Every finding on record at Legacy at Town Creek

Based on observation, interview, and record review the facility failed to immediately consult with the resident's physician when there was an accident involving the resident which resulted in injury and had the potential for requiring physician intervention for 1 of 4 residents (Resident #1) reviewed for notification of changes. The facility failed to notify Resident #1's physician immediately on 12/11/25 at 3:00 a.m. when he fell in the dining room resulting in facial/scalp contusions and a hematoma to his forehead. Resident #1 was on dual antiplatelet therapy of Clopidogrel and Aspirin which increased the risk of intracranial bleeding and the physician was not notified of the fall with head injury until 4:21 a.m., a delay of 81 minutes. This failure could place all residents at risk of delayed medical care, pain, and hospitalization. Findings included: Review of an admission Record dated 1/7/26 for Resident #1 indicated he was a [AGE] year-old male readmitted to the facility on [DATE] with diagnoses of end stage renal disease (kidney failure), dependence on renal dialysis, and atherosclerotic heart disease (plaque in the coronary arteries). Record review of an admission MDS dated [DATE] indicated Resident #1 had intact cognition with a BIMS score of 15. He required supervision with most ADLs, and he was taking an antiplatelet medication. Record review of a comprehensive care plan dated 11/4/25 indicated Resident #1 was on dual antiplatelet therapy of Aspirin and Clopidogrel therapy related to prior myocardial infarction (heart attack). Interventions were in place including labs as ordered, skin inspections as needed, and report changes or increases in bruising. During an observation and interview on 1/7/26 at 9:38 a.m., Resident #1 was observed in his room lying in bed, he had fading bruising around his right eye. Resident #1 said he was trying to get up from his wheelchair to get coffee, and he tripped over the footrest. Resident #1 said he fell and hit the right side of his face and head on the floor and yelled for help. Resident #1 said the nurse arrived and checked him out. Resident #1 said he told the nurse his head was hurting. Resident #1 said the nurse told him that it would get better when the swelling went down. Resident #1 said he went to dialysis later that morning and the doctor there sent him to the ER. Resident #1 said it was all backwards; I should have gone to the ER first. Resident #1 said he was never offered to go to the ER, and he never asked to go. Review of an unwitnessed fall report dated 12/11/25 at 3:00 a.m. by LVN A indicated he was at the nurse's station when he heard a resident yell for help from the kitchen area. LVN A went to the location and observed Resident #1 lying on his right side. LVN A assisted Resident #1 back into his wheelchair and noted a bump on his head. LVN A administered Tylenol for pain and applied an ice pack to resident's head. The same fall report indicated immediate action taken was an assessment with normal vital signs, resident was alert and oriented and reported a pain level of 6/10 (moderate pain); the MD was notified at 4:21 a.m. During an interview on 1/7/26 at 10:00 a.m., RN B said he worked on Resident #1's unit the morning of his fall, on 12/11/25. RN B said he was given report by LVN A that the resident fell at 3:00 a.m. that morning and that all his neurological checks were normal. RN B said he did not see Resident #1 that morning himself due to resident having such an early 7:00 a.m. dialysis appointment, he was already gone from the unit. RN B said the resident went from dialysis to the ER before returning to the facility. RN B said if a resident fell and had a head injury, especially if that resident took an antiplatelet medication, he would call the MD immediately or as soon as possible due to risk of brain bleeding. RN B said any changes to neurological status should prompt contacting the MD again. Review of a Dialysis Communication Form dated 12/11/25 at 05:35 a.m. signed by LVN A indicated there were no new problems or concerns with Resident #1. Review of a physician note from a dialysis center dated 12/11/25 indicated Patient was seen and evaluated this morning on rounds.had a fairly large and prominent bruising and small hematoma on his forehead.He has no headache, no visual changes, or neurological changes.He will be sent to the ER post HD (hemodialysis) by nursing home staff. During an interview on 1/7/26 at 1:00 p.m., the MD said he could not recall when he was notified by facility staff of Resident #1's fall on 12/11/25, but the facility notified him within minutes. The MD said he was unaware there was an 81-minute delay in notification. The MD said he was notified that the resident fell, and all neurological checks were being conducted and were normal. MD said standard teaching for a patient taking clopidogrel is usually to go to the ER if you have a head injury. MD said there was no added risk to resident safety in this case due to neurological checks being completed with normal results. The MD said symptoms of bruising and swelling were reported to him. The MD declined to comment on whether the 81-minute delay was considered prompt notification. During an interview on 1/7/26 at 11:50 a.m., ADON said she was responsible for supervision of nursing staff at the facility. ADON said she expected nursing staff to alert the physician immediately in the result of a resident fall with head injury especially if the resident is taking antiplatelet medication. ADON said that the increased risk of brain bleeding could be fatal. During an interview on 1/7/26 at 12:00 p.m., the DON said she was responsible for supervision of all nursing staff in the facility. The DON said a resident taking antiplatelet medication could increase the risk of injury but as long as neurological checks were normal there was no reason to contact the physician sooner. The DON said nurses notify doctors by either text or phone call depending on the situation and the physician preference. The DON said in this instance she felt the 81-minute delay and texting the physician was acceptable. During an interview on 1/7/26 at 12:23 p.m., the ADM said he was not sure on the timeline of when the physician was notified of the fall. The ADM said his expectation of staff was that the MD be notified immediately or as soon as possible following a fall with head injury. The ADM said he was not sure what the risks would be in delaying notification, it would depend on the situation as long as the resident was stable there may not be additional risk. During an interview on 1/7/25 at 1:00 p.m., LVN A said he was the nurse assigned to Resident #1's care on 12/10/25 on the night shift. LVN A said on 12/11/25 at approximately 3:00 a.m. he heard a resident yell for help from the kitchen area. LVN A said he went to the kitchen area and found the resident lying on his right side on the ground. LVN A said he assessed resident and assisted him back to his wheelchair. LVN A said he gave the resident Tylenol for pain and an icepack for the hematoma on his forehead and initiated neurological checks which were normal. LVN A said Resident #1 never complained to him of blurred vision or any other symptoms but that he was confused. LVN A said he texted MD to notify him of the fall but was unsure of the time of the notification. LVN A said he notified the Resident's family at 3:00 a.m. but did not notify the MD until later due to Resident #1 being confused and unstable. Review of a facility Neurological Assessment sheet dated 12/11/25 at 3:00 a.m. indicated Resident #1 was assessed at 3:20 a.m. and was assessed as not fully oriented. All other assessments documented between 3:00 a.m. and 5:35 a.m. were documented as no confusion/disorientation with vital signs within normal limits. During a phone interview on 1/7/25 at 3:24 p.m., RN C said she was the charge nurse for the dialysis center on 12/11/25 the day Resident #1 came in after falling at the nursing home. RN C said the resident arrived at the appointment early and the nurse working noted significant bruising to his face and a hematoma on his forehead prompting her to immediately call the physician. RN C said the physician okayed the resident to have hemodialysis treatment since he didn't use heparin (an anticoagulant) and his neurological status was normal. RN C said the dialysis center physician came in and saw the resident face to face on rounds and advised the NF that Resident #1 should be evaluated in the ER after finishing hemodialysis. RN C said the facility was contacted and refused to have resident sent to the ER so the physician instructed dialysis center staff to call EMS for the resident. Review of hospital discharge records dated 12/11/25 indicated Resident #1 had a diagnosis of face or scalp contusion and hematoma. Resident #1 received a brain CT in the ER which showed no evidence of acute intracranial process, and he was discharged back to the NF on 12/11/25 with no major negative outcome. Review of a facility policy titled Change in a Resident's Condition or Status revised May 2017 indicated .Our facility shall promptly notify the resident's Attending Physician, Nurse Practitioner, or physician on call when there has been a(an): a. accident or incident involving the resident.

Based on observations, interviews, and records review the facility failed to ensure respiratory care was provided, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 5 residents (Resident #1) reviewed for Respiratory Care. The facility failed to ensure appropriate respiratory care was provided to Resident #1 on 10/1/25 when the facility transported her to a doctor's appointment with an empty oxygen tank. This failure could place residents who require supplemental oxygen at risk of hospitalization and diminished quality of life.Findings included:1.Review of an admission Record for Resident #1 dated 10/8/2025 indicated she was an [AGE] year-old female readmitted to the facility on [DATE] with diagnoses of acute respiratory failure, pleural effusion (fluid between the lung and chest wall), and congestive heart failure (heart can't pump blood well enough to meet the body's needs).Review of a quarterly MDS for Resident #1 dated 8/7/2025 indicated she had moderately impaired thinking with a BIMS of 10. She required continuous oxygen therapy.Review of the care plan for Resident #1 dated 8/27/25 indicated she required oxygen therapy related to chronic respiratory failure with hypercapnia (high carbon dioxide levels), CHF, and history of pneumonia. Appropriate interventions were in place including oxygen via nasal cannula at 2 liters per minute, continuous. During an interview on 10/6/25 at 9:42 a.m., the RP said Resident #1 had a doctor's appointment on 10/1/25 and the RP met her at the appointment. The RP said she looked at Resident #1's oxygen tank and noticed it was empty. The RP said she told CNA A who went back to the facility and brought a new, full, oxygen tank. The RP said Resident #1 was having symptoms of shortness of breath including gasping for air. The RP said the doctor's office staff called an ambulance and the resident was transported to the hospital where she was admitted to the emergency room and was discharged on 10/2/25. The RP said Resident #1 had a diagnosis of CHF and was dependent on supplemental oxygen to control symptoms of shortness of breath.During an observation and interview on 10/07/25 at 10:30 a.m., Resident #1 was observed in her room, seated in a wheelchair. She appeared clean and well-groomed with no offensive odor detected and she had no visible marks, bruises, or skin tears. She was receiving supplemental oxygen at 3 liters per minute. Resident #1 said the facility transported her to a doctor's appointment with an empty oxygen tank. She said she was transported to an oncology appointment and began to feel short of breath when someone noticed her oxygen tank was on empty. Resident #1 said the doctor's office called EMS and she was taken to the hospital where she stayed overnight. Resident #1 said she required supplemental oxygen full-time to control her symptoms of shortness of breath. Resident #1 said it made her feel funny and short of breath when she did not have supplemental oxygen. During an interview on 10/07/25 at 3:00 p.m., CNA A said on 10/1/25 he transported Resident #1 to a doctor's appointment. He said Resident #1's RP met them at the doctor's appointment and noted Resident #1's oxygen tank to be empty. CNA A said LVN B checked Resident #1's oxygen tank prior to leaving the facility and said it was full. CNA A said he went back to the facility and got a new oxygen tank and returned to the doctor's office. CNA A said the doctor's office called an ambulance due to Resident #1 being short of breath and she was transported to the emergency room. CNA A said it was the nurse's responsibility to inspect oxygen tanks and replace the tanks if they are low or empty. During an interview on 10/8/25 at 8:45 a.m., the ADM said on 10/1/25 it was reported to him that Resident #1 was transported to a doctor's appointment with an empty oxygen tank. ADM said it was the nurse's responsibility to ensure oxygen tanks were full prior to a resident leaving the facility. ADM said the DON was actively working on improving the system of checking oxygen tanks to include the transportation driver in the process.During an interview on 10/8/25 at 9:00 a.m., the DON said it was the charge nurse's responsibility to ensure residents leaving the unit had a full oxygen tank. The DON said LVN B reported she checked Resident #1's oxygen tank prior to her leaving the facility and noted it to be full. The DON said she was working on improving the system of checking oxygen tanks to include the transportation driver checking before leaving the facility and again upon arriving at the destination. The DON said she also printed and hung new, brightly colored, signs denoting empty oxygen tank storage from full oxygen tank storage. The DON said nursing staff had reported intermittently seeing a red light on the oxygen refilling station and oxygen tanks were not being filled. The DON said she tested the oxygen tank filling station on 10/1/25 and it functioned properly, but she had it replaced on 10/1/25 with a new unit to be safe.During a telephone interview on 10/8/25 at 10:45 a.m., LVN B said the day of Resident #1's appointment she swapped out her oxygen tank with a full tank at approximately 8:00 a.m., after breakfast. LVN B said she checked Resident #1's oxygen tank again just prior to her leaving the facility and noted it was still full. LVN B said the oxygen refilling station had been malfunctioning and oxygen tanks were showing to be full when they were not. LVN B said the facility had a service technician out recently to repair/replace the oxygen filling station. During an interview on 10/8/25 at 10:55 a.m., LVN C said she was not aware of any problems with the oxygen filling station. LVN C said it was the charge nurse's responsibility to ensure residents leaving the facility had an adequate supply of oxygen.During an interview on 10/8/25 at 11:00 a.m., RN D said the oxygen filling station had been intermittently displaying a red light and failing to fill oxygen tanks. RN D said the tanks never showed to be full; they were not refilling at all. RN D said the oxygen refilling unit was replaced on 10/1/25. RN D said it was the unit nurse's responsibility to ensure residents leaving the facility had a full oxygen tank.Review of an undated appointment reminder from an oncology office indicated Resident #1 had an appointment on 10/1/25 at 9:50 a.m.Review of a hospital Discharge summary dated [DATE] at 10:53 a.m. indicated Resident #1 was admitted on [DATE] from a doctor's office after her RP noticed her oxygen tank was empty. Resident #1's chest x-ray showed moderate bilateral pleural effusion (fluid in the space between lungs and chest well) with adjacent atelectasis/consolidation (partial collapse of lung tissue). Resident #1 was discharged back to the facility on [DATE] with new orders for breathing treatments daily and an oral antibiotic. Review of facility policy titled Oxygen Administration dated February 2025 indicated .Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered.

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food safety requirements and kitchen sanitation.The facility failed to ensure the [NAME] wore a beard covering on 8/5/2025 when he prepared food.These failures could place residents at risk of foodborne illness and food contamination.Findings included:During an observation on 8/5/2025 at 10:30 AM, revealed the [NAME] was in the kitchen pureeing food for the lunch meal. He had a full beard that was not covered.During an interview on 8/5/2025 at 10:45 AM, the [NAME] said he had been employed at the facility for 10 years and no one ever told him he needed to wear a cover for his beard. He said he should have a beard net on because of his facial hair and if staff did not wear a covering, then hair could drop into the food.During an observation and interview on 8/5/2025 at 11:30 AM, the DM was in the kitchen with the Cook. She said the [NAME] should have on a beard cover and told him to put one on. She said the kitchen had hairnets and beard covers when staff entered the kitchen. She said staff that had facial hair should wear a beard cover, so hair does not get into the food.During an interview on 8/6/2025 at 10:36 AM, the Interim Administrator said she had been at the facility since April 2025. She said staff in the kitchen that prepared food should wear a hair net or beard cover. She said if they did not wear the appropriate coverings for hair then they could contaminate the food. She said she expected for staff to wear the appropriate hair coverings when in the kitchen. Record review of a facility policy titled Food Safety Requirements dated 4/14/2024 indicated, . It is the policy of this facility to procure food from sources approved or considered satisfactory by federal, state, and local authorities. 7. Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects. d. Dietary staff must wear hair restraints (e.g., hairnet, hat, and/or beard restraint) to prevent hair from contacting food .

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #5) and 1 of 6 staff (CNA D) reviewed for infection control. The facility failed to ensure CNA D did not store dirty linens on the floor on 8/5/2025. These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices.Findings include: Record review of an admission Record dated 8/6/2025 indicated Resident #5 readmitted to the facility on [DATE] and was [AGE] years old.Record review of active physician orders dated 8/6/2025 for Resident #5 indicated she had diagnoses of hemiplegia affecting right side (paralyzed on right side), Parkinsonism, and depression.Record review of an Annual MDS assessment dated [DATE] for Resident #5 indicated she did not have any impairment in thinking with a BIMS of 15. She was dependent on staff for all ADL's.Record review of a care plan dated 5/24/2024 for Resident #5 indicated she had an ADL self-care performance deficit related to limited mobility. Interventions included: toileting: total staff assistance with incontinent care for bowel and bladder incontinence.During and observation and interview on 8/5/2025 at 8:41 AM, revealed Resident #5 was in her room, in bed, dressed and said the nurse aide had just left out of the room, and she had been changed. Dirty linens were observed on the floor by the trash can not in a plastic bag.During an observation on 8/5/2025 at 8:43 AM, revealed CNA D entered Resident #5's room with CNA E. CNA E placed gloves on her hands and put the dirty linens that were on the floor in a plastic bag. CNA E took the bag out of the room.During an interview on 8/5/2025 at 2:40 PM, CNA E said she had been employed at the facility for 15 years. She said earlier that day when she helped CNA D in Resident #5's room, she noticed the linens on the floor and picked them up. She said linens should not be placed on the floor and should be placed in a plastic bag. She said there was a risk for infections or cross contamination if dirty linens were placed on the floor.During an interview on 8/6/2025 at 8:31 AM, CNA D said she had been employed at the facility since April 2025. She said on yesterday 8/5/2025, the linens that were in the room of Resident #5 she placed on the floor after she changed her bed. She said she did not know why she put them on the floor and knew that they should have been placed in a bag and not on the floor. She said she was trained to put dirty linens in a bag. She said she made a mistake. She said there could be a risk for contamination if dirty linens were thrown on the floor.During an interview on 8/6/2025 at 10:12 AM, the DON said she had been at the facility for 6 weeks. She said she along with the ADONs at the facility were responsible for training staff on infection control practices. She said dirty linens should be placed in a barrel and not left on the hall and never on the floor. She said there could a risk for contamination.During an interview on 8/6/2025 at 10:24 AM, the ADON said she had been at the facility for 2 years. She said she was the IP for the facility and trained staff on infection control. She said dirty linens should be placed in a plastic bag and then in a soiled linen barrel. She said dirty linens should never be placed on the floor unless they were in a bag. She said there was a risk for bacteria or contamination if dirty linens were placed on the floor. During an interview on 8/6/2025 at 10:36 AM, the Interim Administrator said she had been at the facility since April 2025. She said dirty linens should be placed in the soiled linen barrel and not on the floor. She said the linens should be placed in a plastic bag and then taken out. She said there was a risk for infection control and spreading of things and could be an accident hazard. She expected the staff to properly bag linens and them to be taken to the appropriate container.Record review of a facility policy titled Infection Prevention and Control Program dated 2/5/2025 indicated, .This facility has established and maintains an infection prevention and control designed to provide a safe, sanitary, and comfortable environment and to help prevent and development and transmission of communicable diseases and infections as per accepted national standards and guidelines. 11. Linens: a. Soiled linen shall be collected at the bedside and placed in a linen bag. When the task is complete, the bag shall be closed securely and placed in the soiled utility room. Soiled linen shall not be kept in the resident's room or bathroom .

Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items, per facility policy for 1 of 4 resident's (Resident #80) personal refrigerators reviewed for food safety.The facility failed to ensure the refrigerator for Resident #80 did not contain three containers of yogurt that were past their use by dates from 8/4/2025-8/6/2025.This failure could place residents at risk for food borne illnesses. Findings include:Record review of active physician orders for Resident #80 dated 8/6/2025 indicated she had diagnoses of Parkinson's (a progressive disorder that affects movement), dementia, major depressive disorder (persistent feelings of sadness and loss of interest that may affect daily lift), and osteoporosis (brittle bones). Record review of an admission Record dated 8/5/2025 for Resident #80 indicated she admitted to the facility on [DATE] and she was [AGE] years old.Record review of a Significant Change MDS assessment dated [DATE] for Resident #80 indicated she had moderate impairment in thinking with a BIMS score of 12. She required setup/cleanup assistance with eating.Record review of a care plan dated 7/26/2023 for Resident #80 indicated she had an ADL self-care performance deficit related to Parkinson's. Interventions for eating: required set up help. There was not a care plan that indicated she refused for staff to clean out her refrigerator.During an observation and interview on 8/04/2025 at 11:04 AM, revealed Resident #80 was in her room in bed awake. She said she had been at the facility for a little while. She had a personal refrigerator in the room that contained: one container of Greek yogurt that expired on March 16, 2025; one container of strawberry yogurt that expired on March 16, 2025; and one container of blueberry yogurt dated May 12, 2025. She said she never looked at the expiration dates of foods in her refrigerator and the staff checked it daily. She said she ate items from her refrigerator. During an observation and interview on 8/06/2025 at 8:27 AM, revealed Resident #80 was in her room in bed awake. Her personal refrigerator still had the containers of expired yogurt. She said someone checked her refrigerator daily but did not know who they were.During an interview on 8/06/2025 at 8:35 AM, the HSK Supervisor said the housekeepers checked the personal refrigerators daily for the temperatures and kept a log for them. She said the Activity Directors checked them for expired food items and was not sure how often.During an interview on 08/06/2025 at 8:36 AM, the Activity Director said the facility had two activity directors who were responsible for checking the personal refrigerators for expired foods. She said Activity Director F was responsible for checking Resident #80's refrigerator but she was out of the facility on vacation. She said they checked the refrigerators weekly. She said if a resident had foods that were expired, then they should be removed and if residents ate food past their expiration dates, they could get sick. She said she was not aware Resident #80 had expired foods in her refrigerator but would take care of it. During an interview 8/6/2025 at 10:36 AM, the Interim Administrator said she had been at the facility since April 2025. She said activities was responsible for checking the personal refrigerators weekly for outdated foods. She said if residents ate foods that were outdated or expired, they could get sick. She said her expectations were for the staff to make sure foods were safe and if there were any issues to involve the families.Record review of a facility policy titled Foods Brought by Family/Visitors revised July 2017 indicated, .Food [NAME] to the facility by visitors and family is permitted. 8. The nursing staff will discard perishable foods on or before the use by date .

Based on observations, interviews, and record review the facility failed to ensure all drugs were stored properly, for 1 of 3 medication carts reviewed for medication storage. The facility failed to ensure Resident #101's insulin Lispro multi-dose vial with an expired date of 7/10/2025 was disposed of. This failure could place residents at risk of not receiving the therapeutic benefit of medications prescribed. Findings included: 1.Record review of Resident #101's face sheet, dated 8/5/25, indicated a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus (a condition where the body does not use insulin effectively, leading to high blood sugar levels), dementia ( A group of symptoms that affects memory, thinking and interferes with daily life), and bipolar disorder (causes extreme changes in mood and behavior). Record review of Resident #101's significant change MDS assessment, dated 7/28/25, indicated she was able to make herself understood and understood others. Resident #101 had a BIMS score of 07, which indicated her cognition was moderately impaired. Resident #101 required dependent assistance with ADL's. Resident #101 was always incontinent of bowel and bladder. Record review of Resident #101's physician orders, dated 8/05/25, indicated an order of Insulin Lispro solution 100 units per milliliter. Inject subcutaneously before meals and at bedtime according to sliding scale. Sliding scale as follows: Blood sugar of 150-200= 2 units; 201-250= 4 units; 251-300= 6 units; 301-350= 10 units; 350-400= 12 units. Record review of Resident #101's care plan dated 7/08/25 indicated resident had a diagnosis of Diabetes Mellitus. Interventions were for staff to observe resident for signs of hyperglycemia (blood glucose above 140 milligrams/dl; increase thirst, increase urination; increase appetite followed by lack of appetite; nausea, vomiting) and observe for signs of hypoglycemia (blood glucose less than 60milligrams/dl; sweating; cold; clammy skin; numbness of fingers, toes, mouth; rapid heartbeat; nervousness; tremors, faintness, dizziness). During an observation on 8/5/25 at 8:30 A.M., with LVN A, an inspection of a nurse medication cart revealed a bottle of insulin Lispro, with Resident #101's information on the label, and was located in the top drawer. The multi-dose vial had an open date of 6/10/25 printed on the vial and an expired date 07/10/25 on the box, which indicated the vial had been used. Observation of the vial indicated it was opened and approximately half of the contents missing. During an interview on 8/5/25 at 10:00 A.M., LVN A said the insulin should have been removed and replaced with a new bottle 30 days after being opened. She said after a multi-dose vial of insulin was opened the date it was opened should be written on the bottle. She stated multi-dose insulin vials were good for 30 days. She said the vial should be observed for the date opened by the nurse prior to administering any multi-dose medication. She stated the charge nurses were responsible for monitoring expiration dates on medications and replacing them when needed. She said medications that are expired could be less effective. During an interview on 8/6/2025 at 8:00 AM, LVN B stated the charge nurse was responsible for monitoring the medication cart for expired medications. She stated medication expiration dates should be checked prior to administering any medications. She stated if a multi-dose vial of insulin was used, an open date was written on the vial when it was opened. She stated that most multi-dose vial insulins were good to use for 30 days after opening but manufacturers vary. She said if a vial was out of date, it was taken from the cart and placed in the discontinued medication area and a new vial was opened and dated for the resident. She stated using medications that were expired could be less effective. During an interview on 8/6/2025 at 8:15 AM, LVN C stated the charge nurse was responsible for monitoring the medication cart for expired medications. She stated medication expiration dates should be checked prior to administering any medications. She stated if a multi-dose vial of insulin was used, an open date was written on the vial when it was opened. She stated that most multi-dose vial insulins are good to use for 30 days after opening. She said if a vial is out of date, it was removed from the cart and a new vial was opened and dated for the resident. She stated using medications that are expired could be less effective and insulins could affect the residents blood sugar levels. During an interview on 8/6/2025 at 8:30 AM, the Administrator stated the charge nurses were responsible for monitoring the expiration dates of medications. She stated the nurses should remove any expired medications from the medication cart. She stated the nurse should be checking expiration dates of medications daily. She stated she expected staff to monitor all expiration dates and to remove medications that are expired. She stated a possible effect of administering expired medications is decreased effectiveness of the medication. During an interview on 8/6/2025 at 8:45 AM, the DON stated the charge nurse was responsible for monitoring expiration dates on all medications. She stated the nurses should check the carts daily for any expired medications and prior to administering medications. She stated expiration dates for insulin vary with manufacturer and that the nurses have the information available to them at each nurses station. She stated moving forward the charge nurses would be checking medications daily and the nurse management would be conducting observations checks weekly. She stated that a possible outcome of administering expired medications would be decreased effectiveness of medication. Record review of the facility's policy, Medication Storage revised 01/2025 indicated:14. Outdated, contaminated, discontinued, or deteriorated medications.are immediately removed from stock, disposed of according to procedures for medication disposal. Manufacturer of insulin Lispro, Lilly Pharmaceuticals, recommend Insulin Lispro that has been opened can be kept at room temperature (59-86 degrees Fahrenheit) for up to 28 days.

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food safety requirements and kitchen sanitation. 1. The facility failed to ensure [NAME] wore a hair net effectively to cover all his hair on [DATE]. 2. The facility failed to ensure DA wore a hair net effectively and did not have hair out on the front and side of her head not covered by her hair covering on [DATE]. 3. The facility failed to ensure all foods stored in the refrigerators, freezers, and dry pantry were labeled, dated, and not kept past their expiration dates. 4. The facility failed to ensure proper hand washing between tasks. 5. The facility failed to ensure ovens were clean and free of debris. 6. The facility failed to ensure the ice machine was free from a black, slimy substance. These failures could place residents at risk of foodborne illness and food contamination. Findings included: During an observation of the cooler/refrigerator on [DATE] at 9:30am, the following items were observed: 1 pan of pre-wrapped pancakes with no use by date (out of original package). 1 box of red onions not dated or labeled. 1 box of lettuce wilted, uncovered, use date [DATE]. 1 pan of ribs not dated or labeled (out of original package). 1 10 lb. log of ground beef not dated or labeled. During an observation of the Dairy Cooler on [DATE] at 9:37am, the following items were observed: 1 gallon zip loc bag of cheese slices with no label or date. 1 gallon package of diced chicken no date or label (out of original box). 1 package of beef patties sitting in original box open not sealed. 1 gallon zip loc bag of hamburger buns no date or label. During an observation of the Freezer on [DATE] at 9:46am, the following items were observed: 1 gallon bag of Frozen chicken mushroom gravy with an open date of [DATE] with no expiration date. 1 cup of sherbet ice cream half thawed sitting on shelf alone with no expiration date. 1 box of pizza's open in original box uncovered or sealed. 1 gallon bag of Corn nuggets open not labeled or dated. 1 large bag of sweet potatoes with no expiration date. During an observation of the Refrigerator on [DATE] at 9:56am, the following items were observed: 1-box of Whipped topping mix with no expiration date. 1-pan of pre portioned puree bread dated [DATE], expired [DATE]. 1-Pan of pre portioned apple sauce in individual dishes with no expiration date. 1-Pan of pre portioned chocolate pudding in individual dishes with no expiration date. 1 zip loc bag of raisins with no expiration date. 1 pan of prebaked apple cobbler with no label or expiration date. During an observation on [DATE] at 10:00am, the Tilt Cooler was observed with brown and black substance and food particles on both sides. During an observation on [DATE] at 10:01am the oven appliance identified as extra oven and not in use per the DM with brown and black substance on the sides and top of the oven door. During an observation on [DATE] at 10:03am the DM did not wash hands between discarding expired foods and prepping rolls to be cooked for lunch. The DM picked up a can of spray-on prep for rolls and sprayed the rolls, put the can down, and continued discarding expired items without washing hands. During an observation of the Pantry on [DATE] at 10:05pm, the following items were observed: 2-quart size bottles of prune juice expired [DATE]. 1 container of Dijon mustard expired [DATE]. 4-quart size containers of sliced strawberry topping with no received or use by date. During an observation on [DATE] at 10:27am the [NAME] was observed with a baseball cap on with a hair net under it. The hair net was not seen until he pulled off his cap. The [NAME] had hair out in the front, sides, and back of his head. During an observation on [DATE] at 9:00 AM the ice machine was observed with a black, slimy substance on the top left and right corners and sides of the ice machine. During an interview on [DATE] at 4:00pm the DA said she was designated to date, label, and put food in the freezer as one of her duties. She said she realized she needed to date and label all items when they arrived and add the dates the items were opened and the dates they should be discarded. The DA said she understood that out of date foods could put the residents at risk of getting sick. She said she would make sure things were dated and labeled in the future and would be more cautious of assuring the safety of the food for her residents. During an interview on [DATE] at 4:07pm the [NAME] said he was not aware that his baseball cap had raised his hair net off his hair. He said he understood that hair could get in food and cause illness, and he would make other accommodations to assure his hair was completely covered in the future. During an interview on [DATE] at 4:10 pm the DA said she did not realize her hair was out in the front and side of her hair covering. She said she understood that all hair should be covered, and it could get into food and that was not sanitary. In the future she said she would assure all her hair was covered. During an interview on [DATE] at 4:15pm the DM said she was responsible for all staff to ensure food cleanliness and safety. She did not realize the number of items with no date or label, expired food, hair coverings, or other inappropriate issues. She already started in-services with staff on dating and labeling all items on arrival and when opened and unused. She said she would complete more in-services and assure that in the future all items were properly stored or discarded. She said inappropriately stored food and out of date food put the entire facility at risk of food borne illnesses. During an interview on [DATE] at 4:25pm the [NAME] said she did not realize her puree bread was expired and some of her baked goods were not dated or labeled. She said she understood that bad food could make people sick and that in the future she would be mindful of her dates and labels to assure a safer environment for the residents. During an interview on [DATE] at 01:55 PM the Administrator said the DM had already begun some in-services regarding the kitchen food storage and sanitation. She said she was responsible for ensuring staff properly wore the hair nets and properly dated, labeled, and discarded expired foods and she expected her staff to follow proper procedures. She said residents could be at risk of food borne illnesses if proper food storage and kitchen sanitation were not followed. Record review of a facility policy titled Employee Sanitation read .Hairnets, headbands, caps, beard coverings, or other effective hair restraints must be worn to keep hair from food and food-contact surfaces . Facility uses manufacture recommendations to clean the ice machine. Record Review of manufacture recommendations state Hoshizaki recommends .cleaning and sanitizing this unit at least once a year. More frequent cleaning and sanitizing, however, may be required in some existing water conditions . Record review of a facility policy titled Date marking for Food Safety dated [DATE] with revision date of [DATE] read .the facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food . Record review of a facility policy titled Employee Sanitation read .The Nutrition & Food service employees of the facility will practice good sanitation practices in accordance with the state and US Food Codes, in order to minimize the risk of infection and food borne illness . 50071

Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of medications for 2 of 24 residents (Resident #81, and Resident #68) and 2 of 5 medication rooms (Medication room [ROOM NUMBER] and #2) reviewed for medication administration. The facility failed to dispose of expired medications from Medication Rooms #1 and #2 on 7/29/2024 These failures could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications, decreased quality of life, and hospitalization . Findings included: 1. Record review of an Admission Record for Resident #81 dated 7/30/2024 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of dementia, anxiety disorder (disorder involves persistent and excessive worry that interferes with daily activities), depression (feeling of sadness or loss of interest), and hypertension. Record review of a Quarterly MDS Assessment for Resident #81 dated 5/7/2024 indicated she had severe impairment in thinking with a BIMS score of 2. Special Treatments, Procedures, and Programs indicated she received hospice care while a resident. Record review of a care plan for Resident #81 revised on 1/23/2023 indicated she had impaired cognitive function/dementia or impaired thought processes with interventions to administered medications as ordered. Monitor/document for side effects and effectiveness. Record review of active physician orders for Resident #81 dated 7/30/2024 indicated an order for scopolamine stick 0.2% apply behind ear topically every 6 hours as needed for secretions, apply 2 clicks with a start date of 2/2/2024. During an observation on 7/29/2024 at 3:18 PM in the Medication room [ROOM NUMBER] with Agency Medication Aide revealed: 1 bottle of aspirin with an expiration date of 4/2024. A refrigerator had medication for Resident #81 for scopolamine 0.2% topical compound filled 2/2/2024 with a discard date of 7/14/24. During an interview on 7/29/2024 at 3:25 PM, the Agency Medication Aide said that she had only been to the facility twice and that day was her second time working at the facility. She said she was not sure who was responsible for checking the medication rooms for expired medications . 2. Record review of an Admission Record dated 7/30/2024 for Resident #68 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of chronic systolic heart failure (the heart is weak, and the left ventricle is unable to contract (squeeze) normally when the heartbeat), depression, dementia with agitation, and hypertension. Record review of a care plan for Resident #68 dated 7/4/2023 indicated he had an alteration in neurological status related to dementia with interventions to give medications as ordered. Monitor/document for side effects and effectiveness. Record review of a Quarterly MDS Assessment for Resident #68 dated 6/22/2024 indicated he had moderate impairment in thinking with a BIMS score of 8. Record review of active physician orders for Resident #68 dated 7/30/2024 indicated an order for acetaminophen suppository 650 mg, insert 650 mg rectally every 6 hours as needed for pain with a start date of 6/15/2022. During an observation on 7/29/2024 at 4:00 PM in Medication room [ROOM NUMBER] with LVN K revealed: a refrigerator that had 8 rectal suppositories of Tylenol 650 mg for Resident # 68 with a discard date of 7/25/24. During an interview on 7/29/2024 at 4:10 PM, the DON said the facility had three-unit managers who were the ADON's in the facility that were responsible for checking the medication rooms and carts. She said each unit had an assigned unit manager. During an interview on 7/31/2024 at 8:25 AM, the ADON said she had been employed at the facility for a year and was the unit manager for Medication room [ROOM NUMBER]. She said she was responsible for checking the medication rooms and carts weekly for expired medications. She said the last time she checked Medication room [ROOM NUMBER] one day last week. She said she forgot to check the refrigerator that had medications. She said there was a risk of accidentally giving the medications to a resident if the medications were expired. During an interview on 7/31/2024 at 10:10 AM, the DON said she had been employed at the facility since February 2023. She said the ADON's were responsible for checking the medication rooms and carts for expired medications. She said there was a risk of medication errors or if given past their discard or expiration dates, they could be less effective. During an interview on 7/31/2024 at 11:00 AM, the Administrator said the charge nurses and medication aides were responsible for checking the medication rooms and carts with the ADON's as backup. She said there was a risk of decreased effectiveness of if given medications that were past their expiration dates . Record review of a facility policy titled Administering Medications revised December 2012 indicated, .Medications shall be administered in a safe and timely manner, and as prescribed. 9. The expiration/beyond use date on the medication label must be checked prior to administering . Record review of a facility policy titled Storage of Medications revised date of April 2007 indicated, .The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. 4. The facility shall not use discontinued, outdated, or deteriorated drugs and biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed .

Based on observations, interviews, and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible for 1 of 1 facility reviewed for accident hazards. The facility failed to develop and implement a policy and procedure to properly handle the care of Hoyer lift slings including interventions to inspect the Hoyer sling for signs of damage before each use and not removing damaged slings from service. This deficient practice could result in falls and injuries if damaged lift sling broke during mechanical lift transfers. The findings were: 1. Record review of a facility face sheet dated 07/30/2024 indicated Resident #43 was a [AGE] year-old female that admitted to the facility on [DATE] with diagnoses of muscle weakness, diabetes (high glucose level in the blood), and essential (primary) hypertension (high blood pressure). Record review of a comprehensive care plan revised 06/17/2024 indicated Resident #43 was a lift transfer for all transfers. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #43 had a BIMS score of 7 indicating severe impaired cognition, impairment of both lower extremities, and dependent for all transfers. 2. Record review of a facility face sheet dated 07/30/2024 indicated Resident #36 was a [AGE] year-old female that admitted to the facility on [DATE] with diagnoses of history of breast cancer and essential (primary) hypertension (high blood pressure). Record review of a comprehensive care plan revised 06/06/2024 indicated Resident #36 was a mechanical lift transfer for all transfers. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #36 had a BIMS score of 14 indicating intact cognition, impairment of both lower extremities, and dependent for all transfers. During an observation on 07/29/2024 at 10:11 AM, Resident #43 sitting in a wheelchair with a lift sling underneath her buttocks, the straps were faded in color, the blue strap was almost gray in color, the care tags were illegible, torn, crinkled, and [NAME]. During an observation and interview on 07/30/2024 at 10:40 AM Resident #43 was in bed sleeping. A lift sling was lying on Resident #43's wheelchair. The Hoyer sling straps were light in color almost gray, the tag was illegible, torn, and shredded. CNA A said he worked when needed, he was agency staff. CNA A said he would take any Hoyer sling out of service that had tears or fraying and does not know how long they stay in service before they were removed. CNA A was not aware the manufacturer recommended for them to be taken out of service if the sling had a change in color or the label was illegible, that it indicated it had been worn, bleached, or was compromised. He said he would remove the sling being used for Resident #43 because it was unsafe. CNA A said he had several residents that required a Hoyer lift for transfers. CNA A said that if a sling was not available on the hallway he would go to the linen closet and retrieve one for use. CNA A said the resident could suffer an injury or could be scared to get up with a lift if they were dropped. During an observation and interview on 07/30/24 at 11:15 AM of the laundry area revealed there were 4 Hoyer slings hanging to dry. Laundry Staff B worked at the facility for 2 years and Laundry Staff C worked here for [AGE] years and said she had received training to air dry the Hoyer slings, remove slings that have ravels on the edges, and threads that were pulling out. Laundry Staff B and Laundry staff C were not aware the manufacturer recommended for the Hoyer slings to be taken out of service if the sling had a change in color or the label was illegible, that it indicated it had been worn, bleached, or was compromised. During an observation and interview on 07/30/24 at 11:35 AM Resident #36 had a Hoyer sling sitting on her wheelchair, straps were faded light in color, the tag was crinkled. Resident #36 said the sling was provided by her hospice service and she had no issues with the staff using it for her transfers. During an interview on 07/30/24 at 11:45 AM the Hospice Nurse said the sling was provided by the hospice company for Resident #36. She said she was not aware that the slings were to be removed from service if they were faded or the tags were illegible. The Hospice Nurse called the Hospice durable medical equipment representative for a replacement sling and to initiate inspection of all slings provided to the facility. During an interview with the DON on 07/30/2024 at 12:15 PM, the DON said she worked for the facility for almost 6 months. She said she removed slings if they have holes, frays, or strings but she was not aware the manufacturer recommended for them to be taken out of service if the sling had a change in color or the label was illegible, that it indicated it had been worn, bleached, or was compromised. The DON said the resident could suffer an injury if the straps broke and it was all the staff's responsibility to remove defective slings from service. During an interview on 07/31/2024 at 9:30 AM, the Administrator said she was aware the slings required special care, the facility needed to follow manufacturers suggested guidelines. She said if the sling broke it could cause injury to the resident being transferred . A record review of Full Body Slings- Medline, Instructions for use www.medline.com accessed 07/23/2024 reflected .Always inspect slings prior to each use. Signs of rips, tears, or frays indicate sling wear which is unsafe and could result in injury. Signs of color fading, bleached areas, or permanent wrinkles on the straps indicate improper laundering which is unsafe and could result in injury. Any slings with signs of wear or improper laundering should be immediately removed from use Sling maintenance best practices .Check condition before each use. If there is any fraying or visible wear and tear, do not use. Reusable slings should be replaced every six months. Follow care instructions on wash tag. If illegible, do not use. Keep at least two reusable slings per patient on hand-one available and one in the laundry. A record review of a facility policy for Safe Resident Handling/Transfers dated 06/03/2024 indicated .It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable experience for the resident while keeping the employees safe in accordance with the current standards and guidelines .16. Slings will be laundered according to manufacturer's instructions and any damaged, broken, or unsafe slings will be removed from service and replaced.

Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #80) and 1 of 8 staff (CNA F) reviewed for infection control. CNA F did not sanitize or wash her hands between glove changes when providing incontinent care to Resident #80 on 7/30/2024. These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices. Findings included: Record review of an Admission Record for Resident #80 dated 7/31/2024 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of myopathy (disease that makes the muscles weak), atrial fibrillation (irregular heartbeat), major depressive disorder (persistent sadness or loss of interest that interferes with daily life), and hypertension. Record review of a Quarterly MDS Assessment for Resident #80 dated 5/20/2024 indicated she had severe impairment in thinking with a BIMS score of 3. She was dependent on staff for personal hygiene. She was frequently incontinent of bladder/bowel. Record review of a care plan for Resident #80 dated 10/23/2023 indicated she had an ADL self-care performance deficit related to impaired balance with interventions for toilet use: the resident was not toileted. She required assistance of staff x1. During an observation on 7/30/2024 at 10:31 AM, CNA F and CNA G were both in the room of Resident #80 to provide incontinent care. Both washed their hands in the bathroom, and donned (put on) PPE that consisted of a gown and gloves. Resident #80's brief was opened by CNA F and pulled down between her legs. CNA F removed a wipe from the package, wiped the resident's right inner thigh, folded it over, wiped the left inner thigh, and placed the wipe in the trash. CNA G rolled Resident #80 onto her right side. CNA F removed a wipe from the package and wiped Resident #80's rectum from front to back and removed the brief and placed them in the trash. CNA F applied barrier cream to Resident #80's buttocks and removed her gloves and placed them in the trash. CNA F put on gloves without washing or sanitizing her hands and placed a clean brief underneath the resident's buttocks. Resident #80 was rolled onto her left side by CNA G and then positioned onto her back and the brief was secured. CNA F removed her gloves and placed them in the trash, took a shirt out of the dresser drawer, and placed it on the bed. CNA F placed gloves on her hands without washing or sanitizing them, removed the shirt that was on the resident and put it in a laundry hamper. CNA F placed the clean shirt on the resident and repositioned the resident in bed. Both CNA F and CNA G removed their gloves and gown and placed them in the trash. Both washed their hands in the bathroom before exiting the room. During an interview on 7/30/2024 at 10:44 AM, CNA F said she had been employed at the facility for many years. She said during the care provided to Resident #80, she should have used sanitizer between glove changes. She said she just forgot to grab the hand sanitizer and usually kept it in her pocket. She said residents could be at risk for infections. She said she had skills check off on incontinent care in the past few months. Record review of a validation checklist for hand hygiene for CNA F dated 6/24/2024 indicated she was satisfactory with hand hygiene. Record review of a skill assessment for CNA F dated 2/8/2024 indicated she was satisfactory with hand hygiene and incontinent care. During an interview on 7/31/2024 at 8:25 AM, the ADON said she had been employed at the facility for a year. She said she and the other the ADON's and the DON were responsible for conducting skill checkoffs with the staff. She said they conduct check offs for new hires before they were allowed to provide direct patient care and yearly thereafter. She said hands should be sanitized or washed before care was started, during care provided, after changing gloves, when going from dirty to clean, and after care was completed. She said there was a risk of passing germs from their hands to someone else if they did not wash or sanitize their hands. During an interview on 7/31/2024 at 10:10 AM, the DON said she had been employed at the facility since February 2023. She said staff should be washing or sanitizing their hands before care, after removing gloves, during care, and after care was provided. She said CNA F had a check off on hand hygiene during incontinent care not long ago and had another one today. She said residents could be at risk for infections if staff did not wash or sanitize their hands. During an interview on 7/31/2024 at 11:00 AM, the Administrator said she was made aware of the incident with hand hygiene not being performed yesterday on 7/30/2024 with CNA F. She said hand hygiene should be performed prior to providing care, after removing gloves, when hands were visibly soiled, when care was completed, and before leaving the room. She said there was a risk for spreading infections if staff did not. Record review of a facility policy titled Hand Hygiene dated 6/13/2024 indicated, .All staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. 6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves .

Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program and ensure it was free of pests for 2 of 4 halls ([NAME] Lane and [NAME] Center) reviewed for incidents and accidents related to pests. The facility failed to ensure ants were kept out of the rooms and beds for Resident #31 and Resident #75. This failure could place residents at risk for injury due to an ineffective pest control program at the facility. Findings included: 1. Record review of a facility face sheet dated 7/29/24 for Resident #31 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including: chronic obstructive pulmonary disease (a common, preventable and treatable disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough), convulsions, and history of pulmonary embolism (blood clot located in the lung). Record review of a Quarterly MDS assessment dated [DATE] for Resident #31 indicated that she had a BIMS score of 9, which indicated that she had moderately impaired cognition. She required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. She required supervision with eating. Record review of a comprehensive care plan dated 7/22/24 for Resident #31 indicated she had impairment to skin integrity of the right upper extremity (RUE) related to ant bites. Interventions included to Identify/document potential causative factors and eliminate/resolve where possible. 2. Record review of a facility face sheet dated 7/31/24 for Resident #75 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: Sarcopenia (the age-related loss of muscle mass and strength that affects older adults), anxiety disorder, and dementia. Record review of a Quarterly MDS assessment dated [DATE] for Resident #75 indicated that she had a BIMS score of 4, which indicated that she had severely impaired cognition. She required moderate to maximum assistance with bed mobility, dressing, toilet use, and personal hygiene. She required set up help with eating. Record review of a comprehensive care plan for Resident #75 indicated that it did not address ant bites or ants in her room. During an observation and interview on 7/30/24 at 3:30 pm Resident #31 said the bites never itched or bothered her. No bites seen at this time. Bed linen appeared clean. No food was observed in room. No ants were observed in room. Resident #31 had no complaints with facility's handling of the incident. During an observation and interview on 7/31/24 at 10:00 am Resident #75 was observed in bed asleep. No ant bites were observed. Resident #75 had been moved from her original room while the original room was being treated for ants. LVN M said when she came to work the resident was out of the room and there were some ants by the wall with the window and air conditioner. She said Maintenance had sprayed the room and was told pest control was coming in as well. Record review of an incident report dated 7/16/24 for Resident # 31 read .The resident was noted with several ants in her bed, was noted with 3-4 small bites to her right upper extremity . and .Resident removed from bed, skin assessment, ants removed by maintenance, bed linen changed, and room inspected for ants. Resident was eating in her bed. Area treated . During an interview on 07/30/24 at 3:45 PM the Administrator said no other residents had been bitten. She said that residents could be at risk of an allergic reaction, skin eruption, and itching if they were bitten by ants. She said the maintenance man was responsible for pest control in the facility. During an interview on 7/31/24 at 11:06 AM the Maintenance Man said he treated for ants weekly on the grounds and treated rooms when identified. He said Pest Control also treated when they came once a month. He said he had come today and treated the entire premises along with the room on secured unit that had been identified. He said residents could be at risk if bitten and they were allergic to ants. During an interview on 7/31/24 at 1:57 PM the Administrator said she now has a PIP in place for pest control and they have added a full treatment for fire ants monthly along with their regular treatment. She said the Maintenance Man walks the perimeter twice weekly looking for ants and treats as needed. She said she would also be doing twice monthly rounds with the Maintenance Man looking specifically for ants. She said residents could be at risk of ant bites and allergic reactions if ants were to get inside the facility. Record review of a pest control log form for Pest Control in a binder for [NAME] Lane indicated that staff had seen ants in 3 different rooms on 7/23/24. Record review of a pest control invoice dated 6/19/24 from Pest Control indicated they treated the facility for ants and used a product called FastCap (Esfenvalerate) 6.4% and Delta Dust (Deltamethrin) 0.05%. Invoice indicated that he treated/inspected the exterior perimeter of the facility, the kitchen, landscaped areas, offices, and dishwashing room. Record review of a pest control invoice dated 7/18/24 from Pest Control indicated they treated the facility for ants and used a product called Extinguish (Hydramethylon) 0.365%, Shockwave 1 (Pyrethrins) 0.50%, and Talstar P (Bifenthrin) 7.9%. Invoice indicated that he treated/inspected the dining/break rooms, kitchen, landscaped areas, public areas, and warming area. Record review of a facility policy titled Pest Control Program dated 4/14/24 read .It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents . and .Effective pest control program is defined as measures to eradicate and contain common household pests (e.g., bed bugs, lice, roaches, ants, mosquitos, flies, mice, and rats) .

Based on observations, interviews, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles for 1 of 5 medication storage rooms (Medication room [ROOM NUMBER]) and 1 of 24 residents (Resident #30) reviewed for medication administration. The facility did not ensure medications were not stored at the bedside for Resident #30 on 7/29/2024. The facility failed to ensure Medication room [ROOM NUMBER]'s refrigerator was free of contaminants on 7/29/2024 when it was observed leaking water inside and had a medicine cup of white capsules that water was dripping on. This failure could place all residents at an increased risk of receiving contaminated medications/supplements resulting in adverse health consequences. Findings included: 1.Record review of an admission record for Resident #30 dated 7/30/2024 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of senile degeneration of brain (age related decline in thinking), COPD (a group of lung diseases that make it difficult to breathe), major depressive disorder (a mood disorder that causes persistent feelings of sadness and loss of interest), and muscle wasting (loss of muscle mass). Record review of a care plan for Resident #30 dated 7/15/2022 indicated she had impaired cognitive function/dementia or impaired thought processed related to dementia with interventions that included to administer medications as ordered. Monitor/document for side effects and effectiveness. Record review of active physician orders for Resident #30 dated 7/30/2024 indicated an order for glycopyrrolate capsule (used to treat excessive drooling) 14 mcg give 3 ml by mouth every 4 hours as needed for increased secretions open capsule and mix with 3 ml 0.9% normal saline nebulize with a start date of 7/10/2024. Record review of Medication Administration Record (MAR) for Resident #30 dated 7/1/2024-7/31/2024 indicated an order for glycopyrrolate 14 mcg give 3 ml by mouth every 4 hours for increased secretions with a start date of 7/10/2024 indicated from 7/10/2024-7/30/2024 that the medication was not administered. Record review of a Significant Change MDS assessment dated [DATE] indicated she was unable to complete the interview with a score of 99. Special Treatments, Procedures, and Programs indicated the resident received hospice while a resident. During an observation on 7/29/2024 at 9:46 AM Resident #30 was in bed resting with her eyes closed. There were eleven vials of normal saline on the nightstand next to a nebulizer. During an observation and interview on 7/29/2024 at 3:18 PM in the medication storage room with the Agency Medication Aide revealed a refrigerator that was leaking water and had a medicine cup of white capsules that the water was dripping on. She said the white capsules were lactobacillus capsules (used to promote good bacteria in the gut). She said she was not aware that the refrigerator was leaking and would let someone know. During an interview on 7/29/2024 at 3:25 PM, the Agency Medication Aide said that she had only been to the facility twice and that day was her second time working at the facility. She said she was not sure who was responsible for checking the medication rooms for expired medications. During an observation on 7/29/2024 at 3:50 PM in the room of Resident #30 who was not in the room revealed eleven vials of normal saline still on the nightstand. During an interview on 7/29/2024 at 3:52 PM in the room of Resident #30 who was not in the room. LVN E observed the eleven vials of normal saline on the nightstand. LVN E said Resident #30 did not get any scheduled inhalers or nebulizer medications. She said Resident #30 did have a medication that was supposed to be mixed with normal saline. She said she only gave Resident #30 medications prn and had not given her anything that day. She said she was agency staff and her last day worked in the facility was a day the week prior. She said there was a risk of overdose of medication and improper use if medications were left at the bedside. She said medications were not allowed to be left in rooms and must be kept on the medication carts. During an interview on 7/29/2024 at 4:10 PM, the DON said the facility had three-unit managers who were the ADON's in the facility that were responsible for checking the medication rooms and carts. She said each unit had an assigned unit manager. During an interview on 7/31/2024 at 8:25 AM, the ADON said she had been employed at the facility for a year and was the unit manager for Medication room [ROOM NUMBER]. She said she was responsible for checking the medication rooms and carts weekly for expired medications. She said the last time she checked Medication room [ROOM NUMBER] one day last week. She said she forgot to check the refrigerator that had medications. She said there was a risk of accidentally giving the medications to a resident if the medications were expired. During an interview on 7/31/2024 at 10:10 AM, the DON said she had been employed at the facility since February 2023. She said medications should never be left at the bedside because there was a risk of overdose or someone else coming in the room and taking them. She said the ADON's were responsible for checking the medication rooms and carts for expired medications. She said there was a risk of medication errors or if given past their discard or expiration dates, they could be less effective. During an interview on 7/31/2024 at 11:00 AM, the Administrator said she was made aware of medications being left at the bedside and the other meds that were in the refrigerators. She said the charge nurses and medication aides were responsible for checking the medication rooms and carts with the ADON's as backup. She said medications should not be left at the bedside unless a resident had been deemed appropriate to take their own medications. She said there was a risk of decreased effectiveness of if given medications that were past their expiration dates. Record review of a facility policy titled Administering Medications revised December 2012 indicated, .Medications shall be administered in a safe and timely manner, and as prescribed. 9. The expiration/beyond use date on the medication label must be checked prior to administering . Record review of a facility policy titled Storage of Medications revised date of April 2007 indicated, .The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. 4. The facility shall not use discontinued, outdated, or deteriorated drugs and biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed .

Based on interviews and record review, the facility failed to transmit encoded, accurate, and complete MDS data to the CMS System for 1 of 6 residents (Resident #33) reviewed for MDS accuracy and completion. Resident #33's Discharge MDS assessment dated [DATE] was not transmitted within 14 days of completion to CMS. This deficient practice could result in MDS inaccuracies. The findings were: Record review of a closed record revealed a Discharge MDS Assessment Return Anticipated dated 4/11/2024 was completed on 4/18/2024 and accepted, but not transmitted as of 7/30/2024. Record review of a MDS Final Validation Report dated 7/30/2024 indicated Resident #33 had an assessment with a target date of 4/11/2024 that was accepted and indicated the record was submitted late and the submission was more than 14 days. During an interview on 7/30/2024 at 11:46 AM, the MDS Coordinator said she had been employed at the facility since March 2024. She said there were two MDS Coordinators and she was responsible for completing the assessments with the last names of A-K. She said she completed the discharge assessment dated [DATE] for Resident #33. She said the MDS assessment was not transmitted, and she had reopened, corrected, and transmitted the assessment. She said there was a risk for PBJ information to be inaccurate and it could show that the resident was still in the facility and not discharged along with an inaccurate census for the facility. She said the assessment should have been transmitted by 4/25/2024. During an interview on 7/31/2024 at 10:10 AM, the DON said she had been employed at the facility since February 2023. She said the MDS Coordinators were responsible for completing and transmitting the MDS assessments and all she did was sign them . During an interview on 7/31/2024 at 10:30 AM, the VP of Clinical Reimbursement said the facility should be following the RAI manual for completion and transmission of MDS assessments. She said the assessments should be transmitted within 14 days after the assessment had been closed. She said the MDS Coordinators should be reviewing the validation report to see if there were any problems that needed to be corrected. She said when the MDS was submitted the validation report would let them know if the assessment was accepted or not. She said if assessments were not transmitted to CMS, it could throw off the census numbers and CMS would not be able to recognize that the resident had been discharged . During an interview on 7/31/2024 at 11:00 AM, the Administrator said the MDS assessments should be transmitted within 7 days of completion. She said the MDS Coordinators should be looking at the validation report once completed. She said on yesterday 7/30/2024 the MDS Coordinator corrected and transmitted the discharge assessment for Resident #33. She said there was a risk for facility's data not being accurate if assessments were not transmitted timely. She said the facility did not have a policy on transmitting MDS assessments and they followed the RAI manual.

Based on interview and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 7 of 10 residents (Residents #1, #4, #3, #9, #6, #7 and #10) reviewed for abuse and neglect. 1. The facility failed to protect Resident #1 from abuse from Resident #2, Resident #3, Resident #4, Resident #6, and Resident #10 between 5/8/23-1/11/24. on 1/11/24 Resident #6 slapped Resident #1 on his helmet. on 11/13/23 Resident #3 grabbed Resident #1's arm causing 2 skin tears. On 10/29/23 Resident #1 was in the lobby hollering and Resident #2 went over and flipped Resident #1 out of his wheelchair causing him to fall on the floor. On 10/29/23 Resident #3 grabbed Resident #1's right arm causing skin tears to right arm. On 9/29/23 Resident #1 sitting in recliner yelling and Resident #2 went over to Resident #1 and hit him in the mouth causing his lip to bust open. on 9/19/23 Resident #1 hit Resident #10 and Resident #10 hit Resident #1 back causing a skin tear to the right forearm. on 9/4/23 Resident #3 scratched the left side of Resident #1's chin leaving 3 scratches. On 9/3/23 Resident #2 flipped Res #1 out of his wheelchair on to the floor. On 8/20/23 Resident #2 walked over to Resident #1 and slapped him in the face. on 7/21/23 with Res #1 and Res #3. Res #3 scratched Res #1 on his right lower arm. On 7/20/23 Resident #2 walked over to Resident #1 and hit him on the left cheek and chin causing redness. On 7/10/23 Resident #3 pinched and scratched Resident #1 on the right side of his neck. On 7/8/23 Resident #2 lunged over to Resident #1 and put his hands around Res #1's neck. On 7/4/23 Resident #3 scratched Resident #1 with multiple skin tears and scratches to the face, neck, right finger, and left forearm. On 6/23/23 Resident #1 pinched Resident #3, Resident #1 also received a skin tear. On 6/5/23 Resident #4 grabbed Resident #1's arm. On 5/8/23 Resident #3 scratched Resident #1's left hand. 2. The facility failed to protect Resident #4 from abuse from Resident #1, and Resident #3 between 7/25/23- 3/8/24. On 7/25/23 Resident #1 grabbed Resident #4's right wrist and lower arm. On 3/8/24 Resident #3 grabbed Resident #4 by the wrist causing a skin tear to the left wrist. 3. The facility failed to protect Resident #3 from abuse from Resident #1 and Resident #8 between 6/23/23-5/1/24. On 6/23/23 Resident #1 pinched Resident #3, Resident #1 also received a skin tear. on 5/1/24 Resident #8 hit Resident #3 with a dinner plate causing a split between lip and nose. 4. The facility failed to protect Resident #9 from abuse from Resident #6 on 5/22/24 Resident #6 pulled Res #9's hair and pushed her down onto the floor. 5. The facility failed to protect Resident #6 from abuse from Resident #5 on 3/12/24. on 3/12/24 Resident #5 grabbed Resident #6 by the elbow causing a bruise. 6. The facility failed to protect Resident #7 from abuse from Resident #3 on 3/21/24 Resident #3 grabbed Resident #7 causing a skin tear to right forearm. 7. The facility failed to protect Resident #10 from abuse from Resident #1 on 9/19/23. on 9/19/23 Resident #1 hit Resident #10 and Resident #10 hit Resident #1 back causing a skin tear to the right forearm. 8. The facility failed to keep residents safe following resident to resident altercations to prevent further harm. An Immediate Jeopardy (IJ) situation was identified on 06/05/2024 at 2:52 PM While the IJ was removed on 06/06/2024 at 05:05 PM, the facility remained out of compliance at a scope of a pattern and severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of their corrective systems. These failures could place residents at risk for severe negative psychosocial outcomes which could prevent them from achieving their highest practicable physical, mental, and psychosocial well-being. Findings include: 1. Record review of Resident #1's electronic face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included Dementia with other behavioral disturbance (problem in the brain affecting memory), schizoaffective disorder (hallucinations and mood symptoms), and sarcopenia (musculoskeletal disease in which muscle mass, strength, and performance are significantly compromised with age). Record review of Resident #1's quarterly MDS assessment, dated 05/27/2024, reflected a BIMS score of 03, which indicated the resident's cognition was severely impaired. Resident #1's thinking was continuously disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject). Record review of Resident #1's care plan, dated 4/21/2023, reflected he had the potential to be physically and verbally aggressive related to dementia and schizoaffective disorder with interventions that included: 5. Monitor/document/report as needed and signs or symptoms of resident posing danger to self and others. 6. Psychiatric/Psychogeriatric consult as indicated. Resident #1 had impaired cognitive function/dementia or impaired thought processes related to Alzheimer's dementia (disease that destroys memory and other important mental functions) with interventions that included: 3. Cue, reorient and supervise as needed. Resident #1 used psychotropic medications related to schizoaffective disorder with interventions that included: 3 .Review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy. Record review of Resident #1's care plan dated 4/21/2023 indicated Resident #1 had the potential to be physically and verbally aggressive related to dementia and schizoaffective disorder. No new interventions were added to the care plan following aggressive incidents on 6/23/2023 and 9/19/2023. Record review of an incident report, dated 1/11/2024, reflected Resident #1 .was in the dining room hollering out repeatedly and another resident slapped him on his helmet. Record review of incident report, dated 11/13/2023, reflected Resident #1 .was in bed in his room and hollered out. Another resident wandered into his room and grabbed his arm causing him to get 2 skin tears on his left forearm. Record review of incident report, dated 10/29/2023, reflected Resident #1 .was in dining room at table yelling out. Another resident got frustrated with him hollering and grabbed his right arm causing skin tears. Record review of incident report, dated 10/29/2023, reflected Resident #1 was .in the lobby and was hollering out randomly .when another resident came over and flipped his wheelchair with him in it before staff could intervene. Record review of incident report, dated 9/29/2023, reflected Resident #1 was .sitting in recliner yelling, before staff could intervene another resident approached him and hit him in the mouth, busting his lip open Record review of incident report, dated 9/19/2023, reflected Resident #1 .hit another resident and the other resident hit him back and he received a skin tear to right forearm Record review of incident report, dated 9/04/2023, reflected Resident #1 .was yelling. Another resident went up to him and scratched left side of chin leaving 3 marks Record review of incident report, dated 9/03/2023, reflected Resident #1 was in a wheelchair .outside of dining room and another resident got mad at him because he was yelling out and dumped him out on the floor and the wheelchair fell on top of him. Record review of incident report, dated 8/20/2023, reflected Resident #1 .was sitting at dining room table and another resident walked up and he stated, 'What are you going to do about it?' and the other resident slapped him in the face. Record review of incident report, dated 7/25/2023, reflected Resident #1 .grabbed another resident by her right wrist/lower arm. Residents immediately separated Record review of incident report, dated 7/21/2023, reflected Resident #1 .heard yelling and found Resident #3 near resident scratching him. Residents immediately separated. Scratches noted to right lower arm Record review of incident report, dated 7/20/2023, reflected Resident #1 was sitting in a recliner and with Resident #2 standing over him. Resident #1 said Resident #2 hit him on the left side of chin and cheek with slight redness observed. Record review of incident report, dated 7/10/2023, reflected Resident #1 .was having verbal outbursts and another resident rolled up to him and pinched and scratched resident near the right side of his neck. Record review of incident report, dated 7/08/2023, reflected Resident #1 .was walking by another resident who was having verbal outbursts. The resident called out you son of a bitch and he lunged towards resident and put his hand around his neck, residents were immediately separated. Record review of incident report, dated 7/04/2023, reflected Resident #1 .was yelling out loudly. Another resident rolled up to him and she began scratching and grabbing at him .staff was unable to get to the residents in time before contact was made. Resident received multiple skin tears and scratches. Record review of incident report, dated 6/23/2023, reflected Resident #1 .reached out and pinched another resident while the resident was wheeling past him to go to dining room. Record review of incident report, dated 6/05/2023, reflected Resident #1 .was dozing in quiet area when his arm was grabbed by a fell ow resident. Record review of incident report, dated 5/08/2023, reflected Resident #1 .was heard yelling no you get out of the way, when staff intervened resident was noted with scratch to left hand 3.0 x 1.0, both residents were separated and assessed During an observation and interview on 6/03/2024 at 2:35 PM, Resident #1 was observed sitting up in wheelchair in common area in secured unit. Resident #1 was sitting at a table with 2 other residents with two building blocks on the table. Staff brought activities to the table after the State Surveyor started to interview Resident #1. Resident #1 said when asked if anyone had ever hurt him, yes. Resident #1 was alert and did not answer questions appropriately due to cognition. Resident #1 had a soft helmet in place to the top of his head with no injuries noted. 2. Record review of Resident #2's electronic face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included Dementia with other behavioral disturbance (problem in the brain affecting memory), bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), Alzheimer's disease (disease involves parts of the brain that control thought, memory, and language), and anxiety disorder (feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Record review of Resident #2's quarterly MDS assessment, dated 05/03/2024, reflected a BIMS score was not able to be obtained. Staff assessment for mental status reflected Resident #2 had short- and long-term memory problem. Resident #2's thinking was continuously disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject). Record review of Resident #2's care plan, dated 7/11/2023, reflected he had potential to be physically aggressive related to bipolar disorder and dementia with actual physical aggression on 7/20/2023, 8/20/2023, 9/03/2023, 9/29/2023, 10/29/2023, 11/02/2023, 1/30/2024, 4/10/2024, 5/25/2024. Interventions: The resident's triggers for physical aggression are (the yelling out loud noises) resident's behaviors is de-escalated by (providing quiet environment redirecting attention removing from situation). Order to send to behavioral facility to evaluate and treat. Psychiatric/psychogeriatric consult as indicated. Request labs and do assessment to rule out medical reason for aggressive behaviors. When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later when possible. The resident had impaired cognitive function/dementia or impaired thought processes related to Alzheimer's with interventions that included: Cue, reorient and supervise as needed. Discuss concerns about confusion, disease process, and nursing home placement with resident/family/caregivers. Record review of Resident #2's care plan dated 7/11/2023 indicated Resident #2 had the potential to be physically and verbally aggressive related to dementia and bipolar disorder. No new interventions were added to the care plan following aggressive incidents on 8/20/2023, 10/29/2023, 1/30/2024, and 5/25/2024. Record review of incident report, dated 10/29/2023, reflected Resident #2 .came into living area and flipped another resident's wheelchair on its side before staff could intervene. Record review of incident report, dated 9/29/2023, indicated another resident sitting up in recliner in lounge area close to the dining room yelling when [Resident #2] approached him and hit him in the mouth Record review of incident report, dated 9/03/2023, reflected Resident #2 .got angry at another resident due to him yelling. He then tipped wheelchair over making resident fall into floor and wheelchair went on top of resident Record review of incident report, dated 8/20/2023, reflected Resident #2 .was walking by another resident who was sitting in his wheelchair at table eating. Resident stated, 'what are you going to do about it?' and resident then slapped the other resident in the face on the left cheek. Record review of incident report, dated 7/20/2023, reflected Resident #2 was standing over Resident #1. Resident #1 said Resident #2 hit him on the left chin and cheek with slight redness noted. Record review of incident report, dated 7/08/2023, reflected Resident #2 .was walking by another resident who was having verbal outbursts. The resident called out you son of a bitch and he lunged towards resident and put his hand around his neck During an observation and interview on 6/03/2024 at 3:08 PM, Resident #2 was observed lying in bed awake and alert in his room with his roommate present and was attempting to hang call light on the wall Resident #2's room door was closed and Resident #2 was no visible by staff. Resident #2 did not answer questions appropriately due to cognition. Resident #2 did not have any visible injuries noted. 3. Record review of Resident #3's electronic face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included: bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), Alzheimer's disease (disease involves parts of the brain that control thought, memory, and language), and anxiety disorder (feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and schizophrenia (affects a person's ability to think, feel, and behave clearly). Record review of Resident #3's quarterly MDS assessment, dated 05/03/2024, reflected a BIMS score was 8, which indicated moderate cognitive impairment. Resident #3's thinking was continuously disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject). Record review of Resident #3's care plan, dated 5/04/2022, reflected she had potential to be physically aggressive towards another resident related to dementia with actual physical aggression on 3/21/2024, 3/08/2024, 1/06/2024, 11/13/2023, 9/04/2023, 7/19/2023, 5/25/2023, 5/19/2023, 5/06/2022, 5/05/2022. Interventions: If behavior is a threat to myself or others, immediately call for assistance. Psychiatric/psychological consult as indicated and ordered by physician. Triggers for physical aggression are other residents yelling out. The behavior is de-escalated by removing from the situation. [Resident #3] had memory loss/dementia related to schizophrenia, delusional behaviors with interventions that included: Cue, reorient, and supervise or assist me as needed. [Resident #3] had a behavior problem (including becoming physically violent toward other residents at times and refusing care at times related to advanced dementia/Alzheimer's with physical aggression on: 7/04/2023, 7/10/2023 and 8/08/2023, interventions included: monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Psych consult for medication review. Record review of Resident #3's care plan dated 5/04/2022 indicated Resident #3 had the potential to be physically and verbally aggressive related to dementia. No new interventions were added to the care plan following aggressive incidents on 1/6/2024 and 5/6/2022. Record review of incident report, dated 11/13/2023 reflected Resident #3 .went into another residents room and grabbed his arm causing 2 skin tears to left forearm Record review of incident report, dated 10/29/2023, reflected Resident #3 .grabbed ahold of another residents arm causing skin tears. Record review of incident report, dated 9/04/2023, reflected another resident was yelling and [Resident #3] went up to him and scratched left side of chin. Record review of incident report, dated 7/21/2023, reflected Resident #3 .was near [Resident #1] scratching him. Residents immediately separated. Record review of incident report, dated 7/10/2023, reflected Resident #3 .rolled up to another resident who was having verbal outbursts and pinched and scratched resident near the right side of his neck. Record review of incident report, dated 7/04/2023, reflected Resident #3 .rolled up to another resident who was yelling out loudly. She began scratching and grabbing at him .Staff was unable to get to the residents in time before contact was made. Record review of incident report, dated 6/23/2023, reflected Resident #3 .was wheeling past another resident when she yelled ouch. Record review of incident report, dated 5/08/2023, reflected Resident #3 .was heard shouting at other resident stating get out of way, other resident heard stating no you move, staff intervened, and other resident noted with scratch to left hand 3.0 x1.0. Record review of incident report, dated 5/01/2024, reflected staff heard but did not see residents arguing and possible hitting at each other. Then other resident slinging a plate leaving, then noted a split between upper lip and nose 2 x .1 centimeter. She was bleeding from area. Record review of incident report, dated 3/21/2024, reflected Resident #3 .went to another resident in the living area and grabbed ahold of her shirt and her right arm causing a skin tear to her lower right forearm. Record review of incident report, dated 3/08/2024, reflected another resident tried to grab her tray and Resident #3 grabbed ahold of the resident and caused her to get a skin tear. During an observation on 6/03/2024 at 3:12 PM, Resident #3 was observed sitting up in wheelchair in the secured unit common area. Resident #3 did not answer questions appropriately due to cognition. 4. Record review of Resident #4's electronic face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a condition affecting the brain in which a person loses the ability to think, remember, learn, make decisions, and solve problems), and senile degeneration of the brain (loss of intellectual ability). Record review of Resident #4's quarterly MDS assessment, dated 05/17/2024, reflected a BIMS score was 8, which indicated moderate cognitive impairment. Resident #4's thinking was continuously disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject). Record review of Resident #4's care plan, dated 5/03/2023, reflected she had potential to be physically aggressive, and combative with staff during ADL care related to dementia with actual physical aggression on: 2/16/2024, 11/21/2023, 11/20/2023, 11/14/2023, 10/18/2023, 9/23/2023, 5/22/2023 with interventions that included: Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. Monitor/document/report PRN any signs/symptoms of resident posing danger to self and others. Psychiatric/Psychogeriatric consult as needed. Staff monitor for aggression and redirect as needed. Staff to monitor for personal space. When the resident becomes agitated: intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Record review of Resident #4's care plan dated 5/03/2023 indicated Resident #4 had the potential to be physically and verbally aggressive related to dementia. No new interventions were added to the care plan following aggressive incidents on 11/20/2023 and 10/18/2023. Record review of incident report, dated 7/25/2023, reflected another resident grabbed [Resident #4] by her right wrist/lower arm Record review of incident report, dated 6/05/2023, reflected Resident #4 .was redirecting to a quiet area for safety when she reached out and grabbed another resident by the arm. Record review of incident report, dated 3/08/2024, reflected Resident #4 .was in dining room and tried to take another resident's tray of food, before staff could get there, other resident grabbed her wrist causing a skin tear to left wrist area. During an observation on 6/03/2024 at 3:17 PM, Resident #4 was observed sitting up in wheelchair in secured the unit common area. Resident #4 did not answer questions appropriately due to cognition. No injuries noted and no aggressive behaviors noted at that time. 5. Record review of Resident #5's electronic face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included: unspecified dementia, unspecified severity, with other behavioral disturbance, (mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems), bipolar disorder severe with psychotic features (psychosis, including hallucinations, delusions, or jumbled thoughts) and unspecified psychosis (disconnection from reality). Record review of Resident #5's quarterly MDS assessment, dated 05/18/2024, reflected a BIMS score was not able to be obtained. Staff assessment for mental status reflected Resident #5 had short- and long-term memory problem. Resident #5's thinking was continuously disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject). Resident #5 had difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said. Record review of Resident #5's care plan, dated 01/31/2024, reflected he had potential to be physically aggressive related to poor impulse control and bipolar severe with psychotic features with actual physical aggression on 3/28/2024, 3/12/2024 and 1/22/2024. Interventions included: if behavior is a threat to themselves or others, immediately call for assistance. Observe for and immediately report to the nurse and coordinator any signs or symptoms posing a danger to self and/or others. Psychiatric/psychological consult as indicated and ordered by MD .The resident is/has potential to be verbally and physically aggressive towards staff (patient hit other patient with wet floor sign on 9/02/2023), tends to hold onto female residents, becomes angry and aggressive when redirected with interventions that included: Assess residents understanding of the situation. Allow time for the resident to express self and feelings towards the situation. Psychiatric/Psychogeriatric consult as indicated. Record review of incident report, dated 3/12/2024, reflected Resident #5 .went into another residents room and grabbed her left arm and elbow causing bruising. During an observation on 6/03/2024 at 3:01 PM, Resident #5 was observed sitting up in bed in the room awake and alert. Resident #5 said no one had ever hurt him in any way. Resident #5 said staff did not always treat him nice but would not give any other details. Resident #5 said he took care of himself and did not let anyone treat him badly. 6. Record review of a facility face sheet dated 6/5/24 for Resident #6 indicated that she was an [AGE] year-old female admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including: Alzheimer's disease, heart failure, type 2 diabetes mellitus and cerebral infarction (stroke). Record review of a quarterly MDS assessment dated [DATE] for Resident #6 indicated that she had a BIMS score of 5, which indicated that she had severe cognitive impairment. Section C (Cognitive Patterns) indicated that she suffered from inattention and disorganized thinking. Record review of a comprehensive care plan dated 4/17/23 with last revision date of 6/4/24 for Resident #6 indicated that she had the potential to be physically aggressive r/t paranoid schizophrenia with actual physical aggression on 04/04/2023, 05/03/2023, 06/29/2023, 10/22/20203, 12/12/2023, 01/09/2024, 01/11/2024, and 05/22/2024 with interventions including: .If behavior is a threat to myself or others, immediately call for assistance .; .Observe for and immediately report to the nurse and coordinator any signs or symptoms posing a danger to myself and/or others .; and .Triggers for physical aggression are (other residents in my personal space or messing with my belongings). The behavior is de-escalated by (keeping my personal space and no one messing with my belongings) . Intervention added on 5/24/24 after incident on 5/22/24 read .Send to ER for evaluation and treatment reference to behaviors . Record review of an incident report dated 5/22/24 for Resident #6 indicated that she .got agitated at another resident for banging on the door, pulled her hair and pushed her . 7. Record review of a facility face sheet dated 6/5/24 for Resident #7 indicated that she was an [AGE] year-old female admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including: Sarcopenia (gradual loss of muscle mass, strength and function), dysphagia (trouble swallowing), bipolar disorder(a mental health condition that causes extreme mood swings between emotional highs and lows), and dementia. Record review of a quarterly MDS assessment dated [DATE] for Resident #7 indicated that she had a BIMS score of 2, which indicated that she had severely impaired cognition. Section C (Cognitive Patterns) indicated that she suffered from inattention and disorganized thinking. Record review of a comprehensive care plan for Resident #7 initiated on 6/2/22 and revised on 5/14/24 indicated that Resident #7 had physical aggressive behaviors at times r/t dementia, poor impulse control. Interventions included: .If I show signs of agitation, intervene before it escalates: remain calm, take a deep centering breath, stand out of reach, listen, and respond with empathy, guide away from source of distress; calmly engage in conversation. If response is aggressive, team member is to calmly walk away, ask others to leave the area, ensure everyone is safe, and immediately report this to nurse, discuss other approaches and approach later .; .Observe for and immediately report to the nurse and coordinator any signs or symptoms posing a danger to myself and/or others .; and .Talk with a low pitch, calm voice to decrease/eliminate undesired behavior & provide diversional activity . No new interventions were added to the care plan following incident on 3/21/24 when resident was victim of physical aggression. Record review of an incident report dated 3/21/24 for Resident #7 indicated that she suffered a skin tear when another resident grabbed her shirt and arm. 8. Record review of a facility face sheet dated 6/5/24 for Resident #8 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: dementia, dysphagia (trouble swallowing), major depressive disorder, and hyperlipidemia (high cholesterol). Record review of an annual MDS assessment dated [DATE] for Resident #8 indicated that he had a BIMS score of 6, which indicated that he was severely cognitively impaired. Record review of a comprehensive care plan for Resident #8 dated 5/18/22 and revised on 5/13/24 indicated that he had the potential to be physically aggressive r/t dementia, poor impulse control and was physically aggressive with another resident on 5/17/23 and 5/1/24. Interventions included: .Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document in notes .; .Modify environment: adjust room temperature to comfortable level, reduce noise, dim lights, place familiar objects in room, keep door closed .; and .Monitor for anxiety/aggression and redirect as needed . The followig intervention was added after incident on 5/1/24: .Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document in notes . Record review of an incident report dated 5/1/24 for Resident #8 indicated that he was .slinging dinner plate, possibly hit another resident leaving a split between upper lip and nose 2 x 0.1 cm. She was bleeding from area . 9. Record review of a facility face sheet dated 6/5/24 for Resident #9 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: dementia, repeated falls, osteoporosis (weak, brittle bones), and anxiety disorder. Record review of a quarterly MDS dated [DATE] for Resident #9 indicated that she had a BIMS score of 4, which indicated that she had severely impaired cognition. Section C (Cognitive Patterns) indicated that she suffered from inattention and disorganized thinking. Record review of a comprehensive care plan for Resident #9 indicated that she had potential to be physically aggressive (hitting staff and residents) r/t Dementia with physical Aggression received on 05/22/2024. No new interventions were added to the care plan following resident being a victim of aggression on 5/22/24. Record review of an incident report dated 5/22/24 for Resident #9 indicated that she had her hair pulled and was pushed down by another resident. 10. Record review of a facility face sheet dated 6/5/24 for Resident #10 indicated that she was an [AGE] year-old female admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including: dementia, repeated falls, depression, and type 2 diabetes. Record review of a quarterly MDS assessment dated [DATE] for Resident #10 indicated that she had a BIMS score of 4 which indicated that she had severely impaired cognition. Section C (Cognitive Patterns) indicated that she suffered from fluctuating inattention and disorganized thinking. Record review of a comprehensive care plan for Resident #10 dated 9/25/23 indicated that resident had potential to be physically aggressive r/t Dementia. Interventions implemented on 9/25/23 after incident on 9/19/23 included: .Administrator medications as ordere [TRUNCATED]

Based on observation, interview, and record review the facility failed to have evidence violations were thoroughly investigated to prevent further abuse for 7 of 10 residents (Resident #1, Resident #4, Resident #3, Resident #9, Resident #6, Resident #7, and Resident #10) reviewed for investigating abuse. The facility failed to ensure a thorough investigation of allegations of resident-to-resident abuse in that: 1. The facility failed to implement the abuse policy by failing to investigate the incidents involving Resident #1 receiving abuse from Resident #2, Resident #3, Resident #4, Resident #6, and Resident #10 between 5/8/23-1/11/24. 2. The facility failed to investigate multiple incidents of resident-to-resident altercations. 3. The facility failed to implement the abuse policy by failing to investigate Resident #4 recieving abuse from Resident #1, and Resident #3 between 7/25/23- 3/8/24. 4. The facility failed to implement the abuse policy by failing to investigate Resident #3 recieving abuse from Resident #1, and Resident #8 between 6/23/23-5/1/24. 5. The facility failed to implement the abuse policy by failing to investigate Resident #9 recieving abuse from Resident #6 on 5/22/24. 6. The facility failed to implement the abuse policy by failing to investigate Resident #6 receiving abuse from Resident #5 on 3/12/24. 7. The facility failed to implement the abuse policy by failing to investigate Resident #7 recieving abuse from Resident #3 on 3/21/24. 8. The facility failed to implement the abuse policy by failing to investigate Resident #10 receiving abuse from Resident #1 on 9/19/23. 9. The facility failed to implement the abuse policy by failing to investigate the resident-to-resident altercations. The facility failed to implement their abuse policy which stated .The Health Care Center will conduct an investigation of all alleged or suspected cases of abuse, neglect or misappropriation of property, and will provide notifications and information to the proper authorities according to state and federal regulations . An IJ was identified on 6/5/24. The IJ template was provided to the facility on [DATE] at 2:52 pm. While the IJ was removed on 6/6/24, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate threat due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures placed residents at risk of not having allegations of abuse/neglect investigated. Findings included: 1.Record review of Resident #1's electronic face sheet revealed an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Dementia with other behavioral disturbance (problem in the brain affecting memory), schizoaffective disorder (hallucinations and mood symptoms), and sarcopenia (musculoskeletal disease in which muscle mass, strength, and performance are significantly compromised with age). Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 03, which indicated residents' cognition was severely impaired. Resident #1's thinking was continuously disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject). Record review of Resident #1's care plan dated 4/21/2023 revealed he had the potential to be physically and verbally aggressive related to dementia and schizoaffective disorder with interventions that included: 5. Monitor/document/report as needed and signs or symptoms of resident posing danger to self and others. 6. Psychiatric/Psychogeriatric consult as indicated. Resident #1 had impaired cognitive function/dementia or impaired thought processes related to Alzheimer's dementia with interventions that included: 3. Cue, reorient and supervise as needed. Resident #1 used psychotropic medications related to schizoaffective disorder with interventions that included: 3.Review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy. Record review of an incident report dated 1/11/2024 indicated Resident #1 .was in the dining room hollering out repeatedly and another resident slapped him on his helmet. Record review of incident report dated 11/13/2023 indicated Resident #1 .was in bed in his room and hollered out. Another resident wandered into his room and grabbed his arm causing him to get 2 skin tears on his left forearm. Record review of incident report dated 10/29/2023 indicated Resident #1 .was in dining room at table yelling out. Another resident got frustrated with him hollering and grabbed his right arm causing skin tears. Record review of incident report dated 10/29/2023 indicated Resident #1 was .in the lobby and was hollering out randomly, .when another resident came over and flipped his wheelchair with him in it before staff could intervene. Record review of incident report dated 9/29/2023 indicated Resident #1 was .sitting in recliner yelling, before staff could intervene another resident approached him and hit him in the mouth, busting his lip open . Record review of incident report dated 9/19/2023 indicated Resident #1 .hit another resident and the other resident hit him back and he received a skin tear to right forearm . Record review of incident report dated 9/04/2023 indicated Resident #1 .was yelling. Another resident went up to him and scratched left side of chin leaving 3 marks . Record review of incident report dated 9/03/2023 indicated Resident #1 was in wheelchair .outside of dining room and another resident got mad at him because he was yelling out and dumped him out on the floor and the wheelchair fell on top of him. Record review of incident report dated 8/20/2023 indicated Resident #1 .was sitting at dining room table and another resident walked up and he stated, What are you going to do about it? and the other resident slapped him in the face. Record review of incident report dated 7/25/2023 indicated Resident #1 .grabbed another resident by her right wrist/lower arm. Residents immediately separated . Record review of incident report dated 7/21/2023 indicated Resident #1 .heard yelling and found Resident #3 near resident scratching him. Residents immediately separated. Scratches noted to right lower arm . Record review of incident report dated 7/20/2023 indicated Resident #1 was sitting in recliner and with Resident #2 standing over him. Resident #1 said Resident #2 hit him on the left side of chin and cheek with slight redness observed. Record review of incident report dated 7/10/2023 indicated Resident #1 .was having verbal outbursts and another resident rolled up to him and pinched and scratched resident near the right side of his neck. Record review of incident report dated 7/08/2023 indicated Resident #1 .was walking by another resident who was having verbal outbursts. The resident called out you son of a bitch and he lunged towards resident and put his hand around his neck, residents were immediately separated. Record review of incident report dated 7/04/2023 indicated Resident #1 .was yelling out loudly. Another resident rolled up to him and she began scratching and grabbing at him .staff was unable to get to the residents in time before contact was made. Resident received multiple skin tears and scratches. Record review of incident report dated 6/23/2023 indicated Resident #1 .reached out and pinched another resident while the resident was wheeling past him to go to dining room. Record review of incident report dated 6/05/2023 indicated Resident #1 .was dozing in quiet area when his arm was grabbed by a fell ow resident. Record review of incident report dated 5/08/2023 indicated Resident #1 .was heard yelling no you get out of the way, when staff intervened resident was noted with scratch to left hand 3.0 x 1.0, both residents were separated and assessed . During an observation and interview on 6/03/2024 at 2:35 PM, Resident #1 was observed sitting up in wheelchair in common area in secured unit. Resident #1 was sitting at a table with 2 other residents with two building blocks on the table. Staff brought activities to the table after surveyor had started to interview Resident #1. Resident #1 said when asked if anyone had ever hurt him, yes. Resident #1 was alert and did not answer questions appropriately due to cognition. Resident #1 had a soft helmet in place to the top of his head. 2.Record review of Resident #2's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Dementia with other behavioral disturbance (problem in the brain affecting memory), bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), Alzheimer's disease (disease involves parts of the brain that control thought, memory, and language), and anxiety disorder (feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed a BIMS score was not able to be obtained. Staff assessment for mental status revealed Resident #2 had short- and long-term memory problem. Resident #2's thinking was continuously disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject). Record review of Resident #2's care plan dated 7/11/2023 revealed he had potential to be physically aggressive related to bipolar disorder and dementia with actual physical aggression on 7/20/2023, 8/20/2023, 9/03/2023, 9/29/2023, 10/29/2023, 11/02/2023, 1/30/2024, 4/10/2024, 5/25/2024. Interventions: The resident's triggers for physical aggression are (the yelling out loud noises) resident's behaviors is de-escalated by (providing quiet environment redirecting attention removing from situation). Order to send to behavioral facility to evaluate and treat. Psychiatric/psychogeriatric consult as indicated. Request labs and do assessment to rule out medical reason for aggressive behaviors. When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later when possible. The resident had impaired cognitive function/dementia or impaired thought processes related to Alzheimer's with interventions that included: Cue, reorient and supervise as needed. Discuss concerns about confusion, disease process, and nursing home placement with resident/family/caregivers. Record review of incident report dated 10/29/2023 indicated Resident #2 .came into living area and flipped another resident's wheelchair on its side before staff could intervene. Record review of incident report dated 9/29/2023 indicated another resident sitting up in recliner in lounge area close to the dining room yelling when Resident #2 approached him and hit him in the mouth . Record review of incident report dated 9/03/2023 indicated Resident #2 .got angry at another resident due to him yelling. He then tipped wheelchair over making resident fall into floor and wheelchair went on top of resident . Record review of incident report dated 8/20/2023 indicated Resident #2 .was walking by another resident who was sitting in his wheelchair at table eating. Resident stated, what are you going to do about it? and resident then slapped the other resident in the face on the left cheek. Record review of incident report dated 7/20/2023 indicated Resident #2 was standing over Resident #1. Resident #1 said Resident #2 hit him on the left chin and cheek with slight redness noted. Record review of incident report dated 7/08/2023 indicated Resident #2 .was walking by another resident who was having verbal outbursts. The resident called out you son of a bitch and he lunged towards resident and put his hand around his neck . During an observation and interview on 6/03/2024 at 3:08 PM, Resident #2 was observed lying in bed awake and alert. Resident #2 was attempting to hang call light on the wall. Resident #2 did not answer questions appropriately due to cognition. 3.Record review of Resident #3's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), Alzheimer's disease (disease involves parts of the brain that control thought, memory, and language), and anxiety disorder (feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and schizophrenia (affects a person's ability to think, feel, and behave clearly). Record review of Resident #3's quarterly MDS assessment dated [DATE] revealed a BIMS score was 8 which indicated moderate cognitive impairment. Resident #3's thinking was continuously disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject). Record review of Resident #3's care plan dated 5/04/2022 revealed She had potential to be physically aggressive towards another resident related to dementia with actual physical aggression on 3/21/2024, 3/08/2024, 1/06/2024, 11/13/2023, 9/04/2023, 7/19/2023, 5/25/2023, 5/19/2023, 5/06/2022, 5/05/2022. Interventions: If behavior is a threat to myself or others, immediately call for assistance. Psychiatric/psychological consult as indicated and ordered by physician. Triggers for physical aggression are other residents yelling out. The behavior is de-escalated by removing from the situation. Resident #3 had memory loss/dementia related to schizophrenia, delusional behaviors with interventions that included: Cue, reorient, and supervise or assist me as needed. Resident #3 had a behavior problem (including becoming physically violent toward other residents at times and refusing care at times related to advanced dementia/Alzheimer's with physical aggression on: 7/04/2023, 7/10/2023 and 8/08/2023, interventions included: monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Psych consult for medication review. Record review of incident report dated 11/13/2023 indicated Resident #3 .went into another residents room and grabbed his arm causing 2 skin tears to left forearm . Record review of incident report dated 10/29/2023 indicated Resident #3 .grabbed ahold of another residents arm causing skin tears. Record review of incident report dated 9/04/2023 indicated another resident was yelling and Resident #3 went up to him and scratched left side of chin. Record review of incident report dated 7/21/2023 indicated Resident #3 .was near Resident #1 scratching him. Residents immediately separated. Record review of incident report dated 7/10/2023 indicated Resident #3 .rolled up to another resident who was having verbal outbursts and pinched and scratched resident near the right side of his neck. Record review of incident report dated 7/04/2023 indicated Resident #3 .rolled up to another resident who was yelling out loudly. She began scratching and grabbing at him .Staff was unable to get to the residents in time before contact was made. Record review of incident report dated 6/23/2023 indicated Resident #3 .was wheeling past another resident when she yelled ouch. Record review of incident report dated 5/08/2023 indicated Resident #3 .was heard shouting at other resident stating get out of way, other resident heard stating no you move, staff intervened, and other resident noted with scratch to left hand 3.0 x1.0. Record review of incident report dated 5/01/2024 indicated staff heard but did not see residents arguing and possible hitting at each other. Then other resident slinging a plate leaving, then noted a split between upper lip and nose 2 x .1cm. She was bleeding from area. Record review of incident report dated 3/21/2024 indicated Resident #3 .went to another resident in the living area and grabbed ahold of her shirt and her right arm causing a skin tear to her lower right forearm. Record review of incident report dated 3/08/2024 indicated another resident tried to grab her tray and Resident #3 grabbed ahold of the resident and caused her to get a skin tear. During an observation on 6/03/2024 at 3:12 PM, Resident #3 was observed sitting up in wheelchair in secured unit common area. Resident #3 did not answer questions appropriately due to cognition. 4.Record review of Resident #4's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a condition affecting the brain in which a person loses the ability to think, remember, learn, make decisions, and solve problems), and senile degeneration of the brain (loss of intellectual ability). Record review of Resident #4's quarterly MDS assessment dated [DATE] revealed a BIMS score was 8 which indicated moderate cognitive impairment. Resident #4's thinking was continuously disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject). Record review of Resident #4's care plan dated 5/03/2023 revealed She had potential to be physically aggressive, and combative with staff during ADL care related to dementia with actual physical aggression on: 2/16/2024, 11/21/2023, 11/20/2023, 11/14/2023, 10/18/2023, 9/23/2023, 5/22/2023 with interventions that included: Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. Monitor/document/report PRN any signs/symptoms of resident posing danger to self and others. Psychiatric/Psychogeriatric consult as needed. Staff monitor for aggression and redirect as needed. Staff to monitor for personal space. When the resident becomes agitated: intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Record review of incident report dated 7/25/2023 indicated another resident grabbed Resident #4 by her right wrist/lower arm . Record review of incident report dated 6/05/2023 indicated Resident #4 .was redirecting to a quiet area for safety when she reached out and grabbed another resident by the arm. Record review of incident report dated 3/08/2024 indicated Resident #4 .was in dining room and tried to take another resident's tray of food, before staff could get there, other resident grabbed her wrist causing a skin tear to left wrist area. During an observation on 6/03/2024 at 3:17 PM, Resident #4 was observed sitting up in wheelchair in secured unit common area. Resident #4 did not answer questions appropriately due to cognition. 5.Record review of Resident #5's electronic face sheet revealed an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: unspecified dementia, unspecified severity, with other behavioral disturbance, (mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems), bipolar disorder severe with psychotic features (psychosis, including hallucinations, delusions, or jumbled thoughts) and unspecified psychosis (disconnection from reality). Record review of Resident #5's quarterly MDS assessment dated [DATE] revealed a BIMS score was not able to be obtained. Staff assessment for mental status revealed Resident #5 had short- and long-term memory problem. Resident #5's thinking was continuously disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject). Resident #5 had difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said. Record review of Resident #5's care plan dated 01/31/2024 revealed he had potential to be physically aggressive related to poor impulse control and bipolar severe with psychotic features with actual physical aggression on 3/28/2024, 3/12/2024, and 1/22/2024. Interventions included: if behavior is a threat to themselves or others, immediately call for assistance. Observe for and immediately report to the nurse and coordinator any signs or symptoms posing a danger to self and/or others. Psychiatric/psychological consult as indicated and ordered by MD. The resident is/has potential to be verbally and physically aggressive towards staff (patient hit other patient with wet floor sign on 9/02/2023), tends to hold onto female residents, becomes angry and aggressive when redirected with interventions that included: Assess residents understanding of the situation. Allow time for the resident to express self and feelings towards the situation. Psychiatric/Psychogeriatric consult as indicated. Record review of incident report dated 3/12/2024 indicated Resident #5 .went into another residents room and grabbed her left arm and elbow causing bruising. During an observation and interview on 6/03/2024 at 3:01 PM, Resident #5 was Observed sitting up in bed in room awake and alert. Resident #5 said no one had ever hurt him in any way. Resident #5 said staff did not always treat him nice but would not give any other details. Resident #5 said he took care of himself and did not let anyone treat him badly. 6. Record review of a facility face sheet dated 6/5/24 for Resident #6 indicated that she was an [AGE] year-old female admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including: Alzheimer's disease, heart failure, type 2 diabetes mellitus and cerebral infarction (stroke). Record review of a quarterly MDS assessment dated [DATE] for Resident #6 indicated that she had a BIMS score of 5, which indicated that she had severe cognitive impairment. Section C (Cognitive Patterns) indicated that she suffered from inattention and disorganized thinking. Record review of a comprehensive care plan dated 4/17/23 with last revision date of 6/4/24 for Resident #6 indicated that she had the potential to be physically aggressive r/t paranoid schizophrenia with actual physical aggression on 04/04/2023, 05/03/2023, 06/29/2023, 10/22/20203, 12/12/2023, 01/09/2024, 01/11/2024, and 05/22/2024 with interventions including: .If behavior is a threat to myself or others, immediately call for assistance .; .Observe for and immediately report to the nurse and coordinator any signs or symptoms posing a danger to myself and/or others .; and .Triggers for physical aggression are (other residents in my personal space or messing with my belongings). The behavior is de-escalated by (keeping my personal space and no one messing with my belongings) . Intervention added on 5/24/24 after incident on 5/22/24 read .Send to ER for evaluation and treatment reference to behaviors . Record review of an incident report dated 5/22/24 for Resident #6 indicated that she .got agitated at another resident for banging on the door, pulled her hair and pushed her . 7. Record review of a facility face sheet dated 6/5/24 for Resident #7 indicated that she was an [AGE] year-old female admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including: Sarcopenia (gradual loss of muscle mass, strength and function), dysphagia (trouble swallowing), bipolar disorder(a mental health condition that causes extreme mood swings between emotional highs and lows), and dementia. Record review of a quarterly MDS assessment dated [DATE] for Resident #7 indicated that she had a BIMS score of 2, which indicated that she had severely impaired cognition. Section C (Cognitive Patterns) indicated that she suffered from inattention and disorganized thinking. Record review of a comprehensive care plan for Resident #7 initiated on 6/2/22 and revised on 5/14/24 indicated that Resident #7 had physical aggressive behaviors at times r/t dementia, poor impulse control. Interventions included: .If I show signs of agitation, intervene before it escalates: remain calm, take a deep centering breath, stand out of reach, listen, and respond with empathy, guide away from source of distress; calmly engage in conversation. If response is aggressive, team member is to calmly walk away, ask others to leave the area, ensure everyone is safe, and immediately report this to nurse, discuss other approaches and approach later .; .Observe for and immediately report to the nurse and coordinator any signs or symptoms posing a danger to myself and/or others .; and .Talk with a low pitch, calm voice to decrease/eliminate undesired behavior & provide diversional activity . No new interventions were added to the care plan following incident on 3/21/24 when resident was victim of physical aggression. Record review of an incident report dated 3/21/24 for Resident #7 indicated that she suffered a skin tear when another resident grabbed her shirt and arm. 8. Record review of a facility face sheet dated 6/5/24 for Resident #8 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: dementia, dysphagia (trouble swallowing), major depressive disorder, and hyperlipidemia (high cholesterol). Record review of an annual MDS assessment dated [DATE] for Resident #8 indicated that he had a BIMS score of 6, which indicated that he was severely cognitively impaired. Record review of a comprehensive care plan for Resident #8 dated 5/18/22 and revised on 5/13/24 indicated that he had the potential to be physically aggressive r/t dementia, poor impulse control and was physically aggressive with another resident on 5/17/23 and 5/1/24. Interventions included: .Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document in notes .; .Modify environment: adjust room temperature to comfortable level, reduce noise, dim lights, place familiar objects in room, keep door closed .; and .Monitor for anxiety/aggression and redirect as needed . The followig intervention was added after incident on 5/1/24: .Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document in notes . Record review of an incident report dated 5/1/24 for Resident #8 indicated that he was .slinging dinner plate, possibly hit another resident leaving a split between upper lip and nose 2 x 0.1 cm. She was bleeding from area . 9. Record review of a facility face sheet dated 6/5/24 for Resident #9 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: dementia, repeated falls, osteoporosis (weak, brittle bones), and anxiety disorder. Record review of a quarterly MDS dated [DATE] for Resident #9 indicated that she had a BIMS score of 4, which indicated that she had severely impaired cognition. Section C (Cognitive Patterns) indicated that she suffered from inattention and disorganized thinking. Record review of a comprehensive care plan for Resident #9 indicated that she had potential to be physically aggressive (hitting staff and residents) r/t Dementia with physical Aggression received on 05/22/2024. No new interventions were added to the care plan following resident being a victim of aggression on 5/22/24. Record review of an incident report dated 5/22/24 for Resident #9 indicated that she had her hair pulled and was pushed down by another resident. 10. Record review of a facility face sheet dated 6/5/24 for Resident #10 indicated that she was an [AGE] year-old female admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including: dementia, repeated falls, depression, and type 2 diabetes. Record review of a quarterly MDS assessment dated [DATE] for Resident #10 indicated that she had a BIMS score of 4 which indicated that she had severely impaired cognition. Section C (Cognitive Patterns) indicated that she suffered from fluctuating inattention and disorganized thinking. Record review of a comprehensive care plan for Resident #10 dated 9/25/23 indicated that resident had potential to be physically aggressive r/t Dementia. Interventions implemented on 9/25/23 after incident on 9/19/23 included: .Administrator medications as ordered. Monitor/document for side effects and effectiveness .; .Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc .; and .Psychiatric/Psychogeriatric consult as indicated . Record review of an incident report for Resident #10 dated 9/19/23 indicated that she was involved in a physical altercation with another resident. During an interview on 6/04/2024 at 2:50 PM SW said when there was a resident-to-resident altercation she would normally be notified by the charge nurse, or the next day in the morning meeting or nurse meeting. The SW said she would try to find the reason for the altercation and address it, she would make sure residents needs were met to see if that was why they were agitated, then possibly add activities. The SW said Administrator was responsible for reporting resident to resident altercations to HHSC or any other appropriate agencies, and they (administrative staff) worked together to ensure that allegations were investigated. During an interview on 6/04/2024 at 3:10 PM, the DON said she had worked at the facility since February of 2023 She said that when the CNA's were making rounds, the nurse and med aid were watching other residents. The DON said the staff would notify the unit manager, DON, or the Administrator of any resident-to-resident altercations. The DON said Administrator does all the reporting and she was not sure what the last incident was that got reported. She said they all work together to investigate incidents during the investigation process. During an interview on 6/04/2024 at 3:26 PM, Administrator said she had worked at the facility since January of 2023. Administrator said that staff tried to watch aggressive residents as best they could. She said if an altercation happened, they would separate the residents, notify family, and notify the physician. She said they have 2 CNA's, a nurse and med aide on the secured unit. She said before she worked at the facility, the secured unit was more of a behavior unit than a memory care unit. Administrator said when a resident-to-resident altercation occurred they (herself, DON, SW, MDS, ADON, Dietary, charge nurses) investigated the incident to see what the root cause of the incident was so they could apply the right interventions. She said their IDT met every morning and went over every incident that had happened for the previous 24 hours but there was no documentation of this. She said that if an incident happened between 2 residents and the residents had calmed down, they did not contact the police department unless an assault had taken place. Administrator said if the resident was still aggressive then they would call the police department. She said they try to send aggressive residents out to a behavioral facility. She said she did not believe resident-to-resident altercations were reportable when the residents have a diagnosis of dementia, because there was not a willful intent behind their actions. Administrator said she

Based on interview and record review the facility failed to develop and implement written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents and misappropriation of resident property for 7 of 10 residents (Resident #1, Resident #4, Resident #3, Resident #9, Resident #6, Resident #7 and Resident #10) reviewed for abuse policies. 1. The facility failed to implement the abuse policy by failing to protect Resident #1 from abuse from Resident #2, Resident #3, Resident #4, Resident #6, and Resident #10 between 5/8/23-1/11/24. 2. The facility failed to implement interventions after multiple incidents of resident-to-resident altercations. 3. The facility failed to implement the abuse policy by failing to protect Resident #4 from abuse from Resident #1, and Resident #3 between 7/25/23- 3/8/24. 4. The facility failed to implement the abuse policy by failing to protect Resident #3 from abuse from Resident #1, and Resident #8 between 6/23/23-5/1/24. 5. The facility failed to implement the abuse policy by failing to protect Resident #9 from abuse from Resident #6 on 5/22/24. 6. The facility failed to implement the abuse policy by failing to protect Resident #6 from abuse from Resident #5 on 3/12/24. 7. The facility failed to implement the abuse policy by failing to protect Resident #7 from abuse from Resident #3 on 3/21/24. 8. The facility failed to implement the abuse policy by failing to protect Resident #10 from abuse from Resident #1 on 9/19/23. 9. The facility failed to implement the abuse policy by failing to report the resident-to-resident altercations to HHSC. An Immediate Jeopardy (IJ) situation was identified on 06/05/2024 at 2:52 PM. While the IJ was removed on 06/06/2024 at 05:05 PM, the facility remained out of compliance at a scope of a pattern and severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of their corrective systems. These failures could place residents at risk of abuse which could lead to further abuse and neglect of other residents. Findings include: 1. Record review of Resident #1's electronic face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included Dementia with other behavioral disturbance (problem in the brain affecting memory), schizoaffective disorder (hallucinations and mood symptoms), and sarcopenia (musculoskeletal disease in which muscle mass, strength, and performance are significantly compromised with age). Record review of Resident #1's quarterly MDS assessment, dated 05/27/2024, reflected a BIMS score of 03, which indicated the resident's cognition was severely impaired. Resident #1's thinking was continuously disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject). Record review of Resident #1's care plan, dated 4/21/2023, reflected he had the potential to be physically and verbally aggressive related to dementia and schizoaffective disorder with interventions that included: 5. Monitor/document/report as needed and signs or symptoms of resident posing danger to self and others. 6. Psychiatric/Psychogeriatric consult as indicated. Resident #1 had impaired cognitive function/dementia or impaired thought processes related to Alzheimer's dementia (disease that destroys memory and other important mental functions) with interventions that included: 3. Cue, reorient and supervise as needed. Resident #1 used psychotropic medications related to schizoaffective disorder with interventions that included: 3 .Review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy. Record review of Resident #1's care plan dated 4/21/2023 indicated Resident #1 had the potential to be physically and verbally aggressive related to dementia and schizoaffective disorder. No new interventions were added to the care plan following aggressive incidents on 6/23/2023 and 9/19/2023. Record review of an incident report, dated 1/11/2024, reflected Resident #1 .was in the dining room hollering out repeatedly and another resident slapped him on his helmet. Record review of incident report, dated 11/13/2023, reflected Resident #1 .was in bed in his room and hollered out. Another resident wandered into his room and grabbed his arm causing him to get 2 skin tears on his left forearm. Record review of incident report, dated 10/29/2023, reflected Resident #1 .was in dining room at table yelling out. Another resident got frustrated with him hollering and grabbed his right arm causing skin tears. Record review of incident report, dated 10/29/2023, reflected Resident #1 was .in the lobby and was hollering out randomly .when another resident came over and flipped his wheelchair with him in it before staff could intervene. Record review of incident report, dated 9/29/2023, reflected Resident #1 was .sitting in recliner yelling, before staff could intervene another resident approached him and hit him in the mouth, busting his lip open Record review of incident report, dated 9/19/2023, reflected Resident #1 .hit another resident and the other resident hit him back and he received a skin tear to right forearm Record review of incident report, dated 9/04/2023, reflected Resident #1 .was yelling. Another resident went up to him and scratched left side of chin leaving 3 marks Record review of incident report, dated 9/03/2023, reflected Resident #1 was in a wheelchair .outside of dining room and another resident got mad at him because he was yelling out and dumped him out on the floor and the wheelchair fell on top of him. Record review of incident report, dated 8/20/2023, reflected Resident #1 .was sitting at dining room table and another resident walked up and he stated, 'What are you going to do about it?' and the other resident slapped him in the face. Record review of incident report, dated 7/25/2023, reflected Resident #1 .grabbed another resident by her right wrist/lower arm. Residents immediately separated Record review of incident report, dated 7/21/2023, reflected Resident #1 .heard yelling and found Resident #3 near resident scratching him. Residents immediately separated. Scratches noted to right lower arm Record review of incident report, dated 7/20/2023, reflected Resident #1 was sitting in a recliner and with Resident #2 standing over him. Resident #1 said Resident #2 hit him on the left side of chin and cheek with slight redness observed. Record review of incident report, dated 7/10/2023, reflected Resident #1 .was having verbal outbursts and another resident rolled up to him and pinched and scratched resident near the right side of his neck. Record review of incident report, dated 7/08/2023, reflected Resident #1 .was walking by another resident who was having verbal outbursts. The resident called out you son of a bitch and he lunged towards resident and put his hand around his neck, residents were immediately separated. Record review of incident report, dated 7/04/2023, reflected Resident #1 .was yelling out loudly. Another resident rolled up to him and she began scratching and grabbing at him .staff was unable to get to the residents in time before contact was made. Resident received multiple skin tears and scratches. Record review of incident report, dated 6/23/2023, reflected Resident #1 .reached out and pinched another resident while the resident was wheeling past him to go to dining room. Record review of incident report, dated 6/05/2023, reflected Resident #1 .was dozing in quiet area when his arm was grabbed by a fell ow resident. Record review of incident report, dated 5/08/2023, reflected Resident #1 .was heard yelling no you get out of the way, when staff intervened resident was noted with scratch to left hand 3.0 x 1.0, both residents were separated and assessed During an observation and interview on 6/03/2024 at 2:35 PM, Resident #1 was observed sitting up in wheelchair in common area in secured unit. Resident #1 was sitting at a table with 2 other residents with two building blocks on the table. Staff brought activities to the table after the State Surveyor started to interview Resident #1. Resident #1 said when asked if anyone had ever hurt him, yes. Resident #1 was alert and did not answer questions appropriately due to cognition. Resident #1 had a soft helmet in place to the top of his head with no injuries noted. 2. Record review of Resident #2's electronic face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included Dementia with other behavioral disturbance (problem in the brain affecting memory), bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), Alzheimer's disease (disease involves parts of the brain that control thought, memory, and language), and anxiety disorder (feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Record review of Resident #2's quarterly MDS assessment, dated 05/03/2024, reflected a BIMS score was not able to be obtained. Staff assessment for mental status reflected Resident #2 had short- and long-term memory problem. Resident #2's thinking was continuously disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject). Record review of Resident #2's care plan, dated 7/11/2023, reflected he had potential to be physically aggressive related to bipolar disorder and dementia with actual physical aggression on 7/20/2023, 8/20/2023, 9/03/2023, 9/29/2023, 10/29/2023, 11/02/2023, 1/30/2024, 4/10/2024, 5/25/2024. Interventions: The resident's triggers for physical aggression are (the yelling out loud noises) resident's behaviors is de-escalated by (providing quiet environment redirecting attention removing from situation). Order to send to behavioral facility to evaluate and treat. Psychiatric/psychogeriatric consult as indicated. Request labs and do assessment to rule out medical reason for aggressive behaviors. When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later when possible. The resident had impaired cognitive function/dementia or impaired thought processes related to Alzheimer's with interventions that included: Cue, reorient and supervise as needed. Discuss concerns about confusion, disease process, and nursing home placement with resident/family/caregivers. Record review of Resident #2's care plan dated 7/11/2023 indicated Resident #2 had the potential to be physically and verbally aggressive related to dementia and bipolar disorder. No new interventions were added to the care plan following aggressive incidents on 8/20/2023, 10/29/2023, 1/30/2024, and 5/25/2024. Record review of incident report, dated 10/29/2023, reflected Resident #2 .came into living area and flipped another resident's wheelchair on its side before staff could intervene. Record review of incident report, dated 9/29/2023, indicated another resident sitting up in recliner in lounge area close to the dining room yelling when [Resident #2] approached him and hit him in the mouth Record review of incident report, dated 9/03/2023, reflected Resident #2 .got angry at another resident due to him yelling. He then tipped wheelchair over making resident fall into floor and wheelchair went on top of resident Record review of incident report, dated 8/20/2023, reflected Resident #2 .was walking by another resident who was sitting in his wheelchair at table eating. Resident stated, 'what are you going to do about it?' and resident then slapped the other resident in the face on the left cheek. Record review of incident report, dated 7/20/2023, reflected Resident #2 was standing over Resident #1. Resident #1 said Resident #2 hit him on the left chin and cheek with slight redness noted. Record review of incident report, dated 7/08/2023, reflected Resident #2 .was walking by another resident who was having verbal outbursts. The resident called out you son of a bitch and he lunged towards resident and put his hand around his neck During an observation and interview on 6/03/2024 at 3:08 PM, Resident #2 was observed lying in bed awake and alert in his room with his roommate present and was attempting to hang call light on the wall Resident #2's room door was closed and Resident #2 was no visible by staff. Resident #2 did not answer questions appropriately due to cognition. Resident #2 did not have any visible injuries noted. 3. Record review of Resident #3's electronic face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included: bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), Alzheimer's disease (disease involves parts of the brain that control thought, memory, and language), and anxiety disorder (feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and schizophrenia (affects a person's ability to think, feel, and behave clearly). Record review of Resident #3's quarterly MDS assessment, dated 05/03/2024, reflected a BIMS score was 8, which indicated moderate cognitive impairment. Resident #3's thinking was continuously disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject). Record review of Resident #3's care plan, dated 5/04/2022, reflected she had potential to be physically aggressive towards another resident related to dementia with actual physical aggression on 3/21/2024, 3/08/2024, 1/06/2024, 11/13/2023, 9/04/2023, 7/19/2023, 5/25/2023, 5/19/2023, 5/06/2022, 5/05/2022. Interventions: If behavior is a threat to myself or others, immediately call for assistance. Psychiatric/psychological consult as indicated and ordered by physician. Triggers for physical aggression are other residents yelling out. The behavior is de-escalated by removing from the situation. [Resident #3] had memory loss/dementia related to schizophrenia, delusional behaviors with interventions that included: Cue, reorient, and supervise or assist me as needed. [Resident #3] had a behavior problem (including becoming physically violent toward other residents at times and refusing care at times related to advanced dementia/Alzheimer's with physical aggression on: 7/04/2023, 7/10/2023 and 8/08/2023, interventions included: monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Psych consult for medication review. Record review of Resident #3's care plan dated 5/04/2022 indicated Resident #3 had the potential to be physically and verbally aggressive related to dementia. No new interventions were added to the care plan following aggressive incidents on 1/6/2024 and 5/6/2022. Record review of incident report, dated 11/13/2023 reflected Resident #3 .went into another residents room and grabbed his arm causing 2 skin tears to left forearm Record review of incident report, dated 10/29/2023, reflected Resident #3 .grabbed ahold of another residents arm causing skin tears. Record review of incident report, dated 9/04/2023, reflected another resident was yelling and [Resident #3] went up to him and scratched left side of chin. Record review of incident report, dated 7/21/2023, reflected Resident #3 .was near [Resident #1] scratching him. Residents immediately separated. Record review of incident report, dated 7/10/2023, reflected Resident #3 .rolled up to another resident who was having verbal outbursts and pinched and scratched resident near the right side of his neck. Record review of incident report, dated 7/04/2023, reflected Resident #3 .rolled up to another resident who was yelling out loudly. She began scratching and grabbing at him .Staff was unable to get to the residents in time before contact was made. Record review of incident report, dated 6/23/2023, reflected Resident #3 .was wheeling past another resident when she yelled ouch. Record review of incident report, dated 5/08/2023, reflected Resident #3 .was heard shouting at other resident stating get out of way, other resident heard stating no you move, staff intervened, and other resident noted with scratch to left hand 3.0 x1.0. Record review of incident report, dated 5/01/2024, reflected staff heard but did not see residents arguing and possible hitting at each other. Then other resident slinging a plate leaving, then noted a split between upper lip and nose 2 x .1 centimeter. She was bleeding from area. Record review of incident report, dated 3/21/2024, reflected Resident #3 .went to another resident in the living area and grabbed ahold of her shirt and her right arm causing a skin tear to her lower right forearm. Record review of incident report, dated 3/08/2024, reflected another resident tried to grab her tray and Resident #3 grabbed ahold of the resident and caused her to get a skin tear. During an observation on 6/03/2024 at 3:12 PM, Resident #3 was observed sitting up in wheelchair in the secured unit common area. Resident #3 did not answer questions appropriately due to cognition. 4. Record review of Resident #4's electronic face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a condition affecting the brain in which a person loses the ability to think, remember, learn, make decisions, and solve problems), and senile degeneration of the brain (loss of intellectual ability). Record review of Resident #4's quarterly MDS assessment, dated 05/17/2024, reflected a BIMS score was 8, which indicated moderate cognitive impairment. Resident #4's thinking was continuously disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject). Record review of Resident #4's care plan, dated 5/03/2023, reflected she had potential to be physically aggressive, and combative with staff during ADL care related to dementia with actual physical aggression on: 2/16/2024, 11/21/2023, 11/20/2023, 11/14/2023, 10/18/2023, 9/23/2023, 5/22/2023 with interventions that included: Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. Monitor/document/report PRN any signs/symptoms of resident posing danger to self and others. Psychiatric/Psychogeriatric consult as needed. Staff monitor for aggression and redirect as needed. Staff to monitor for personal space. When the resident becomes agitated: intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Record review of Resident #4's care plan dated 5/03/2023 indicated Resident #4 had the potential to be physically and verbally aggressive related to dementia. No new interventions were added to the care plan following aggressive incidents on 11/20/2023 and 10/18/2023. Record review of incident report, dated 7/25/2023, reflected another resident grabbed [Resident #4] by her right wrist/lower arm Record review of incident report, dated 6/05/2023, reflected Resident #4 .was redirecting to a quiet area for safety when she reached out and grabbed another resident by the arm. Record review of incident report, dated 3/08/2024, reflected Resident #4 .was in dining room and tried to take another resident's tray of food, before staff could get there, other resident grabbed her wrist causing a skin tear to left wrist area. During an observation on 6/03/2024 at 3:17 PM, Resident #4 was observed sitting up in wheelchair in secured the unit common area. Resident #4 did not answer questions appropriately due to cognition. No injuries noted and no aggressive behaviors noted at that time. 5. Record review of Resident #5's electronic face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included: unspecified dementia, unspecified severity, with other behavioral disturbance, (mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems), bipolar disorder severe with psychotic features (psychosis, including hallucinations, delusions, or jumbled thoughts) and unspecified psychosis (disconnection from reality). Record review of Resident #5's quarterly MDS assessment, dated 05/18/2024, reflected a BIMS score was not able to be obtained. Staff assessment for mental status reflected Resident #5 had short- and long-term memory problem. Resident #5's thinking was continuously disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject). Resident #5 had difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said. Record review of Resident #5's care plan, dated 01/31/2024, reflected he had potential to be physically aggressive related to poor impulse control and bipolar severe with psychotic features with actual physical aggression on 3/28/2024, 3/12/2024 and 1/22/2024. Interventions included: if behavior is a threat to themselves or others, immediately call for assistance. Observe for and immediately report to the nurse and coordinator any signs or symptoms posing a danger to self and/or others. Psychiatric/psychological consult as indicated and ordered by MD .The resident is/has potential to be verbally and physically aggressive towards staff (patient hit other patient with wet floor sign on 9/02/2023), tends to hold onto female residents, becomes angry and aggressive when redirected with interventions that included: Assess residents understanding of the situation. Allow time for the resident to express self and feelings towards the situation. Psychiatric/Psychogeriatric consult as indicated. Record review of incident report, dated 3/12/2024, reflected Resident #5 .went into another residents room and grabbed her left arm and elbow causing bruising. During an observation on 6/03/2024 at 3:01 PM, Resident #5 was observed sitting up in bed in the room awake and alert. Resident #5 said no one had ever hurt him in any way. Resident #5 said staff did not always treat him nice but would not give any other details. Resident #5 said he took care of himself and did not let anyone treat him badly. 6. Record review of a facility face sheet dated 6/5/24 for Resident #6 indicated that she was an [AGE] year-old female admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including: Alzheimer's disease, heart failure, type 2 diabetes mellitus and cerebral infarction. Record review of a quarterly MDS assessment dated [DATE] for Resident #6 indicated that she had a BIMS score of 5, which indicated that she had severe cognitive impairment. Section C (Cognitive Patterns) indicated that she suffered from inattention and disorganized thinking. Record review of a comprehensive care plan dated 4/17/23 with last revision date of 6/4/24 for Resident #6 indicated that she had the potential to be physically aggressive r/t paranoid schizophrenia with actual physical aggression on 04/04/2023, 05/03/2023, 06/29/2023, 10/22/20203, 12/12/2023, 01/09/2024, 01/11/2024, and 05/22/2024 with interventions including: .If behavior is a threat to myself or others, immediately call for assistance .; .Observe for and immediately report to the nurse and coordinator any signs or symptoms posing a danger to myself and/or others .; and .Triggers for physical aggression are (other residents in my personal space or messing with my belongings). The behavior is de-escalated by (keeping my personal space and no one messing with my belongings) . Intervention added on 5/24/24 after incident on 5/22/24 read .Send to ER for evaluation and treatment reference to behaviors . Record review of an incident report dated 5/22/24 for Resident #6 indicated that she .got agitated at another resident for banging on the door, pulled her hair and pushed her . 7. Record review of a facility face sheet dated 6/5/24 for Resident #7 indicated that she was an [AGE] year-old female admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including: Sarcopenia, dysphagia, bipolar disorder, and dementia. Record review of a quarterly MDS assessment dated [DATE] for Resident #7 indicated that she had a BIMS score of 2, which indicated that she had severely impaired cognition. Section C (Cognitive Patterns) indicated that she suffered from inattention and disorganized thinking. Record review of a comprehensive care plan for Resident #7 initiated on 6/2/22 and revised on 5/14/24 indicated that Resident #7 had physical aggressive behaviors at times r/t dementia, poor impulse control. Interventions included: .If I show signs of agitation, intervene before it escalates: remain calm, take a deep centering breath, stand out of reach, listen, and respond with empathy, guide away from source of distress; calmly engage in conversation. If response is aggressive, team member is to calmly walk away, ask others to leave the area, ensure everyone is safe, and immediately report this to nurse, discuss other approaches and approach later .; .Observe for and immediately report to the nurse and coordinator any signs or symptoms posing a danger to myself and/or others .; and .Talk with a low pitch, calm voice to decrease/eliminate undesired behavior & provide diversional activity . No new interventions were added to the care plan following incident on 3/21/24 when resident was victim of physical aggression. Record review of an incident report dated 3/21/24 for Resident #7 indicated that she suffered a skin tear when another resident grabbed her shirt and arm. 8. Record review of a facility face sheet dated 6/5/24 for Resident #8 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: dementia, dysphagia, major depressive disorder, and hyperlipidemia. Record review of an annual MDS assessment dated [DATE] for Resident #8 indicated that he had a BIMS score of 6, which indicated that he was severely cognitively impaired. Record review of a comprehensive care plan for Resident #8 dated 5/18/22 and revised on 5/13/24 indicated that he had the potential to be physically aggressive r/t dementia, poor impulse control and was physically aggressive with another resident on 5/17/23 and 5/1/24. Interventions included: .Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document in notes .; .Modify environment: adjust room temperature to comfortable level, reduce noise, dim lights, place familiar objects in room, keep door closed .; and .Monitor for anxiety/aggression and redirect as needed . The followig intervention was added after incident on 5/1/24: .Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document in notes . Record review of an incident report dated 5/1/24 for Resident #8 indicated that he was .slinging dinner plate, possibly hit another resident leaving a split between upper lip and nose 2 x 0.1 cm. She was bleeding from area . 9. Record review of a facility face sheet dated 6/5/24 for Resident #9 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: dementia, repeated falls, osteoporosis, and anxiety disorder. Record review of a quarterly MDS dated [DATE] for Resident #9 indicated that she had a BIMS score of 4, which indicated that she had severely impaired cognition. Section C (Cognitive Patterns) indicated that she suffered from inattention and disorganized thinking. Record review of a comprehensive care plan for Resident #9 indicated that she had potential to be physically aggressive (hitting staff and residents) r/t Dementia with physical Aggression received on 05/22/2024. No new interventions were added to the care plan following resident being a victim of aggression on 5/22/24 Record review of an incident report dated 5/22/24 for Resident #9 indicated that she had her hair pulled and was pushed down by another resident. 10. Record review of a facility face sheet dated 6/5/24 for Resident #10 indicated that she was an [AGE] year-old female admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including: dementia, repeated falls, depression, and type 2 diabetes. Record review of a quarterly MDS assessment dated [DATE] for Resident #10 indicated that she had a BIMS score of 4 which indicated that she had severely impaired cognition. Section C (Cognitive Patterns) indicated that she suffered from fluctuating inattention and disorganized thinking. Record review of a comprehensive care plan for Resident #10 dated 9/25/23 indicated that resident had potential to be physically aggressive r/t Dementia. Interventions implemented on 9/25/23 after incident on 9/19/23 included: .Administrator medications as ordered. Monitor/document for side effects and effectiveness .; .Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc .; and .Psychiatric/Psychogeriatric consult as indicated . Record review of an incident report for Resident #10 dated 9/19/23 indicated that she was involved in a physical altercation with another resident. During an interview on 6/04/2024 at 2:50 PM, SW said when Resident #2 first admitted his behaviors were not that bad. SW said Resident #2 had gone to a behavioral facility in the last 4 or 5 months and had returned but had not been to a behavioral facility before April of 2024. She said when they had a resident-to-resident altercation, they always try the least invasive approach first such as redirecting, then calling psychiatric services, and a behavioral facility as a last resort. She said when there was a resident-to-resident altercation she is notified by the charge nurse or the next day in the morning meeting or nurse meeting. The SW said she tries to find the reason for the altercation and address it, she would make sure residents needs are met to see if that is why they were agitated, then possibly add activities. She said Resident #1's yelling out got to a lot of the residents at times. The SW said everyone on the secured unit was on psychiatric services. She said there was staff on the secured unit that were watching for behaviors. The SW said the Administrator was responsible for reporting resident to resident altercations to HHSC or any other appropriate agencies. During an interview on 6/04/2024 at 3:10 PM, the DON said she had worked at the facility since February of 2023. She said Resident #1 had a lot of anxiety and hollers out a lot but is doing better. She said that they had noticed if you occupy Resident #1's his hands or staff talks to him, he did not holler out as bad. The DON said Resident #2 got over stimulated with loud noises. The DON said Resident #2 had gone in [TRUNCATED]

Based on interview, and record review, the facility failed to provide adequate supervision and assistance devices to prevent accidents for 1 of 10 residents reviewed for accidents. (Resident #27). On [DATE] CNA A failed to ensure a safe transfer for Resident #27 by transferring with only 1 staff member when she required 2 staff members for transfers which led to Resident #27 suffering a 4 cm toe laceration requiring sutures. The noncompliance was identified as PNC (past non-compliance). The non-compliance began on [DATE] and ended [DATE]. The facility had corrected the noncompliance before the survey began. This failure could place residents who required supervision at risk of injury or accidents and hospitalization . Findings included: Record review of a facility face sheet dated [DATE] indicated that Resident #27 was a [AGE] year-old female admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including: dementia, sarcopenia (gradual loss of muscle mass, strength, and function) and dysphagia (trouble swallowing). Record review of a quarterly MDS assessment dated [DATE] for Resident #27 indicated that she was unable to complete the Brief Interview of Mental Status interview. Section C (Cognitive Patterns) indicated that she had severe cognitive impairment. Section GG (Functional Abilities and Goals) indicated that she required extensive assistance of 2+ persons with transfers. Record review of a comprehensive care plan for Resident #27 dated [DATE] indicated that she was at risk for falls and interventions included .Provide a safe environment: clutter free; support/assistive devices are available and in good repair . Record review of an ADL task documentation sheet for Resident #27 for the month of [DATE] indicated that she was a 2 person transfer and on [DATE] CNA A documented transfer with Resident #27 with a ,d+[DATE] on flow sheet: 3 indicated that she required extensive assistance and 2 indicated 1-person physical assist. Record review of a progress note dated [DATE] at 10:58 am for Resident #27 indicated that she was observed by staff .with a large amount of blood on sock .noted with a large slit from inside of great toe around the back of toe. Laceration measures 4cm in length. Area cleansed with NS and pressure dressing applied. [physician name] notified received order to send her to ER for eval. Administrator, DON, ADON, RP, all notified . signed by LVN AD. Record review of a witness statement dated [DATE] and signed by CNA A read .After breakfast, I laid [Resident #27 name] in a recliner shortly after she was done eating. She did not complain of any pain or signs distress. [Resident] was anxious to lay down. Did not notice any blood on sock or on floor . Record review of hospital records for Resident #27 dated [DATE] indicated that she was seen in the emergency room for a laceration of the great toe, received sutures, and was returned to the facility the same day with an order to remove sutures in ,d+[DATE] days. Record review of a proficiency form titled Gait Belt Transfer Proficiency dated [DATE] indicated that CNA A received training on gait belt transfers on [DATE] and passed the proficiency check off with 1 and 2 person transfers on [DATE]. No prior trainings were provided. Record review of a form titled Employee Disciplinary/Counseling Action Notice dated [DATE] for CNA A read .suspension pending investigation of injury to a resident by transferring with only one staff when resident is care planned for 2 staff during transfers . Form was signed by CNA A, Administrator, and DON. Record review of Resident #27's electronic medical record indicated that she expired in facility on [DATE] due to unrelated causes. Therefore, Resident #27 was not observed or interviewed. During a joint interview on [DATE] at 5:30 pm Administrator and DON said CNA A expressed that he just did not realize Resident #27 was always to be a 2-person transfer. He was suspended pending investigation and written up for an unsafe transfer. He returned to work on [DATE] after education and training and had no further incidents with unsafe transfers or resident injuries. Administrator said she expected her staff to follow protocol by checking the Kardex (documentation system that enables nurses to write, organize, and easily reference key patient information that shapes their nursing care plan) and to keep residents safe. Both said residents could be at risk of injuries if transferred improperly. Attempted telephone interview with CNA A on [DATE] at 1:35 pm, there was no answer. A voicemail was left requesting a return phone call. No return call received before exiting facility. Record review of a proficiency check off titled Gait Belt Transfer Proficiency with revision date of ,d+[DATE] read .5. Obtain assistance, if needed .9. Safely transfer resident .

Based on observations, interviews, and record reviews, the facility failed to ensure that all alleged violations involving abuse or mistreatment were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse, to the administrator of the facility and to other officials (including to the State Survey Agency where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 7 of 10 residents (Resident #1, Resident #4, Resident #3, Resident #9, Resident #6, Resident #7, and Resident #10) reviewed for reporting abuse. The facility failed to ensure that allegations of resident-to-resident abuse were reported to appropriate State Agency in that: 1. The facility failed to protect Resident #1 from abuse from Resident #2, Resident #3, Resident #4, Resident #6, and Resident #10 between 5/8/23-1/11/24. on 1/11/24 Resident #6 slapped Resident #1 on his helmet. on 11/13/23 Resident #3 grabbed Resident #1's arm causing 2 skin tears. On 10/29/23 Resident #1 was in the lobby hollering and Resident #2 went over and flipped Resident #1 out of his wheelchair causing him to fall on the floor. On 10/29/23 Resident #3 grabbed Resident #1's right arm causing skin tears to right arm. On 9/29/23 Resident #1 sitting in recliner yelling and Resident #2 went over to Resident #1 and hit him in the mouth causing his lip to bust open. on 9/19/23 Resident #1 hit Resident #10 and Resident #10 hit Resident #1 back causing a skin tear to the right forearm. on 9/4/23 Resident #3 scratched the left side of Resident #1's chin leaving 3 scratches. On 9/3/23 Resident #2 flipped Res #1 out of his wheelchair on to the floor. On 8/20/23 Resident #2 walked over to Resident #1 and slapped him in the face. on 7/21/23 with Res #1 and Res #3. Res #3 scratched Res #1 on his right lower arm. On 7/20/23 Resident #2 walked over to Resident #1 and hit him on the left cheek and chin causing redness. On 7/10/23 Resident #3 pinched and scratched Resident #1 on the right side of his neck. On 7/8/23 Resident #2 lunged over to Resident #1 and put his hands around Res #1's neck. On 7/4/23 Resident #3 scratched Resident #1 with multiple skin tears and scratches to the face, neck, right finger, and left forearm. On 6/23/23 Resident #1 pinched Resident #3, Resident #1 also received a skin tear. On 6/5/23 Resident #4 grabbed Resident #1's arm. On 5/8/23 Resident #3 scratched Resident #1's left hand. 2. The facility failed to protect Resident #4 from abuse from Resident #1, and Resident #3 between 7/25/23- 3/8/24. On 7/25/23 Resident #1 grabbed Resident #4's right wrist and lower arm. On 3/8/24 Resident #3 grabbed Resident #4 by the wrist causing a skin tear to the left wrist. 3. The facility failed to protect Resident #3 from abuse from Resident #1 and Resident #8 between 6/23/23-5/1/24. On 6/23/23 Resident #1 pinched Resident #3, Resident #1 also received a skin tear. on 5/1/24 Resident #8 hit Resident #3 with a dinner plate causing a split between lip and nose. 4. The facility failed to protect Resident #9 from abuse from Resident #6 on 5/22/24 Resident #6 pulled Res #9's hair and pushed her down onto the floor. 5. The facility failed to protect Resident #6 from abuse from Resident #5 on 3/12/24. on 3/12/24 Resident #5 grabbed Resident #6 by the elbow causing a bruise. 6. The facility failed to protect Resident #7 from abuse from Resident #3 on 3/21/24. on 3/21/24 Resident #3 grabbed Resident #7 causing a skin tear to right forearm. 7. The facility failed to protect Resident #10 from abuse from Resident #1 on 9/19/23. on 9/19/23 Resident #1 hit Resident #10 and Resident #10 hit Resident #1 back causing a skin tear to the right forearm. 8. The facility failed to keep residents safe following resident to resident altercations to prevent further harm. . The facility failed to implement their abuse policy which stated .The Health Care Center will report all allegations and substantiated occurrences of abuse .to the state agency and to all other agencies as required by law . These failures could place residents at risk for continued alleged violations, diminished quality of life and harm due to allegations not being reported. Findings included: 1.Record review of Resident #1's electronic face sheet revealed an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Dementia with other behavioral disturbance (problem in the brain affecting memory), schizoaffective disorder (hallucinations and mood symptoms), and sarcopenia (musculoskeletal disease in which muscle mass, strength, and performance are significantly compromised with age). Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 03, which indicated residents' cognition was severely impaired. Resident #1's thinking was continuously disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject). Record review of Resident #1's care plan dated 4/21/2023 revealed he had the potential to be physically and verbally aggressive related to dementia and schizoaffective disorder with interventions that included: . 5. Monitor/document/report as needed and signs or symptoms of resident posing danger to self and others. 6. Psychiatric/Psychogeriatric consult as indicated. Resident #1 had impaired cognitive function/dementia or impaired thought processes related to Alzheimer's dementia with interventions that included: . 3. Cue, reorient and supervise as needed. Resident #1 used psychotropic medications related to schizoaffective disorder with interventions that included: .3.Review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy. Record review of an incident report dated 1/11/2024 indicated Resident #1 .was in the dining room hollering out repeatedly and another resident slapped him on his helmet. Record review of incident report dated 11/13/2023 indicated Resident #1 .was in bed in his room and hollered out. Another resident wandered into his room and grabbed his arm causing him to get 2 skin tears on his left forearm. Record review of incident report dated 10/29/2023 indicated Resident #1 .was in dining room at table yelling out. Another resident got frustrated with him hollering and grabbed his right arm causing skin tears. Record review of incident report dated 10/29/2023 indicated Resident #1 was .in the lobby and was hollering out randomly, .when another resident came over and flipped his wheelchair with him in it before staff could intervene. Record review of incident report dated 9/29/2023 indicated Resident #1 was .sitting in recliner yelling, before staff could intervene another resident approached him and hit him in the mouth, busting his lip open . Record review of incident report dated 9/19/2023 indicated Resident #1 .hit another resident and the other resident hit him back and he received a skin tear to right forearm . Record review of incident report dated 9/04/2023 indicated Resident #1 .was yelling. Another resident went up to him and scratched left side of chin leaving 3 marks . Record review of incident report dated 9/03/2023 indicated Resident #1 was in wheelchair .outside of dining room and another resident got mad at him because he was yelling out and dumped him out on the floor and the wheelchair fell on top of him. Record review of incident report dated 8/20/2023 indicated Resident #1 .was sitting at dining room table and another resident walked up and he stated, What are you going to do about it? and the other resident slapped him in the face. Record review of incident report dated 7/25/2023 indicated Resident #1 .grabbed another resident by her right wrist/lower arm. Residents immediately separated . Record review of incident report dated 7/21/2023 indicated Resident #1 .heard yelling and found Resident #3 near resident scratching him. Residents immediately separated. Scratches noted to right lower arm . Record review of incident report dated 7/20/2023 indicated Resident #1 was sitting in recliner and with Resident #2 standing over him. Resident #1 said Resident #2 hit him on the left side of chin and cheek with slight redness observed. Record review of incident report dated 7/10/2023 indicated Resident #1 .was having verbal outbursts and another resident rolled up to him and pinched and scratched resident near the right side of his neck. Record review of incident report dated 7/08/2023 indicated Resident #1 .was walking by another resident who was having verbal outbursts. The resident called out you son of a bitch and he lunged towards resident and put his hand around his neck, residents were immediately separated. Record review of incident report dated 7/04/2023 indicated Resident #1 .was yelling out loudly. Another resident rolled up to him and she began scratching and grabbing at him .staff was unable to get to the residents in time before contact was made. Resident received multiple skin tears and scratches. Record review of incident report dated 6/23/2023 indicated Resident #1 .reached out and pinched another resident while the resident was wheeling past him to go to dining room. Record review of incident report dated 6/05/2023 indicated Resident #1 .was dozing in quiet area when his arm was grabbed by a fell ow resident. Record review of incident report dated 5/08/2023 indicated Resident #1 .was heard yelling no you get out of the way, when staff intervened resident was noted with scratch to left hand 3.0 x 1.0, both residents were separated and assessed . During an observation and interview on 6/03/2024 at 2:35 PM, Resident #1 was observed sitting up in wheelchair in common area in secured unit. Resident #1 was sitting at a table with 2 other residents with two building blocks on the table. Staff brought activities to the table after surveyor had started to interview Resident #1. Resident #1 said yes when asked if anyone had ever hurt him, Resident #1 was alert and did not answer additional questions appropriately due to cognition. Resident #1 had a soft helmet in place to the top of his head. 2.Record review of Resident #2's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Dementia with other behavioral disturbance (problem in the brain affecting memory), bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), Alzheimer's disease (disease involves parts of the brain that control thought, memory, and language), and anxiety disorder (feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed a BIMS score was not able to be obtained. Staff assessment for mental status revealed Resident #2 had short- and long-term memory problem. Resident #2's thinking was continuously disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject). Record review of Resident #2's care plan dated 7/11/2023 revealed he had potential to be physically aggressive related to bipolar disorder and dementia with actual physical aggression on 7/20/2023, 8/20/2023, 9/03/2023, 9/29/2023, 10/29/2023, 11/02/2023, 1/30/2024, 4/10/2024, 5/25/2024. Interventions: The resident's triggers for physical aggression are (the yelling out loud noises) resident's behaviors is de-escalated by (providing quiet environment redirecting attention removing from situation). Order to send to behavioral facility to evaluate and treat. Psychiatric/psychogeriatric consult as indicated. Request labs and do assessment to rule out medical reason for aggressive behaviors. When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later when possible. The resident had impaired cognitive function/dementia or impaired thought processes related to Alzheimer's with interventions that included: Cue, reorient and supervise as needed. Discuss concerns about confusion, disease process, and nursing home placement with resident/family/caregivers. Record review of incident report dated 10/29/2023 indicated Resident #2 .came into living area and flipped another resident's wheelchair on its side before staff could intervene. Record review of incident report dated 9/29/2023 indicated another resident sitting up in recliner in lounge area close to the dining room yelling when Resident #2 approached him and hit him in the mouth . Record review of incident report dated 9/03/2023 indicated Resident #2 .got angry at another resident due to him yelling. He then tipped wheelchair over making resident fall into floor and wheelchair went on top of resident . Record review of incident report dated 8/20/2023 indicated Resident #2 .was walking by another resident who was sitting in his wheelchair at table eating. Resident stated, what are you going to do about it? and resident then slapped the other resident in the face on the left cheek. Record review of incident report dated 7/20/2023 indicated Resident #2 was standing over Resident #1. Resident #1 said Resident #2 hit him on the left chin and cheek with slight redness noted. Record review of incident report dated 7/08/2023 indicated Resident #2 .was walking by another resident who was having verbal outbursts. The resident called out you son of a bitch and he lunged towards resident and put his hand around his neck . During an observation and attempted interview on 6/03/2024 at 3:08 PM, Resident #2 was observed lying in bed awake and alert. Resident #2 was attempting to hang call light on the wall. Resident #2 did not answer questions appropriately due to cognition. 3.Record review of Resident #3's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), Alzheimer's disease (disease involves parts of the brain that control thought, memory, and language), and anxiety disorder (feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and schizophrenia (affects a person's ability to think, feel, and behave clearly). Record review of Resident #3's quarterly MDS assessment dated [DATE] revealed a BIMS score was 8 which indicated moderate cognitive impairment. Resident #3's thinking was continuously disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject). Record review of Resident #3's care plan dated 5/04/2022 revealed She had potential to be physically aggressive towards another resident related to dementia with actual physical aggression on 3/21/2024, 3/08/2024, 1/06/2024, 11/13/2023, 9/04/2023, 7/19/2023, 5/25/2023, 5/19/2023, 5/06/2022, 5/05/2022. Interventions: If behavior is a threat to myself or others, immediately call for assistance. Psychiatric/psychological consult as indicated and ordered by physician. Triggers for physical aggression are other residents yelling out. The behavior is de-escalated by removing from the situation. Resident #3 had memory loss/dementia related to schizophrenia, delusional behaviors with interventions that included: Cue, reorient, and supervise or assist me as needed. Resident #3 had a behavior problem (including becoming physically violent toward other residents at times and refusing care at times related to advanced dementia/Alzheimer's with physical aggression on: 7/04/2023, 7/10/2023 and 8/08/2023, interventions included: monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Psych consult for medication review. Record review of incident report dated 11/13/2023 indicated Resident #3 .went into another residents room and grabbed his arm causing 2 skin tears to left forearm . Record review of incident report dated 10/29/2023 indicated Resident #3 .grabbed ahold of another residents arm causing skin tears. Record review of incident report dated 9/04/2023 indicated another resident was yelling and Resident #3 went up to him and scratched left side of chin. Record review of incident report dated 7/21/2023 indicated Resident #3 .was near Resident #1 scratching him. Residents immediately separated. Record review of incident report dated 7/10/2023 indicated Resident #3 .rolled up to another resident who was having verbal outbursts and pinched and scratched resident near the right side of his neck. Record review of incident report dated 7/04/2023 indicated Resident #3 .rolled up to another resident who was yelling out loudly. She began scratching and grabbing at him .Staff was unable to get to the residents in time before contact was made. Record review of incident report dated 6/23/2023 indicated Resident #3 .was wheeling past another resident when she yelled ouch. Record review of incident report dated 5/08/2023 indicated Resident #3 .was heard shouting at other resident stating get out of way, other resident heard stating no you move, staff intervened, and other resident noted with scratch to left hand 3.0 x1.0. Record review of incident report dated 5/01/2024 indicated staff heard but did not see residents arguing and possible hitting at each other. Then other resident slinging a plate leaving, then noted a split between upper lip and nose 2 x .1cm. She was bleeding from area. Record review of incident report dated 3/21/2024 indicated Resident #3 .went to another resident in the living area and grabbed ahold of her shirt and her right arm causing a skin tear to her lower right forearm. Record review of incident report dated 3/08/2024 indicated another resident tried to grab her tray and Resident #3 grabbed ahold of the resident and caused her to get a skin tear. During an observation on 6/03/2024 at 3:12 PM, Resident #3 was observed sitting up in wheelchair in secured unit common area. Resident #3 did not answer questions appropriately due to cognition. 4.Record review of Resident #4's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a condition affecting the brain in which a person loses the ability to think, remember, learn, make decisions, and solve problems), and senile degeneration of the brain (loss of intellectual ability). Record review of Resident #4's quarterly MDS assessment dated [DATE] revealed a BIMS score was 8 which indicated moderate cognitive impairment. Resident #4's thinking was continuously disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject). Record review of Resident #4's care plan dated 5/03/2023 revealed She had potential to be physically aggressive, and combative with staff during ADL care related to dementia with actual physical aggression on: 2/16/2024, 11/21/2023, 11/20/2023, 11/14/2023, 10/18/2023, 9/23/2023, 5/22/2023 with interventions that included: Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. Monitor/document/report PRN any signs/symptoms of resident posing danger to self and others. Psychiatric/Psychogeriatric consult as needed. Staff monitor for aggression and redirect as needed. Staff to monitor for personal space. When the resident becomes agitated: intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Record review of incident report dated 7/25/2023 indicated another resident grabbed Resident #4 by her right wrist/lower arm . Record review of incident report dated 6/05/2023 indicated Resident #4 .was redirecting to a quiet area for safety when she reached out and grabbed another resident by the arm. Record review of incident report dated 3/08/2024 indicated Resident #4 .was in dining room and tried to take another resident's tray of food, before staff could get there, other resident grabbed her wrist causing a skin tear to left wrist area. During an observation on 6/03/2024 at 3:17 PM, Resident #4 was observed sitting up in wheelchair in secured unit common area. Resident #4 did not answer questions appropriately due to cognition. 5.Record review of Resident #5's electronic face sheet revealed an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: unspecified dementia, unspecified severity, with other behavioral disturbance, (mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems), bipolar disorder severe with psychotic features (psychosis, including hallucinations, delusions, or jumbled thoughts) and unspecified psychosis (disconnection from reality). Record review of Resident #5's quarterly MDS assessment dated [DATE] revealed a BIMS score was not able to be obtained. Staff assessment for mental status revealed Resident #5 had short- and long-term memory problem. Resident #5's thinking was continuously disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject). Resident #5 had difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said. Record review of Resident #5's care plan dated 01/31/2024 revealed he had potential to be physically aggressive related to poor impulse control and bipolar severe with psychotic features with actual physical aggression on 3/28/2024, 3/12/2024, and 1/22/2024. Interventions included: if behavior is a threat to themselves or others, immediately call for assistance. Observe for and immediately report to the nurse and coordinator any signs or symptoms posing a danger to self and/or others. Psychiatric/psychological consult as indicated and ordered by MD. The resident is/has potential to be verbally and physically aggressive towards staff (patient hit other patient with wet floor sign on 9/02/2023), tends to hold onto female residents, becomes angry and aggressive when redirected with interventions that included: Assess residents understanding of the situation. Allow time for the resident to express self and feelings towards the situation. Psychiatric/Psychogeriatric consult as indicated. Record review of incident report dated 3/12/2024 indicated Resident #5 .went into another residents room and grabbed her left arm and elbow causing bruising. During an observation and interview on 6/03/2024 at 3:01 PM, Resident #5 was Observed sitting up in bed in room awake and alert. Resident #5 said no one had ever hurt him in any way. Resident #5 said staff did not always treat him nice but would not give any other details. Resident #5 said he took care of himself and did not let anyone treat him badly. 6. Record review of a facility face sheet dated 6/5/24 for Resident #6 indicated that she was an [AGE] year-old female admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including: Alzheimer's disease, heart failure, type 2 diabetes mellitus and cerebral infarction (stroke). Record review of a quarterly MDS assessment dated [DATE] for Resident #6 indicated that she had a BIMS score of 5, which indicated that she had severe cognitive impairment. Section C (Cognitive Patterns) indicated that she suffered from inattention and disorganized thinking. Record review of a comprehensive care plan dated 4/17/23 with last revision date of 6/4/24 for Resident #6 indicated that she had the potential to be physically aggressive r/t paranoid schizophrenia with actual physical aggression on 04/04/2023, 05/03/2023, 06/29/2023, 10/22/20203, 12/12/2023, 01/09/2024, 01/11/2024, and 05/22/2024 with interventions including: .If behavior is a threat to myself or others, immediately call for assistance .; .Observe for and immediately report to the nurse and coordinator any signs or symptoms posing a danger to myself and/or others .; and .Triggers for physical aggression are (other residents in my personal space or messing with my belongings). The behavior is de-escalated by (keeping my personal space and no one messing with my belongings) . Record review of an incident report dated 5/22/24 for Resident #6 indicated that she .got agitated at another resident for banging on the door, pulled her hair and pushed her . 7. Record review of a facility face sheet dated 6/5/24 for Resident #7 indicated that she was an [AGE] year-old female admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including: Sarcopenia (gradual loss of muscle mass, strength and function), dysphagia (trouble swallowing), bipolar disorder(a mental health condition that causes extreme mood swings between emotional highs and lows), and dementia. Record review of a quarterly MDS assessment dated [DATE] for Resident #7 indicated that she had a BIMS score of 2, which indicated that she had severely impaired cognition. Section C (Cognitive Patterns) indicated that she suffered from inattention and disorganized thinking. Record review of a comprehensive care plan for Resident #7 initiated on 6/2/22 and revised on 5/14/24 indicated that Resident #7 had physical aggressive behaviors at times r/t dementia, poor impulse control. Interventions included: .If I show signs of agitation, intervene before it escalates: remain calm, take a deep centering breath, stand out of reach, listen, and respond with empathy, guide away from source of distress; calmly engage in conversation. If response is aggressive, team member is to calmly walk away, ask others to leave the area, ensure everyone is safe, and immediately report this to nurse, discuss other approaches and approach later .; .Observe for and immediately report to the nurse and coordinator any signs or symptoms posing a danger to myself and/or others .; and .Talk with a low pitch, calm voice to decrease/eliminate undesired behavior & provide diversional activity . Record review of an incident report dated 3/21/24 for Resident #7 indicated that she suffered a skin tear when another resident grabbed her shirt and arm. 8. Record review of a facility face sheet dated 6/5/24 for Resident #8 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: dementia, dysphagia (trouble swallowing), major depressive disorder, and hyperlipidemia (high cholesterol). Record review of an annual MDS assessment dated [DATE] for Resident #8 indicated that he had a BIMS score of 6, which indicated that he was severely cognitively impaired. Record review of a comprehensive care plan for Resident #8 dated 5/18/22 and revised on 5/13/24 indicated that he had the potential to be physically aggressive r/t dementia, poor impulse control and was physically aggressive with another resident on 5/17/23 and 5/1/24. Interventions included: .Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document in notes .; .Modify environment: adjust room temperature to comfortable level, reduce noise, dim lights, place familiar objects in room, keep door closed .; and .Monitor for anxiety/aggression and redirect as needed . Record review of an incident report dated 5/1/24 for Resident #8 indicated that he was .slinging dinner plate, possibly hit another resident leaving a split between upper lip and nose 2 x 0.1 cm. She was bleeding from area . 9. Record review of a facility face sheet dated 6/5/24 for Resident #9 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: dementia, repeated falls, osteoporosis (weak, brittle bones), and anxiety disorder. Record review of a quarterly MDS dated [DATE] for Resident #9 indicated that she had a BIMS score of 4, which indicated that she had severely impaired cognition. Section C (Cognitive Patterns) indicated that she suffered from inattention and disorganized thinking. Record review of a comprehensive care plan for Resident #9 indicated that she had potential to be physically aggressive (hitting staff and residents) r/t Dementia with physical Aggression received on 05/22/2024. Record review of an incident report dated 5/22/24 for Resident #9 indicated that she had her hair pulled and was pushed down by another resident. 10. Record review of a facility face sheet dated 6/5/24 for Resident #10 indicated that she was an [AGE] year-old female admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including: dementia, repeated falls, depression, and type 2 diabetes. Record review of a quarterly MDS assessment dated [DATE] for Resident #10 indicated that she had a BIMS score of 4 which indicated that she had severely impaired cognition. Section C (Cognitive Patterns) indicated that she suffered from fluctuating inattention and disorganized thinking. Record review of a comprehensive care plan for Resident #10 dated 9/25/23 indicated that resident had potential to be physically aggressive r/t Dementia. Interventions included: .Administrator medications as ordered. Monitor/document for side effects and effectiveness .; .Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc .; and .Psychiatric/Psychogeriatric consult as indicated . Record review of an incident report for Resident #10 dated 9/19/23 indicated that she was involved in a physical altercation with another resident. During an interview on 6/04/2024 at 2:50 PM, SW said when there was a resident-to-resident altercation she would be notified by the charge nurse or the next day in the morning meeting or nurse meeting. SW said everyone on the secured unit was on psychiatric services. She said there was staff on the secured unit that were watching for behaviors. SW said Administrator was responsible for reporting resident to resident altercations to HHSC or any other appropriate agencies. During an interview on 6/04/2024 at 3:10 PM, DON said she had worked at the facility since February of 2023. DON said Administrator was responsible for reporting and was not sure what the last incident was that got reported. During an interview on 6/04/2024 at 3:26 PM, Administrator said she had worked at the facility since January of 2023. She said she was the abuse coordinator. Administrator said she made the determination of what incidents got reported to HHSC and she was responsible for the reporting. She said resident-to-resident altercations when the residents have a diagnosis of dementia were not reportable because there was not a willful intent behind their actions. Administrator said she was looking at the incidents as the residents did not have the cognition to make a willful decision and that is why she did not realize that they were reportable. Record review of TULIP for facility account indicated that there were no self-reports for above incidents. Record review of a f [TRUNCATED]

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 1 of 3 residents (Resident #31) reviewed for infection control. The facility failed to ensure CNA B performed proper hand hygiene when providing incontinent care to Resident #31 on 6/3/2024. This failure could place residents at risk of exposure to communicable diseases and infections. Findings include: Record review of a facility face sheet dated 6/5/24 for Resident #31 indicated that he was an [AGE] year-old male admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including: metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), depression, dementia, and hypertension (high blood pressure). Record review of a comprehensive MDS assessment dated [DATE] for Resident #31 indicated that he had a BIMS score of 4, which indicated that he had severely impaired cognition. Section H (Bowel and Bladder) indicated that he was always incontinent of bowel and bladder. Record review of a comprehensive care plan dated 5/27/23 for Resident #31 indicated that he was incontinent of bladder and bowel and included an intervention to clean peri-area after each incontinent episode. During an observation on 6/3/24 at 2:20 pm CNA B was observed inside the room of Resident #31. Resident #31 was observed lying in bed. CNA B was observed to lay a plastic bag on the bed for dirty brief, wipes, and trash. She was then observed to put on gloves and proceeded to undo resident's brief. She wiped the resident's peri area and then, keeping on same gloves, she rolled resident over to clean bottom area. Once bottom was cleaned, she removed the brief and placed it and used wipes in the plastic bag. She kept on the same gloves and put a clean brief on the resident and secured it. She then removed her gloves and exited the room without washing her hands. During an interview on 6/3/24 at 2:29 pm CNA B was observed at clean linen cart getting clean trash bags. She said she did not wash her hands yet because she still had to take the dirty linens out. She said she would wash them after that. During an interview on 6/3/24 at 3:30 pm DON said that she would expect her CNAs providing incontinent care to wash their hands before, during and after providing incontinent care to a resident. She said this was an agency CNA and she would ensure she got training today. During an interview on 6/4/24 at 8:30 am the Administrator said that CNA B would not be returning to facility. She said the DON was checking her off on female peri care and CNA B did not pass the proficiency. She said they had placed CNA B on a do not return list. During a joint interview on 6/6/24 at 5:30 pm DON and Administrator said they expect their staff to follow proper procedure during incontinent care and perform handwashing appropriately. They both said that residents could be at risk of infection if staff were not properly washing their hands. Record review of a facility policy titled Handwashing/Hand Hygiene dated 2001 and revised August 2015 read .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, resident, and visitors . and use an alcohol-based hand rub containing at least 62% alcohol; or, alternately, soap (antimicrobial or non-antimicrobial) and water for the following situations: .h. before moving to a contaminated body site to a clean body site during resident care; .m. after removing gloves . and .Hand hygiene is the final step after removing and disposing of personal protective equipment . Record review of a facility policy titled Infection Control Guidelines for All Nursing Procedures dated 2001 and revised in August 2015 read .Employees must wash their hands for ten (10) to fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: a. before and after direct contact with residents .d. After removing gloves; e. After handling items potentially contaminated with blood, body fluids, or secretions .

Based on observation, interview and record review, the facility failed to ensure medications were secured on 1 of 3 medication carts reviewed for pharmacy services. (Unit-RR Medication Aide Cart) -Medication Aide Cart for Unit-RR was left unlocked, unsecured, and unattended near the nurse station. -Seven medications were stored a bedside of Resident #2 . These failures could affect the residents, who resided on Unit-RR and received medications from these carts, by placing them at risk of drug diversions or misuse of medications. Findings included: During an observation on 1/13/24 at 11:03 a.m., revealed the Medication Aide Cart for Unit-RR had an unopened 30 count blister pack of Amlodipine Besylate 10 mg tablets (it works by relaxing your blood vessels to lower your blood pressure) unsecured and unattended on top of the cart. The cart was unlocked, and unattended stored against the wall in the dining room on Unit-RR for unknown amount of time. Residents and staff were observed passing by the medication cart. During an observation and interview on 1/13/24 at 12:09 p.m., and on 1/22/24 at 2:27 p.m., Resident #2 at bedside had an open undated bottle of 240 count women's multi dietary supplement (for energy, immunity, and healthy appearance); three 3oz bottles of Biofreeze Menthol 4% (relieves minor aches and pains of muscles and joint); two 7.1 oz bottles of Theraworx Relief contains magnesium sulfate (muscle cramp and spasm relief); open undated box of 70 single use vials of lubricant eye drops, contains carboxymethylcellulose sodium 0.5% (moisturizes and relieves dry, irritated eyes); and an open 1.75 oz jar of Vaseline, contained 100% pure petroleum jelly. Resident #2 said a family member had purchased most of the items on the bedside table and staff had not told her she was not allowed to have those items in her room. She said a family member or sometimes staff if she asked would help give and/or rub on the medications for her. During an observation on 1/20/24 at 8:37 p.m., revealed the Medication Aide Cart for Unit-RR was unlocked, and unattended stored against the wall in the dining room on Unit-RR for unknown amount of time. All the drawers of the medication could be opened, and the medication was easily accessible. A resident was observed wondering in the dining room on Unit-RR by the medication cart. During an interview on 1/20/24 at 8:45 p.m., Agency LVN B she was responsible for leaving the medication aide cart unlocked, she said staff from another hall was needing something from the cart and she unlocked the cart and forgot to lock the cart. Agency LVN B said the medication carts are never supposed to be left unlocked and don't know why she did it, was a mistake. During an interview on 1/22/24 at 2:55 p.m., LVN D said she was the charge nurse for Unit- RR and said there was no residents on her Unit who self-administered medications and was not aware of residents on her Unit who had medications at bedside. LVN D said if she was aware of medications in residents' room, she would remove it and notify DON. During an interview on 1/22/24 at CMA C said she was not aware of any residents who self-administered medications. Also, said residents were not allowed to keep medications in their room and she was not aware of any residents who had medications stored in their room. CMA C said if she was to see medications in a resident room she would remove it and notify the nurse. During an observation and interview on 1/22/24 at 5:31p.m., the DON said medication carts should remain locked and secured anytime not attended. She said no medications should be left at bedside unless the resident was assessed to self-administer; she said the facility did not have any residents who self-administered therefore, no medications should be at bedside to self-administer. State Surveyor notified the DON regarding Resident #2's medications at bedside and the DON notified Resident #2 that she was not allowed to keep medications at bedside and she removed the following items: Three bottles of Bio Freeze, Two bottles of Theraworx, open box of vials of eye drops, one bottle of vitamins, and one saline bottle (DON said she did not know why saline bottle was in Resident #2's room because they mainly used saline for wounds and Resident #2 did not have any wounds). The DON said she was not aware at that time if Resident #2 had orders for any of the items she removed from Resident #2's room. During an interview on 1/22/24 at 5:30 p.m., LVN D said she was aware Resident #2 had medications at bedside and said she did not give Resident #2 the medications and she instructed her CNAs to not give Resident #2 the bedside medications. LVN D said she did not notify DON or the Administrator regarding Resident #2's medications she had stored at bedside and said she probably should have. Record review of storage of medication revised policy dated April 2007 revealed The facility shall store all drugs and biologicals in a safe, secure, and orderly manner . 7) Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.

Based on observation, interview, and record review, the facility failed to ensure an acceptable parameter of nutritional status was maintained for 1 of 24 residents (Resident #121) who was reviewed for nutritional status, in that: 1. Resident #121 had a significant weight loss of 26 pounds, a 21.13% loss, in less than 30 days. The facility did not provide nutritional supplements as ordered, did not notify the physician, did not notify the RD, and did not notify the family of the significant weight loss. This failure could place residents at risk for further weight loss and decline in health due to nutritional needs not being met. Finding included: 1. Record review of a face sheet dated 04/25/2023 revealed Resident #121 was a 95- year-old- female, admitted on [DATE] with the diagnoses of malnutrition (occurs when the body doesn't get enough nutrients), pneumonia (Infection that inflames air sacs in one or both lungs, which may fill with fluid), and rhabdomyolysis (a serious medical condition that can be fatal or result in permanent disability). Record review of an admission MDS assessment dated [DATE] for Resident #121 revealed a BIMS of 14, which indicated no cognitive impairment. The MDS indicated Resident #121 used oxygen daily. The MDS indicated Resident #121 weighed 123 pounds and was 64 inches tall. The MDS indicated Resident #121 had no skin issues on admission. The MDS indicated Resident #121 had no problems with chewing, swallowing, and no dental or mouth pain. Record review of the weight log revealed the following weights: 03/27/2023- 123 pounds 04/10/2023- 99 pounds---24-pound loss in 15 days 19.5% 04/17/2023- 97 pounds-26-pound loss in < 30 days 21.13% Record review of an RD assessment dated [DATE] indicated Resident #121 weighed 123 pounds. The RD assessment indicated Resident #121 always required assistance while eating and recommended house shakes 4 ounces three times daily and a snack once daily related to increased need for nutrition for new wounds and COVID diagnosis. No RD assessment was completed after significant weight loss was discovered. Record review of the physicians' consolidated orders for April 2023 indicated Resident #121 had an order dated 04/13/2023 for a regular diet, mechanical soft consistency. The orders also indicated on 04/07/2023 a snack once daily and health shake 4 ounces three times daily were ordered. The orders indicated a (wound care doctor) consult dated 04/14/2023, and weekly weights dated 04/26/2023. Record review of a skin assessment dated [DATE] indicated Resident #121 had a Stage II pressure ulcer measuring 2.5cm by 0.5 cm to coccyx. Record review of wound care doctor note dated 04/07/2023 indicated Resident #121 had a new Stage III pressure to Right upper back measuring 5.0 cm by 4.5 cm x 0.1cm with some necrtoic tissue at base. A deep tissue injury to the left heel measuring 0.5 cm x 0.3 cm was noted on wound care doctor note. Record review of the progress notes dated 04/01/2023 to 04/24/2023 indicated no notification of the RD, physician, or family. Record review of meal consumption for Resident #121 from 04/01/2023-04/24/2023 revealed the following: 10 meals- 0% to 25% consumed 15 meals- 26% to 50% consumed 20 meals- 51% to 75% consumed 8 meals 76% to 100% consumed 8 meals- refused Record review of the snack consumption for Resident #121 from 04/07/2023 to 04/24/2023 revealed only one day when a snack was accepted. All other days the snack was marked refused. Record review of the CNA documentation of level of assistance needed for eating for Resident #121 from 04/01/2023 to 04/24/2023 revealed the following: 38 meals- resident was independent with eating 7 meals - resident required supervision only for eating 12 meals- resident required limited assistance from 1 staff member to eat 8 meals- resident required extensive assistance from 1 staff member to eat 2 meals- resident required total assistance from 1 staff member to eat During an observation on 04/24/2023 at 10:05 a.m., Resident #121 was sitting in her wheelchair in her room. No snack or health shake was offered. During an observation on 04/24/2023 at 1:10 p.m., Resident #121 was eating lunch alone in her room and no health shake was noted on the tray. Resident #121 fed self but spilled 25% of her meal on herself and the floor. Resident #121's lunch ticket indicated health shakes three times a day, but none were provided. During an observation on 04/24/2023 at 2:15 p.m., Resident #121 was sitting in her wheelchair in her room. No snack or health shake was offered. During an observation and interview on 04/24/2023 at 5:12 p.m., Resident #121 was in bed eating supper and no health shake was noted on her tray. Resident #121 said she did not get milk shakes every day, just when they felt like putting it on her tray. Resident #121 said the food did not taste bad there was just too much of it and seeing all that food made her not hungry. Resident #121 said she had trouble keeping the chopped- up meat on the fork and making it to her mouth. During an interview on 04/25/2023 at 10:10 a.m., RN K said snacks were delivered by the kitchen and passed by the CNAs at 10a.m., 2 p.m., and bedtime. RN K said she did not go behind the CNAs to ensure they were passing them out. RN K said Resident #121 received health shakes with meals and was sent a snack out every day. RN K said she had not worked with Resident #121 long because she was on the main floor and about a week later went to the COVID hall for a couple weeks. RN K said Resident #121 was not a person that ate 100%. Resident #121 ate 50% most of the time. RN K said Resident #121 liked the house shakes and drank those well in the past. During an interview on 04/25/2023 at 11:00 a.m., RNA J said monthly weights were not to be started before the 1st of the month and must be but in the book by the 10th of each month. All new admits were weighed weekly for 4 weeks and then would be discussed in the standard of care meeting. The standards of care meetings were held weekly. RNA J said a few weights were missed when residents had COVID and a couple of standards of care meetings were missed because the ADON was on vacation and then was sick. RNA J said she could not recall directly if Resident #121's 04/03/2023 weekly weight was missed because Resident #121 was on the COVID hall. RNA J said she was instructed to limit her time on the COVID unit and most of the time agency worked the COVID unit. During an interview on 04/26/2023 at 9:10 a.m., Resident #121's family member said she was not informed of any weight loss prior to 04/25/2023 by the facility. Resident #121's family member said she was informed of a weight loss of over 20 pounds when the nurse called. Resident #121's family member said she brought some things the resident liked to eat when she was at home and planned to be at the facility more during mealtime. An attempt to reach the RD was made at 11:10 a.m., 1:30 p.m., and 3:30p.m. on 04/26/2023. Voicemail was recorded and no return call was received prior to exit. An attempt to reach the physician was made at 11:15 a.m. and 3:15 p.m. on 04/26/2023. Messages were left with an answering service. No return call was received prior to exit. During an interview on 04/26/2023 at 1:50 p.m., the DON said she was now over the weight system (records) as of 04/26/2023. The DON said the facility identified some missing and late weights, and she was going to do a full investigation into what occurred. The DON said the normal procedure was the RNAs got the weights for new admits, weekly weights, daily weights, and monthly weights. They had books on each hall they recorded the weights in and the ADON was to input those weights into the EMR weekly before standards of care meeting. At the standards of care meeting the weight loss and gains were discussed and the physician was notified, as well as the family. The DON said she did not think notification of the RD, physician or family had taken place for Resident #121 regarding weight loss. The DON explained because of COVID in the building and the ADON being on vacation and becoming sick things were missed. The DON said she expected residents with COVID to be taken care and get food, supplements, weighed, and therapy services just like those without COVID. The DON said nutrition was very important to the elderly. It ensured health and skin integrity. The DON said poor nutrition led to weight loss, no energy, and skin breakdown. During an interview on 04/26/2023 at 2:15 p.m., the Administrator said it was brought to her attention by the DON that the weight system needed to be more closely monitored and the DON had taken over the weight system monitoring as of 04/26/2023. The Administrator said all the weights at that point were current and the physicians and family had been notified of any weight gains and losses. A policy dated September 2012; titled Nutrition-Unplanned Weight loss indicated. The physician and staff will closely monitor residents who have been identified as having impaired nutrition or risk factors for developing impaired nutrition. Such monitoring may include: a. evaluating the care plan to determine if the interventions are being implemented and whether they are effective in attaining the established nutritional and weight goals c. recognizing the emergence of new risk factors for example pressure ulcers, fever, and/or acute illness.

Based on observation, interview and record review, the facility failed to ensure adequate supervision and assistance devices were provided to prevent accidents for 1 of 8 residents reviewed for accidents. (Resident #1) CNA A did not use a 2-person, mechanical lift to transfer Resident #1 from her bed to her wheelchair as indicated by her care plan. Resident #1 sustained a comminuted (a splinter of the bone into more than 2 fragments) fracture of her right tibia fibula (the 2 bones of the lower leg) on 7/23/19. Resident #1 developed [DIAGNOSES REDACTED] (a painful condition that occurs when pressure within the muscles builds to a dangerous level) requiring a fasciotomy (the muscle compartment is cut open to allow muscle tissue to swell, decrease pressure and restore blood flow in an attempt to save a limb) and 4 days later an amputation of her right leg above the knee. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 08/07/19. While the IJ was removed on 08/08/19, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents who required the use of a mechanical lift for transfers at risk of injury. Findings included: Physician orders [REDACTED].#1 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. A transfer care plan updated 01/29/19 indicated Resident #1 was changed to a Hoyer lift (mechanical lift) with 2 staff total assistance transfer. The most recent MDS dated [DATE] indicated Resident #1 had severely impaired daily decision-making skills, experienced disorganized thinking and required extensive assistance of two staff for bed mobility, toileting, and transfers. A hospital x-ray report dated 07/23/19 at 11:59 p.m., indicated Resident #1 had a comminuted [MEDICAL CONDITION] (upper part of bone) tibia with additionally mildly impacted [MEDICAL CONDITION] fibula. A hospitalist admission note dated 07/24/19 indicated Resident #1 was transferred from another hospital for a higher level of care due to the concern of [DIAGNOSES REDACTED]. The note indicated Resident #1 was to be taken to the operating room for a fasciotomy. An operative report dated 07/27/19 indicated Resident #1 had a right leg tibial fracture and [DIAGNOSES REDACTED] with massive muscle and skin necrosis and underwent an above the knee amputation of her right leg. During an observation and interview on 08/07/19 at 3:00 p.m., Resident #1 was sitting in her Geri chair with a mechanical lift sling under her. She had a dressing to the right above knee amputation. She responded appropriately to simple conversation. She denied discomfort and said she did not recall what happened to her leg and said she felt safe. A Mechanical Lifts skills check-off sheet dated 05/09/19 signed by CNA A and CNA B indicated: Hoyer lift is for totally dependent partial non-weight baring individuals required staff assistance times two. An Accident/Incident report dated 07/23/19 (no time indicated) completed by LVN D indicated Resident #1 sustained a 2 cm x 1 cm skin tear to her right shin due to CNAs bumped her leg on her wheelchair during a transfer from her bed to her wheelchair. A nursing note dated 07/23/19 at 3:13 p.m., by LVN D indicated she was notified by CNAs while transferring Resident #1 from her bed to the wheelchair, her right shin bumped the wheelchair. The note indicated Resident #1 had a 2 cm x 1 cm skin tear to her right shin with well approximated edges and Resident #1 had no signs or symptoms of pain or distress. A nursing note dated 07/23/19 at 6:45 p.m., by LVN D indicated she reassessed Resident #1's right leg and it was noted to be swollen with a large, dark purple bruise above the skin tear up to the knee. The note indicated the physician was notified and the resident was sent to the emergency room for evaluation. A handwritten statement dated 07/23/19 by Resident #1's private sitter indicated at the time of the transfer, she stepped out of Resident #1's room. The statement indicated CNA A went in to get Resident #1 up and the sitter heard Resident #1 yell. She indicated CNA A left the room and went to get LVN D. The statement indicated the incident occurred at approximately 7:40 a.m. A handwritten statement by LVN D dated 07/23/19 indicated she was notified by CNAs when transferring Resident #1 by Hoyer lift that Resident #1 bumped her leg on the wheelchair. The statement indicated Resident #1's right leg had a skin tear without swelling or bruising. The statement indicated LVN D reassessed Resident #1's right lower leg later in the shift and noted it was swollen with dark purple bruising. LVN D notified Resident #1's physician and initiated his orders to transfer the resident to the emergency room for evaluation. During an interview on 08/07/19 at 3:33 p.m., LVN D said the morning of the incident, CNA A told her Resident #1 bumped her leg on the wheelchair. She said she assessed the resident's right leg and there was no bruising. She said Resident #1 did not complain of pain or have any signs of distress or discomfort. LVN D said she reassessed Resident #1 after supper because she was grimacing. LVN D said Resident #1's right leg was swollen and bruised. She said she notified the physician and initiated the transfer to the emergency room . She said there was no change in Resident #1's condition, affect, or appetite during that day that indicated she was in discomfort or distress until after supper. She said Resident #1 was transferred back to bed from her wheelchair by mechanical lift by CNA W and CNA Y but she did not observe the transfer. A handwritten statement by CNA A dated 07/23/19 stated, When transferring resident (#1) via Hoyer, her leg got caught on wheelchair. We noticed a skin tear after, told nurse immediately. A handwritten statement by CNA B dated 07/23/19 stated, (CNA A) and I were transferring (Resident #1) by Hoyer and noticed a skin tear after we got her situated in the wheelchair. A handwritten statement by CNA A dated 07/24/19 indicated she transferred Resident #1 by herself and when Resident #1's leg caught on her wheelchair, she reported the skin tear to the nurse. A handwritten statement by CNA B dated 07/24/19 indicated she was not around the room when CNA A transferred Resident #1 and Resident #1 sustained a skin tear after CNA A transferred her. A handwritten statement by LVN D dated 07/24/19 indicated she did not know CNA A transferred Resident #1 by herself and was told Resident #1 was transferred using the mechanical lift with CNA B. An employee disciplinary/counseling action notice dated 07/24/19 signed by LVN D indicated LVN D received a verbal warning because she did not observe Resident #1 transfer with the Hoyer lift. An employee disciplinary/counseling action notice dated 07/24/19 signed by CNA A indicated CNA A transferred Resident #1 with assistance of one but reported Resident #1 was transferred by Hoyer, and Resident #1 sustained a skin tear later found to be a fracture. An employee disciplinary/counseling action notice dated 07/24/19 signed by CNA B indicated CNA B wrote a falsified statement indicating she was present during the Hoyer lift transfer when she was not present for the transfer. A termination form dated 07/25/19 signed by the administrator indicated CNA A was involuntarily terminated from employment due to resident neglect and misrepresented the facts of an incident, resulting in injury to the resident. A termination form dated 07/25/19 signed by the administrator indicated CNA B was involuntarily terminated from employment due to misrepresentation of the facts of an incident, resulting in injury to the resident. During an attempt to contact CNA A on 07/31/19 at 2:11 p.m., her number was restricted and was not accepting messages. During an attempt to contact CNA B on 07/31/19 at 2:12 p.m., a voicemail message was left with contact information and a request for a return call. The surveyor did not receive a return call. During an interview on 07/31/19 at 9:51 a.m., LVN E said all staff were in-serviced in June 2019 regarding facility protocol requiring residents 2 person transfers for all mechanical lift transfers and the presence of a charge nurse during the transfer. During an interview on 07/31/19 at 10:08 a.m., LVN C said Resident #1 was 1 of 2 residents on Unit 2 that required mechanical lift transfers. She said Resident #1 was dependent on mechanical lift transfers and could not bear weight. She said all nursing staff were in-serviced in June 2019 regarding all mechanical lift transfers required 2 staff without exception and the charge nurse was required to observe the transfer. LVN C said Resident #1 had been a 2 staff mechanical lift transfer for months. She said she always watched the transfers but there was no monitoring process and that all staff just knew to do this. During an interview on 07/31/19 at 10:23 a.m., CNA G said Resident #1 was dependent for mechanical lift transfers and could not transfer without the lift. She said the charge nurse was required to observe mechanical lift transfers and 2 staff were required to operate the mechanical lift each and every time without exception. She said transfer policy and procedure was in-serviced a month ago. During an interview on 08/07/19 at 3:37 p.m., CNA X said there were 2 residents on the unit Resident #1 resided that required mechanical lift transfers. She said protocol required 2 staff and the charge nurse to observe every transfer. She said the charge nurse observed most of the time, but staff were not always available. She said she made sure the nurse was present. During an interview on 08/07/19 at 3:07 p.m., RN U said she was the charge nurse and cared for Resident #1. She said she was not the charge nurse at the time of the incident. She said Resident #1 was readmitted on [DATE] after her right above knee amputation and was doing well. She said she did not know how the protocol that the charge nurse had to observe 2 CNAs complete all mechanical lift transfers was being monitored, but all staff just knew. She said she there was no process for documenting it. During an interview on 08/07/19 at 3:19 p.m., RN V said she was Resident #1's granddaughter. She said after the incident occurred, she asked the LVN D why she didn't follow the protocol to observe the Hoyer transfers to make sure it was safe. She said the charge nurse told her she thought the protocol was temporary and no longer required. RN V said Resident #1's incident boiled down to an improper transfer. She said her grandmother (Resident #1) had a high pain tolerance and the private sitter was present from before breakfast to early afternoon on the day of the incident and denied the resident complained of pain or had signs of injury. An undated typed statement by the DON indicated on 07/23/19 at approximately 8:00 a.m., she was notified Resident #1 had sustained a skin tear while transferring with assistance of 2 CNAs. The statement indicated she received witness statements from CNA A and CNA B indicating they were present for the transfer. The statement indicated later in the evening the DON was notified Resident #1 was transferred to the emergency room due to her right leg was swollen and bruised. The statement indicated about 9:00 p.m., Resident #1's family notified her Resident #1's leg was fractured, and she was being transferred to a different hospital for a higher level of care. The statement indicated on the morning of 07/24/19, The DON was notified Resident #1's sitter observed only CNA A go into Resident #1's room and the facility investigation revealed CNA A transferred Resident #1 alone. The statement indicated CNA A asked CNA B to write a statement indicating they were both in the room and used the Hoyer lift to transfer Resident #1. The DON indicated she requested the termination of both employees due to falsifying documentation to cover up an incident. During an interview on 07/31/19 at 9:04 a.m., the DON said she was notified on 07/23/19 by LVN D, Resident #1 had sustained a skin tear to her right leg during a 2 person mechanical lift transfer. She said LVN D reassessed Resident #1's right leg later in the shift and noted it was swollen and bruised. She said LVN D notified the physician and Resident #1 was transferred to the hospital for evaluation. The DON said Resident #1 had a private sitter the family provided who submitted a written statement indicating she had seen only one staff enter the room and close the door during the incident. She said the sitter said no equipment or mechanical lift was taken into Resident #1's room. The DON said it was discovered CNA A transferred Resident #1 by herself and had not used the mechanical lift. She said CNA A had gotten CNA B to falsify a statement that she assisted CNA A with the transfer and used the mechanical lift. She said both CNAs were terminated from employment when the falsification was discovered. The DON said she implemented transfer training, including Hoyer lift transfers, and skills checklists in May 2019. She said both CNA A and B attended and were checked off on their skills. She said charge nurses were required to observe 2 staff mechanical lift transfers as an added safety measure and none of that occurred during Resident #1's transfer resulting in her injury. During an interview on 07/31/19 at 3:22 p.m., the DON said she discovered CNA A lied about Resident #1's transfer and got (CNA B) to falsify her statement because she was scared to get into trouble. She said CNA A broke down and admitted it and cried for twenty minutes. She said CNA A said she never meant to break (Resident #1)'s leg. During an interview on 07/31/19 at 9:07 a.m., the administrator said both CNAs had recently been retrained regrading transfers but disregarded the policy and protocol. He said both CNAs involved in the incident were terminated During an interview on 08/07/19 at 4:05 p.m., The DON said she initiated staff in-services and training regarding integrity of reporting incidents, identifying resident who required extensive vs. mechanical lift transfers but did not have a formal oversight process to verify charge nurses observe each 2 person mechanical lift transfer. An abuse policy and procedure dated August 2014 defined neglect as the failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain, or mental anguish. A Lifting Machine, Using a Mechanical policy revised July 2017 indicated at least two nursing assistants were needed to safely move a resident with a mechanical lift. A Safe Lifting and Movement of Residents policy revised July 2017 indicated mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary. An undated Certified Nursing Aide job description indicated responsibilities included assuring the resident is repositioned turned, toileted, clean, and safe and provides intervention to provide a safe environment at all times. The assistant administrator was notified on 08/07/19 at 2:45 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The IJ notification and template were provided. The facility's Plan of Removal was accepted on 08/07/19 and 6:58 p.m. and included: 1. Resident (#1) returned to the facility/ 08/01/19. Resident has been monitored by licensed nursing staff every shift and remained stable. Completed 08/07/19 at 4:46 p.m. 2. Resident referred to therapy for screening for proper transfer procedure and technique 08/07/19. Completed 08/07/19 at 4:37 p.m. 3. Notified facility Medical Director informed of facility IJ status. Completed 08/07/19 at 3:30 p.m. 4. Notified (regional nurse consultant) and (regional director of operations) of facility IJ status. Completed 08/07/19 at 3:00 p.m. 5. Identified residents requiring Hoyer lift process. Completed 08/07/19 at 3:30 p.m. 6. Residents requiring Hoyer lift procedures will have orders completed and entered in (electronic treatment administration record) for a licensed nurse monitoring every shift. Initiated 08/07/19 at 4:30 p.m. Completed 08/07/19 at 6:45 p.m. 7. Education: A. Reporting incidents immediately. B. Honesty/integrity-do not falsify documentation. Answer any and all questions related to incidents and/or investigation processes honestly. C. Proper Hoyer lift use and informing nurse prior to using Hoyer lift on residents. D. Resident transfer needs are located in (facility electronic documentation) on the kiosk in the ADL care guide section. The ADL care guide provides information for each specific residents level of support per ADL task Initiated 08/07/19 at 4:00 p.m. Remaining active employee training will be completed prior to working next scheduled shift. 8. Education: Licensed nursing staff were provided education by facility director of staff development on: A. Residents who require Hoyer lift procedure will be listed on the 24-hour report to facilitate monitoring and communication B. ETAR documentation/monitoring related to licensed nurse responsibilities related to Hoyer transfer procedures C. Charge nurse to monitor Hoyer transfer procedures every shift. Document observation on the ETAR and indicate any concern related to procedure in resident medical record. If concerns during procedure are identified, appropriate notification procedure (Primary care physician, responsible party, nursing management) will be completed. Initiated 08/07/19 at 4:00 p.m. 9. Facility residents requiring Hoyer lift transfer have had care plans and (facility electronic documentation) kiosk guides reviewed and updated as appropriate by nursing management. Initiated 3:30 p.m. 8/07/19. Completed 5:00 p.m. 08/07/19. 10. Compliance to be monitored by: Review of Accident/Incident Reports and observation of Hoyer lift transfer procedures three times per week by Nursing Management with corrective action taken within 24 hours of concern identified. Facility nursing management will be provided education by the regional nurse consultant regarding incident and accident review and Hoyer transfer observation by the DON/designee three times per week during clinical meetings. Identified concerns will have corrective actions completed within 24 hours of identified concern. 11. Findings to be submitted to facility Quality Assurance Planning and Interventions committee monthly for review and additional action if indicated. The DON provided a list of 30 residents who required Hoyer lift transfers in addition to 3 residents currently out of the facility in the hospital. The investigator confirmed the plan of removal had been implemented sufficiently to remove the IJ by staff interviews: During an interview on 8/08/19 at 12:10 p.m., CNA J said she received in-service training prior to her shift starting this morning regarding using a Hoyer lift and honesty and integrity when reporting incidents. She indicated Hoyer lift transfers always required 2 nursing staff and the charge nurse must be present during the transfer. She indicated the charge nurse documented transfers in the electronic treatment administration record. She said resident safety was the first priority and she would report incidents honestly immediately to the charge nurse. During an interview on 8/08/19 at 12:14 p.m., CNA K said she received in-service training prior to her shift starting this morning regarding using a Hoyer lift and honesty and integrity when reporting incidents. She indicated Hoyer lift transfers always required 2 nursing staff and the charge nurse must be present during the transfer. She indicated the charge nurse documented transfers in the electronic treatment administration record. She said resident safety was the first priority and she would report incidents honestly immediately to the charge nurse. During an interview on 8/08/19 at 12:20 p.m., LVN C said she received in-service training prior to her shift starting this morning regarding using a Hoyer lift and honesty and integrity when reporting incidents. She indicated Hoyer lift transfers always required 2 nursing staff and the charge nurse must be present during the transfer. She indicated the charge nurse documented transfers in the electronic treatment administration record and it was recorded on the 24-hour report. She said resident safety was the first priority and she and all staff would report incidents honestly immediately. During an interview on 8/08/19 at 12:34 p.m., CNA L said she received in-service training prior to her shift starting this morning regarding using a Hoyer lift and honesty and integrity when reporting incidents. She indicated Hoyer lift transfers always required 2 nursing staff and the charge nurse must be present during the transfer. She said resident safety was the first priority and she would report incidents honestly immediately to the charge nurse. During an interview on 8/08/19 at 12:40 p.m., CNA M said she received in-service training prior to her shift starting this morning regarding using a Hoyer lift and honesty and integrity when reporting incidents. She indicated Hoyer lift transfers always required 2 nursing staff and the charge nurse must be present during the transfer. She said she would report incidents honestly immediately to the charge nurse. During an interview on 8/08/19 at 1:24 p.m., LVN N said she received in-service training prior to her shift starting this morning regarding using a Hoyer lift and honesty and integrity when reporting incidents. She indicated Hoyer lift transfers always required 2 nursing staff and the charge nurse must be present during the transfer. She indicated the charge nurse documented transfers in the electronic treatment administration record and it was recorded on the 24-hour report. She said resident safety was the first priority and she and all staff would report incidents honestly immediately. During an interview on 8/08/19 at 1:35 p.m., LVN O said she received in-service training prior to her shift starting this morning regarding using a Hoyer lift and honesty and integrity when reporting incidents. She indicated Hoyer lift transfers always required 2 nursing staff and the charge nurse must be present during the transfer. She indicated the charge nurse documented transfers in the electronic treatment administration record and it was recorded on the 24-hour report. She said resident safety was the first priority and she and all staff would report incidents honestly immediately. During an interview on 8/08/19 at 1:47 p.m., CNA P said she received in-service training prior to her shift starting this morning regarding using a Hoyer lift and honesty and integrity when reporting incidents. She indicated Hoyer lift transfers always required 2 nursing staff and the charge nurse must be present during the transfer. She said she should report incidents honestly immediately to the charge nurse. During an interview on 8/08/19 at 2:04 p.m., LVN Q said she received in-service training prior to her shift starting this morning regarding using a Hoyer lift and honesty and integrity when reporting incidents. She indicated Hoyer lift transfers always required 2 nursing staff and the charge nurse must be present during the transfer. She indicated the charge nurse documented transfers in the electronic treatment administration record and it was recorded on the 24-hour report. She said resident safety was the first priority and she and all staff should report incidents honestly immediately. During an interview on 8/08/19 at 2:12 p.m., CNA R said she received in-service training prior to her shift starting this morning regarding using a Hoyer lift and honesty and integrity when reporting incidents. She indicated Hoyer lift transfers always required 2 nursing staff and the charge nurse must be present during the transfer. She nurses would document they had observed the mechanical lift transfer. She said resident safety was the first priority and she would report incidents honestly immediately to the charge nurse. During an interview on 8/08/19 at 2:30 p.m., Nutritional Aide S said she received in-service training prior to her shift starting this morning regarding nursing staff was to have 2 staff when using a Hoyer lift with a charge nurse observing. She said staff were to report incidents honestly and because the safety of residents was the priority. During an interview on 8/08/19 at 2:58 p.m., LVN T said she received in-service training prior to her shift starting this morning regarding using a Hoyer lift and honesty and integrity when reporting incidents. She indicated Hoyer lift transfers always required 2 nursing staff and the charge nurse must be present during the transfer. She indicated the charge nurse documented transfers in the electronic treatment administration record and it was recorded on the 24-hour report. She said reporting incidents and accidents honestly was necessary because the safety of residents was the most important thing. On 08/08/19 and 3:38 p.m., the assistant administrator, regional nurse consultant, vice president of operations, administrator in training, and the DON were informed the IJ was removed; However, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure the advance directive was provided to EMT personnel upon transfer for 1 of 10 residents reviewed for advanced directives. (Resident #1) The facility did not send the completed Out of Hospital Do Not Resuscitate (OOH-DNR) form for Resident #1 when she was transferred to the hospital on [DATE]. Resident #1 received cardiopulmonary resuscitation (CPR), defibrillation, advanced airway management, and artificial ventilation performed against her wishes. This was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place residents at risk of not having end of life choices respected. Findings included: Physician orders [REDACTED].#1 was an [AGE] year-old female admitted on [DATE] with [DIAGNOSES REDACTED]. An order dated [DATE] indicated the resident had a code status of DNR (Do Not Resuscitate). An OOH-DNR dated [DATE] indicated Resident #1 directed cardiopulmonary resuscitation (CPR), transcutaneous cardiac pacing, defibrillation, advanced airway management, and artificial ventilation not be initiated or maintained. The form indicated the following: This document or a copy thereof must accompany the person during his/her medical transport. An emergency medical services (EMS) patient care report dated [DATE] indicated Resident #1 was alert and conscious and transported via ambulance with no lights, then turned over to emergency staff on [DATE] at 3:45 p.m. without complication. A hospital discharge summary dated [DATE] indicated Resident #1 admitted on [DATE] and discharged on [DATE]. The hospital summary indicated she was being transferred to another hospital for a higher level of care when she became bradycardic (fast heart rate) and went into pulseless electrical activity. CPR was initiated by the paramedics and the patient was intubated. Upon reaching the emergency department, the family indicated that she had an advance directive and did not want to be resuscitated. Family requested palliative care. An EMS patient care report dated [DATE] indicated upon EMS arrival to the hospital on [DATE] at 8:25 p.m., Resident #1 was alert, in no apparent distress and being transferred due to cardiology not available at the sending hospital. The report indicated during transport, patient's condition began to deteriorate, EMS turned back to the emergency room due to patient becoming unstable and she was intubated and received CPR in the emergency room at 9:02 p.m. During an interview on [DATE] at 8:45 a.m., the medical records director of the hospital indicated Resident #1 was admitted to hospice on [DATE] and died at 3:22 a.m. on [DATE]. During an interview on [DATE] at 3:13 p.m., LVN A said she was the charge nurse who initiated Resident #1's transfer on [DATE] via non-emergent ambulance transfer to the hospital. She said Resident #1 was alert and not in distress. She said she printed the transfer summary but forgot to send a copy of her OOH-DNR with the emergency medical technicians (EMT). She said Resident #1's DNR status was included in the transfer summary but she was supposed to send a copy of the DNR. She said the hospital called for a copy of Resident #1's DNR after 6:00 p.m. on [DATE] and she faxed it. She said she attended the in-service on [DATE] regarding sending a copy of a resident's DNR paperwork with the transfer paperwork. During an interview on [DATE] at 1:35 p.m., social worker D said the charge nurse did not give the EMTs a copy of Resident #1's of DNR when she was transferred to the hospital. SW D said he updated the red envelopes to make sure copies of DNR paperwork was available to the charge nurses, but they had to hand it to the EMTs upon transfers. He said he did not identify any other concerns with this system OOH-DNR system. He said Resident #1's family called him sometime after she was transferred to the hospital and died on [DATE] and were upset Resident #1 was coded and suffered unnecessarily. During an interview on [DATE] at 2:31 p.m., LVN C said copies of each resident's DNR was kept in a red envelope in the front of their charts designated with a red dot. She said a copy was to be sent along with a transfer summary when a resident was transferred for any reason. She said she attended an in-service on [DATE] regarding this protocol but it was the protocol for as long as she could remember. During an interview on [DATE] at 2:50 p.m., LVN E said she cared for Resident #1 and recalled she was a DNR. She said she attended an in-service on [DATE] regarding sending copy of the DNR found in the red envelope with the resident's transfer summary upon transfers. LVN E said that was the way it was always done. During an interview on [DATE] at 2:00 p.m., the DON said the OOH-DNR form should have been sent with Resident #1 when she transferred to the hospital. She said she was made aware when she returned from medical leave on [DATE] Resident #1's OOH-DNR was not sent but was documented on page 4 of Resident #1's transfer summary. She said the incident was serious and she completed an audit and in-serviced the staff on [DATE] that a copy of the DNR paperwork should be sent with a transfer summary anytime a resident is transferred. During an interview on [DATE] at 2:37 p.m., the administrator said he was made aware sometime last week that Resident #1's OOH-DNR was not sent with her upon transfer and she was coded. He said he signed off on the plan the DON and SW D initiated to audit all charts and in-servicing all staff to make sure similar incidents did not happen. An in-service training report dated [DATE] indicated when sending a resident out to the emergency room , always check the chart for DNR paperwork/red envelopes. These envelopes must be sent with the resident's paperwork to the emergency room . Ambulance EMTs need this prior to leaving the facility with the resident. An in-service training report dated [DATE] indicated DNRs were to be put in a separate folder and sent to the doctor for signature and social workers were to be notified immediately of resident arrival to discuss the DNR status with the resident and/or family. An undated Do Not Resuscitate Order policy regarding providing OOH-DNR form to EMT personnel indicated if a resident was transferred to the hospital, a photocopy of the OOH-DNR form should be provided to the EMT personnel transporting the resident to the hospital.

Based on interview and record review, the facility failed to ensure residents were free from neglect for 1 of 13 residents reviewed for neglect. (Resident #1) Resident #1 had a history of [REDACTED].#1 fell and sustained a laceration to his head requiring 17 staples. The facility did not implement revised interventionns to prevent falls. This failure contributed to Resident #1's fall and laceration to the back of his head. This failure could place 61 residents with a history of falls at risk of injuries and neglect. Findings included: Physician orders [REDACTED].#1 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #1 understood others and made himself understood and functioned with severely impaired cognitive skills for daily decision making. This MDS indicated Resident #1 required extensive two person physical assistance with bed mobility and transfers and had falls since admission. A care plan with date initiated 07/01/16 addressed Resident #1 being at risk for falls related to [MEDICAL CONDITION], left eye [MEDICAL CONDITION] and history of falls. Goals listed were to minimize risk for fall and risk for injury if fall occurs. The noted approaches included .fall mats were to be on the floor beside the bed and the bed alarm was to be in place . An added approach dated 12/14/16 at 6:41 p.m., that staff were ,,, to monitor Resident #1's fall alarm was to be in place at all times and to verify alarm placement hourly . There were no ends dates listed for any of the noted interventions. A care plan with date initiated 07/01/16 addressed Resident #1 being at risk for falls related to [MEDICAL CONDITION], left eye [MEDICAL CONDITION] and history of falls. Goals listed were .to minimize risk for fall and risk for injury if fall occurs . An added approach dated 07/03/16 at 4:46 p.m., indicated Resident #1 was .not to be left in the dining room unattended when he was through eating . There were no ends dates listed for any of the noted interventions. A Resident Incident Report dated 12/14/16 at 6:41 p.m., indicated Resident #1 had fallen to the floor and was found by the visitor of another resident. This report noted his alarms had to be replaced. A Resident Incident Report dated 12/30/16 at 7:35 p.m., indicated Resident #1 was removed from his wheelchair and assisted to walk down the hall and then assisted with being again seated back in his wheelchair. This incident report noted Resident #1 had fallen to the floor in hallway on the unit and was found by the visitor of another resident. Noted on this same report was the injury described as an abrasion on his right elbow about 2 centimeter (cm) X 1cm with scant sanguineous drainage. The report did not have revised interventions to prevent falls. A Resident Incident Report dated 01/07/17 at 11:15 a.m., indicated Resident #1 sustained a fall with a head injury. This incident report noted Resident #1 suffered a laceration to his forehead which measured 2.5cm X 0.1cm, he sustained a skin tear to his right hand which measured 2 cm X 2 cm, there was a laceration to his left knee which measured 2.5 cm X 2.5 cm and bruising was noted to his nose. This report noted the resident was seen by a staff member with no mention of his safety alarm in place or alarming to alert staff. The report did not have revised interventions to prevent falls. A care plan with date initiated 07/01/16 and revised 12/14/16 addressed Resident #1 being at risk for falls related to [MEDICAL CONDITION], left eye [MEDICAL CONDITION] and history of falls. Goals listed were .to minimize risk for fall and risk for injury if fall occurs . An added approach dated 12/14/16 at 6:41 p.m., staff was .to monitor Resident #1's fall alarm was to be in place at all times and to verify alarm placement hourly . An added approach to the fall care plan updated 01/07/17 at 11:15 a.m., indicated Resident #1 was .to be provided one-on-one supervision by staff . There were no end dates listed for any of the noted interventions. A Resident Incident Report dated 01/09/17 at 7:50 p.m., indicated Resident #1 was found on the floor in the dining room with a laceration to the back of his with the alarm hanging from the back of the wheelchair and 911 was notified. Resident #1 suffered a deep laceration to the back of his head which measured 6 cm X 2cm. The 24 hour follow up noted on this same report indicated Resident #1 received 17 staples to the back of the crown of his head down the back of his head and still had the injury to the front of his head from the 01/07/17 fall. The report did not have revised interventions to prevent falls. A Nursing Departmental Note dated 01/09/17 a late entry at 10:02 p.m., indicated Resident #1 was found on the floor in the dining room by a CNA (later identified as CNA Z) with a laceration to the back of his head and emergency transport was notified. A Nursing Departmental Note dated 01/07/17 at 2:16 p.m., indicated Resident #1 was seen getting out of his wheelchair and fell to the floor this same date at 11:15 a.m This note indicated pressure was applied to the laceration to his forehead in order to stop the bleeding. A Nursing Departmental Note dated 01/08/17 at 8:53 p.m., indicated Resident #1's steri strips were reapplied and he had dressing to his left hand as a result of the 01/07/017 fall. A Nursing Departmental Note dated 01/10/17 at 12:13 a.m., indicated Resident #1 returned to the facility with orders to remove the staples in five to six days. During an observation on 01/26/17 at 9:30 a.m., Resident #1 was sleeping in a recliner with a gerichair beside the recliner and alarm in place. There was not a fall mat in Resident #1's room as care planned. During an interview on 01/26/17 at 10:13 a.m., DON C and ADON D said chair alarms were to be transferred from the chair to the bed with resident and vice versa. They said the alarms were to follow the resident so the resident should not ever be without their safety equipment. DON C and ADON D said it was the responsibility of whomever transferred the resident to be sure the alarm went with them, was turned on and working properly. During an observation on 01/26/17 at 12:15 p.m., Resident #1 was seated at the last table in the left rear of the dining room nearest the windows, visually concealed by the wall of the living room. He was being assisted with his noon meal by a staff member. During an interview on 01/26/17 at 9:42 a.m., with ADON C and DON C said Resident #1 was left in the living room by the nursing station while staff provided care to other residents down the hall. ADON D and DON C said when staff returned, Resident #1 was found in the dining room bleeding from the back of his head on 01/09/17. They said he was found by CNA Z, who immediately notified LVN P. They said LVN P assessed the resident and determined he needed to be transported to the emergency room . They said Resident #1 suffered eight falls in the last six months. They said he fell on [DATE] and required steri strips to his forehead. Both said after the 01/09/17 fall, Resident #1 was removed from his high backed wheelchair to a geri chair. During observations on 01/26/17 at 1:00 p.m., and 2:40 p.m., Resident #1 was sleeping in a recliner with a gerichair beside the recliner and alarm in place. There was not a fall mat in Resident #1's room as care planned. During an interview on 01/26/17 at 3:12 p.m., CNA Z said the night of the incident, Resident #1 was left alone in the dining room after the evening meal. CNA Z said all the staff were assisting other residents with incontinent care and to bed. CNA Z said when she returned to the dining room to get Resident #1, he was on the floor with blood coming from his head. CNA Z said there was no other staff member or resident in the dining room when she found him. CNA Z said Resident #1 cannot be seen by staff if they are at the nursing station, because he sits nearest the windows, which are at the back of the dining room. CNA Z said she immediately ran to get the nurse, who was back at the nursing station by that time, and the nurse immediately assessed Resident #1. CNA Z said the nurse instructed her to apply pressure to the back of Resident #1's head while she went to call 911. CNA Z said the alarm pad was in the seat of the wheelchair underneath Resident #1 but it was not turned on. CNA Z said the alarm made no sound. She was unsure of how long he had been on the floor bleeding. During an interview on 01/26/17 at 2:25 p.m., LVN Q said she provided care for Resident #1. She said fall alarms should be turned on at all times. During an interview on 01/26/17 at 2:41 p.m., ADON D said fall alarms should be turned on at all times and per the resident care plans. She said the alarms were to alert staff when residents were in need of immediate assistance. She said she was not sure if nurses were at the nursing station when Resident #1 fell on [DATE]. A facility packet entitled Policy and Procedure for Task 5-G (Abuse/Neglect Prevention) dated 08/2014 indicated neglect was defined as .the failure to provide goods or services, including medical services that are necessary to avoid physical harm . The facility 802 dated 01/26/17 indicated there were 61 residents with falls.

Based on observation, interview and record review, the facility failed to provide adequate supervision and assistance devices to prevent accidents for 1 of 13 residents reviewed for accidents. (Resident #1) Resident #1 had a history of [REDACTED].#1 fell and sustained a laceration to his head requiring 17 staples. The facility did not implement revised interventions to prevent falls. This failure contributed to Resident #1's fall and laceration to the back of his head. This failure could place 61 residents with a history of falls at risk of injuries and neglect. Findings included: Physician orders [REDACTED].#1 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #1 understood others and made himself understood and functioned with severely impaired cognitive skills for daily decision making. This MDS indicated Resident #1 required extensive two person physical assistance with bed mobility and transfers and had falls since admission. A care plan with date initiated 07/01/16 addressed Resident #1 being at risk for falls related to Parkinson's disease, left eye blindness and history of falls. Goals listed were to minimize risk for fall and risk for injury if fall occurs. The noted approaches included .fall mats were to be on the floor beside the bed and the bed alarm was to be in place . An added approach dated 12/14/16 at 6:41 p.m., that staff were ,,, to monitor Resident #1's fall alarm was to be in place at all times and to verify alarm placement hourly . There were no ends dates listed for any of the noted interventions. A care plan with date initiated 07/01/16 addressed Resident #1 being at risk for falls related to Parkinson's disease, left eye blindness and history of falls. Goals listed were .to minimize risk for fall and risk for injury if fall occurs . An added approach dated 07/03/16 at 4:46 p.m., indicated Resident #1 was .not to be left in the dining room unattended when he was through eating . There were no ends dates listed for any of the noted interventions. A Resident Incident Report dated 12/14/16 at 6:41 p.m., indicated Resident #1 had fallen to the floor and was found by the visitor of another resident. This report noted his alarms had to be replaced. A Resident Incident Report dated 12/30/16 at 7:35 p.m., indicated Resident #1 was removed from his wheelchair and assisted to walk down the hall and then assisted with being again seated back in his wheelchair. This incident report noted Resident #1 had fallen to the floor in hallway on the unit and was found by the visitor of another resident. Noted on this same report was the injury described as an abrasion on his right elbow about 2 centimeter (cm) X 1cm with scant sanguineous drainage. The report did not have revised interventions to prevent falls. A Resident Incident Report dated 01/07/17 at 11:15 a.m., indicated Resident #1 sustained a fall with a head injury. This incident report noted Resident #1 suffered a laceration to his forehead which measured 2.5cm X 0.1cm, he sustained a skin tear to his right hand which measured 2 cm X 2 cm, there was a laceration to his left knee which measured 2.5 cm X 2.5 cm and bruising was noted to his nose. This report noted the resident was seen by a staff member with no mention of his safety alarm in place or alarming to alert staff. The report did not have revised interventions to prevent falls. A care plan with date initiated 07/01/16 and revised 12/14/16 addressed Resident #1 being at risk for falls related to Parkinson's disease, left eye blindness and history of falls. Goals listed were .to minimize risk for fall and risk for injury if fall occurs . An added approach dated 12/14/16 at 6:41 p.m., staff was .to monitor Resident #1's fall alarm was to be in place at all times and to verify alarm placement hourly . An added approach to the fall care plan updated 01/07/17 at 11:15 a.m., indicated Resident #1 was .to be provided one-on-one supervision by staff . There were no end dates listed for any of the noted interventions. A Resident Incident Report dated 01/09/17 at 7:50 p.m., indicated Resident #1 was found on the floor in the dining room with a laceration to the back of his with the alarm hanging from the back of the wheelchair and 911 was notified. Resident #1 suffered a deep laceration to the back of his head which measured 6 cm X 2cm. The 24 hour follow up noted on this same report indicated Resident #1 received 17 staples to the back of the crown of his head down the back of his head and still had the injury to the front of his head from the 01/07/17 fall. The report did not have revised interventions to prevent falls. A Nursing Departmental Note dated 01/09/17 a late entry at 10:02 p.m., indicated Resident #1 was found on the floor in the dining room by a CNA (later identified as CNA Z) with a laceration to the back of his head and emergency transport was notified. A Nursing Departmental Note dated 01/07/17 at 2:16 p.m., indicated Resident #1 was seen getting out of his wheelchair and fell to the floor this same date at 11:15 a.m This note indicated pressure was applied to the laceration to his forehead in order to stop the bleeding. A Nursing Departmental Note dated 01/08/17 at 8:53 p.m., indicated Resident #1's steri strips were reapplied and he had dressing to his left hand as a result of the 01/07/017 fall. A Nursing Departmental Note dated 01/10/17 at 12:13 a.m., indicated Resident #1 returned to the facility with orders to remove the staples in five to six days. During an observation on 01/26/17 at 9:30 a.m., Resident #1 was sleeping in a recliner with a gerichair beside the recliner and alarm in place. There was not a fall mat in Resident #1's room as care planned. During an interview on 01/26/17 at 10:13 a.m., DON C and ADON D said chair alarms were to be transferred from the chair to the bed with resident and vice versa. They said the alarms were to follow the resident so the resident should not ever be without their safety equipment. DON C and ADON D said it was the responsibility of whomever transferred the resident to be sure the alarm went with them, was turned on and working properly. During an observation on 01/26/17 at 12:15 p.m., Resident #1 was seated at the last table in the left rear of the dining room nearest the windows, visually concealed by the wall of the living room. He was being assisted with his noon meal by a staff member. During an interview on 01/26/17 at 9:42 a.m., with ADON C and DON C said Resident #1 was left in the living room by the nursing station while staff provided care to other residents down the hall. ADON D and DON C said when staff returned, Resident #1 was found in the dining room bleeding from the back of his head on 01/09/17. They said he was found by CNA Z, who immediately notified LVN P. They said LVN P assessed the resident and determined he needed to be transported to the emergency room . They said Resident #1 suffered eight falls in the last six months. They said he fell on [DATE] and required steri strips to his forehead. Both said after the 01/09/17 fall, Resident #1 was removed from his high backed wheelchair to a geri chair. During observations on 01/26/17 at 1:00 p.m., and 2:40 p.m., Resident #1 was sleeping in a recliner with a gerichair beside the recliner and alarm in place. There was not a fall mat in Resident #1's room as care planned. During an interview on 01/26/17 at 3:12 p.m., CNA Z said the night of the incident, Resident #1 was left alone in the dining room after the evening meal. CNA Z said all the staff were assisting other residents with incontinent care and to bed. CNA Z said when she returned to the dining room to get Resident #1, he was on the floor with blood coming from his head. CNA Z said there was no other staff member or resident in the dining room when she found him. CNA Z said Resident #1 cannot be seen by staff if they are at the nursing station, because he sits nearest the windows, which are at the back of the dining room. CNA Z said she immediately ran to get the nurse, who was back at the nursing station by that time, and the nurse immediately assessed Resident #1. CNA Z said the nurse instructed her to apply pressure to the back of Resident #1's head while she went to call 911. CNA Z said the alarm pad was in the seat of the wheelchair underneath Resident #1 but it was not turned on. CNA Z said the alarm made no sound. She was unsure of how long he had been on the floor bleeding. During an interview on 01/26/17 at 2:25 p.m., LVN Q said she provided care for Resident #1. She said fall alarms should be turned on at all times. During an interview on 01/26/17 at 2:41 p.m., ADON D said fall alarms should be turned on at all times and per the resident care plans. She said the alarms were to alert staff when residents were in need of immediate assistance. She said she was not sure if nurses were at the nursing station when Resident #1 fell on [DATE]. A facility packet entitled Policy and Procedure for Task 5-G (Abuse/Neglect Prevention) dated 08/2014 indicated neglect was defined as the failure to provide goods or services, including medical services that are necessary to avoid physical harm . The facility 802 dated 01/26/17 indicated there were 61 residents with falls.

Based on observation, interview and record review, the facility failed to provide services in accordance with each resident's written plan of care for 6 of 7 residents reviewed for falls. (Resident #s 1, 2, 3, 4, 5, and 6) Resident #s 1, 2, 3, 4, 5, and 6 had a history of [REDACTED]. This failure could place 61 residents with a history of falls at risk of not recieving care and services to meet their needs. Findings included: 1. Physician orders [REDACTED].#1 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #1 understood others and made himself understood and functioned with severely impaired cognitive skills for daily decision making. This MDS indicated Resident #1 required extensive two person physical assistance with bed mobility and transfers and had falls since admission. A care plan with date initiated 07/01/16 addressed Resident #1 being at risk for falls related to [MEDICAL CONDITION], left eye [MEDICAL CONDITION] and history of falls. Goals listed were to minimize risk for fall and risk for injury if fall occurs. The noted approaches included .fall mats were to be on the floor beside the bed and the bed alarm was to be in place . An added approach dated 12/14/16 at 6:41 p.m., that staff were ,,, to monitor Resident #1's fall alarm was to be in place at all times and to verify alarm placement hourly . There were no ends dates listed for any of the noted interventions. A care plan with date initiated 07/01/16 addressed Resident #1 being at risk for falls related to [MEDICAL CONDITION], left eye [MEDICAL CONDITION] and history of falls. Goals listed were .to minimize risk for fall and risk for injury if fall occurs . An added approach dated 07/03/16 at 4:46 p.m., indicated Resident #1 was .not to be left in the dining room unattended when he was through eating . There were no ends dates listed for any of the noted interventions. A Resident Incident Report dated 12/14/16 at 6:41 p.m., indicated Resident #1 had fallen to the floor and was found by the visitor of another resident. This report noted his alarms had to be replaced. A Resident Incident Report dated 12/30/16 at 7:35 p.m., indicated Resident #1 was removed from his wheelchair and assisted to walk down the hall and then assisted with being again seated back in his wheelchair. This incident report noted Resident #1 had fallen to the floor in hallway on the unit and was found by the visitor of another resident. Noted on this same report was the injury described as an abrasion on his right elbow about 2 centimeter (cm) X 1cm with scant sanguineous drainage. The report did not have revised interventions to prevent falls. A Resident Incident Report dated 01/07/17 at 11:15 a.m., indicated Resident #1 sustained a fall with a head injury. This incident report noted Resident #1 suffered a laceration to his forehead which measured 2.5cm X 0.1cm, he sustained a skin tear to his right hand which measured 2 cm X 2 cm, there was a laceration to his left knee which measured 2.5 cm X 2.5 cm and bruising was noted to his nose. This report noted the resident was seen by a staff member with no mention of his safety alarm in place or alarming to alert staff. The report did not have revised interventions to prevent falls. A care plan with date initiated 07/01/16 and revised 12/14/16 addressed Resident #1 being at risk for falls related to [MEDICAL CONDITION], left eye [MEDICAL CONDITION] and history of falls. Goals listed were .to minimize risk for fall and risk for injury if fall occurs . An added approach dated 12/14/16 at 6:41 p.m., staff was .to monitor Resident #1's fall alarm was to be in place at all times and to verify alarm placement hourly . An added approach to the fall care plan updated 01/07/17 at 11:15 a.m., indicated Resident #1 was .to be provided one-on-one supervision by staff . There were no end dates listed for any of the noted interventions. A Resident Incident Report dated 01/09/17 at 7:50 p.m., indicated Resident #1 was found on the floor in the dining room with a laceration to the back of his with the alarm hanging from the back of the wheelchair and 911 was notified. Resident #1 suffered a deep laceration to the back of his head which measured 6 cm X 2cm. The 24 hour follow up noted on this same report indicated Resident #1 received 17 staples to the back of the crown of his head down the back of his head and still had the injury to the front of his head from the 01/07/17 fall. The report did not have revised interventions to prevent falls. A Nursing Departmental Note dated 01/09/17 a late entry at 10:02 p.m., indicated Resident #1 was found on the floor in the dining room by a CNA (later identified as CNA Z) with a laceration to the back of his head and emergency transport was notified. A Nursing Departmental Note dated 01/07/17 at 2:16 p.m., indicated Resident #1 was seen getting out of his wheelchair and fell to the floor this same date at 11:15 a.m This note indicated pressure was applied to the laceration to his forehead in order to stop the bleeding. A Nursing Departmental Note dated 01/08/17 at 8:53 p.m., indicated Resident #1's steri strips were reapplied and he had dressing to his left hand as a result of the 01/07/017 fall. A Nursing Departmental Note dated 01/10/17 at 12:13 a.m., indicated Resident #1 returned to the facility with orders to remove the staples in five to six days. During an observation on 01/26/17 at 9:30 a.m., Resident #1 was sleeping in a recliner with a gerichair beside the recliner and alarm in place. There was not a fall mat in Resident #1's room as care planned. During an interview on 01/26/17 at 10:13 a.m., DON C and ADON D said chair alarms were to be transferred from the chair to the bed with resident and vice versa. They said the alarms were to follow the resident so the resident should not ever be without their safety equipment. DON C and ADON D said it was the responsibility of whomever transferred the resident to be sure the alarm went with them, was turned on and working properly. During an observation on 01/26/17 at 12:15 p.m., Resident #1 was seated at the last table in the left rear of the dining room nearest the windows, visually concealed by the wall of the living room. He was being assisted with his noon meal by a staff member. During an interview on 01/26/17 at 9:42 a.m., with ADON C and DON C said Resident #1 was left in the living room by the nursing station while staff provided care to other residents down the hall. ADON D and DON C said when staff returned, Resident #1 was found in the dining room bleeding from the back of his head on 01/09/17. They said he was found by CNA Z, who immediately notified LVN P. They said LVN P assessed the resident and determined he needed to be transported to the emergency room . They said Resident #1 suffered eight falls in the last six months. They said he fell on [DATE] and required steri strips to his forehead. Both said after the 01/09/17 fall, Resident #1 was removed from his high backed wheelchair to a geri chair. During observations on 01/26/17 at 1:00 p.m., and 2:40 p.m., Resident #1 was sleeping in a recliner with a gerichair beside the recliner and alarm in place. There was not a fall mat in Resident #1's room as care planned. During an interview on 01/26/17 at 3:12 p.m., CNA Z said the night of the incident, Resident #1 was left alone in the dining room after the evening meal. CNA Z said all the staff were assisting other residents with incontinent care and to bed. CNA Z said when she returned to the dining room to get Resident #1, he was on the floor with blood coming from his head. CNA Z said there was no other staff member or resident in the dining room when she found him. CNA Z said Resident #1 cannot be seen by staff if they are at the nursing station, because he sits nearest the windows, which are at the back of the dining room. CNA Z said she immediately ran to get the nurse, who was back at the nursing station by that time, and the nurse immediately assessed Resident #1. CNA Z said the nurse instructed her to apply pressure to the back of Resident #1's head while she went to call 911. CNA Z said the alarm pad was in the seat of the wheelchair underneath Resident #1 but it was not turned on. CNA Z said the alarm made no sound. She was unsure of how long he had been on the floor bleeding. During an interview on 01/26/17 at 2:25 p.m., LVN Q said she provided care for Resident #1. She said fall alarms should be turned on at all times. During an interview on 01/26/17 at 2:41 p.m., ADON D said fall alarms should be turned on at all times and per the resident care plans. She said the alarms were to alert staff when residents were in need of immediate assistance. She said she was not sure if nurses were at the nursing station when Resident #1 fell on [DATE]. 2. Physician orders [REDACTED].#2 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #2 had unclear speech, rarely was able to make herself understood, sometimes understood others and functioned with severely impaired cognitive skills for daily decision making. This MDS indicated Resident #2 required extensive two person physical assistance with bed mobility, transfers and triggered for falls. A care plan with date initiated 07/08/13 addressed Resident #2 being at risk for falls related to [MEDICAL CONDITION], poor insight/balance and history of falls. Goals listed were to minimize risk for falls. The noted approaches included . fall matts to be on the floor beside the bed and magnetic alarm at all times . There were no end dates listed for any of the noted interventions. During observation on 01/26/17 at 10:30 a.m., 11:00 a.m., and 11:40 a.m., Resident #2 was in bed with alarm in place set to the off position and fall mat underneath the bed. During an observation on 01/26/17 at 11:40 a.m., CNAs M, N and O assisted Resident #2 with dressing, while in bed and transferred her to the Geri-chair. Resident #2's fall alarm did not sound. During an interview on 01/26/17 at 11:40 a.m., CNA O said the fall alarm was on Resident #2's bed, but it was set to the off position. She said the alarm should have been set to the on position because it does no good when set to the off position. 3. Physician orders [REDACTED].#3 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #3 had unclear speech, rarely was able to make himself understood, rarely understood others and functioned with severely impaired cognitive skills for daily decision making. This MDS indicated Resident #3 required extensive two person physical assistance with bed mobility and transfers. A care plan with date initiated 12/26/16 addressed Resident #3 being at risk for falls. Goals listed were to minimize risk for falls and injury related to falls. The noted approaches included . staff would assist resident into a recliner immediately after meals . A care plan updated 01/18/17 indicated Resident #3 would . use a hi-back tilt wheelchair with positioning cushion and pad alarm . There were no end dates listed for any of the noted interventions. A Resident Incident Report dated 12/31/16 at 9:30 p.m. indicated Resident #3 fell out of his wheelchair when only one CNA moved him to provide care. Resident #3 sustained a skin tear which required steri strips. This incident noted Resident #3 was to be moved to a recliner immediately after meals. A Resident Incident Report dated 01/01/17 at 5:15 p.m. indicated Resident #3 fell out of the recliner. This incident noted staff should attempt to wake resident and get him to the dining room for meals. Additionally, an alarm was put in place according to this report. A Resident Incident Report dated 01/22/17at 7:37 a.m. indicated Resident #3 fell from the wheelchair and sustained a skin tear to his right hand which required steri strips. The narrative of this report noted Resident #3 would utilize a hi-back wheelchair and pad alarm to prevent falling. A Resident Incident Report dated 01/25/17 at 2:46 a.m. indicated the nurse was at the nurses ' station when Resident #3 let the recliner legs down and fell on to the floor from the recliner. There was no indication the alarm was in place at the time of the fall or when resident repositioned his body to let the leg of the recliner down. A Nursing Departmental Note dated 01/01/17 noted the physician and responsible party were notified of Resident #3's fall and consented for placement of a fall alarm. A Nursing Departmental Notes dated 01/07/17 and 01/25/17 noted the safety alarm was to be in place at all times. During observations on 01/26/17 from 2:30 p.m. until 3:10 p.m., Resident #3 was sitting up in his wheelchair, unsupervised and without an alarm in place. During an interview on 01/26/17 at 3:00 p.m., ADON D entered the living room area and said, Where is his alarm? ADON D said Resident #3 was supposed to have an alarm in place at all times because he was constantly trying to get up. 4. Physician orders [REDACTED].#4 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #4 had clear speech, usually was able to make herself understood as well as understood others and functioned with no cognitive deficits noted. This MDS indicated Resident #4 required extensive two person physical assistance with bed mobility and transfers. A Resident Incident Report dated 01/06/17 at 2:45 p.m. indicated Resident #4 fell in her room and suffered a 10 centimeter (cm) X 7cm skin tear. A care plan with date initiated 10/10/16 addressed Resident #4 being at risk for falls related to [MEDICAL CONDITION], attempts to furniture walk in the room and history of falls. The noted approaches were to place an alarm to the chair and an alarm to the bed. There were no end dates listed for any of the noted interventions. During observation on 01/26/17 from 2:00 p.m. until 2:20 p.m., Resident #4 was in bed, the fall mat was under the bed, the alarm was in place but not on. The alarm was set to the off position per this observation. During an interview on 01/26/17 at 2:20 p.m., LVN Q said she checked the alarm and said it was turned off. LVN Q said the alarm should always be turned on. She said Resident #4 had fallen recently. 5. Physician orders [REDACTED].#6 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #5 had unclear speech, sometimes was able to make herself understood, sometimes understood others and cognitive skills for daily decision making was blank. This MDS indicated Resident #2 required extensive two person physical assistance with bed mobility and transfers. A care plan with dated 8/20/31 addressed Resident #5's history of falling at home and noted the continued risk for falls due to impaired memory and judgments and was very impulsive. Goals listed were to minimize risk for falls. The noted approaches included .alarm to the bed . and alarm to the chair . During observation on 01/26/17 at 10:19 a.m., 11:10 a.m., 11:40 a.m., continuous observation during the noon meal from 12:00 p.m. until 12:40 p.m., and 2:37 p.m., Resident #5 was sitting in her wheelchair. There was an empty alarm case on the left wheelchair handle, but there was not an alarm present. During an interview and joint observation on 01/26/17 at 2:41 p.m., ADON D said Resident #5 was supposed to have an alarm on for safety at all times. ADON D said staff had been trained and there was no reason for this failure in resident safety. 6. Physician orders [REDACTED].#6 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. An undated care plan addressed Resident # 6 being at risk for falls. Goals listed were to minimize risk for falls. The noted approaches were: matts to the floor beside the bed, alarm to the bed, alarm to the chair, provide assistance with transfers and participated win the Falling Leaf Program. There were no end dates listed for any of the noted interventions. A Resident Incident Report dated 01/22/17 at 3:15 p.m. indicated Resident #6 was found on the floor in her room and sustained an abrasion to her back. According to this report, an alarm was placed under the resident to alarm staff when resident gets up without assistance as immediate post-incident action. A Resident Incident Report dated 01/23/17 at 9:06 p.m. indicated an aide heard Resident #6 yelling for help and found her on the floor in her room. This report noted Resident #6 complained of pain to her right arm, shoulder and hip so the resident was transported out by an ambulance to the emergency room . According to this report, the unnamed CNA was written up and advised to check on the residents. According to this report, an alarm was placed under the resident to alarm staff when resident gets up without assistance as immediate post-incident action. During a continuous observation on 01/26/17 from 12:00 p.m. until 12:40 p.m., Resident #6 was sitting in her wheelchair, in the dining room. Resident #6 did not have an alarm. During an observation on 01/26/17 at 2:43 p.m., Resident #6 was sitting in her recliner in her room. During a continuous observation on 01/26/17 from 12:00 p.m. until 12:40 p.m., Resident #6 was sitting in her wheelchair, in the dining room. Resident #6 did not have an alarm. During an observation on 01/26/17 at 2:43 p.m., Resident #6 was sitting in her recliner in her room. During an interview on 01/26/17 at 12:40 p.m., when asked, CNA O said the alarm in the recliner belonged to Resident #6. CNA O said when staff transferred her from the recliner to her wheelchair they forgot to transfer the alarm with her. CNA O denied she assisted with that transfer. CNA O said Resident #6 attempted to get up often without assistance. During an observation on 01/26/17 at 12:50 p.m., Resident #6 was unsupervised in the living room area. She unlocked the wheels on her wheelchair and attempted to stand unassisted. The alarm on her wheelchair did not sound. During an interview on 01/26/17 at 3:06 p.m., CNA O said staff members had taken Resident #6 to her room. CNA O said she told the oncoming CNAs to put Resident #6 ' s alarm in place, after surveyor intervention. During an interview on 01/26/17 at 10:13 a.m., DON C and ADON D said chair alarms were to be transferred from the chair to the bed and vice versa. They both said the alarms were to follow the resident so the resident should not ever be without their safety equipment. They said it was the responsibility of whomever transferred the resident to be sure the alarm went with them, was turned on and working properly. The facility facility 802 dated 01/26/17 indicated there were 61 residents with falls.

Based on interview and record review, the facility failed to develop and implement their written policies and procedures to prohibit mistreatment, neglect or abuse for 1 of 13 residents reviewed for neglect. (Resident #1) Resident #1 had a history of [REDACTED].#1 fell and sustained a laceration to his head requiring 17 staples. The facility did not implement revised interventionns to prevent falls. This failure contributed to Resident #1's fall and laceration to the back of his head. This failure could place 61 residents with a history of falls at risk of injuries and neglect. Findings included: A facility packet entitled Policy and Procedure for Task 5-G (Abuse/Neglect Prevention) dated 08/2014 indicated neglect was defined as . the failure to provide goods or services, including medical services that are necessary to avoid physical harm . Physician orders [REDACTED].#1 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #1 understood others and made himself understood and functioned with severely impaired cognitive skills for daily decision making. This MDS indicated Resident #1 required extensive two person physical assistance with bed mobility and transfers and had falls since admission. A care plan with date initiated 07/01/16 addressed Resident #1 being at risk for falls related to [MEDICAL CONDITION], left eye [MEDICAL CONDITION] and history of falls. Goals listed were to minimize risk for fall and risk for injury if fall occurs. The noted approaches included .fall mats were to be on the floor beside the bed and the bed alarm was to be in place . An added approach dated 12/14/16 at 6:41 p.m., that staff were ,,, to monitor Resident #1's fall alarm was to be in place at all times and to verify alarm placement hourly . There were no ends dates listed for any of the noted interventions. A care plan with date initiated 07/01/16 addressed Resident #1 being at risk for falls related to [MEDICAL CONDITION], left eye [MEDICAL CONDITION] and history of falls. Goals listed were .to minimize risk for fall and risk for injury if fall occurs . An added approach dated 07/03/16 at 4:46 p.m., indicated Resident #1 was .not to be left in the dining room unattended when he was through eating . There were no ends dates listed for any of the noted interventions. A Resident Incident Report dated 12/14/16 at 6:41 p.m., indicated Resident #1 had fallen to the floor and was found by the visitor of another resident. This report noted his alarms had to be replaced. A Resident Incident Report dated 12/30/16 at 7:35 p.m., indicated Resident #1 was removed from his wheelchair and assisted to walk down the hall and then assisted with being again seated back in his wheelchair. This incident report noted Resident #1 had fallen to the floor in hallway on the unit and was found by the visitor of another resident. Noted on this same report was the injury described as an abrasion on his right elbow about 2 centimeter (cm) X 1cm with scant sanguineous drainage. The report did not have revised interventions to prevent falls. A Resident Incident Report dated 01/07/17 at 11:15 a.m., indicated Resident #1 sustained a fall with a head injury. This incident report noted Resident #1 suffered a laceration to his forehead which measured 2.5cm X 0.1cm, he sustained a skin tear to his right hand which measured 2 cm X 2 cm, there was a laceration to his left knee which measured 2.5 cm X 2.5 cm and bruising was noted to his nose. This report noted the resident was seen by a staff member with no mention of his safety alarm in place or alarming to alert staff. The report did not have revised interventions to prevent falls. A care plan with date initiated 07/01/16 and revised 12/14/16 addressed Resident #1 being at risk for falls related to [MEDICAL CONDITION], left eye [MEDICAL CONDITION] and history of falls. Goals listed were .to minimize risk for fall and risk for injury if fall occurs . An added approach dated 12/14/16 at 6:41 p.m., staff was .to monitor Resident #1's fall alarm was to be in place at all times and to verify alarm placement hourly . An added approach to the fall care plan updated 01/07/17 at 11:15 a.m., indicated Resident #1 was .to be provided one-on-one supervision by staff . There were no end dates listed for any of the noted interventions. A Resident Incident Report dated 01/09/17 at 7:50 p.m., indicated Resident #1 was found on the floor in the dining room with a laceration to the back of his with the alarm hanging from the back of the wheelchair and 911 was notified. Resident #1 suffered a deep laceration to the back of his head which measured 6 cm X 2cm. The 24 hour follow up noted on this same report indicated Resident #1 received 17 staples to the back of the crown of his head down the back of his head and still had the injury to the front of his head from the 01/07/17 fall. The report did not have revised interventions to prevent falls. A Nursing Departmental Note dated 01/09/17 a late entry at 10:02 p.m., indicated Resident #1 was found on the floor in the dining room by a CNA (later identified as CNA Z) with a laceration to the back of his head and emergency transport was notified. A Nursing Departmental Note dated 01/07/17 at 2:16 p.m., indicated Resident #1 was seen getting out of his wheelchair and fell to the floor this same date at 11:15 a.m This note indicated pressure was applied to the laceration to his forehead in order to stop the bleeding. A Nursing Departmental Note dated 01/08/17 at 8:53 p.m., indicated Resident #1's steri strips were reapplied and he had dressing to his left hand as a result of the 01/07/017 fall. A Nursing Departmental Note dated 01/10/17 at 12:13 a.m., indicated Resident #1 returned to the facility with orders to remove the staples in five to six days. During an observation on 01/26/17 at 9:30 a.m., Resident #1 was sleeping in a recliner with a gerichair beside the recliner and alarm in place. There was not a fall mat in Resident #1's room as care planned. During an interview on 01/26/17 at 10:13 a.m., DON C and ADON D said chair alarms were to be transferred from the chair to the bed with resident and vice versa. They said the alarms were to follow the resident so the resident should not ever be without their safety equipment. DON C and ADON D said it was the responsibility of whomever transferred the resident to be sure the alarm went with them, was turned on and working properly. During an observation on 01/26/17 at 12:15 p.m., Resident #1 was seated at the last table in the left rear of the dining room nearest the windows, visually concealed by the wall of the living room. He was being assisted with his noon meal by a staff member. During an interview on 01/26/17 at 9:42 a.m., with ADON C and DON C said Resident #1 was left in the living room by the nursing station while staff provided care to other residents down the hall. ADON D and DON C said when staff returned, Resident #1 was found in the dining room bleeding from the back of his head on 01/09/17. They said he was found by CNA Z, who immediately notified LVN P. They said LVN P assessed the resident and determined he needed to be transported to the emergency room . They said Resident #1 suffered eight falls in the last six months. They said he fell on [DATE] and required steri strips to his forehead. Both said after the 01/09/17 fall, Resident #1 was removed from his high backed wheelchair to a geri chair. During observations on 01/26/17 at 1:00 p.m., and 2:40 p.m., Resident #1 was sleeping in a recliner with a gerichair beside the recliner and alarm in place. There was not a fall mat in Resident #1's room as care planned. During an interview on 01/26/17 at 3:12 p.m., CNA Z said the night of the incident, Resident #1 was left alone in the dining room after the evening meal. CNA Z said all the staff were assisting other residents with incontinent care and to bed. CNA Z said when she returned to the dining room to get Resident #1, he was on the floor with blood coming from his head. CNA Z said there was no other staff member or resident in the dining room when she found him. CNA Z said Resident #1 cannot be seen by staff if they are at the nursing station, because he sits nearest the windows, which are at the back of the dining room. CNA Z said she immediately ran to get the nurse, who was back at the nursing station by that time, and the nurse immediately assessed Resident #1. CNA Z said the nurse instructed her to apply pressure to the back of Resident #1's head while she went to call 911. CNA Z said the alarm pad was in the seat of the wheelchair underneath Resident #1 but it was not turned on. CNA Z said the alarm made no sound. She was unsure of how long he had been on the floor bleeding. During an interview on 01/26/17 at 2:25 p.m., LVN Q said she provided care for Resident #1. She said fall alarms should be turned on at all times. During an interview on 01/26/17 at 2:41 p.m., ADON D said fall alarms should be turned on at all times and per the resident care plans. She said the alarms were to alert staff when residents were in need of immediate assistance. She said she was not sure if nurses were at the nursing station when Resident #1 fell on [DATE]. The facility 802 dated 01/26/17 indicated there were 61 residents with falls.

Based on interview and record review, the facility failed to implement their written policies and procedures to prohibit neglect for 3 of 27 residents reviewed for abuse/neglect (Resident #181, #165, and #90). On [DATE] at 11:00 a.m., Resident #181 was found lying in bed without respirations. Neither LVN A nor ADON A (an RN) attempted CPR prior to ADON A pronouncing Resident #181's death at 11:05 a.m. Seven nurses did not know the assessment criteria to use prior to pronouncing death. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure likely contributed to the death of Resident #181 and could place 47 residents who have chosen to remain full code status at risk of death. Non-Immediate Jeopardy *Resident #165 sustained a fractured clavicle (collar bone). The facility did not report an injury of unknown origin nor obtain statements from all staff working as part of their investigation. *Resident # 90 sustained a fall with requiring surgical repair of her finger, the facility failed to ensure alarms were properly attached and adjusted and to change care plans when interventions were not working and to provide training to staff for proper attachment and adjustment of alarms. They failed to investigate thoroughly and obtain witness statements of those in the vacinity of the incident. This failure placed 180 residents at risk of abuse and neglect due to the facility failing to have a complete and accurate abuse and neglect policy. Findings included: A Task 5-G (Abuse Prohibition) Policy and Procedure dated [DATE] indicated, "The facility must determine if the injury, harm, or death of the resident was due to facility failure to provide services, treatment or care to a resident." 1. The following reference accessed on [DATE] from the Board of Nursing http://www.bon.texas.gov/practice/position.html#15.20 <http://www.bon.texas.gov/practice/position.html> indicated the following: Registered Nurses in the Management of an Unwitnessed arrest in a Resident in a Long Term Care Facility: "In the case of an unwitnessed resident arrest without DNR (do not resuscitate) orders, determination of the appropriateness of CPR (cardiopulmonary resuscitation) initiation should be undertaken by the registered nurse through a resident assessment, and interventions appropriate to the findings initiated. Assessment of death in which CPR would be a futile and inappropriate intervention requires that (ALL) seven of the following signs be present and that the arrest is unwitnessed. Presumptive Signs of Death: 1. The resident is unresponsive, 2. The resident has no respirations, 3. The resident has no pulse, 4. Resident's pupils are fixed and dilated, 5. The resident's body temperature indicates hypothermia: skin is cold relative to the residents' baseline skin temperature, 6. The resident has generalized cyanosis, and Conclusive Sign of Death 7. There is presence of livor mortis (venous pooling of blood in dependent body parts causing purple discoloration of the skin which does blanch with pressure). After assessment of the resident is completed and appropriate interventions are taken, documentation of the circumstances and the assessment of the resident in the resident record are a requirement. Examples of important documentation elements include: Description of the discovery of the resident Any treatment of [REDACTED]. The findings for each of the assessment elements outlined in the standards All individuals notified of the resident's status (e.g., [DATE], the health care provider, the administrator of the facility, family, coroner, etc.) Any directions that were provided to staff or others during the assessment and/or treatment of [REDACTED]. The results of any communications Presence or absence of witnesses Documentation should be adequate to give a clear picture of the situation and all of the actions that were taken or not taken on behalf of the resident". 2. Physician orders [REDACTED]. His orders indicated his status as Full Code (desiring CPR). The most recent MDS dated [DATE] indicated Resident #181 had cognitive impairment, required limited to extensive assistance with activities of daily living, and had a life expectancy of more than 6 months. An undated baseline temperature sheet for Resident #181 indicated his base line temperature was 97.8 degrees Fahrenheit. Resident #181's care plan dated [DATE] indicated "I am a 'Full Code'. My family and I have been offered information on 'Out of Hospital DNR' and choose to continue at this time on Full Code Status... Resident's wishes will be followed within the ethical and legal guidelines." A life sustaining measures-resuscitate status dated [DATE] and signed by the physician [DATE] for Resident #181 indicated the facility "requests that your signature be obtained in advance regarding the desire for Life Sustaining Measures (Cardiopulmonary Resuscitation-CPR) to be initiated for the resident who has experienced sudden cessation of cardiac and/or respiratory function." The option initiated and signed by the responsible party was resuscitate. A Completed Care Tasks log for Resident #181 dated [DATE] indicated: *LVN A at 8:31 a.m., "resident ate ,[DATE]% of his breakfast". *CNA A at 9:00 a.m., "resident had bowel movement". Nursing notes dated [DATE] for Resident #181 indicated: 9:23 a.m. - "vital signs: blood pressure was ,[DATE], pulse was 68, respirations was 18, temperature was 97.5, and (oxygen) saturation was 97% on room air. His respirations were even and unlabored. His abdomen was soft and non-distended and his skin was warm and dry. He continues to have dry dressing to his right heel." (LVN A) 11:36 a.m. - at 11:00 a.m., "was called to resident's room by housekeeper. When went to room, resident was not breathing. He had no chest movements. The RN Supervisor (ADON A) was called who went in and pronounced him dead at 11:05 a.m. Resident's son was notified and he was on his way. Resident's bandage was changed earlier in the morning and he was talking to staff. Staff had made rounds at 9 a.m. and resident was sleeping comfortably on his side facing the window and staff turned him back to his back." (LVN A) 11:40 a.m. - "at 11:05 a.m., was called to resident's room. Resident in bed, no respiration...pulse, pupils fixed dilated, very peaceful. Family notified per charge nurse." (ADON A) A death release form for Resident #181 indicated his date of death was [DATE] at 11:05 a.m. During interviews on [DATE] at 4:42 p.m. and [DATE] at 8:49 a.m., DON A said Resident #181 had a full code designation. While reading the nursing notes, she said CPR should have been initiated on Resident #181, but she would need to speak with the social worker because she thought his family desired for him to be a DNR. She said the doctor should have been notified. She did not see the documentation supporting when he was notified. During an interview on [DATE] at 9:25 a.m., Housekeeper B said she went into Resident #181's room and noticed he was not breathing so she informed LVN A. During an interview on [DATE] at 9:05 a.m., LVN A said Resident #181 "seemed to be doing well and one day, he was gone." She said she saw him earlier in the morning when she dressed his heel and he was talking. She said he asked her about his heel. She said Housekeeper B told her she thought Resident #181 passed away, so she locked her cart and went to his room. LVN A said it took her about ,[DATE] minutes to get to the room once the housekeeper came and told her about the resident. She said he was starting to get cool. She said she called ADON A who checked his vitals and pronounced him dead. She said his death shocked her. She said he had illness, but was not expecting him to pass on so soon. She said she called the doctor after she spoke to the son after the resident was pronounced dead. She said she thought she documented it. LVN A said she did not attempt CPR because, "He was already gone and it would not have been of use." She said if she knew he had just passed, she would have attempted CPR, but ADON A and she could tell he had been dead approximately an hour. She said the resident's son had not completed the out of hospital DNR, but he was working on it. During an interview on [DATE] at 10:05 a.m., the Social Worker said Resident #181's family did not want him on a ventilator, but wanted him to receive CPR. During an interview on [DATE] at 10:05 a.m., ADON A said when they found Resident #181, he was not actively dying, but was deceased . She said when the housekeeper went in to clean his room, she found him and LVN A determined there were no signs of life. She said it had been at least an hour since he was last seen on rounds. She said Resident #181 was unresponsive, did not have respirations, his pupils were fixed and dilated, he was cool, but she could not recall exact body temperature, he had a little discoloration, and had pale/grayish skin color. She said she did not determine he had livor mortis. She said she did not recall checking the bottom of Resident #181's feet. She said there was no rigor mortis (stiffening of body after death). She said she did not initiate CPR. ADON A said she paged the doctor and pronounced him dead. She said she could not say for certain she heard back from the doctor before pronouncing his death. She said the aides on duty cleaned him. She said she assumed their policy went along with the Board of Nursing standards. She said if it had been ,[DATE] minutes since a resident was observed and there were no signs of life, they do not initiate CPR. During an interview on [DATE] at 10:50 a.m., DON A, DON B, ADON B, RN C (Nurse Aide Instructor), RN D and RN E (entered at 10:53 a.m.) were not familiar with the seven presumptive signs of death according to the Texas Board of Nursing. During an interview on [DATE] at 1:50 p.m., CNA A said she was the nurse aide assigned to Resident #181. She said he ate well earlier in the morning. She said after he died , she and CNA B cleaned him. She said they cleaned him ,[DATE] minutes after ADON A pronounced him because his son came to the facility. She said he was lying on his back. She said he was pale and was starting to get cold, but was still warm. She said his skin was getting blue, but was not blue yet. She said his back was white which was his usual skin color. During an interview on [DATE] at 3:31 p.m., CNA B said she changed Resident #181 with CNA A earlier in the morning. She said she heard the housekeeper say something was wrong with Resident #181. She said ADON A pronounced Resident #181 dead. She said she heard LVN A say something about a doctor on the phone, so she assumed she was talking to the doctor. She said they immediately cleaned Resident #181. She said Resident #181 was very pale. She said his back was blue when they rolled him over. She said he had a small amount of substance which looked like bowel movement coming out of his mouth when they rolled him over. An undated CPR policy and procedure indicated: "I. It is the policy of this nursing home to follow all legally executed resident or surrogate directives within the generally accepted standards of medical practice... IV. For those residents that DO NOT have a physician's or mid-level practitioner's order prohibiting CPR, the following procedures will be followed. A. When a resident is observed to have a cardiopulmonary arrest (or apparent arrest), the staff will initiate CPR promptly and a 911 phone call made requesting EMS assistance and possible transfer to the hospital. B. When a resident is discovered by the staff to be without obvious signs of life and the resident has not been observed in the preceding ten or more minutes, the nurse (RN or LVN) in charge can determine that no signs of life are present and not initiate CPR. Both the Nurse Practice Act for RN's and the Licensing Act for LVN's prescribe that they assess and intervene to stabilize a resident's condition as appropriate. The nurse can determine the absence of signs of life and not start CPR by carefully observing and recording the following: The absence of ventilatory excursions of the chest or any spontaneous movement. The absence of breath sounds and heart tones by stethoscope auscultation. The absence of a detectable blood pressure. The absence of palpable pulses in the carotid and/or femoral areas. In addition, if there is a presence of fixed and/or dilated pupils, cyanosis, lividity or cool skin temperature. If the conditions outlined and described above have been documented, CPR should not be initiated. Following such a decision, the nurse in charge should notify the appropriate physician or registered nurse who can pronounce the resident to be dead." A Death of a Resident (Pronouncing Death) policy and procedure dated 2001 indicated, "The apparent death of a resident must be reported immediately to the attending physician..." The administrator and DONs were notified on [DATE] at 3:05 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on [DATE] at 4:30 p.m. and included: "All Full Code residents will be immediately identified. All current licensed nursing staff will be immediately in-serviced on the following protocol for those residents. Any nurses employed in the future will also be in-serviced relative to this policy. In the event a resident is discovered to have an unwitnessed arrest and absence of obvious signs of life and the attending nurse is a LVN, they will have another staff person call a Code Blue and call 911, and initiate CPR. If the attending nurse is an RN, that nurse will assess the resident for the Presumptive Signs of Death including: The resident is unresponsive The resident has no respirations The resident has no pulse The resident's pupils are fixed and dilated The resident's body temperature indicates hypothermia: Skin is cold relative to the resident's baseline skin temperature. The resident has generalized cyanosis As well as the Conclusive Sign of Death: Presence of livor mortis The RN can determine the absence of signs of life and not start CPR by observing and documenting all of the above. The RN will notify physician prior to pronouncing death." The surveyors confirmed the Plan of Removal had been implemented sufficiently to remove the IJ by: Twelve LVNs and four RNs were interviewed and were knowledgeable of the facility's new CPR policy which included the seven presumptive signs of death in accordance with the Texas Board of Nursing. On [DATE] at 6:55 p.m., the administrator was informed the IJ was removed; however, the facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. Non- Immediate Jeopardy 3. Physician orders [REDACTED]. The most recent MDS dated [DATE] indicated Resident #165 cognition was severely impaired. She experienced periods of inattention and disorganized thinking. Resident #165 was sometimes understood by others and sometimes able to make herself understood. She expressed no behavioral symptoms towards others such as physical, behavioral, rejection of care, or wandering. According to this MDS assessment, Resident #165 required extensive assistance with bed mobility, transfers, walking in room and one person assist with locomotion on/off unit. A Resident Incident Report dated [DATE] at 7:00 a.m. indicated, Resident #165 was up in her wheelchair in the dining area with a 2.0 cm x 2.0 cm bruise to the right shoulder. The report noted,"...puffiness to right back and up to right clavicle...Pain to touch..." An x-ray report dated [DATE] for Resident #165 noted, "...X-rays have indicated a [MEDICAL CONDITION] distal end of the clavicle with no displacement, as well as a questionable midshaft fracture...The patient herself cannot tell us exactly when this happened. Nor can the lady from the nursing home who is with her..." An Incident Investigation report dated [DATE] at 7:00 a.m. signed by ADON A had one entry. It noted, "...Resident up at the breakfast table when charge nurse observed a 2.0 cm x 2.0 cm bruise to rt (right) shoulder with slight welling to rt back and clavicle area. Pain to touch with facial grimmace noted. PRN Tylenol given. Appt (appointment) made with PCP. Bruise Protocol initiated..." During an interview on [DATE] at 8:48 a.m., DON A said she did not report the incident because Resident #165 went to the doctor. During an interview on [DATE] at 3:03 p.m., ADON A said she had concluded her investigation of the incident but did not get any statements from staff. An Abuse Policy dated [DATE] noted, "...The initial investigation will include but is not limited to the following:..4. Name of witnesses and their account of the accident/incident/allegation...Once the investigation reports are complete and should the nature of the incident/accident/allegation require reporting the report will made in accordance to the rules..." 4. Resident #90's physician orders [REDACTED]. A quarterly MDS dated [DATE] indicated Resident #90 was confused with disorganized thinking. No behaviors were noted. She needed extensive assistance of two persons for transfer and extensive assistance of one person for dressing. She used a wheelchair for mobility and had a history of [REDACTED]. Resident #90's care plan updated [DATE] indicated she fell and received a laceration to her head; "fall protocol initiated, resident instructed to call for help". Resident fell on [DATE], [DATE], [DATE], [DATE], and [DATE]. A incident report she sustained another fall on [DATE]. She sustained a laceration to her forehead and was sent to the emergency room with altered mental status. Interventions after investigation were fall protocol and educate the resident on importance of not getting up without assistance. She was assessed as needing extensive assistance, no special supervision, and did not have the capacity to make informed decisions. Resident #90's care plan had no interventions indicating how to adjust alarm, what type alarm to be used, how to attach alarms properly, or who would be responsible for monitoring them. During an interview on [DATE] at 3:40 p.m., RN E said the alarm did not sound until the resident was on the floor. She said the string that was attached to the resident was too long. During an interview on [DATE] at 8:00 p.m., MA B said she was in the medication room, located just behind the nursing station with the door open. Resident #90 was in the TV room located in front of the nursing station. She heard a "thud", but did not hear the alarm go off. She said she had no in-services or training on alarm placement. During an interview on [DATE], at 1:55 p.m., CNA N said she was coming down the hall on the Jane's Crossing unit and heard an alarm go off just about the same time as someone said Resident #90 was on the floor. She said Resident #90 had the alarm on because she (CNA N) put it there. She said she had not been trained on the proper way to attach or adjust the alarms. There were no witness statements taken during the investigation. During an interview on [DATE] at 9:35a.m., DON A said she did not get witness statements during her investigation if the nurse filled out the incident report or if the medication aide was there, but did not actually see it, she would not get a statement. A list provided by DON A, dated [DATE] indicated 47 residents were Full Code status. The CMS 672 dated [DATE] indicated a census of 180.

Based on interview and record review, the facility failed to implement their policy and procedures to prohibit neglect for 1 of 27 residents reviewed for neglect. (Resident #181) On [DATE] at 11:00 a.m., Resident #181 was found lying in bed without respirations. Neither LVN A nor ADON A (an RN) attempted CPR prior to ADON A pronouncing Resident #181's death at 11:05 a.m. Seven nurses did not know the assessment criteria to use prior to pronouncing death. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure likely contributed to the death of Resident #181 and could place 47 residents who have chosen to remain full code status at risk of death. Findings included: 1. The following reference accessed on [DATE] from the Board of Nursing http://www.bon.texas.gov/practice/position.html#15.20 <http://www.bon.texas.gov/practice/position.html> indicated the following: Registered Nurses in the Management of an Unwitnessed arrest in a Resident in a Long Term Care Facility: "In the case of an unwitnessed resident arrest without DNR (do not resuscitate) orders, determination of the appropriateness of CPR (cardiopulmonary resuscitation) initiation should be undertaken by the registered nurse through a resident assessment, and interventions appropriate to the findings initiated. Assessment of death in which CPR would be a futile and inappropriate intervention requires that (ALL) seven of the following signs be present and that the arrest is unwitnessed. Presumptive Signs of Death: 1. The resident is unresponsive, 2. The resident has no respirations, 3. The resident has no pulse, 4. Resident's pupils are fixed and dilated, 5. The resident's body temperature indicates hypothermia: skin is cold relative to the residents' baseline skin temperature, 6. The resident has generalized cyanosis, and Conclusive Sign of Death 7. There is presence of livor mortis (venous pooling of blood in dependent body parts causing purple discoloration of the skin which does blanch with pressure). After assessment of the resident is completed and appropriate interventions are taken, documentation of the circumstances and the assessment of the resident in the resident record are a requirement. Examples of important documentation elements include: Description of the discovery of the resident Any treatment of [REDACTED]. The findings for each of the assessment elements outlined in the standards All individuals notified of the resident's status (e.g., [DATE], the health care provider, the administrator of the facility, family, coroner, etc.) Any directions that were provided to staff or others during the assessment and/or treatment of [REDACTED]. The results of any communications Presence or absence of witnesses Documentation should be adequate to give a clear picture of the situation and all of the actions that were taken or not taken on behalf of the resident". 2. Physician orders [REDACTED]. His orders indicated his status as Full Code (desiring CPR). The most recent MDS dated [DATE] indicated Resident #181 had cognitive impairment, required limited to extensive assistance with activities of daily living, and had a life expectancy of more than 6 months. An undated baseline temperature sheet for Resident #181 indicated his base line temperature was 97.8 degrees Fahrenheit. Resident #181's care plan dated [DATE] indicated "I am a 'Full Code'. My family and I have been offered information on 'Out of Hospital DNR' and choose to continue at this time on Full Code Status... Resident's wishes will be followed within the ethical and legal guidelines." A life sustaining measures-resuscitate status dated [DATE] and signed by the physician [DATE] for Resident #181 indicated the facility "requests that your signature be obtained in advance regarding the desire for Life Sustaining Measures (Cardiopulmonary Resuscitation-CPR) to be initiated for the resident who has experienced sudden cessation of cardiac and/or respiratory function." The option initiated and signed by the responsible party was resuscitate. A Completed Care Tasks log for Resident #181 dated [DATE] indicated: *LVN A at 8:31 a.m., "resident ate ,[DATE]% of his breakfast". *CNA A at 9:00 a.m., "resident had bowel movement". Nursing notes dated [DATE] for Resident #181 indicated: 9:23 a.m. - "vital signs: blood pressure was ,[DATE], pulse was 68, respirations was 18, temperature was 97.5, and (oxygen) saturation was 97% on room air. His respirations were even and unlabored. His abdomen was soft and non-distended and his skin was warm and dry. He continues to have dry dressing to his right heel." (LVN A) 11:36 a.m. - at 11:00 a.m., "was called to resident's room by housekeeper. When went to room, resident was not breathing. He had no chest movements. The RN Supervisor (ADON A) was called who went in and pronounced him dead at 11:05 a.m. Resident's son was notified and he was on his way. Resident's bandage was changed earlier in the morning and he was talking to staff. Staff had made rounds at 9 a.m. and resident was sleeping comfortably on his side facing the window and staff turned him back to his back." (LVN A) 11:40 a.m. - "at 11:05 a.m., was called to resident's room. Resident in bed, no respiration...pulse, pupils fixed dilated, very peaceful. Family notified per charge nurse." (ADON A) A death release form for Resident #181 indicated his date of death was [DATE] at 11:05 a.m. During interviews on [DATE] at 4:42 p.m. and [DATE] at 8:49 a.m., DON A said Resident #181 had a full code designation. While reading the nursing notes, she said CPR should have been initiated on Resident #181, but she would need to speak with the social worker because she thought his family desired for him to be a DNR. She said the doctor should have been notified. She did not see the documentation supporting when he was notified. During an interview on [DATE] at 9:25 a.m., Housekeeper B said she went into Resident #181's room and noticed he was not breathing so she informed LVN A. During an interview on [DATE] at 9:05 a.m., LVN A said Resident #181 "seemed to be doing well and one day, he was gone." She said she saw him earlier in the morning when she dressed his heel and he was talking. She said he asked her about his heel. She said Housekeeper B told her she thought Resident #181 passed away, so she locked her cart and went to his room. LVN A said it took her about ,[DATE] minutes to get to the room once the housekeeper came and told her about the resident. She said he was starting to get cool. She said she called ADON A who checked his vitals and pronounced him dead. She said his death shocked her. She said he had illness, but was not expecting him to pass on so soon. She said she called the doctor after she spoke to the son after the resident was pronounced dead. She said she thought she documented it. LVN A said she did not attempt CPR because, "He was already gone and it would not have been of use." She said if she knew he had just passed, she would have attempted CPR, but ADON A and she could tell he had been dead approximately an hour. She said the resident's son had not completed the out of hospital DNR, but he was working on it. During an interview on [DATE] at 10:05 a.m., the Social Worker said Resident #181's family did not want him on a ventilator, but wanted him to receive CPR. During an interview on [DATE] at 10:05 a.m., ADON A said when they found Resident #181, he was not actively dying, but was deceased . She said when the housekeeper went in to clean his room, she found him and LVN A determined there were no signs of life. She said it had been at least an hour since he was last seen on rounds. She said Resident #181 was unresponsive, did not have respirations, his pupils were fixed and dilated, he was cool, but she could not recall exact body temperature, he had a little discoloration, and had pale/grayish skin color. She said she did not determine he had livor mortis. She said she did not recall checking the bottom of Resident #181's feet. She said there was no rigor mortis (stiffening of body after death). She said she did not initiate CPR. ADON A said she paged the doctor and pronounced him dead. She said she could not say for certain she heard back from the doctor before pronouncing his death. She said the aides on duty cleaned him. She said she assumed their policy went along with the Board of Nursing standards. She said if it had been ,[DATE] minutes since a resident was observed and there were no signs of life, they do not initiate CPR. During an interview on [DATE] at 10:50 a.m., DON A, DON B, ADON B, RN C (Nurse Aide Instructor), RN D and RN E (entered at 10:53 a.m.) were not familiar with the seven presumptive signs of death according to the Texas Board of Nursing. During an interview on [DATE] at 1:50 p.m., CNA A said she was the nurse aide assigned to Resident #181. She said he ate well earlier in the morning. She said after he died , she and CNA B cleaned him. She said they cleaned him ,[DATE] minutes after ADON A pronounced him because his son came to the facility. She said he was lying on his back. She said he was pale and was starting to get cold, but was still warm. She said his skin was getting blue, but was not blue yet. She said his back was white which was his usual skin color. During an interview on [DATE] at 3:31 p.m., CNA B said she changed Resident #181 with CNA A earlier in the morning. She said she heard the housekeeper say something was wrong with Resident #181. She said ADON A pronounced Resident #181 dead. She said she heard LVN A say something about a doctor on the phone, so she assumed she was talking to the doctor. She said they immediately cleaned Resident #181. She said Resident #181 was very pale. She said his back was blue when they rolled him over. She said he had a small amount of substance which looked like bowel movement coming out of his mouth when they rolled him over. An undated CPR policy and procedure indicated: "I. It is the policy of this nursing home to follow all legally executed resident or surrogate directives within the generally accepted standards of medical practice... IV. For those residents that DO NOT have a physician's or mid-level practitioner's order prohibiting CPR, the following procedures will be followed. A. When a resident is observed to have a cardiopulmonary arrest (or apparent arrest), the staff will initiate CPR promptly and a 911 phone call made requesting EMS assistance and possible transfer to the hospital. B. When a resident is discovered by the staff to be without obvious signs of life and the resident has not been observed in the preceding ten or more minutes, the nurse (RN or LVN) in charge can determine that no signs of life are present and not initiate CPR. Both the Nurse Practice Act for RN's and the Licensing Act for LVN's prescribe that they assess and intervene to stabilize a resident's condition as appropriate. The nurse can determine the absence of signs of life and not start CPR by carefully observing and recording the following: The absence of ventilatory excursions of the chest or any spontaneous movement. The absence of breath sounds and heart tones by stethoscope auscultation. The absence of a detectable blood pressure. The absence of palpable pulses in the carotid and/or femoral areas. In addition, if there is a presence of fixed and/or dilated pupils, cyanosis, lividity or cool skin temperature. If the conditions outlined and described above have been documented, CPR should not be initiated. Following such a decision, the nurse in charge should notify the appropriate physician or registered nurse who can pronounce the resident to be dead." A Death of a Resident (Pronouncing Death) policy and procedure dated 2001 indicated, "The apparent death of a resident must be reported immediately to the attending physician..." A Task 5-G (Abuse Prohibition) Policy and Procedure dated [DATE] indicated, "The facility must determine if the injury, harm, or death of the resident was due to facility failure to provide services, treatment or care to a resident." The administrator and DONs were notified on [DATE] at 3:05 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on [DATE] at 4:30 p.m. and included: "All Full Code residents will be immediately identified. All current licensed nursing staff will be immediately in-serviced on the following protocol for those residents. Any nurses employed in the future will also be in-serviced relative to this policy. In the event a resident is discovered to have an unwitnessed arrest and absence of obvious signs of life and the attending nurse is a LVN, they will have another staff person call a Code Blue and call 911, and initiate CPR. If the attending nurse is an RN, that nurse will assess the resident for the Presumptive Signs of Death including: The resident is unresponsive The resident has no respirations The resident has no pulse The resident's pupils are fixed and dilated The resident's body temperature indicates hypothermia: Skin is cold relative to the resident's baseline skin temperature. The resident has generalized cyanosis As well as the Conclusive Sign of Death: Presence of livor mortis The RN can determine the absence of signs of life and not start CPR by observing and documenting all of the above. The RN will notify physician prior to pronouncing death." The surveyors confirmed the Plan of Removal had been implemented sufficiently to remove the IJ by: Twelve LVNs and four RNs were interviewed and were knowledgeable of the facility's new CPR policy which included the seven presumptive signs of death in accordance with the Texas Board of Nursing. On [DATE] at 6:55 p.m., the administrator was informed the IJ was removed; however, the facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. A list provided by DON A, dated [DATE] indicated 47 residents were Full Code status.

Based on interview and record review, the DONs failed to use facility resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 4 deceased residents. (Resident #181) Two of Two DONs (DON A and DON B) did not know the assessment criteria for RNs to utilize when pronouncing death. DON A and DON B did not ensure facility nurses were trained on the assessment criteria to utilize when pronouncing death. DON A and DON B did not ensure the facility's policy adhered to the required assessment criteria when pronouncing death as directed by the Texas Board of Nursing. When Resident #181 expired, DON A and DON B did not investigate the circumstances leading up to death to determine that CPR was not provided. On [DATE] at 11:00 a.m., Resident #181 was found lying in bed without respirations. Neither LVN A nor ADON A (an RN) attempted CPR prior to ADON A pronouncing Resident #181's deth. Seven nurses said they did not know the assessment criteria to use prior to pronouncing death. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure likely contributed to the death of Resident #181 and could place 47 residents who have chosen to remain full code status at risk of death. Findings included: 1. The following reference accessed on [DATE] from the Board of Nursing http://www.bon.texas.gov/practice/position.html#15.20 <http://www.bon.texas.gov/practice/position.html> indicated the following: Registered Nurses in the Management of an Unwitnessed arrest in a Resident in a Long Term Care Facility: "In the case of an unwitnessed resident arrest without DNR (do not resuscitate) orders, determination of the appropriateness of CPR (cardiopulmonary resuscitation) initiation should be undertaken by the registered nurse through a resident assessment, and interventions appropriate to the findings initiated. Assessment of death in which CPR would be a futile and inappropriate intervention requires that (ALL) seven of the following signs be present and that the arrest is unwitnessed. Presumptive Signs of Death 1. The resident is unresponsive, 2. The resident has no respirations, 3. The resident has no pulse, 4. Resident's pupils are fixed and dilated, 5. The resident's body temperature indicates hypothermia: skin is cold relative to the residents' baseline skin temperature, 6. The resident has generalized cyanosis, and Conclusive Sign of Death 7. There is presence of livor mortis (venous pooling of blood in dependent body parts causing purple discoloration of the skin which does blanch with pressure). After assessment of the resident is completed and appropriate interventions are taken, documentation of the circumstances and the assessment of the resident in the resident record are a requirement. Examples of important documentation elements include: Description of the discovery of the resident Any treatment of [REDACTED]. The findings for each of the assessment elements outlined in the standards All individuals notified of the resident's status (e.g., [DATE], the health care provider, the administrator of the facility, family, coroner, etc.) Any directions that were provided to staff or others during the assessment and/or treatment of [REDACTED]. The results of any communications Presence or absence of witnesses Documentation should be adequate to give a clear picture of the situation and all of the actions that were taken or not taken on behalf of the resident". 2. Physician orders [REDACTED]. His orders indicated his status as Full Code (desiring CPR). The most recent MDS dated [DATE] indicated Resident #181 had cognitive impairment, required limited to extensive assistance with activities of daily living, and had a life expectancy of more than 6 months. An undated baseline temperature sheet for Resident #181 indicated his base line temperature was 97.8 degrees Fahrenheit.. Resident #181's care plan dated [DATE] indicated "I am a 'Full Code'. My family and I have been offered information on 'Out of Hospital DNR' and choose to continue at this time on Full Code Status... Resident's wishes will be followed within the ethical and legal guidelines." A life sustaining measures-resuscitate status dated [DATE] and signed by the physician [DATE] for Resident #181 indicated the facility "requests that your signature be obtained in advance regarding the desire for Life Sustaining Measures (Cardiopulmonary Resuscitation-CPR) to be initiated for the resident who has experienced sudden cessation of cardiac and/or respiratory function." The option initiated and signed by the responsible party was resuscitate. A Completed Care Tasks log for Resident #181 dated [DATE] indicated: *LVN A at 8:31 a.m., "resident ate ,[DATE]% of his breakfast". *CNA A at 9:00 a.m., "resident had bowel movement". Nursing notes dated [DATE] for Resident #181 indicated: 9:23 a.m. - "vital signs: blood pressure was ,[DATE], pulse was 68, respirations was 18, temperature was 97.5, and (oxygen) saturation was 97% on room air. His respirations were even and unlabored. His abdomen was soft and non-distended and his skin was warm and dry. He continues to have dry dressing to his right heel." (LVN A) 11:36 a.m. - at 11:00 a.m., "was called to resident's room by housekeeper. When went to room, resident was not breathing. He had no chest movements. The RN Supervisor (ADON A) was called who went in and pronounced him dead at 11:05 a.m. Resident's son was notified and he was on his way. Resident's bandage was changed earlier in the morning and he was talking to staff. Staff had made rounds at 9 a.m. and resident was sleeping comfortably on his side facing the window and staff turned him back to his back." (LVN A) 11:40 a.m. - "at 11:05 a.m., was called to resident's room. Resident in bed, no respiration...pulse, pupils fixed dilated, very peaceful. Family notified per charge nurse." (ADON A) A death release form for Resident #181 indicated his date of death was [DATE] at 11:05 a.m. During interviews on [DATE] at 4:42 p.m. and [DATE] at 8:49 a.m., DON A said Resident #181 had a full code designation. While reading the nursing notes, she said CPR should have been initiated on Resident #181, but she would need to speak with the social worker because she thought his family desired for him to be a DNR. She said the doctor should have been notified. She did not see the documentation supporting when he was notified. During an interview on [DATE] at 9:25 a.m., Housekeeper B said she went into Resident #181's room and noticed he was not breathing so she informed LVN A. During an interview on [DATE] at 9:05 a.m., LVN A said Resident #181 "seemed to be doing well and one day, he was gone." She said she saw him earlier in the morning when she dressed his heel and he was talking. She said he asked her about his heel. She said Housekeeper B told her she thought Resident #181 passed away, so she locked her cart and went to his room. LVN A said it took her about ,[DATE] minutes to get to the room once the housekeeper came and told her about the resident. She said he was starting to get cool. She said she called ADON A who checked his vitals and pronounced him dead. She said his death shocked her. She said he had illness, but was not expecting him to pass on so soon. She said she called the doctor after she spoke to the son after the resident was pronounced dead. She said she thought she documented it. LVN A said she did not attempt CPR because, "He was already gone and it would not have been of use." She said if she knew he had just passed, she would have attempted CPR, but ADON A and she could tell he had been dead approximately an hour. She said the resident's son had not completed the out of hospital DNR, but he was working on it. During an interview on [DATE] at 10:05 a.m., the Social Worker said Resident #181's family did not want him on a ventilator, but wanted him to receive CPR. During an interview on [DATE] at 10:05 a.m., ADON A said when they found Resident #181, he was not actively dying, but was deceased . She said when the housekeeper went in to clean his room, she found him and LVN A determined there were no signs of life. She said it had been at least an hour since he was last seen on rounds. She said Resident #181 was unresponsive, did not have respirations, his pupils were fixed and dilated, he was cool, but she could not recall exact body temperature, he had a little discoloration, and had pale/grayish skin color. She said she did not determine he had livor mortis. She said she did not recall checking the bottom of Resident #181's feet. She said there was no rigor mortis (stiffening of body after death). She said she did not initiate CPR. ADON A said she paged the doctor and pronounced him dead. She said she could not say for certain she heard back from the doctor before pronouncing his death. She said the aides on duty cleaned him. She said she assumed their policy went along with the Board of Nursing standards. She said if it had been ,[DATE] minutes since a resident was observed and there were no signs of life, they do not initiate CPR. During an interview on [DATE] at 10:50 a.m., DON A, DON B, ADON B, RN C (Nurse Aide Instructor), RN D and RN E (entered at 10:53 a.m.) were not familiar with the seven presumptive signs of death according to the Texas Board of Nursing. During an interview on [DATE] at 1:50 p.m., CNA A said she was the nurse aide assigned to Resident #181. She said he ate well earlier in the morning. She said after he died , she and CNA B cleaned him. She said they cleaned him ,[DATE] minutes after ADON A pronounced him because his son came to the facility. She said he was lying on his back. She said he was pale and was starting to get cold, but was still warm. She said his skin was getting blue, but was not blue yet. She said his back was white which was his usual skin color. During an interview on [DATE] at 3:31 p.m., CNA B said she changed Resident #181 with CNA A earlier in the morning. She said she heard the housekeeper say something was wrong with Resident #181. She said ADON A pronounced Resident #181 dead. She said she heard LVN A say something about a doctor on the phone, so she assumed she was talking to the doctor. She said they immediately cleaned Resident #181. She said Resident #181 was very pale. She said his back was blue when they rolled him over. She said he had a small amount of substance which looked like bowel movement coming out of his mouth when they rolled him over. An undated CPR policy and procedure indicated: "I. It is the policy of this nursing home to follow all legally executed resident or surrogate directives within the generally accepted standards of medical practice... IV. For those residents that DO NOT have a physician's or mid-level practitioner's order prohibiting CPR, the following procedures will be followed. A. When a resident is observed to have a cardiopulmonary arrest (or apparent arrest), the staff will initiate CPR promptly and a 911 phone call made requesting EMS assistance and possible transfer to the hospital. B. When a resident is discovered by the staff to be without obvious signs of life and the resident has not been observed in the preceding ten or more minutes, the nurse (RN or LVN) in charge can determine that no signs of life are present and not initiate CPR. Both the Nurse Practice Act for RN's and the Licensing Act for LVN's prescribe that they assess and intervene to stabilize a resident's condition as appropriate. The nurse can determine the absence of signs of life and not start CPR by carefully observing and recording the following: The absence of ventilatory excursions of the chest or any spontaneous movement. The absence of breath sounds and heart tones by stethoscope auscultation. The absence of a detectable blood pressure. The absence of palpable pulses in the carotid and/or femoral areas. In addition, if there is a presence of fixed and/or dilated pupils, cyanosis, lividity or cool skin temperature. If the conditions outlined and described above have been documented, CPR should not be initiated. Following such a decision, the nurse in charge should notify the appropriate physician or registered nurse who can pronounce the resident to be dead." A Death of a Resident (Pronouncing Death) policy and procedure dated 2001 indicated, "The apparent death of a resident must be reported immediately to the attending physician..." A Task 5-G (Abuse Prohibition) Policy and Procedure dated [DATE] indicated, "The facility must determine if the injury, harm, or death of the resident was due to facility failure to provide services, treatment or care to a resident." The administrator and DONs were notified on [DATE] at 3:05 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on [DATE] at 4:30 p.m. and included: "All Full Code residents will be immediately identified. All current licensed nursing staff will be immediately in-serviced on the following protocol for those residents. Any nurses employed in the future will also be in-serviced relative to this policy. In the event a resident is discovered to have an unwitnessed arrest and absence of obvious signs of life and the attending nurse is a LVN, they will have another staff person call a Code Blue and call 911, and initiate CPR. If the attending nurse is an RN, that nurse will assess the resident for the Presumptive Signs of Death including: The resident is unresponsive The resident has no respirations The resident has no pulse The resident's pupils are fixed and dilated The resident's body temperature indicates hypothermia: Skin is cold relative to the resident's baseline skin temperature. The resident has generalized cyanosis As well as the Conclusive Sign of Death: Presence of livor mortis The RN can determine the absence of signs of life and not start CPR by observing and documenting all of the above. The RN will notify physician prior to pronouncing death." The surveyors confirmed the Plan of Removal had been implemented sufficiently to remove the IJ by: Twelve LVNs and four RNs were interviewed and were knowledgeable of the facility's new CPR policy which included the seven presumptive signs of death in accordance with the Texas Board of Nursing. On [DATE] at 6:55 p.m., the administrator was informed the IJ was removed; however, the facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. A list provided by DON A, dated [DATE] indicated 47 residents were Full Code status.

Based on interview and record review, the facility failed to meet professional standards of quality for 1 of 4 deceased residents. (Resident #181) On [DATE] at 11:00 a.m., Resident #181 was found lying in bed without respirations. Neither LVN A nor ADON A (an RN) attempted CPR prior to ADON A pronouncing Resident #181's death at 11:05 a.m. Seven nurses did not know the assessment criteria to use prior to pronouncing death. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure likely contributed to the death of Resident #181 and could place 47 residents who have chosen to remain full code status at risk of death. Findings included: 1. The following reference accessed on [DATE] from the Board of Nursing http://www.bon.texas.gov/practice/position.html#15.20 <http://www.bon.texas.gov/practice/position.html> indicated the following: Registered Nurses in the Management of an Unwitnessed arrest in a Resident in a Long Term Care Facility: "In the case of an unwitnessed resident arrest without DNR (do not resuscitate) orders, determination of the appropriateness of CPR (cardiopulmonary resuscitation) initiation should be undertaken by the registered nurse through a resident assessment, and interventions appropriate to the findings initiated. Assessment of death in which CPR would be a futile and inappropriate intervention requires that (ALL) seven of the following signs be present and that the arrest is unwitnessed. Presumptive Signs of Death: 1. The resident is unresponsive, 2. The resident has no respirations, 3. The resident has no pulse, 4. Resident's pupils are fixed and dilated, 5. The resident's body temperature indicates hypothermia: skin is cold relative to the residents' baseline skin temperature, 6. The resident has generalized cyanosis, and Conclusive Sign of Death 7. There is presence of livor mortis (venous pooling of blood in dependent body parts causing purple discoloration of the skin which does blanch with pressure). After assessment of the resident is completed and appropriate interventions are taken, documentation of the circumstances and the assessment of the resident in the resident record are a requirement. Examples of important documentation elements include: Description of the discovery of the resident Any treatment of [REDACTED]. The findings for each of the assessment elements outlined in the standards All individuals notified of the resident's status (e.g., [DATE], the health care provider, the administrator of the facility, family, coroner, etc.) Any directions that were provided to staff or others during the assessment and/or treatment of [REDACTED]. The results of any communications Presence or absence of witnesses Documentation should be adequate to give a clear picture of the situation and all of the actions that were taken or not taken on behalf of the resident". 2. Physician orders [REDACTED]. His orders indicated his status as Full Code (desiring CPR). The most recent MDS dated [DATE] indicated Resident #181 had cognitive impairment, required limited to extensive assistance with activities of daily living, and had a life expectancy of more than 6 months. An undated baseline temperature sheet for Resident #181 indicated his base line temperature was 97.8 degrees Fahrenheit. Resident #181's care plan dated [DATE] indicated "I am a 'Full Code'. My family and I have been offered information on 'Out of Hospital DNR' and choose to continue at this time on Full Code Status... Resident's wishes will be followed within the ethical and legal guidelines." A life sustaining measures-resuscitate status dated [DATE] and signed by the physician [DATE] for Resident #181 indicated the facility "requests that your signature be obtained in advance regarding the desire for Life Sustaining Measures (Cardiopulmonary Resuscitation-CPR) to be initiated for the resident who has experienced sudden cessation of cardiac and/or respiratory function." The option initiated and signed by the responsible party was resuscitate. A Completed Care Tasks log for Resident #181 dated [DATE] indicated: *LVN A at 8:31 a.m., "resident ate ,[DATE]% of his breakfast". *CNA A at 9:00 a.m., "resident had bowel movement". Nursing notes dated [DATE] for Resident #181 indicated: 9:23 a.m. - "vital signs: blood pressure was ,[DATE], pulse was 68, respirations was 18, temperature was 97.5, and (oxygen) saturation was 97% on room air. His respirations were even and unlabored. His abdomen was soft and non-distended and his skin was warm and dry. He continues to have dry dressing to his right heel." (LVN A) 11:36 a.m. - at 11:00 a.m., "was called to resident's room by housekeeper. When went to room, resident was not breathing. He had no chest movements. The RN Supervisor (ADON A) was called who went in and pronounced him dead at 11:05 a.m. Resident's son was notified and he was on his way. Resident's bandage was changed earlier in the morning and he was talking to staff. Staff had made rounds at 9 a.m. and resident was sleeping comfortably on his side facing the window and staff turned him back to his back." (LVN A) 11:40 a.m. - "at 11:05 a.m., was called to resident's room. Resident in bed, no respiration...pulse, pupils fixed dilated, very peaceful. Family notified per charge nurse." (ADON A) A death release form for Resident #181 indicated his date of death was [DATE] at 11:05 a.m. During interviews on [DATE] at 4:42 p.m. and [DATE] at 8:49 a.m., DON A said Resident #181 had a full code designation. While reading the nursing notes, she said CPR should have been initiated on Resident #181, but she would need to speak with the social worker because she thought his family desired for him to be a DNR. She said the doctor should have been notified. She did not see the documentation supporting when he was notified. During an interview on [DATE] at 9:25 a.m., Housekeeper B said she went into Resident #181's room and noticed he was not breathing so she informed LVN A. During an interview on [DATE] at 9:05 a.m., LVN A said Resident #181 "seemed to be doing well and one day, he was gone." She said she saw him earlier in the morning when she dressed his heel and he was talking. She said he asked her about his heel. She said Housekeeper B told her she thought Resident #181 passed away, so she locked her cart and went to his room. LVN A said it took her about ,[DATE] minutes to get to the room once the housekeeper came and told her about the resident. She said he was starting to get cool. She said she called ADON A who checked his vitals and pronounced him dead. She said his death shocked her. She said he had illness, but was not expecting him to pass on so soon. She said she called the doctor after she spoke to the son after the resident was pronounced dead. She said she thought she documented it. LVN A said she did not attempt CPR because, "He was already gone and it would not have been of use." She said if she knew he had just passed, she would have attempted CPR, but ADON A and she could tell he had been dead approximately an hour. She said the resident's son had not completed the out of hospital DNR, but he was working on it. During an interview on [DATE] at 10:05 a.m., the Social Worker said Resident #181's family did not want him on a ventilator, but wanted him to receive CPR. During an interview on [DATE] at 10:05 a.m., ADON A said when they found Resident #181, he was not actively dying, but was deceased . She said when the housekeeper went in to clean his room, she found him and LVN A determined there were no signs of life. She said it had been at least an hour since he was last seen on rounds. She said Resident #181 was unresponsive, did not have respirations, his pupils were fixed and dilated, he was cool, but she could not recall exact body temperature, he had a little discoloration, and had pale/grayish skin color. She said she did not determine he had livor mortis. She said she did not recall checking the bottom of Resident #181's feet. She said there was no rigor mortis (stiffening of body after death). She said she did not initiate CPR. ADON A said she paged the doctor and pronounced him dead. She said she could not say for certain she heard back from the doctor before pronouncing his death. She said the aides on duty cleaned him. She said she assumed their policy went along with the Board of Nursing standards. She said if it had been ,[DATE] minutes since a resident was observed and there were no signs of life, they do not initiate CPR. During an interview on [DATE] at 10:50 a.m., DON A, DON B, ADON B, RN C (Nurse Aide Instructor), RN D and RN E (entered at 10:53 a.m.) were not familiar with the seven presumptive signs of death according to the Texas Board of Nursing. During an interview on [DATE] at 1:50 p.m., CNA A said she was the nurse aide assigned to Resident #181. She said he ate well earlier in the morning. She said after he died , she and CNA B cleaned him. She said they cleaned him ,[DATE] minutes after ADON A pronounced him because his son came to the facility. She said he was lying on his back. She said he was pale and was starting to get cold, but was still warm. She said his skin was getting blue, but was not blue yet. She said his back was white which was his usual skin color. During an interview on [DATE] at 3:31 p.m., CNA B said she changed Resident #181 with CNA A earlier in the morning. She said she heard the housekeeper say something was wrong with Resident #181. She said ADON A pronounced Resident #181 dead. She said she heard LVN A say something about a doctor on the phone, so she assumed she was talking to the doctor. She said they immediately cleaned Resident #181. She said Resident #181 was very pale. She said his back was blue when they rolled him over. She said he had a small amount of substance which looked like bowel movement coming out of his mouth when they rolled him over. An undated CPR policy and procedure indicated: "I. It is the policy of this nursing home to follow all legally executed resident or surrogate directives within the generally accepted standards of medical practice... IV. For those residents that DO NOT have a physician's or mid-level practitioner's order prohibiting CPR, the following procedures will be followed. A. When a resident is observed to have a cardiopulmonary arrest (or apparent arrest), the staff will initiate CPR promptly and a 911 phone call made requesting EMS assistance and possible transfer to the hospital. B. When a resident is discovered by the staff to be without obvious signs of life and the resident has not been observed in the preceding ten or more minutes, the nurse (RN or LVN) in charge can determine that no signs of life are present and not initiate CPR. Both the Nurse Practice Act for RN's and the Licensing Act for LVN's prescribe that they assess and intervene to stabilize a resident's condition as appropriate. The nurse can determine the absence of signs of life and not start CPR by carefully observing and recording the following: The absence of ventilatory excursions of the chest or any spontaneous movement. The absence of breath sounds and heart tones by stethoscope auscultation. The absence of a detectable blood pressure. The absence of palpable pulses in the carotid and/or femoral areas. In addition, if there is a presence of fixed and/or dilated pupils, cyanosis, lividity or cool skin temperature. If the conditions outlined and described above have been documented, CPR should not be initiated. Following such a decision, the nurse in charge should notify the appropriate physician or registered nurse who can pronounce the resident to be dead." A Death of a Resident (Pronouncing Death) policy and procedure dated 2001 indicated, "The apparent death of a resident must be reported immediately to the attending physician..." A Task 5-G (Abuse Prohibition) Policy and Procedure dated [DATE] indicated, "The facility must determine if the injury, harm, or death of the resident was due to facility failure to provide services, treatment or care to a resident." The administrator and DONs were notified on [DATE] at 3:05 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on [DATE] at 4:30 p.m. and included: "All Full Code residents will be immediately identified. All current licensed nursing staff will be immediately in-serviced on the following protocol for those residents. Any nurses employed in the future will also be in-serviced relative to this policy. In the event a resident is discovered to have an unwitnessed arrest and absence of obvious signs of life and the attending nurse is a LVN, they will have another staff person call a Code Blue and call 911, and initiate CPR. If the attending nurse is an RN, that nurse will assess the resident for the Presumptive Signs of Death including: The resident is unresponsive The resident has no respirations The resident has no pulse The resident's pupils are fixed and dilated The resident's body temperature indicates hypothermia: Skin is cold relative to the resident's baseline skin temperature. The resident has generalized cyanosis As well as the Conclusive Sign of Death: Presence of livor mortis The RN can determine the absence of signs of life and not start CPR by observing and documenting all of the above. The RN will notify physician prior to pronouncing death." The surveyors confirmed the Plan of Removal had been implemented sufficiently to remove the IJ by: Twelve LVNs and four RNs were interviewed and were knowledgeable of the facility's new CPR policy which included the seven presumptive signs of death in accordance with the Texas Board of Nursing. On [DATE] at 6:55 p.m., the administrator was informed the IJ was removed; however, the facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. A list provided by DON A, dated [DATE] indicated 47 residents were Full Code status.