the phone and email due to being on vacation. The Administrator stated the Medical Director also received a scanned copy of the signed IJ template. During an interview on 8/6/2024 at 6:56 PM LVN S stated he had in-service on medication right of medication administration. He stated he was told not to pre pull medication because it could cause a medication error. He stated he had not seen anyone pre pull medication. He stated if he saw anyone pre pull medication he would advise them not to administer medication that way and inform the DON. He stated that 2 nurses were to sign off on any narcotic to be given. He stated he would not give narcotics to anyone who would be drowsy, but instead hold it and call the doctor and notify the supervisor. Observation on 8/6/2024 at 7:03 PM revealed LVN F removed a Norco for Resident #3 and LVN M verified and signed off with LVN F before medication was administered. There were no pre pulled pills in the top drawer of the cart. He administered the medication to the resident using the 5 rights of medication administration. Observation on 8/6/2024 at 7:08 PM revealed Med Aide B1 administered to Resident #3 -Cymbalta 20 mg, Atorvastatin 40mg, and Trazadone 50 mg using the 5 rights of medication administration. There were no pre pulled pills in the top drawer. An IJ was identified on 8/4/2024. The IJ template was presented to the facility on [DATE] at 7:02 PM. While the IJ was removed on 8/6/2024 at 8:03 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm due to the facilities need to continue to monitor the effectiveness of their plan.

Based on interviews, and record reviews,the facility failed to ensure residents are free of any significant medication error for 1 of 2 residents (Resident #1). The facility failed to prevent Resident #1 from having a methadone overdose due to receiving incorrect medications. An IJ was identified on 8/4/2024. The IJ template was presented to the facility on [DATE] at 7:02PM. While the IJ was removed on 8/6/2024 at 8:03PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm due to the facilities need to continue to monitor the effectiveness of their plan. This deficient practice could place residents at risk of receiving incorrect medications resulting in hospitalization or death. The findings included: Record review of Resident #1's eMAR (electronic Medication Administration Record) revealed an admitted [DATE] with diagnoses that included: coronary artery disease, heart failure, Parkinson's, and dementia with behaviors. Resident #1 had a BIMS score of 3. Record review of Resident #1's physician orders and MARS revealed no order for Methadone. Record reviews of facility physician orders revealed the only resident in the facility receiving Methadone was Resident #2, who resided across the hall from Resident #1. Record review Resident #2's eMar revealed LVN F (4:00PM); Med Aide B1 (10:00PM), and Med Aide A1 (10:00AM) administered Methadone to resident on 8/2/2024. During an interview on 8/4/2024 at 12:28 PM, LVN A stated Resident #1 on 8/3/2024 at 2:53PM was becoming less active and falling asleep and not his normal behavior. LVN A stated she took his vitals and his O2 saturation was low at 87%-91%. She stated she gave him oxygen and put him back to bed, called the NP, and got the order to send him to the hospital. During an interview on 8/4/2024 1:10 PM, the RN at a local hospital stated Resident #1 displayed all the signs of drug overdose. The hospital RN stated he was blue and had 3 breaths per minute (agonal breaths). She stated he received Narcan and tested positive for Methadone overdose. She stated after he received the Narcan, he woke up but needed another dose of Narcan. She stated she Resident #1 eventually admitted to ICU and he woke up again. During an interview on 8/4/2024 at 6:30 PM, the DON stated Resident #1 could have received the Methadone because someone pre-pulled the medication that caused a medication error because they did not remember what pills belonged to which resident. She stated medications are to be pulled using the 5 rights of medication administration. The individual administering the medication checks the label 3 times the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication to the resident. During an interview 8/5/2024 at 4:35 PM, the Pharmacist that was contracted with the facility stated the effects of methadone overdose was confusion, disorientation, fatigue, and sleepiness. She stated the dosage that would cause an overdose would depend on the dosage and depend on how fast they metabolized it. Record Review of the facility's policy titled Administering Medications dated April 2019 stated in part; Medications are administered in a safe and timely manner, and as prescribed. (9). The individual administering medications verifies the resident's identity before giving the resident medication. Methods of identifying the resident include checking identification band, photograph attached to medical record, and if necessary, verify resident identification with other facility personnel.(10). The individual administering the medication checks the label 3 times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. On on 8/4/2024 at 7:02PM, an Immediate Jeopardy (IJ) was identified. The Administrator and the DON were notified. The Administrator and the DON was provided with the IJ template, and a Plan of Removal (POR) was requested at that time. The POR was accepted on 8/5/2024 and verification began on 8/6/2024: IJ Component: F 755 Pharmaceutical Services Facility failed to ensure resident was receiving the appropriate medication. Immediate Actions: 1. DON/designee reviewed all resident narcotic administration records to ensure residents are receiving the correct medication as ordered by the physician. All counts were correct. Initiated on 8/4/2024. Completed 8/5/2024 2. DON/designee moved all scheduled and PRN narcotic medications from the certified medication aide cart to the licensed nurse medication cart-this will be permanent. Only Licensed Nurses will be administering routine ordered and PRN ordered narcotics. The CMA's will not have access or keys to the Nurses medication carts. Initiated on 8/4/2024. Completed 8/4/2024 Facility Plan to ensure compliance: 1. DON/designee to re-educate licensed nurses and certified medication aides in the process of medication administration with an emphasis of verifying the resident's identity before giving the resident his/her medications and adverse consequences of medication errors. The Regional Nurse Consultant and [NAME] President of Operations provided in-service to DON and administrator on 8/4/2024. Staff that are on leave from the facility, as well as newly hired staff in the future will be given medication administration education by the same individuals noted above before starting their next shift. This facility does not employ the use of agency personnel. Initiated on 8/4/2024. Completed 8/5/2024. 2. DON/designee to educate licensed nurses that all narcotics given will require 2 licensed nurses to initial administration to ensure administration of medication to the correct resident. The Regional Nurse Consultant and [NAME] President of Operations provided in-service to DON and administrator on 8/4/2024. Staff that are on leave from the facility, as well as newly hired staff will be given medication administration education by the same individuals noted above before starting their next shift. This facility does not employ the use of agency personnel. This training will be on an ongoing basis for all new hires. Initiated on 8/4/2024. Completed 8/5/2024. 3. The Medical Director was notified by the Administrator on 8/4/2024 at 7:20 pm on the immediate jeopardy citation. 4. An Ad-hoc QAPI meeting was held on 8/4/2024 by the interdisciplinary team to discuss the immediate jeopardies and review the plan of removal. Monitoring 1. DON/designee will perform medication administration observations on the licensed nurses and certified medication aides twice a week beginning 8/4/2024 and ongoing to ensure medications are administered to the correct resident. A medication observation tool will be used to document compliance with the medication administration beginning 8/4/2024 for 60 days. The pharmacy consultant will perform medication observation monthly during her routine monthly visit on an ongoing basis. 2. The above will be reviewed in the monthly facility QAPI meeting for no less than 60 days or until the Administrator determines substantial compliance has been achieved and maintained. Monitoring of the Plan of Removal from 8/6/2024 to 8/6/2024 included the following: Interviews with 27 out of 28 were done with 27 nurses and 2 Medication Aides were done (one terminated). 4 nurses for day and evening; 5 nurses for day shift; 7 nurses and 1 Medication Aide for evening; 4 nurses for all shifts (PRN); 4 nurses for overnight; and 3 RN Managers. The one nurse that was PRN (as needed) would receive the in-service before she can start her shift. All that received the in-service stated the carts were audited and the narcotics were only on the nurses' carts, not to be administered by Medication Aides any longer. They were in-serviced on medication rights of administration: right resident, right time, right dose, and right route and right documentation. During an interview on 8/6/2024 at 9:38 AM LVN A who worked day shift stated she had been a nurse 5 years. She stated she had in-service on passing medication. She stated she was told that they had to have another person to witness narcotics being passed for at least 60 days. She stated they would be checked weekly on medication passed and it was done yesterday. She stated Med Aides no longer have access to narcotics and only nurses would administer as needed narcotics and scheduled narcotics. She stated they went over the 5 rights of administering medication; nursing assessment and when medication should be held and call doctor to inform of reason of holding medication and document. She stated before passing medication they did a count of the narcotics with the previous shift nurse or Med Aide. She stated if there was an error with the narcotics, she would not take the keys and immediately inform the DON. She stated she would take vitals on her residents when needed before administering her medications. She stated pre-pulling medications could cause confusion and it would be better to do the medications one resident at a time. During an interview on 8/6/2024 at 9:50 AM LVN U who worked day shift stated he had in-service on narcotics administration that now needed 2 signatures as a witness. He stated he did not pre-pull medication, take vitals, assessment for pain and makes sure he does the 5 rights order, patient, time, dose, and medication. He stated that there was no Med Aide on the unit he worked and was not aware there would be random medication observations. During an interview on 8/6/2024 at 9:58 AM LVN C who worked day shift stated she had the in-service on nurses passed narcotics for scheduled and as needed and 2 nurses had to sign off on the narcotics. She stated DON audited her narcotics on her cart and moved all narcotics to her cart. She stated she did not pre-pull her medications because it would be easy to make a mistake with administering medication. She stated she did one resident at a time, even if it was over the counter medications. She stated that administering someone the wrong medication may have an allergic reaction. She stated she would check MAR, resident, blood pressure and document, check name of medication, dose, frequency, time and day using 5 rights of medication administration. She stated when there had been times, she found medications on the cart that had been pre-pulled she would notify the ADON and they would discard the medications. During an interview on 8/6/2024 at 10:16 AM Med Aide A1 stated she had the in-service on medication pass. She stated she was taught the 5 rights of medication pass and taking vitals. She stated she was told to pass medication one resident at a time. She stated it was important not to pre-pull medication because a mistake could happen, giving the wrong medication to a resident. She stated she pre-pulled today and was terminated. She stated the last time she gave Resident #1 was Friday at 10 or 11 in the morning. She stated she would have to buy him a cupcake or a soda for him to take his medications. She stated he would agree to take it after an hour or so without buying him anything. She stated she had not seen anyone else pre-pull medications. During an interview on 8/6/2024 at 10:41 AM LVN D who worked day shift stated she had in-service on medication pass. She stated she was informed not to pre-pull, medication rights. She stated only the nurses would pass out medication with 2 nurses' signatures. She stated pre-pulling medication could cause a medication error. She stated her cart was audited by the DON and all the narcotic sheets and keys were now on her cart and not the Med Aide's cart. She stated she had not seen anyone pre-pull medications but if she had seen it, she would report it to the DON. During an interview on 8/6/2024 at 10:53 AM LVN E who worked day shift new hired nurse and had been a nurse since 2004. She stated she had an in-service on Monday. She stated she was off on the weekend and the training was about the rights of the resident with medication pass. She stated she always kept the rights on her. She stated she did not pre-pull because it could cause confusion and med pass error. She stated it should be done one resident at a time. She stated she had not seen anyone pre- pulling medication but if she had seen it, she would inform them of the issues with doing that and then notify the DON. She stated only the nurses passed the narcotics with 2 signatures each time a narcotic was pulled. She stated she did not know how long the 2-signature process would last. During an interview on 8/6/2024 at 11:48 AM LVN G who worked overnight shift stated the in-service was about medication pass and narcotics. He stated it was about the 6 rights, counting and documentation: not giving unprescribed medications. He stated only nurses were to administer narcotics. He stated he had not seen anyone pre-pull medication. He stated pre-pull medication can be a safety hazard, it would be loose medication in the cart. He stated pre-pulled medication could cause a medication error. He stated 2 nurses were to sign out narcotics. During an interview on 8/6/2024 at 12:20 PM LVN K who worked evening shift stated she had been at the facility for 4 days. She was called to the DON's office to discuss medication administration with the 5 rights and another nurse to sign off for narcotics. She stated only the nurses were allowed to pass narcotics. She stated she was in the Memory Care Unit and she did not have a MA. She stated pre-pulling medications can cause medication error and she would only do one resident at a time. She stated she was unaware if the cart was audited because yesterday was her first day working alone. She stated there was no issue with the narcotic count and when she ended her shift, she and the other nurse both signed out. She stated if there was an issue with the narcotic count, she would not accept the keys and inform the DON. She stated if she saw if someone pre-pulled medication, she would inform a supervisor. During an interview on 8/6/2024 at 12:35 PM RN Weekend Supervisor (P) she stated that 2 nurses were to sign off on narcotics. She stated as the supervisor to enforce the new policy, she would do a medication pass audit/in-service because she only worked on the weekend. She stated she would be more adamant about checking carts for pre-pulled medications on each shift. Most times there were shift changes but most of them worked doubles. During an interview on 8/6/2024 at 12:44 PM LVN W who worked day and evening shifts stated she had the in-service Sunday about medication pass, and verifying with the 5 rights of medication pass. She stated she would not pre-pull medication because it could cause medication error and she only does one medication at time. She stated she had not seen anyone pre-pull medication. She stated she would report it to a supervisor. She stated the narcotics were the only one to give out narcotics and the process is for 2 nurses to verify and sign. She stated she would not give medications to a resident that was drowsy. She would take vitals, check medications given previously, and call the doctor. During an interview on 8/6/2024 at 12:57 PM LVN L who worked day and evening shifts stated she had the in-service and were told Med Aides were not allowed to pass the narcotics and 2 nurses were to verify and sign out narcotics. She stated she noticed that all of the narcotics and the keys were on her cart. She stated pre-pulling medications were not allowed and medications were not allowed to be administered before the scheduled time. She stated pre-pulling medication could cause medication error. She stated she used the 6 rights of the residents to pass her medication. She stated she had not seen anyone pre-pulled medication and if she had seen it, she would notify the supervisor. She stated she would not allow the medication to be passed and immediately call a supervisor. She stated if she observed someone drowsy, she would take vitals and call the doctor to get an order to hold a medication that may cause drowsiness she would also notify a supervisor. She states she only worked on the weekends. During an interview on 8/6/2024 at 1:05 PM RN X who worked evening shift stated she had an in-service on Sunday about medication pass and the 5 rights of medication pass. She stated the narcotics were not to be administered by Medication Aides and all the narcotics were moved to her cart with the keys given to her. She stated 2 nurses now need to verify and sign for narcotic administration. She stated she did not pre pull her medications because it could cause medication error- giving the wrong medication to a resident, confusing medications. If she saw someone drowsy, she would take vitals and call the physician to hold the medication, or any other orders given. She stated if she saw someone had pre pulled medication she would notify the supervisor. During an interview on 8/6/2024 at 1:40 PM LVN O who worked day and evening shifts worked on the weekends. He stated he had the in-service on the 5 rights of medication administration and was also observed doing a medication pass. He stated all the narcotics were on the nurses' carts and no longer on the Med Aide's carts. He stated he was informed that the narcotics were to be signed by 2 nurses for verification. He stated medications should not be pre pulled because the medication could be given to the wrong resident. He stated he was newly hired at the facility and had not seen anyone pre pull medication. If he were to see it, he would notify the supervisor. He stated he had been observed by the DON doing medication pass. During an interview on 8/6/2024 at 1:49 PM LVN I who worked overnight shift stated she had an in-service this morning about medication administration and the 5 rights. She stated 2 nurses needed to confirm and sign for narcotics. She stated the med aides would not be passing narcotics any longer. She stated she had not seen any pre pulled medications. She stated she would ask about the medication if it was left in the cart and she would call the supervisor. She stated pre pulled medications could result in a medication error. During an interview on 8/6/2024 at 2:00 PM LVN H who worked overnight shift stated he had received the in-services about drug administration and the 5 rights. He stated he did not pre-pull medication because it could result in a medication error. He stated he had not seen any pre pulled medications in the cart and if he had seen it, he would report it to the DON. He stated 2 nurses needed to verify and sign off for the administration of narcotics. He was informed that med aides would not be allowed to pass narcotics. He stated if he saw someone very drowsy, he would take a set of vitals, notify the doctor, and hold the medication until he spoke with the doctor. During an interview on 8/6/2024 at 2:06 PM LVN N who worked as needed and weekends stated she had the in-service and was informed only nurses would administer narcotics, all the narcotics were removed from the med aides' carts, and 2 nurses would be needed to administer the narcotics to verify and sign. She stated it was important to not pre pull medications because it would be easy to make a medication error giving the medication to the wrong resident. She stated they also discussed the 5 rights of medication administration. She stated if she saw pre pulled medication on the cart, she would report it to the DON or ADON. During an interview on 8/6/2024 at 2:07 PM LVN M who worked evening shift stated she had the in-service yesterday and was told the nurses would administer the narcotic. She stated she was told to use the 5 rights to administer medications. She stated that 2 nurses needed to sign out narcotics to verify the correct medication was administered. She stated all the narcotics and the books with the sheets were put into the nurses' carts. She stated it was important not to pre pull medications because it could cause a medication error- by forgetting who the medication belonged to. She stated she had not seen medication pre pulled on a cart. She stated she would question who or what the medication was for, she would discard it and inform the supervisor. She stated if she saw a resident groggy, she would do an assessment, take vitals, notify the supervisor, notify the physician, and hold the medication until further orders from the doctor. During an interview on 8/6/2024 at 2:16 PM Med Aide B1 who worked evening shift stated she had the in service about medication process using 5 rights and not to pre pull medications. She stated narcotics were removed from her cart and would be administer by the nurses only to prevent too many people handling the narcotics. She stated it was important not to pre pull medication to prevent medication error. She stated she had not seen anyone pre pulling medications. She stated if she had seen it, she would report it to the charge nurse and if nothing was done about it, she would report it to the DON. She stated there had been times that Resident #2 had been very drowsy and she reported it the nurse and she did not give the medication to him. During an interview on 8/6/2024 at 2:29 PM RN R who worked evening shift stated she had the in-service of medication administration and the 5 rights of medication administration. She stated there would need to be 2 nurses to sign for a delivery of a narcotic and to administer to a resident. She stated it was important not to pre pull to prevent medication error- wrong time, wrong med, wrong resident. She stated she had seen medication pre pulled medication and she informed the person that did it not to do it and she told the ADON about it. She stated if she saw that a resident was very drowsy, she would do an assessment with a set of vitals, hold the medication, notify the doctor, the DON, family, and wait for further orders from the doctor. During an interview on 8/6/2024 at 2:49PM RN J worked all shifts stated she had the in service yesterday. She stated they discussed 5 rights of medication administration. 2 nurses were needed to administer narcotics. She stated the carts were audited and is aware Med Aides were no longer able to pass narcotics. She stated she had not seen anyone pre pull medications. She stated pre pulled medications could cause medication error. She stated if she had seen someone who pre pulled, she would stop the administration first and notify a supervisor immediately. During an interview on 8/6/2024 at 2:58 PM RN V who worked evening shift stated she had the in-service on medication administration on the 7 rights of administration. She stated that narcotics required 2 nurses to verify and sign. She stated pre pulled medications-ask the resident first if it was needed before pulling a narcotic. She stated pre pulled medications could result in medication error that could have dangerous results. She stated Med Aides were no longer allowed to administer narcotics. She stated she had not seen anyone pre pull medications and she had only been employed with the facility for 2 months. She stated if she saw someone pre pulled medications, she would inquire to the person who had done it, she stated it would be best to report it to the supervisor. She stated if she saw someone groggy, she would not administer a narcotic and do an assessment with vitals, report it to the doctor, the supervisor, and the family await further instructions from the doctor. During an interview on 8/6/2024 at 3:06 PM LVN Y who worked overnight shift stated she had the in-service this morning about resident 7 rights of medication administration. She stated she was informed that 2 nurses would need to sign out narcotics to verify. She stated the cart and narcotic book was audited. She stated she was informed that the Med Aides were not allowed to pass narcotics. She stated she had not seen anyone pre pull medications, and pre pulled med errors could cause a medication error. She stated she would do an assessment with vital signs, hold the medication, and notify the doctor. She stated if she would see someone with pre pulled medications, she would advise them to discard the medications and assist them if needed. She stated if the person were to do it more than once, she would then go to the DON. During an interview on 8/6/2024 at 3:21 PM LVN T who worked overnight shift stated she had the in- service about medication administration that now required 2 nurses to sign for verification. She stated that medications should not be pre pulled and use the 7 rights of medication administration. She stated it was important not to pre pull to prevent medication error. She stated she had not seen anyone pre pull medications, but had she seen it, she would inform the person not to do that and then report. She stated if she saw someone drowsy, she would not administer a narcotic because it could mask another problem. She stated she would call the supervisor, the doctor, and the family and wait for further orders from the doctor. During an observation on 8/6/2024 at 3:50 PM, the medication carts on the 100-hall unit had all the narcotics on the nurses' carts and no narcotics on the Medication Aide's cart. Observed LVN F on 100 hall passed medication and LVN F verified a narcotic he pulled with RN V. During an interview on 8/6/2024 at 10:10 AM, the DON stated she did not want staff to know she would do random medication observations because she wanted to ensure they were doing the medication pass per facility policy. She stated she did an in-service with Med Aide A1 that morning and she was informed not to pre-pull medication. She stated she allowed her to prepare for medication pass and decided to do a random observation with her. She stated she found that the Med Aide A1 was about to enter a residents' room with 2 cups of medication- one cup for each resident. The Med Aide was terminated. During an interview on 8/6/2024 at 1:40 PM LVN O who worked day and evening shifts worked on the weekends. He stated he had the in-service on the 5 rights of medication administration and was also observed doing a medication pass. He stated all the narcotics were on the nurses' carts and no longer on the Med Aide's carts. He stated he was informed that the narcotics were to be signed by 2 nurses for verification. He stated medications should not be pre pulled because the medication could be given to the wrong resident. He stated he was newly hired at the facility and had not seen anyone pre pull medication. If he were to see it, he would notify the supervisor. He stated he had been observed by the DON doing medication pass. Record review of QAPI signature page dated 8/4/2024 revealed the Medical Director gave verbal approval over the phone and email due to being on vacation. The Administrator stated the Medical Director also received a scanned copy of the signed IJ template. During an interview on 8/6/2024 at 6:56 PM LVN S stated he had in-service on medication right of medication administration. He stated he was told not to pre pull medication because it could cause a medication error. He stated he had not seen anyone pre pull medication. He stated if he saw anyone pre pull medication he would advise them not to administer medication that way and inform the DON. He stated that 2 nurses were to sign off on any narcotic to be given. He stated he would not give narcotics to anyone who would be drowsy, but instead hold it and call the doctor and notify the supervisor. Observation on 8/6/2024 at 7:03 PM revealed LVN F removed a Norco for Resident #3 and LVN M verified and signed off with LVN F before medication was administered. There were no pre pulled pills in the top drawer of the cart. He administered the medication to the resident using the 5 rights of medication administration. Observation on 8/6/2024 at 7:08 PM revealed Med Aide B1 administered to Resident #3 -Cymbalta 20mg, Atorvastatin 40mg, and Trazadone 50mg using the 5 rights of medication administration. There were no pre pulled pills in the top drawer. An IJ was identified on 8/4/2024. The IJ template was presented to the facility on [DATE] at 7:02PM. While the IJ was removed on 8/6/2024 at 8:03PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm due to the facilities need to continue to monitor the effectiveness of their plan.

Based on interview, and record review the facility failed to consult with the physician when the resident experienced a change in condition for 1 of 1 resident (Residents #1) reviewed for a notification of a change of condition, in that; LVN A did not assess Resident #1 or notify the Physician of Resident #1's change in condition on 12/15/23 when Resident # 1's family member came to LVN A with concerns about the resident's catheter being plugged and abnormal confusion. On 12/22/2023 at 4:31 p.m., an Immediate Jeopardy (IJ) was Identified. While the IJ was removed on 12/23/2023, the facility remained out of compliance at a severity of actual harm but with potential for more than minimal harm and with a scope isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This deficient practice could place residents at risks of not having the physician contacted when they have a change of condition and it could result in delay of medical treatment and hospitalization . Findings included: Record review of Resident #1's face sheet, dated 12/22/23, revealed a male resident with an admitted [DATE] and diagnosis that included [Shortness of Breath] the frightening sensation of being unable to breathe normally or feeling suffocated, [Bladder Cancer] rare form of cancer that starts in the lining of your bladder, and [Severe Protein Calorie Malnutrition] significant muscle wasting, and loss of subcutaneous fat. Record review of Resident #1's Admission MDS assessment, dated 12/13/2023, revealed no BIMS score as the Cognitive assessment was not completed with the resident. Further review revealed a staff assessment for mental status had been completed that revealed short-term and long-term memory problems. Memory/Recall ability indicated resident is unable to recall the current season, the location of their own room, staff names and faces, that the resident in a nursing home and noted resident's cognitive skills to be severely impaired. No behavior issues, such as refusal of care, were identified on the MDS. Further review revealed under section H that Resident # 1 was noted to have an indwelling catheter. Record review of Resident # 1's care plan dated 12/13/23 revealed a focus area for an indwelling catheter with interventions to flush and assess each shift. Record review of Resident #1's assessments for 12/15/23 did not reveal LVN A reassessed resident or progress note regarding family members concerns. Record review of Resident #1's vital signs taken on 12/15/23 documented at 3:55 p.m., revealed normal vital signs, no further vital signs noted reflecting nursing assessment. Record review of Resident #1's assessment for 12/15/23 documented on 12/15/23 at 3:55 p.m., revealed a normal assessment. Record review of Resident #1's progress note for 12/15/23 revealed the catheter showed urine in the drainage bag was clear and draining via gravity. Recoard review of Resident #1's Treatment Administrator Record for 12/15/23 day shift documentation revealed the catheter was flushed. Record review of [Name of Hospital] records for Resident #1, provided by family member, revealed an admitted [DATE] and he was admitted for [ Septic Shock ] a life-threatening condition that happens when your blood pressure drops to a dangerously low level after an infection and [intubation] procedure that's used when you can't breathe on your own. In an interview with LVN A on 12/22/23 at 10:45 a.m., stated she was the assigned nurse for Resident #1 on 12/15/23, 6:00 a.m. - 2:00 p.m., and took vital signs of Resident # 1 at the start of her shift on 12/15/23 at 7:15 a.m. LVN A stated she did not repeat vital signs as she did not see a change in condition, or reason to reassess Resident # 1. LVN A was asked why her assessment of Resident # 1 was started on 12/15/23 at 3:55 p.m., after her shift was over and why the assessment did not include a change of condition, abnormal vital signs or conversation had with family member. LVN A responded that she documented what she saw in the morning around 7:15 a.m., and she replied she did not do a second set of vital signs as Resident # 1 was stable on her shift and did not have a change of condition. In an interview with the DON on 12/22/23 at 10:45 a.m., the DON stated the family member of Resident #1 notified her of a change of condition on 12/15/23 at 2:04 p.m. at that time was when she looked up vital signs on the electronic medical record and no vital signs for Resident # 1 were listed at that time. The DON stated she ordered RN B to take vital signs. They were respirations - 32, Oxygen - 78% and Blood pressure of 74/45. This was when the family called 911 and Resident #1 was sent to the hospital via ambulance. The DON stated that it was her expectation that licensed nurses follow policy and procedure to notify physician of any change and document accurate vital signs. In an interview with RN B on 12/22/23 at 11:30 am she stated that she was the evening nurse for Resident # 1 on 12/15/23 from 2:00 p.m. - 10:00 p.m., shift, she recalled in the nursing report from LVN A on 12/15/23 she was told that family of Resident # 1 wanted him sent to the hospital for a change of condition. RN B stated that after the report, she went to do rounds on her residents. When the DON asked her to do a set of vital signs on Resident # 1, she recalled vital signs were abnormal, and family member was asking for them and writing them down. RN B was asked why there was no change of the condition assessment completed or nursing notes on her shift. RN B stated, it all happened so fast that day her only thought was to send the resident out as he did not look like himself and probably forgot. RN B stated Resident #1 was sent via ambulance to the hospital and family member called 911 In an interview with the family member of Resident #1 on 12/22/23 at 3:15 p.m. revealed she came to LVN A various times on 12/15/23 starting at 12:00 p.m., 12:20 p.m. and 1:00 p.m. with concerns that Resident #1 was more confused, and the resident's catheter was clogged. Resident #1's family member stated not once did LVN A take vital signs of a Resident #1. The family member recalled LVN A telling her that Resident #1 was, fine and not to worry. In an interview with Resident #1's physician on 12/22/23 at 3:30 p.m., he stated that he assessed Resident #1 on 12/14/23 and did not have any concerns at that time. However, it was his expectation that licensed nurses contact him on any change of condition on any of his residents. In an interview with CNA A on 12/22/23 at 3:45 p.m., she stated she was the assigned CNA on 12/15/23 for the day shift (6:00 a.m. - 2:00 p.m.). She recalled speaking to LVN A on one occasion that day at 11:20 a.m. and telling LVN A that Resident #1 was not eating his lunch and not himself. Record review of Facility policy title Acute Condition Changes, dated 2001 , revised March 2018 revealed The Nursing staff will contact the physician based on urgency of the situation, The Physician should request information to clarify the situation for example vital signs and physical findings . This was determined to be an Immediate Jeopardy (IJ) on 12/22/2023 at 4:25 p.m. The Administrator was notified at 4:35 p.m. The Administrator was provided with an IJ template on 12/22/23 at 4:35 p.m. The following Plan of Removal (POR) was submitted by the facility on 12/22/2023 at 7:47 p.m. The following plan of action outlines immediate interventions employed by the facility to remove any further concerns surrounding the issues: Regional Director of Operations re-educated the Administrator on ensuring residents were receiving necessary and accurate follow through with change of condition, notification, and implementation on 12/22/2023. Regional Nurse Consultant for the facility reinforced and re-educated the Director of Nursing on identification, assessment, and notification of change in condition to be maintained consistently following facility policies and monitored for effective and successful outcomes on 12/22/2023. Licensed facility personnel to perform audit of all resident charts to include identification, assessment, outcome, and communication for the past 14 days to assess for proper implementation of change in condition policy with interventions performed accordingly by 12/23/2023. The DON/designee to have completion of change in condition to include identification, assessment, and notification competencies on all licensed nursing personnel by 12/23/2023. Re-education of all licensed staff members began per the DON/ADON and/or designees on abuse/neglect, change in condition to include identification, assessment, documentation, notification, and outcome of resident status per facility policies. Integrity checks by educators began 12/22/2023 and to continue to completion 12/23/2023 with posttest as noted below in interventions and monitoring. Interventions and Monitoring Plan to Ensure Compliance Quickly: The Director of Nursing/Designee educated all licensed nursing staff on abuse/neglect, change in condition to include identification, assessment, documentation, notification, and outcome of resident status including discharge procedures and documentation. Initiated: 12/22/2023 Completion: 12/23/2023 Reeducation to be completed by 12/23/2023 with licensed nurses regarding change of condition, immediate notification, and responsible party integration in care to include notification and follow through with findings. Initiated: 12/22/2023 Completion: 12/23/2023 All resident changes in conditions were to be reported to the Director of Nursing/designee to ensure monitoring all acute change of condition documentation and notification of physician and responsible party with appropriate interventions and actions daily. Initiated: 12/22/2023 Completion: 12/23/2023 Immediate action to notify the physician and receive new orders on any residents identified through audit findings for potential change in condition with appropriate documentation at such time of notification. Initiated: 12/22/2023 Completion: 12/23/2023 100% of the licensed staff that were currently scheduled performed return demonstration of understanding will be noted by post competency check for each person educated with a written post-test administered by the Director of Nursing, the Assistant Director of Nursing, and/or designee for all the nursing staff receiving training on change in condition and appropriate documentation and notification. Staff that are not scheduled or on leave from the facility will perform return demonstration of understanding and will be noted by post competency check for each person educated with a written post-test administered by Director of Nursing, Assistant Director of Nursing, and/or designee before starting their next shift. This facility does not employ the use of agency personnel. Initiated: 12/22/2023 Completion: 12/23/2023. The facility DON/ADON will act as monitoring liaison to coordinate completion of audits and communication of any issues in weekly clinical at risk (CAR) meetings which include the Administrator and interdisciplinary team for continuum of care to be documented through signed attendance sheet. Initiated: 12/22/2023 Completed: 12/23/2023 The policy and procedure for abuse/neglect and change in condition were reviewed by the Regional [NAME] President of Operations and the Regional Nurse Consultant with no changes to policies to be implemented. Continue to follow policies as implemented and monitor compliance as noted above. Initiated: 12/22/2023 Completed: 12/23/2023 The QAPI Team, led by the Administrator, will meet weekly for 3 weeks to discuss that coordination and completion of all education, assessments, and interventions are utilized to ensure that appropriate change of condition procedures and protocol are followed and maintained per current facility policies. The Medical Director was notified of Immediate Jeopardy and QAPI meetings on 12/22/2023 and will be part of the QAPI intervention meetings. Abuse/neglect and change of condition protocols and policies to be added to the QAPI monthly for 3 months following the initial 3 weeks to monitor program progress. Verification: Interview with the Regional [NAME] President of Operations and Regional Nurse Consultant on 12/23/23 at 2:30 p.m. They stated they have reviewed the change of condition and the Abuse/Neglect policy, and no changes will be implemented. Interview with Administrator on 12/23/23 at 12:10 p.m., the Administrator stated the Regional Director of Operations re-educated him on ensuring residents were receiving necessary and accurate follow through with change of condition, notification, and implementation. Verified, via records review signed by the Administrator on 12/22/23 where he acknowledged re-education by the Regional Director of Operations on ensuring residents were receiving necessary and accurate follow through with change of condition, notification, and implementation. Interview with the DON on 12/23/23 at 12:30 p.m., the DON stated she was re-educated by the Regional Nurse Consultant on identification, assessment, and notification of change in condition to be maintained consistently following facility policies and monitored for effective and successful outcomes. Verified, via records review signed by the DON on 12/22/23, where she acknowledges re-education by the Regional Nurse Consultant identification, assessment, and notification of change in condition to be maintained consistently following facility policies and monitored for effective and successful outcomes, Record review of 56 residents' charts, of which 56 charts revealed compliance. Interviews with the DON and ADON revealed the ADON was immediately trained on 12/22/23 in the change of condition procedures to ensure they were able to train other staff. Verified via inservice titled Change of Condition. and post-test for Change of Condition reflecting all licensed nurses employed by facility. Interviewed 3 day shift licensed Nurses, 3 evening shift licensed nurses and 2 night shift licensed nurses all stated they had received recent in-service regarding change of condition identification, assessment, and notification competencies. Interviews with the DON and ADON revealed the ADON was immediately trained on 12/22/23 in the abuse/neglect procedures to ensure they were able to train other staff. Verified inservice titled Abuse/neglect. reflecting all staff employed by facility. Interviewed 3 day shift licensed Nurses, 2 CNA's, 3 evening shift licensed nurses, 3 CNA's and 2 night shift licensed nurses , 1 CNA , night shift; all stated they had received recent in-service regarding change of condition identification, assessment, and notification competencies. Interview with the DON,on 12/23 /23 at 2:00 p.m., the DON was asked , what was the facility's monitoring or oversight process for ensuring residents were assessed timely upon being informed of concerns for a change of condition. She responded her plan was for this to be a continuous quality measure; she planned to utilize the 72-hour report in point-click care to identify any changes of condition and have the ADON ensure proper steps were completed. Interview with the Clinical Regional Nurse on 12/23/2023 at 1:45 p.m. revealed all staff training began on 12/22/2023. Employees who have not worked since the incident have been in-serviced via phone however all will be trained in person on a one-to-one basis by the DON/designee before they are allowed to work their next shift. Of the employees in-serviced via telephone currently; 13 were nursing/direct care staff, 2 were therapy/activities staff, 1 was administrative/office staff, and 4 were ancillary staff. Interviews with 11 employees were conducted on 12/23/2023 by state surveyor, all were able to verbalize an understanding of neglect and change of condition and stated they were provided handouts to reference as needed. Of the employees interviewed all shifts were covered, including: (3) 6 am - 2 pm, (2) 2 pm - 10 pm, (2) 10 pm - 6 pm, (1) 6 am - 6 pm (12-hour shift), (1) 6 am - 10 pm (doubles), (5) 8 am - 5 pm/8 pm (office staff). The Administrator was informed the Immediate Jeopardy was removed on 12/23/2023 at 5:54 p.m. The facility remained out of compliance at a severity level of actual harm that was not an Immediate Jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 1 residents (Resident #1) reviewed quality of care in that: The facility failed to immediately assess Resident #1 or notify the physician when a change of condition was voiced by Resident #1's family member. On 12/22/2023 at 4:31 p.m., an Immediate Jeopardy (IJ) was Identified. While the IJ was removed on 12/23/2023, the facility remained out of compliance at a severity of actual harm but with potential for more than minimal harm and with a scope isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure could place residents at risk for not receiving the appropriate care and treatment. Findings included: Record review of Resident #1's face sheet, dated 12/22/23, revealed a male resident with an admitted [DATE] and diagnosis that included [Shortness of Breath] the frightening sensation of being unable to breathe normally or feeling suffocated, [Bladder Cancer] rare form of cancer that starts in the lining of your bladder, and [Severe Protein Calorie Malnutrition] significant muscle wasting, and loss of subcutaneous fat. Record review of Resident #1's Admission MDS assessment, dated 12/13/2023, revealed no BIMS score as the Cognitive assessment was not completed with the resident. Further review revealed a staff assessment for mental status had been completed that revealed short-term and long-term memory problems. Memory/Recall ability indicated resident is unable to recall the current season, the location of their own room, staff names and faces, that the resident in a nursing home and noted resident's cognitive skills to be severely impaired. No behavior issues, such as refusal of care, were identified on the MDS. Further review revealed under section H that Resident # 1 was noted to have an indwelling catheter. Record review of Resident # 1's care plan dated 12/13/23 revealed a focus area for an indwelling catheter with interventions to flush and assess each shift. Record review of Resident #1's assessments for 12/15/23 did not reveal LVN A reassessed resident or progress note regarding family members concerns. Record review of Resident #1's vital signs taken on 12/15/23 documented at 3:55 p.m., revealed normal vital signs, no further vital signs noted reflecting nursing assessment. Record review of Resident #1's assessment for 12/15/23 documented on 12/15/23 at 3:55 p.m., revealed a normal assessment. Record review of Resident #1's progress note for 12/15/23 revealed the catheter showed urine in the drainage bag was clear and draining via gravity. Recoard review of Resident #1's Treatment Administrator Record for 12/15/23 day shift documentation revealed the catheter was flushed. Record review of [Name of Hospital] records for Resident #1, provided by family member, revealed an admitted [DATE] and he was admitted for [ Septic Shock ] a life-threatening condition that happens when your blood pressure drops to a dangerously low level after an infection and [intubation] procedure that's used when you can't breathe on your own. In an interview with LVN A on 12/22/23 at 10:45 a.m., stated she was the assigned nurse for Resident #1 on 12/15/23, 6:00 a.m. - 2:00 p.m., and took vital signs of Resident # 1 at the start of her shift on 12/15/23 at 7:15 a.m. LVN A stated she did not repeat vital signs as she did not see a change in condition, or reason to reassess Resident # 1. LVN A was asked why her assessment of Resident # 1 was started on 12/15/23 at 3:55 p.m., after her shift was over and why the assessment did not include a change of condition, abnormal vital signs or conversation had with family member. LVN A responded that she documented what she saw in the morning around 7:15 a.m., and she replied she did not do a second set of vital signs as Resident # 1 was stable on her shift and did not have a change of condition. In an interview with the DON on 12/22/23 at 10:45 a.m., the DON stated the family member of Resident #1 notified her of a change of condition on 12/15/23 at 2:04 p.m. at that time was when she looked up vital signs on the electronic medical record and no vital signs for Resident # 1 were listed at that time. The DON stated she ordered RN B to take vital signs. They were respirations - 32, Oxygen - 78% and Blood pressure of 74/45. This was when the family called 911 and Resident #1 was sent to the hospital via ambulance. The DON stated that it was her expectation that licensed nurses follow policy and procedure to notify physician of any change and document accurate vital signs. In an interview with RN B on 12/22/23 at 11:30 am she stated that she was the evening nurse for Resident # 1 on 12/15/23 from 2:00 p.m. - 10:00 p.m., shift, she recalled in the nursing report from LVN A on 12/15/23 she was told that family of Resident # 1 wanted him sent to the hospital for a change of condition. RN B stated that after the report, she went to do rounds on her residents. When the DON asked her to do a set of vital signs on Resident # 1, she recalled vital signs were abnormal, and family member was asking for them and writing them down. RN B was asked why there was no change of the condition assessment completed or nursing notes on her shift. RN B stated, it all happened so fast that day her only thought was to send the resident out as he did not look like himself and probably forgot. RN B stated Resident #1 was sent via ambulance to the hospital and family member called 911 In an interview with the family member of Resident #1 on 12/22/23 at 3:15 p.m. revealed she came to LVN A various times on 12/15/23 starting at 12:00 p.m., 12:20 p.m. and 1:00 p.m. with concerns that Resident #1 was more confused, and the resident's catheter was clogged. Resident #1's family member stated not once did LVN A take vital signs of a Resident #1. The family member recalled LVN A telling her that Resident #1 was, fine and not to worry. In an interview with Resident #1's physician on 12/22/23 at 3:30 p.m., he stated that he assessed Resident #1 on 12/14/23 and did not have any concerns at that time. However, it was his expectation that licensed nurses contact him on any change of condition on any of his residents. In an interview with CNA A on 12/22/23 at 3:45 p.m., she stated she was the assigned CNA on 12/15/23 for the day shift (6:00 a.m. - 2:00 p.m.). She recalled speaking to LVN A on one occasion that day at 11:20 a.m. and telling LVN A that Resident #1 was not eating his lunch and not himself. Record review of Facility policy title Acute Condition Changes, dated 2001 , revised March 2018 revealed The Nursing staff will contact the physician based on urgency of the situation, The Physician should request information to clarify the situation for example vital signs and physical findings . This was determined to be an Immediate Jeopardy (IJ) on 12/22/2023 at 4:25 p.m. The Administrator was notified at 4:35 p.m. The Administrator was provided with an IJ template on 12/22/23 at 4:35 p.m. The following Plan of Removal (POR) was submitted by the facility on 12/22/2023 at 7:47 p.m. The following plan of action outlines immediate interventions employed by the facility to remove any further concerns surrounding the issues: Regional Director of Operations re-educated the Administrator on ensuring residents were receiving necessary and accurate follow through with change of condition, notification, and implementation on 12/22/2023. Regional Nurse Consultant for the facility reinforced and re-educated the Director of Nursing on identification, assessment, and notification of change in condition to be maintained consistently following facility policies and monitored for effective and successful outcomes on 12/22/2023. Licensed facility personnel to perform audit of all resident charts to include identification, assessment, outcome, and communication for the past 14 days to assess for proper implementation of change in condition policy with interventions performed accordingly by 12/23/2023. The DON/designee to have completion of change in condition to include identification, assessment, and notification competencies on all licensed nursing personnel by 12/23/2023. Re-education of all licensed staff members began per the DON/ADON and/or designees on abuse/neglect, change in condition to include identification, assessment, documentation, notification, and outcome of resident status per facility policies. Integrity checks by educators began 12/22/2023 and to continue to completion 12/23/2023 with posttest as noted below in interventions and monitoring. Interventions and Monitoring Plan to Ensure Compliance Quickly: The Director of Nursing/Designee educated all licensed nursing staff on abuse/neglect, change in condition to include identification, assessment, documentation, notification, and outcome of resident status including discharge procedures and documentation. Initiated: 12/22/2023 Completion: 12/23/2023 Reeducation to be completed by 12/23/2023 with licensed nurses regarding change of condition, immediate notification, and responsible party integration in care to include notification and follow through with findings. Initiated: 12/22/2023 Completion: 12/23/2023 All resident changes in conditions were to be reported to the Director of Nursing/designee to ensure monitoring all acute change of condition documentation and notification of physician and responsible party with appropriate interventions and actions daily. Initiated: 12/22/2023 Completion: 12/23/2023 Immediate action to notify the physician and receive new orders on any residents identified through audit findings for potential change in condition with appropriate documentation at such time of notification. Initiated: 12/22/2023 Completion: 12/23/2023 100% of the licensed staff that were currently scheduled performed return demonstration of understanding will be noted by post competency check for each person educated with a written post-test administered by the Director of Nursing, the Assistant Director of Nursing, and/or designee for all the nursing staff receiving training on change in condition and appropriate documentation and notification. Staff that are not scheduled or on leave from the facility will perform return demonstration of understanding and will be noted by post competency check for each person educated with a written post-test administered by Director of Nursing, Assistant Director of Nursing, and/or designee before starting their next shift. This facility does not employ the use of agency personnel. Initiated: 12/22/2023 Completion: 12/23/2023. The facility DON/ADON will act as monitoring liaison to coordinate completion of audits and communication of any issues in weekly clinical at risk (CAR) meetings which include the Administrator and interdisciplinary team for continuum of care to be documented through signed attendance sheet. Initiated: 12/22/2023 Completed: 12/23/2023 The policy and procedure for abuse/neglect and change in condition were reviewed by the Regional [NAME] President of Operations and the Regional Nurse Consultant with no changes to policies to be implemented. Continue to follow policies as implemented and monitor compliance as noted above. Initiated: 12/22/2023 Completed: 12/23/2023 The QAPI Team, led by the Administrator, will meet weekly for 3 weeks to discuss that coordination and completion of all education, assessments, and interventions are utilized to ensure that appropriate change of condition procedures and protocol are followed and maintained per current facility policies. The Medical Director was notified of Immediate Jeopardy and QAPI meetings on 12/22/2023 and will be part of the QAPI intervention meetings. Abuse/neglect and change of condition protocols and policies to be added to the QAPI monthly for 3 months following the initial 3 weeks to monitor program progress. Verification: Interview with the Regional [NAME] President of Operations and Regional Nurse Consultant on 12/23/23 at 2:30 p.m. They stated they have reviewed the change of condition and the Abuse/Neglect policy, and no changes will be implemented. Interview with Administrator on 12/23/23 at 12:10 p.m., the Administrator stated the Regional Director of Operations re-educated him on ensuring residents were receiving necessary and accurate follow through with change of condition, notification, and implementation. Verified, via records review signed by the Administrator on 12/22/23 where he acknowledged re-education by the Regional Director of Operations on ensuring residents were receiving necessary and accurate follow through with change of condition, notification, and implementation. Interview with the DON on 12/23/23 at 12:30 p.m., the DON stated she was re-educated by the Regional Nurse Consultant on identification, assessment, and notification of change in condition to be maintained consistently following facility policies and monitored for effective and successful outcomes. Verified, via records review signed by the DON on 12/22/23, where she acknowledges re-education by the Regional Nurse Consultant identification, assessment, and notification of change in condition to be maintained consistently following facility policies and monitored for effective and successful outcomes, Record review of 56 residents' charts, of which 56 charts revealed compliance. Interviews with the DON and ADON revealed the ADON was immediately trained on 12/22/23 in the change of condition procedures to ensure they were able to train other staff. Verified via inservice titled Change of Condition. and post-test for Change of Condition reflecting all licensed nurses employed by facility. Interviewed 3 day shift licensed Nurses, 3 evening shift licensed nurses and 2 night shift licensed nurses all stated they had received recent in-service regarding change of condition identification, assessment, and notification competencies. Interviews with the DON and ADON revealed the ADON was immediately trained on 12/22/23 in the abuse/neglect procedures to ensure they were able to train other staff. Verified inservice titled Abuse/neglect. reflecting all staff employed by facility. Interviewed 3 day shift licensed Nurses, 2 CNA's, 3 evening shift licensed nurses, 3 CNA's and 2 night shift licensed nurses , 1 CNA , night shift; all stated they had received recent in-service regarding change of condition identification, assessment, and notification competencies. Interview with the DON,on 12/23 /23 at 2:00 p.m., the DON was asked , what was the facility's monitoring or oversight process for ensuring residents were assessed timely upon being informed of concerns for a change of condition. She responded her plan was for this to be a continuous quality measure; she planned to utilize the 72-hour report in point-click care to identify any changes of condition and have the ADON ensure proper steps were completed. Interview with the Clinical Regional Nurse on 12/23/2023 at 1:45 p.m. revealed all staff training began on 12/22/2023. Employees who have not worked since the incident have been in-serviced via phone however all will be trained in person on a one-to-one basis by the DON/designee before they are allowed to work their next shift. Of the employees in-serviced via telephone currently; 13 were nursing/direct care staff, 2 were therapy/activities staff, 1 was administrative/office staff, and 4 were ancillary staff. Interviews with 11 employees were conducted on 12/23/2023 by state surveyor, all were able to verbalize an understanding of neglect and change of condition and stated they were provided handouts to reference as needed. Of the employees interviewed all shifts were covered, including: (3) 6 am - 2 pm, (2) 2 pm - 10 pm, (2) 10 pm - 6 pm, (1) 6 am - 6 pm (12-hour shift), (1) 6 am - 10 pm (doubles), (5) 8 am - 5 pm/8 pm (office staff). The Administrator was informed the Immediate Jeopardy was removed on 12/23/2023 at 5:54 p.m. The facility remained out of compliance at a severity level of actual harm that was not an Immediate Jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview and record review, the facility failed to ensure that a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one of three residents (Resident # 2) reviewed for pressure sores. The facility failed to ensure Resident #2 received wound care treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure could place additional residents at risk for a delay in treatment, a decline in health, hospitalization , or in a significant decline in health. The findings included: Closed record review of Resident #2's admission record revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed a re-admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Weekly Pressure Ulcer Report dated 05/19/22 revealed the resident had a new Stage II pressure ulcer (partial thickness loss of the skin) to the sacrum (a triangular bone wedged into the rear section of the pelvis) measuring 0.2 cm x 0.5 cm x 0. Review of Resident #2's Weekly Pressure Ulcer Report dated 06/16/22 revealed the resident had a new Stage IV (full thickness tissue loss) pressure ulcer to the sacrum measuring 4 cm x 3 cm x 0.1 cm. Review of Resident #2's progress notes revealed in part: 1. 06/03/22 - 12:53 pm - [Ambulance] arrived to pick up resident via stretcher. Pt is lethargic, very minimal response .3:49 pm - IDT meeting held to discuss the following onset of pressure to sacrum .new order for wound care MD to follow-up with resident next week . 2. 06/12/22 with admitted [DATE] - Assessment/Plan: .BL UE [sic] weeping (clear oozing fluid from the wound) [CONDITION(S)] .no wound care orders in chart. Will inquire about wound care consult .Rsd (resident) returned from hospital during the 2-10 shift .Rsd refused all cares, yelling at staff to get out each time we entered the room to attempt . Further review revealed no documentation of an assessment to resident's sacrum area. 3. 06/13/22 - Resident present w/ weeping [CONDITION(S)] to the bilateral upper extremities . Further review revealed no assessment of the resident's sacrum area. 4. 06/14/22 - [Physician] in house to assess progression of the following wounds sacrum 4.2 cm x 3.5 cm x 0.1 cm, heavy exudate (drainage), 90% necrotic, wound deteriorating post hospitalization ,d+[DATE]-[DATE] . Further review revealed no documentation of wound assessment or treatment to Resident #2 between 06/11/22 and 06/14/22. Review of Resident #2's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the TAR for June 2022 revealed Resident #2 began to receive wound care treatment on 06/15/22. Further review revealed no documentation that Resident #2 received wound care treatment on 06/11/22 through 06/14/22, after she was readmitted from the hospital on 06/11/22. During an interview and record review on 11/16/22 at 9:20 a.m., the ADON verified there was no assessment, wound care order or treatment upon Resident #2's readmission from the hospital. She stated if the resident had a pressure ulcer upon re-admission the nurse should have called the doctor to get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 11/16/22 at 10:40 a.m., the Administrator stated the potential resident negative outcome is no continuity of care. He stated the staff expectations would be to have received orders from the hospital and follow them and that the nurse should have called the doctor to initiate an order based on assessment. During an interview on 11/17/22 at 10:55 a.m., LVN E stated Resident #2 was fragile, had wounds, and was on hospice. He stated the resident went to the hospital with a Stage II wound and returned with a Stage III to IV wound.

Based on interview and record review, the facility failed to consult the physician for 1 of 3 Residents (Resident #1) who experienced a significant change in the resident's physical status in that: Resident #1 had an unwitnessed fall. LVN A did not inform the physician of Resident #1's abnormal neurocheck which indicated a change in condition. This deficient practice could affect residents who had unwitnessed falls and could result in injury or death. The findings were: Review of Resident #1's Face Sheet, dated 2/27/20, revealed an admission date of [DATE] and re-admission date of [DATE], with [DIAGNOSES REDACTED]. Review of Resident #1's most recent quarterly MDS dated [DATE], revealed Resident #1 was severely cognitively impaired for daily decision-making skills. Review of Resident #1's Care Plan dated 2/27/20 revealed he had risk for falls and ambulates ad lib-frequently paces. Record review of the Neurological Assessment Flow sheet dated 2/21/20, after an unwitnessed fall, revealed: 5:50 a.m. Resident #1's eyes were checked for pupil response to light by LVN B. LVN B documented Resident #1's left and right eye were PERL (pupils equal and reactive to light) with pupil response to light as brisk. 6:05 a.m. Resident #1's pupil response was documented by LVN B as NR (non-reactive) to the right eye and sluggish on the left. 6:20 a.m. Resident #1's pupil response was documented by LVN A as sluggish to the left and right eye and an observation was documented he was grabbing head. 6:35 a.m. Resident #1's pupil response to light was documented by LVN A as sluggish to the left and right eye and observation was documented leans to right side. 7:05 a.m. Resident #1's pupil response to light was documented by LVN A as sluggish to the left and right eye and an observation was documented vomiting. 7:35 a.m. Resident #1's pupil response to light was documented by LVN A as sluggish to the left and right eye and an observation was documented as vomiting. 8:00 a.m. An entry of sent to hospital was the last entry on the Neurological Assessment Flow sheet for Resident #1. Review of the nursing progress note dated 2/21/20, 8:41 a.m. by LVN A revealed Resident #1, woke to verbal with touch stimuli but could not keep eyes open. Further review of the nursing progress note revealed, Upon neuro (neurological) assessment, left eye unresponsive, right side sluggish. Decreased hand grasp to bilateral hands. LVN A further documented, Night shift nurse (LVN B) advised before departure that NP (Nurse Practitioner) was notified. Record review of the SBAR (Situation, Background, Assessment, Recommendation) Communication Form for Resident #1 dated 2/21/20, 6:13 a.m. and signed by LVN B revealed, NP notified of unwitnessed fall, neurocheck initiated, overall status within his normal baseline, no injury assessed. Record review of the nursing progress note dated 2/21/20, 8:55 a.m. by LVN A revealed, hospital nurse stated Resident (#1) had a large brain bleed and hospital will have to notify family for next step. During an interview on 2/25/20 at 8:27 a.m., the DON stated Resident #1 was discovered on the floor in the hallway on 2/21/20 at approximately 5:45 a.m. by CNA C. The DON stated CNA C heard a thump and saw Resident #1 and another resident on the floor. The DON revealed Resident #1 was sent to the hospital by emergency medical services and was later diagnosed with [REDACTED]. During an interview on 2/25/20 at 1:05 p.m., LVN B stated at approximately 5:45 a.m. on 2/21/20 CNA C notified her that 2 residents were on the floor in the hallway of the secure unit. LVN B stated Resident #1 and another resident were on the floor on their backs on opposite sides of the hallway with their feet touching in a V pattern. LVN B stated Resident #1 was trying to get up. LVN B proceeded to obtain neurological checks on Resident #1 and stated she had obtained the first 2 neurological checks at 5:50 a.m. and again at 6:05 a.m. and the results did no show any abnormalities. LVN B stated she called the NP at approximately 6:15 a.m. to report the fall and no new orders were given. LVN B further stated she gave report to LVN A and then left at approximately 6:53 a.m. A telephone interview was attempted with CNA C on 2/25/20 at 12:16 p.m. but message requesting call back was not returned. During an interview on 2/27/20 at 8:51 a.m., LVN A stated she called the NP at approximately 6:20 a.m. on 2/21/20 to notify her that Resident #1 had an unwitnessed fall. LVN A stated she continued with the neurological assessments and did not call the NP again until approximately 7:15 a.m. when Resident #1 vomited. LVN A stated that the NP ordered her to call 911 and send Resident #1 to the emergency room . LVN A stated after talking to the NP she then called the DON to let her know what had happened and while she was on the phone with the DON, Resident #1 vomited again. LVN A stated the DON told her to hang up and call 911. LVN A stated, I didn't believe that LVN B had gotten a brisk reaction from Resident #1's pupils and I get it I should have called the doctor after the second neuro check at 6:05 a.m. to tell her there had been a change. LVN A stated she could not recall the last time she had been in-serviced on emergencies, SBAR, or neurological checks. During an interview on 2/25/20 at 2:51 p.m., the DON stated it was the expectation of the nurses to initiate neurological checks after an unwitnessed fall. The DON further stated the physician was supposed to be immediately notified when a resident falls, witnessed or unwitnessed, regardless of injury and when there was a change in condition. Review of the facility policy titled Assessment: Neurological procedure, revision dated 10/1/12, revealed in part, . Neurological assessment will be performed as indicated or ordered. When a patient sustains an injury to the head and/or has an unwitnessed fall, neurological assessment will be performed . Purpose: To monitor patient for neurological compromise . Review of the facility policy titled Acute Condition Changes-Clinical Protocol, revision dated 3/2018, revealed in part, . Assessment and Recognition .7. Before contacting a physician about someone with an acute change of condition, the nursing staff will collect pertinent details to report to the physician. 8. The nursing staff will contact the physician based on the urgency of the situation .