Every finding on record at Magnolia Crossing Nursing and Rehabilitation Cente

Based on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan to that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment for 4 of 18 residents (Residents #2, #3, #13 and #22) reviewed for care plans. -The facility did not develop Resident #2's care plan related to bladder and bowel incontinence. -The facility failed to ensure that Resident #3's Comprehensive Care Plan included her diagnoses diagnosis of Alzheimer's disease, pain, Dehydration and Psychosocial wellbeing that were triggered on her admission assessment. -The facility failed to ensure Resident #13, and Resident #22 had a Comprehensive Care Plan in place for pressure ulcers/injury. These failures could affect residents by placing them at risk of not receiving individualized care and services to meet their needs and decreased quality of care.Findings included: Resident #2 Record review of Resident #2's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Myopathy (a disorder of the skeletal muscles), Type 2 Diabetes Mellitus (a chronic disease that is characterized by high levels of sugar in the blood), Bed Confinement Status (a person is unable to get out of bed without total help), MRSA infection (a type of infection caused by Staphylococcus aureus that is resist to several antibiotics), and Cognitive Communication deficit (a condition where a person's ability to communicate effectively is compromised by an underlying impairment in mental processes, rather than a primary problem with language or speech). Record review of Resident #2's MDS Comprehensive assessment dated [DATE] revealed a BIMS score of 8 which indicated moderate cognitive impairment. Resident #2 was coded 3 in section H0300 and H0400 which indicated Resident #2 was always incontinent both bowel and bladder. Record review of Resident #2's comprehensive care plan dated 7/15/2026 did not reveal a focus of incontinence. During an observation and interview on 7/14/2026, Resident #2 was observed lying in bed watching TV. Resident #2 was oriented to person and place only. Resident #2's stated she wore a brief. Resident #2 stated that staff changed her brief when she needed to be changed. During an interview on 7/16/2026 at 12:45 p.m., the MDS nurse stated that she worked at the facility for 4 years. The MDS nurse stated she was responsible for care plans. The MDS nurse stated that Resident #2 had a focus of incontinence on the MDS, but it was not reflected on the care plan and should have been. The MDS nurse stated that the risk to residents of not having a care plan that accurately reflected Resident #2's status was excoriation, infection, wounds, and death. During an interview on 7/16/2026 at 1:51 p.m., CNA M stated she worked at the facility for 4 months. CNA M stated she cared for Resident #2. CNA M stated that Resident #2 was incontinent to both bowel and bladder and wore a brief. CNA M stated that Resident #2 would tell the staff she needed to be changed but other times she would not. CNA M stated she knew that Resident #2 was incontinent through verbal report from the previous CNA that was coming off shift that was assigned to Resident #2. CNA M also stated that she would receive a verbal report from Resident #2's assigned nurse. CNA M stated that that she could look at the care plan on the Kardex because things could have been missed through report and because resident needs can change. CNA M stated that she could document incontinent care on POC. CNA M stated the risk to residents who are not identified as incontinent and do not receive incontinent care was neglect and skin breakdown especially for residents like Resident #2 who do not speak up about the care they need. During an interview on 7/16/2026 at 1:59 p.m., CNA N stated she worked at the facility since March 2026. CNA N stated that she cared for Resident #2. CNA N stated Resident #2 was incontinent to bowel and bladder and wore a brief. CNA stated she knew Resident #2 was incontinent through report from the CNA and nurse. CNA N stated that she also will find out through doing her routine rounds on her residents. CNA N stated she does not have access to the care plan and only has access to POC where she documents her risk. CNA N stated that the risks to residents who are incontinent and do not receive incontinent care are skin breakdowns and infections. During an interview on 7/16/2026 at 2:09 p.m., LVN O stated she had worked at the facility for 4 years. LVN O stated she was familiar with Resident #2. LVN O stated that Resident #2 was incontinent to bowel and bladder. LVN O stated she was not sure if Resident #2 had a care plan that reflected incontinence. LVN O stated that the staff knew the needs of Resident #2 and were providing incontinent care. LVN O stated that Resident #2 often would yell out nurse when she needed to be changed. LVN O stated she knew Resident #2 was incontinent by completing her nursing rounds and assessments of Resident #2. LVN O stated that the risk to residents who are incontinent and do not have a care plan to reflect incontinence was skin breakdown. During an interview on 7/16/2026 at 2:52 p.m., the DON stated that Resident #2's care plan did not reflect she was incontinent and therefore no interventions were listed for this care. The DON stated Resident #2's care plan should have it listed as a focus. The DON stated that all residents are checked for incontinence even if it is not in the care plan. The DON stated that for a resident who was new and not identified as incontinent would bring a high risk including improper care. Resident #3 Record review of Resident #3's face sheet dated 07/16/2026 reflected [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included: Alzheimer's disease (is a loss of brain functions that worsens over time), anxiety disorder, depression, unspecified, pain, . Record review of Resident #3's admission MDS, dated [DATE], reflected a BIMS score of 8, which indicated moderate impairment on cognition. Record review of section V of the MDS indicated Resident #3's MDS assessment triggered the following area pain, Dehydration and Psychosocial wellbeing. Record review of Resident #3's care plan dated 12/18/2025 with a revision date of 09/20/26 revealed the care plan did not include the assessment triggered areas of pain, Dehydration and Psychosocial wellbeing. Resident #3 was not cared plan for her diagnosis of Alzheimer's disease. Interview with DON on 7/16/2026 at 12:10 p.m., the DON reviewed Resident #3's care plan and said she was not present at the facility when Resident #3's assessment and care plan were completed. She said all CAAs areas should be care plan to properly care for the residents. She said she would make sure Resident #3's care plan is updated accordingly. Interview with MDS Coordinator on 7/16/2026 at 10:22 a.m., the MDS Coordinator reviewed Resident #3's care plan and said she was not present at the facility when Resident #3's assessment and care plan were completed. She said all CAAs areas should be care plan to properly care for the residents. She said she would update the care plan to include all CAAs area as identified.Resident #13 Record review of Resident #13's face sheet dated 07/15/2026 reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #13 had diagnoses which included: nontraumatic intracerebral hemorrhage (bleeding inside the brain that happens without any injury or blow to the head), congestive heart failure (when the heart cannot pump blood well enough, causing fluid to build up in the body and making everyday activities harder), End stage renal disease (when kidneys have lost almost all of their ability to work, so they can no longer keep your body healthy on their own) and high blood pressure. Record review of Resident #13's admission MDS, dated [DATE], reflected a BIMS score of 5, which indicated resident cognition was severely impaired. Section M - Skin Conditions, subsection M0150. Risk of Pressure Ulcers/Injuries; Is this resident at risk of developing pressure ulcers/injuries? reflected a zero (0) indicating No was entered. Subsection M0210. Unhealed Pressure Ulcers/Injuries Does this resident have one or more unhealed pressure ulcers/injuries? reflected a zero (0) indicating No was entered. Section V - Care Area Assessment (CAA) Summary, subsection A. CAA Results revealed Item 16. Pressure Ulcer column A. Care Area Triggered was checked and column B. Care Planning Decision was checked indicating Item 16. applied. Record review of Resident #13's Physician Order dated 07/10/2026 reflected the following orders description:- Wound care order - cleanse skin shear to sacrum with wound cleanser/normal saline pat dry apply collagen then calcium alginate to wound bed and cover with dry dressing every 3 days and prn excessive soilage/dislodgement until healed every day shift every 3 days and as needed for excessive soilage/dislodgement until healed. - Cleanse skin shear to left upper back with wound cleanser/normal saline pat dry apply collagen then calcium alginate to wound bed and cover with dry dressing every 3 days and prn excessive soilage/dislodgement until healed every day shift every 3 days and as needed for excessive soilage/dislodgement until healed. - Cleanse skin shear to left buttocks with wound cleanser/normal saline pat dry apply Medi honey and calcium alginate to wound bed and cover with dry dressing every 3 days and prn excessive soilage/dislodgement until healed. Record review of Resident #13's Comprehensive Care Plan, reviewed/revised on 7/7/2026, revealed it did not address pressure ulcer/injury as a focus of care. Resident #22 Record review of Resident #22's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #22 had diagnoses which included: encephalopathy (brain disease damage), congestive heart failure (when the heart is too weak to pump blood), type 2 diabetes (when the body cannot properly process sugar) and high blood pressure. Record review of Resident #22's quarterly MDS, dated [DATE], reflected a BIMS score of zero, which indicated resident cognition was severely impaired. Section M - Skin Conditions, subsection M0150. Risk of Pressure Ulcers/Injuries; Is this resident at risk of developing pressure ulcers/injuries? reflected one (1) indicating yes was entered. Subsection M0210. Unhealed Pressure Ulcers/Injuries Does this resident have one or more unhealed pressure ulcers/injuries? reflected a zero (0) indicating No was entered. Record review of Resident #22's Physician Order descriptions and dated as follows:- 7/14/2026 clean upper left posterior calf stage 4 pressure injury with wound cleanser/normal saline pat dry, apply Santyl and calcium alginate cover with bordered gauze daily and PRN.- 7/9/2026 clean upper left posterior calf stage 4 pressure injury with wound cleanser/normal saline pat dry, apply Santyl and calcium alginate cover with bordered gauze daily and PRN.- 7/1/2026 clean left lateral leg skin tear with wound cleanser/normal saline pat dry, apply Thera honey cover with dry dressing daily and PRN. Record review of Resident #22's Comprehensive Care Plan, reviewed/revised on 4/03/2026, revealed it did not address the presence of upper left posterior calf stage 4 pressure injury as a focus of care. During an interview with DON on 7/15/2026 at 12:07 p.m., the DON stated that the pressure ulcers for Resident #13 and Resident #22 had not been incorporated into their comprehensive care plans and that she was unaware of the omission. She stated that she was new to the facility and expected the previous DON and the MDS Coordinator to ensure residents' pressure ulcers were care planned. The DON stated that she would collaborate with the newly hired ADON and the MDS Coordinator to ensure residents' needs, including pressure ulcers, were incorporated into comprehensive care plans and that staff would be re-educated regarding these expectations. The DON stated that failure to include a resident's pressure ulcer in the care plan could result in the interdisciplinary team not having clear guidance for providing consistent, individualized wound care, which could contribute to delayed healing, wound deterioration, and an increased risk of complications. During an interview with LVN A on 7/15/2026 at 12:30 p.m., LVN A stated that she was not responsible for updating residents' care plans and that her role was to carry out the physician's wound care orders. She stated that she did not review the resident's care plan before providing wound care and instead relied on the physician's orders, documenting the care provided in the progress notes. She stated that she was not aware whether Resident #13's pressure ulcer or Resident #22's pressure ulcer had been included in their respective care plans because she did not access or review the care plans. She was unable to explain why Resident #13 and Resident #22 had no care plan in place for their pressure ulcers/injuries. She stated that failure to include a resident's pressure ulcer in the care plan could result in unmet needs of the residents. During an interview with MDS Coordinator on 7/16/2026 at 10:06 a.m., the MDS Coordinator stated that she was unaware Resident #13's and Resident #22's pressure ulcers had not been incorporated into their comprehensive care plans. She stated that she had been on vacation for approximately six weeks and expected the ADON/DON to ensure residents' care plans were updated during her absence. She stated that her usual practice was to initiate residents' identified needs, including pressure ulcers, in the comprehensive care plan during the assessment process. Then DON/ADON review the care plans for completeness. She was unable to explain why the pressure ulcers/injuries for Resident #13 and Resident #22 had not been care planned. The MDS Coordinator stated that failure to include identified needs in the comprehensive care plan could result in the interdisciplinary team being unaware of the resident's needs, leading to inconsistent care and unmet resident needs. Record review of the facility's policy and procedures on Comprehensive care plan, revision date 10/24/2022, reflected in part: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on interview and record review, the facility failed to ensure that a preadmission PASSAR Level 1(PL-1) screening accurately reflected the resident's status for 1 (Resident #4) of 6 residents reviewed for PL-1 screenings. The facility failed to ensure the accuracy of the PASSAR Level 1 screening for Resident #4. The PL-1 screening for Resident #4 did not reflect the diagnosis of PTSD that was present on admission.This failure could place residents with mental illness of not receiving a PASSAR Evaluation, individualized care, or special services to meet their needs. Record review of Resident #4's face sheet dated 7/16/2026 revealed a [AGE] year-old female originally on 7/12/2025 and readmitted on [DATE]. Resident #4 had a diagnosis of PTSD (a mental health condition that's caused by an extremely stressful or terrifying event either being part of it or witnessing it). Record review of Resident #4's MDS Quarterly assessment dated [DATE] revealed a BIMS score of 7 which indicated a severe cognitive impairment. In Section I-Active Diagnoses, Resident #4's primary medication condition is listed as other neurological conditions. Record review of Resident #4's PL-1 Section C: PASSAR Screening dated 7/10/2025 revealed Resident #4 was coded as 0 which indicated Resident #4 did not have evidence or an indicator of a Mental Illness. Record review of Resident #4's Comprehensive Care Plan dated 7/15/2026 revealed the following problem: Resident #4 has a mood problem related to PTSD. Date initiated 10/10/2025. Revision on 10/10/2025.Goal: Resident #4 will have improved mood stated through the review date. Date initiated 10/10/2025. Revision on: 1/19/2026. Target date 9/1/2026.Goal: Resident #4 will have improved sleep pattern through the review date. Date initiated 10/10/2025. Revision on 1/19/2026. Target date 9/1/2026. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 10/10/2025. Monitor/record/report to physician as needed acute episode feelings or sadness; loss of pleasure and interest in activities; feelings of worthlessness or guilt; change in appetite/ eating habits; change in sleep patterns; diminished ability to concentrate; change in psychomotor skills. Date Initiated: 10/10/2025. Monitor/record/report to MD prn mood patterns signs and symptoms of depression, anxiety, sad mood.Date Initiated: 10/10/2025. During an interview on 7/14/2026 at 10:44 a.m., Resident #4 stated she had a history of trauma. Resident #4 stated the facility offered ways to cope with. Resident #4 stated that going to Bible Study in the facility was one way that she coped with her history of trauma. During an interview on 7/16/2026 at 2:25 p.m., the MDS nurse stated she worked at the facility since June 2025. The MDS nurse stated she was responsible for reviewing and submitting PASSAR screenings into SIMPLE (online portal where PASSAR screenings are entered). The MDS nurse stated that she did not get many admission clinicals for Resident #4. The MDS nurse stated Resident #4 was admitted directly from her residence. The MDS nurse stated residents who are admitted directly from home will bring their own clinicals records and that made it difficult to get all of the resident's clinical records. The MDS nurse stated she would review clinicals carefully for all admissions. The MDS nurse stated the diagnosis of PTSD was not caught and was not sure why. The MDS nurse stated that the risk to residents of an inaccurate PL-1 screening was the lack of specialized care.During an interview on 7/16/2026 at 3:05 p.m., the Administrator was not involved in submitting PL-1 screenings. The Administrator stated the facility followed the Texas HHS Guide for Local Authorities and Nursing Facilities to Complete the PL-1 Screening form dated June 2023. During an interview on 7/16/2026 at 3:05 p.m., the Administrator stated the facility did not have a specific policy regarding PL-screening submissions. The Administrator stated the facility follows the Texas Health and Human Services Manual, titled Detailed Item by Item Guide for Local Authorities and Nursing Facilities to Complete the PASRR Level 1 Screening Form dated June 2023.

Based on observation, interview and record review, the facility failed to review and revise the comprehensive care plan by the interdisciplinary team after assessment or change of condition for 2 of 21 residents reviewed for care plan revision (Residents #7, #42). Resident # 7's fall on 3/21/26 was not documented in the comprehensive care plan.Resident # 42's fall on 4/6/26 was not documented in the comprehensive care plan. These failures placed residents at risk of not receiving proper care.Findings include: Resident #42Record review of Resident #42's admission record revealed admission date 12/6/24 with diagnoses including dementia (loss of memory, thinking and reasoning skills), depression (persistent sadness and loss of interest), hypertension (high blood pressure), anxiety disorder (persistent fear or worry), history of falling, neoplasm of brain (abnormal growth of cells in the brain), reduced mobility. Record review of Resident # 42's Annual MDS dated [DATE] revealed resident was usually understood and usually understands others; BIMS of 02 to indicate severely impaired cognition; supervision by staff for eating, hygiene, and dressing, and maximum assistance by staff for toileting and bathing; and frequently incontinent of bowel and bladder. Record review of Resident #42's care plan revealed high risk for falls related to confusion, gait/balance problems and incontinence: date initiated 3/20/26 and date revised 3/20/26. A separate care plan had a documented fall with no injury on 2/19/25. There was no documentation of a fall on 4/13/26. Record review of Resident #42's progress note dated 4/13/26 revealed the resident stepped out of her room into the hallway and was motioning with her hands and speaking Spanish. Another resident translated, and said Resident #42 was saying one minute she was in bed and the next minute she was on the floor. Staff immediately responded and assessed Resident #42. Observation of Resident #42 on 7/14/26 at 1:25pm revealed she was sitting at a table with other residents in the common area at the end of the hall. She was alert, clean and dressed appropriately. Interview with Resident #42 at that time revealed she was confused, and said she had a different name. Another resident who was sitting at the table next to her said that was her name. Resident #42 could not answer questions about a fall due to cognition limitations. Resident #7Record review of Resident #7's admission record revealed admission date 6/20/24 with diagnoses including traumatic brain injury without loss of consciousness (brain injury caused by an outside source), pancytopenia (low number of blood cells in the body), psychological disorder (cognition, emotion or behavior disorder), seizures (sudden electrical surge in the brain), dementia (loss of memory, thinking, reasoning skills), depression (persistent sadness and loss of interest). Record review of Resident #7's MDS dated [DATE] revealed the resident was sometimes understood and sometimes understands others; BIMS 03, to indicate severely impaired cognitive skills; supervision/set up by staff required for eating, and total dependence on staff for hygiene, toileting, shower and dressing; and always incontinent of bowel and bladder. Record review fo Resident #7's care plan revealed high risk for falls related to confusion and incontinence, initiated 10/25/25, and revised 10/25/25. A separate care plan with actual fall related to unsteady gait and poor safety awareness, initiated 11/17/25, and revised 3/27/26. There was no documentation for a fall on 3/21/26. Record review of resident #7's progress note dated 3/21/26 revealed during rounds, the resident was found on the floor, sitting on the floor mat, and said he hit his head. Staff immediately assessed him and he was sent to the ER. Observation of Resident #7 on 7/14/26 at 9:45am revealed he was in bed, covered with a blanket, mumbling incoherently when spoken to. The resident was unable to answer questions about the fall. Interview with MDS nurse on 7/16/26 at 10:10am revealed she had been off for 6 weeks due to surgery, and had just returned last month, and there was shortage of staff to update the care plans while she was not at work, but two ADON's had been hired recently, and they would be able to assist with the care plan updating. She said all departments contributed to the care plans. She said the risk of not updating the care plan would be the staff would not know how to care for the residents. Interview with the DON on 7/16/26 at 12:15pm revealed the care plans should have the date of the falls documented. She said the risk of not having the care plans updated would be improper care. Interview with the Administrator on 7/16/26 at 12:30pm revealed she said the care plans should have the date of the fall. She said the risk of not having updated care plans would be not being able to see what areas needed interventions. Record review of the facility policy Comprehensive Care Plans, implemented 10/24/22, date revised unknown, revealed, in part:.comprehensive care plans will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.

Based on observation, interview and record review the facility failed to ensure based on the comprehensive assessment of a resident, a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 of 2 residents (Resident #13 and #22) observed for pressure ulcer/injury treatment. LVN A failed to ensure wound care was provided in accordance with accepted standards of nursing practice by failing to use aseptic wound cleansing technique, including using separate clean gauze for cleansing the wound bed and the peri wound during pressure ulcer/injury treatment. This failure could place residents at risk for contamination, infection, delayed wound healing, and further decrease in quality of life. Findings include: Resident #13 Record review of Resident #13's face sheet dated 07/15/2026 reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #13 had diagnoses which included: nontraumatic intracerebral hemorrhage (bleeding inside the brain that happens without any injury or blow to the head), congestive heart failure (when the heart cannot pump blood well enough, causing fluid to build up in the body and making everyday activities harder), End stage renal disease (when kidneys have lost almost all of their ability to work, so they can no longer keep your body healthy on their own) and high blood pressure. Record review of Resident #13's admission MDS, dated [DATE], reflected a BIMS score of 5, which indicated resident cognition was severely impaired. Section M - Skin Conditions, subsection M0150. Risk of Pressure Ulcers/Injuries; Is this resident at risk of developing pressure ulcers/injuries? reflected a zero (0) indicating No was entered. Subsection M0210. Unhealed Pressure Ulcers/Injuries Does this resident have one or more unhealed pressure ulcers/injuries? reflected a zero (0) indicating No was entered. Section V - Care Area Assessment (CAA) Summary, subsection A. CAA Results revealed Item 16. Pressure Ulcer column A. Care Area Triggered was checked and column B. Care Planning Decision was checked indicating Item 16. applied. Record review of Resident #13's Comprehensive Care Plan, reviewed/revised on 7/7/2026 revealed it did not address pressure ulcer/injury as a focus of care. Record review of Resident #13's Physician Order dated 07/10/2026 reflected the following orders description:- Wound care order - cleanse skin shear to sacrum with wound cleanser/normal saline pat dry apply collagen then calcium alginate to wound bed and cover with dry dressing every 3 days and prn excessive soilage/dislodgement until healed every day shift every 3 days and as needed for excessive soilage/dislodgement until healed. - Cleanse skin shear to left upper back with wound cleanser/normal saline pat dry apply collagen then calcium alginate to wound bed and cover with dry dressing every 3 days and prn excessive soilage/dislodgement until healed every day shift every 3 days and as needed for excessive soilage/dislodgement until healed. - Cleanse skin shear to left buttocks with wound cleanser/normal saline pat dry apply Medi honey and calcium alginate to wound bed and cover with dry dressing every 3 days and prn excessive soilage/dislodgement until healed. During observation on 7/15/2026 at 11:12 a.m., the wound care nurse (LVN A) saturated one piece of gauze with the ordered wound cleanser and cleaned the wound bed and the peri wound area with the same piece of gauze, she repeated the process two times. After cleansing the wound bed and peri wound, LVN A then applied the ordered medication treatment to the wound and applied the new dressing. Resident #22 Record review of Resident #22's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #22 had diagnoses which included: encephalopathy (brain disease damage), congestive heart failure (when the heart cannot pump blood well enough, causing fluid to build up in the body and making everyday activities harder), type 2 diabetes (when the body cannot properly process sugar) and high blood pressure. Record review of Resident #22's quarterly MDS, dated [DATE], reflected a BIMS score of zero, which indicated resident cognition was severely impaired. Section M - Skin Conditions, subsection M0150. Risk of Pressure Ulcers/Injuries; Is this resident at risk of developing pressure ulcers/injuries? reflected one (1) indicating yes was entered. Subsection M0210. Unhealed Pressure Ulcers/Injuries Does this resident have one or more unhealed pressure ulcers/injuries? reflected a zero (0) indicating No was entered. Record review of Resident #22's Physician Order descriptions and dated as follows:- 7/14/2026 clean upper left posterior calf stage 4 pressure injury with wound cleanser/normal saline pat dry, apply Santyl and calcium alginate cover with bordered gauze daily and PRN.- 7/9/2026 clean upper left posterior calf stage 4 pressure injury with wound cleanser/normal saline pat dry, apply Santyl and calcium alginate cover with bordered gauze daily and PRN.- 7/1/2026 clean left lateral leg skin tear with wound cleanser/normal saline pat dry, apply Thera honey cover with dry dressing daily and PRN. Record review of Resident #22's Comprehensive Care Plan, reviewed/revised on 4/3/2026 revealed it did not address the presence of upper left posterior calf stage 4 pressure injury as a focus of care. During observation on 7/15/2026 at 9:00 a.m., the wound care nurse (LVN A) was observed performing wound care using aseptic technique to Resident #22's left upper posterior calf pressure ulcer/injury. On observation, LVN A prepared Resident #22 for the treatment, assembled wound care supplies on a clean surface, donned a gown and gloves, removed the old dressing, and discarded the soiled dressing in the designated waste bag. LVN A saturated one piece of gauze with the ordered wound cleanser and cleaned the wound bed. After cleansing the wound bed, the nurse discarded the gauze, then applied Santyl ointment to the wound, and applied the new dressing. During an interview with LVN A on 7/15/2026 at 11:32 a.m., LVN A stated that she routinely used one piece of gauze during wound cleansing. LVN A stated that the accepted wound care practice was to cleanse the wound bed with one piece of gauze, discard it, then use a separate clean piece of gauze to cleanse the peri-wound before applying the ordered treatment and dressing. She stated that the observed wound care on Resident #13 and Resident #22 was not performed according to accepted professional standards because she was nervous. LVN A further stated that using the same piece of gauze for the wound bed and peri-wound or failing to cleanse the peri-wound with a separate clean gauze, could increase the risk of infection, contribute to wound deterioration, and delay wound healing. During an interview with Corporate Clinical Specialist/Infection preventionist (LVN C) 7/15/2026 at 11:40 a.m., the Infection Preventionist stated that she had not personally observed LVN A performing wound care but confirmed the nurses had been trained to provide wound care according to accepted professional standards. She stated that the expected practice was to cleanse the wound bed with one piece of gauze, discard it, and use a separate clean piece of gauze to cleanse the peri-wound. She stated that LVN A was not expected to use one piece of gauze to cleanse wound bed and peri wound area. She was unable to explain why the observed wound care treatment on Resident #13 and Resident #22 by LVN A did not follow accepted standards and stated that LVN A would be re-educated. She further stated that failure to follow accepted wound care practices could increase the risk of infection, spread contaminants to the surrounding tissue, and delay wound healing. During an interview with DON on 7/15/2026 at 12:10 p.m., DON stated that wound care should be performed using proper infection prevention techniques. The wound should be cleansed using the ordered cleansing solution with a clean piece of gauze for each cleansing, discarding each piece of gauze after use. She stated that the expected practice was to cleanse the wound bed with one piece of gauze, discard it, and use a separate clean piece of gauze to cleanse the peri-wound. She stated that LVN A and other nurses had been trained of the expectations of providing wound care treatment according to professional standards. She was unable to explain why the observed wound care treatment on Resident #13 and Resident #22 by LVN A did not follow accepted standards and stated that LVN A would be re-educated. The DON stated that using the same piece of gauze to clean both wound bed and the surrounding skin could introduce contaminants into the wound, increase the risk of infection, and cause the wound to worsen. Policy: On 7/15/2026 and 7/16/2026 respectively, the surveyor requested the facility's policy regarding the provision of care according to accepted professional standards. Although the facility provided several policies, none addressed the expectation for providing care in accordance with accepted professional standards. During the exit conference on 7/16/2026, the Administrator confirmed that the facility did not have a policy addressing the provision of care according to accepted professional standards.

Purpose for Visit: Complaint and Incident Investigations.Entrance date: 4/22/2026Census: 102Intakes:2988707297733729832282975728298799829764842989108 Abbreviations:ADM: AdministratorCMA: Certified Medication AideDON: Director of NursingG-tube: GastrostomyHCI: HydrochlorideMCG: microgramMg: milligramsNP: Nurse Practitioner Based on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys to meet the needs for 1 out of 2 medication (Medication Cart #1) carts reviewed for pharmacy service in that: The facility failed to ensure CMA B did not leave medications on top of the mediation cart. This failure could place residents at risk of not receiving their medications, choking and respiratory distress. Observation of Medication Cart #1, Hall A on 04/23/26 at 9:38 a.m., revealed 4 bottles and 5 blister packs of medication left on top of the medication cart unsupervised. The medications on top of Medication Cart #1 consisted of 1 bottle of Aspirin 81mg Oral Tablet Chewable (Aspirin) (anti-inflammatory drug), Zyrtec Allergy Oral Tablet 10mg (antihistamine used to relieve allergy), Iron Oral Tablet 325mg (prevent iron deficiency anemia), Vitamin B-12 1,000mg (support brain health), Cyanocobalamin Oral Tablet 500 MCG (used to prevent pernicious anemia), Eliquis Oral Tablet 2.5mg (blood thinner), Metformin HCI Oral Tablet 1000mg (manage type 2 diabetes by lowering sugar levels), hydroxyzine Oral Tablet 25mg (antihistamine used to treat anxiety), Lisinopril Oral Tablet 10mg (used to treat high blood pressure), Protonix Oral Tablet delayed release 20mg (used to treat gastroesophageal reflux disease). During an interview on 04/23/26 at 1:24 p.m., CMA B said she was trying to figure out what happened because she was informed that a picture of her medication cart was taken. The picture of Medication Cart #1 was revealed to CMA B. She said, moving too fast. CMA B stated that the medications should be placed inside the medication cart locked before leaving Medication Cart #1 unattended. CMA B stated she was in a resident's room when Medication Cart #1 was left unattended. CMA B said that the potential negative outcome for leaving medications on top of the medication cart would be residents could have taken the medications, resulting in an overdose. During an interview on 04/23/26 at 1:43 p.m., CMA C said to ensure medications remain safe, after preparing medications you should place the medications back into the medication cart and lock it. CMA C said medications should not be on top of the cart unsupervised due to safety and confidentiality concerns. CMA C said that a negative outcome of leaving the medications on top of Medication Cart #1 is that a resident could take the medication and overdose. CMA C said if the resident took Eliquis inappropriately, the resident could experience excessive bleeding. During an interview on 04/24/26 at 1:36 p.m., ADM said the negative effect of the residents taking the medications include drowsiness. The ADM said Metformin can be harmful to the resident if not administered appropriately, and if the resident took Eliquis, it would increase the risk of excessive bleeding. During an interview on 04/24/26 at 2:00 p.m., the DON said to ensure medications are secured, all medications must remain locked inside the medication cart when not in immediate use. The DON said leaving medications unattended on top of the cart creates a significant safety risks. The DON said any resident could access and ingest the medications which could cause serious physical, mental and psychological harm, including nausea, vomiting, neurological complications, allergic reactions, and other adverse effects. The DON said a resident who ingests medication such as Eliquis, it could result in severe bleeding and significant blood loss. During an interview on 04/24/26 at 2:26 p.m., the NP said that if a resident ingested Eliquis, it could result in serious adverse effects, including hypotension, excessive bleeding with the potential to bleed out. The NP said that hypoglycemia or low sugar could occur depending on the resident's overall condition and medications interactions. Record review of the facility policy on medication carts and supplies for administering meds dated 10/01/19., read in part, Policy .The mobile medication cart will be used to facilitate administrations of medication to residents.The purpose of the mobile medication system is to insure appropriate control and surveillance of resident assigned medications. Policy statement procedure 3.Do not leave the medication cart unlocked or unattended in the resident care areas.

Based on interviews and record review, the facility failed to incorporate recommendations from PASSR evaluation report into a resident's assessment, care planning and transition of care for 1 (Resident#1) of 1 residents reviewed for PASSR services.The facility failed to submit the NFSS form in a timely manner to coordinate with the PASRR unit.This failure could place residents who were PASRR positive at risk of not getting the PASARR services for a better quality of life and could lead to a decline in health. Record review of Resident #1's face sheet dated revealed a [AGE] year-old female admitted to the facility originally 3/17/2017 and readmitted on [DATE] with diagnoses that included Parkinson's disease (a progressive neurological disorder that primarily affects movement), epilepsy (a chronic medical condition marked by recurrent epileptic seizures), cognitive communication deficit (a condition where a person's ability to communicate effectively is compromised due to underlying cognitive impairments, affecting attention, memory, and executive functions), and unspecified intellectual disabilities (a specific type of intellectual disability that cannot be classified). Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 6 indicating severe cognitive impairment. Record review of Resident's #1's current comprehensive care plan with an initiation date of 3/11/2025 reveals Resident #1 receives PASSR services related to ID and DD. The interventions listed in Resident #1's care plan dated 3/22/2025 reads CMWC acquired through PASSR on 12/16/2024, W/C provided through date initiated 3/22/2025, and will participate in habilitation coordination to establish PASSR plan date initiated 3/22/2025. Record review of a spreadsheet from the PASSR program specialist indicated that an IDT meeting for Resident #1 took place on 8/25/2025 to which an update was made . An NFSS service request was not received by the PASSR department for an OT assessment and OT services according to the PASSR program spreadsheet. Record review of an order summary dated 3/12/2026 for Resident #1 reads in part OT Clarification Order- Skilled OT to treat 5x a week for 4 weeks for medical dx. and OT to eval and treat as indicated for tremors and positioning in wc. Record review of Resident #1's most recent PCSP Form dated 7/24/2025 section A2800 Nursing Facility Specialized Services of Resident #1's PCSP form dated 7/24/2025 reveals Resident #1 specialized occupational therapy was not needed.Record review of an OT Evaluation and Plan of treatment with a certification period of 8/25/2025- 10 /23/2025 reads in part.Care giver goals: PASSR meeting resulted in request for OT to address self-feeding and seating. The payer source of the OT Evaluation and Plan of treatment with a certification period of 8/25/2025-10/23/2025 is listed as Managed Care Part B. On page 3 of the OT Evaluation and Plan of treatment with a certification period of 8/25/2025- 10 /23/2025 lists Resident #1 is receiving skilled OT services. On page 4 of the OT Evaluation and Plan of treatment with a certification period of 8/25/2025- 10 /23/2025 lists Resident #1 has skilled OT intervention focus of restoration and compensation. Record review of OT Discharge summary dated [DATE] reads in part. Pt is not on PASSR as originally thought so OT will be held. The reason for discharge listed on the OT discharge summary with dates of service beginning 8/25/2025 is listed as resident exhausted benefits. An interview with the MDS nurse on 3/12/2026 at 12:45 pm, he stated the dates in mention occurred before he took his position as the MDS assessment coordinator . The MDS nurse stated that he would investigate the reason why an NFSS was not requested and would call his regional MDS coordinator for assistance. In an interview with the DON on 3/12/2026 at 1:37 pm, she stated she was helping the MDS nurse figure out Resident #1's PASSR related question. The DON stated that the NFFS was not filed because Resident #1 was already receiving OT services. DON stated these services were through PASSR. A request was made for a copy of the NFSS request that showed approval for OT assessment and services, but as of exit no copy was provided. In a phone interview with the Regional MDS nurse on 3/12/2026 at 2:36 pm, he stated that he did not see in Resident #1's record that an IDT meeting occurred for Resident #1 but only saw an IDT meeting on 7/24/2025. The Regional MDS nurse stated Resident #1 received OT services through a payor source of Managed B payor. The Regional MDS nurse was unable to provide a copy of the submission made for NFSS for approval or denial of services,. The Regional MDS nurse stated he did not see the request and stated it might be a computer glitch. The Regional MDS nurse stated, the bottom line was Resident #1 received OT services. The Regional MDS nurse stated by using another payor source for OT services, it saved the state of Texas from spending PASSR funds. When asked why a NFSS was not made as required in the regulations, the Regional MDS nurse stated that the facility thought the OT services that Resident #1 received would be sufficient if the end goal was met.In an interview with the administrator on 3/12/2026 at 3:15 pm, she stated that she did not know if the NFSS request was made but would try and locate the information. Record review of the Texas Administrative Code 26 TAC Chapter 554, Subchapter BB S554.2704 (i)(7) reads in part.nursing facilities must submit a complete and accurate request for nursing facility specialized services (NFSS) in the LTC Online Portal within 20 business days after the date of the Interdisciplinary Team meeting.

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #1) of five residents reviewed for nursing services received adequate supervision and assistive devices to prevent accidents. Findings include:-Resident #1 was transferred without the use of a gait belt.-The CNA conducting the transfer grabbed the resident's left hand to lift her to the sitting position without placing an arm behind the resident's back for support. -Resident #1 was not gently lowered into the wheelchair but was set down abruptly.This failure could place residents at risk for injury and falling. Findings included:Record review of the admission Record (no date) for Resident #1 revealed she was [AGE] years old and admitted [DATE], diagnoses included dementia, a history of falls, abnormalities of gait (walking) and mobility, muscle weakness, and lack of coordination.Record review of the annual MDS assessment, dated 01/25/2026, revealed Resident #1 scored 4 of 15 on the BIMS, indicative of severe cognitive impairment. The MDS revealed Resident #1 required substantial/maximum assistance for repositioning from lying to sitting on the side of the bed. The MDS reflected Resident #1 required substantial/maximum assistance for transitioning from sitting to standing. The MDS reflected Resident #1 required substantial/maximum assistance for transfer to the wheelchair.Record review of the Care Plan for Resident #1, dated 03/29/2025, revealed she required a one person assist for transfers. Record review of a series of time dated and stamped photos from a video produced by a private surveillance video camera in Resident #1's room revealed the following:Date/Time Photo 02/14/2026@5:01 p.m. CNA A transferred Resident #1 with no gait belt. Resident #1 appears to be grimacing.02/14/2026@5:01 p.m. Resident #1 was sitting in the wheelchair. 02/14/2026@5:13 p.m. CNA A transferred Resident #1 with no gait belt.During an interview on 03/04/2026 at 12:23 p.m., the DON said she had a care plan meeting with a family member of Resident #1 and addressed the issue of the transfer. She identified the staff as CNA A. She said she thought CNA A no longer worked at the facility. During an interview via telephone on 03/04/2026 at 12:45 p.m., a family member of Resident #1 said there was an incident on 02/14/2026. She said she spoke with the Administrator about it. Record review on 03/05/2026 of videos date stamped 02/14/2026 from the camera in Resident #1's room revealed a sequence of events initiated at 5:01 p.m.: Resident #1 was visible in bed, lying on her right side. CNA A placed the wheelchair at the right side of the bed, facing the resident. CNA A pulled back the cover. With her right hand, CNA A grabbed Resident #1's left hand and pulled her up to a sitting position. She did not provide support to the resident's back while lifting her to nearly a sitting position. Resident #1 screamed. CNA A grasped Resident #1's upper right arm. She held the resident by the resident's right bicep area. She adjusted the resident's blouse. The bed was not locked and rolled slightly. CNA A then transferred the resident from the bed to the wheelchair without a gait belt. Both appeared to struggle, and Resident #1 was assisted to the wheelchair abruptly. Resident #1 appeared to be crying. The resident was taken to the shower/restroom. Continued observation of the video revealed at 5:12 p.m., CNA A propelled Resident #1 in her wheelchair from the restroom in Resident #1's room to the resident's bedside. The resident's upper body was covered but did not have a brief on. Her private area was exposed. CNA A transferred Resident #1 from the wheelchair to the bed with no gait belt. During an interview on 03/05/2026 at 12:54 p.m. the Director of Therapy said the staff should use a gait belt for transfers. He said if a gait belt was not used, the resident could fall.In an interview on 03/05/2026 at 1:00 p.m., the DON said she was aware of the video but had not seen it. She said staff should use a gait belt for transfers. The DON said if a gait belt was not used, it could result in a fall or injury.In an interview on 03/05/2026 at 1:33 p.m., the Administrator said she saw the video. She said CNA A performed an improper transfer but did not think it was malicious. She said Resident #1 could be combative. During an interview via telephone on 03/15/2026 at 2:05 p.m., CNA A said she sat the resident up. She said she placed her hand behind the resident's back and pulled her up. She said she normally used a gait belt, but did not have one at that time. She said she was supposed to use a gait belt. She said if a gait belt was not used, the resident could get hurt or have a fall. Record review of the facility policy entitled, Safe Resident Handling /Transfers, dated 02/19/2025, revealed, .All residents require safe handling when transferred to prevent or minimize the risk of injury to themselves and the employees that assist them.5. Handling aids may include gait belts.13. Staff members are expected to maintain compliance with safe handling/transfer practices.

Based on interview and record review, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (CR #1) of 5 residents reviewed for quality of care. The facility failed to perform an assessment on CR #1 when she reported to have trouble breathing.This failure could place residents at risk for a delay in treatment or diagnosis, a decline in the resident's condition and/or the need for hospitalization and prolonged treatment.Findings included: Record review of CR #1's face sheet dated 10/28/25, revealed an [AGE] year-old female admitted to the facility with an initial admission date of 2/4/25 and readmitted on [DATE]. Diagnoses included: nontraumatic intracerebral hemorrhage in brain stem (a stroke that occurs when blood vessels in the brain rupture without any external trauma), dysphagia (difficulty swallowing), shortness of breath, other specified symptoms and signs involving the circulatory and respiratory systems, Stage 4 pressure ulcer, anemia (low levels of healthy red blood cells to carry oxygen throughout your body), Type 2 diabetes, hypertension, atherosclerotic heart disease (the buildup of fats, cholesterol and other substances in and on the artery walls), chronic combined systolic and diastolic heart failure, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and peripheral vascular disease. Record review of the comprehensive MDS dated [DATE] indicated CR #1 had a BIMS score of 6 reflecting severe cognitive impairment. Record review of CR #1's care plan dated 8/22/25 indicated CR #1 had shortness of breath r/t perception or cognitive impairment. Interventions included: monitor/document changes in orientation, increased restlessness, anxiety, and air hunger; monitor/document breathing patterns, report abnormalities to MD: nasal flaring, respiratory depth changes, altered chest excursion, use of accessory muscles, pursed-lip breathing or prolonged expiratory phase, increased anteroposterior chest diameter; monitor/document/report breathing abnormalities to MD: bradypnea (abnormally slow breathing), tachypnea (abnormally rapid breathing), hyperventilation, Kussmaul's respirations (deep and labored breathing pattern), Cheyne-Stokes (alternating periods of rapid deep breathing followed by pauses in breathing), apneusis (prolonged, gasping inhalations followed by short, inadequate exhalations), Biot's respirations (alternating periods of rapid, shallow breaths and pauses in breathing); position resident with proper body alignment for optimal breathing pattern. Review of video dated 8/21/25 at 8:56 pm, CR #1 was lying in bed, bed was at 45-degree angle, the Restorative Aide entered the room and asked CR #1 what's going on? CR #1 stated I can't hardly breathe. LVN A walked in the room and the Restorative Aide told LVN A, CR #1 can't hardly breathe. MA D walked in the room followed by RN C. LVN A told CR #1 You have to take your medicine. What's going on with you? Your family member just left. LVN A asked CR #1 Can you take your medicine? CR #1 responded I will take my medicine. LVN A said, So what is the problem now, so we can figure out what we need to do for you? CR #1 responded I do not know. LVN A then stated, Ok we can talk later, you can bring the medicine. LVN A told everyone in the room When she calms down, we can come back, let's go. Everyone exited the room. CR #1 was moaning. MA D came back in the room and brought CR #1 some water. MA D said to CR #1 I'm going to sit you up a little bit. MA D then raised the head of the bed. CR #1 started moaning again. MA D then lowered the bed. Record review of progress note dated 8/21/25 at 11:25 pm written by LVN B read in part .CR #1's family member called facility with concerns about CR #1's breathing. LVN B went to CR #1's room and checked the resident. O2 saturation was checked- O2 saturation 96% and 97% on room air. LVN B repositioned resident and raised her head. This nurse asked CR #1 is that better and CR #1 stated yes while shaking her head. CR #1 is not showing any s/s of distress at this time . Interview with the family member on 10/30/25 at 10:10 am, she said CR #1 started having trouble breathing on the evening of 8/21/25. She said CR #1 told the Restorative Aide I can't breathe, so the Restorative Aide got the nurse. The family member said MA D was trying to give CR #1 her medicine. The family member said LVN A went into CR #1's room and started yelling at CR #1 to take her medication. LVN A said to CR #1 What is wrong with you?. The family member said LVN A ordered everyone out of the room and did not take CR #1's vitals. The family member said CR #1 was cognitive and was able to tell staff her needs. Interview with the Hospice Nurse on 10/28/25 at 11:40 am, she said the family member called her on 8/21/25 at approximately 10:41 pm. The Hospice Nurse said she did a PRN visit on 8/21/25 and was at the facility around 11:20 pm. She said CR #1 was stable at the time of her visit. She said CR #1 was resting and her O2 saturation was 98% on RA. The Hospice Nurse said she did not see any signs of distress from the resident. The Hospice Nurse said she received a portion of the video from CR #1's family member because the family member was upset. She said the video she received did not show what happened prior to the incident or after the incident. The Hospice Nurse said CR #1's base line was intermittently confused. Interview with MA D on 10/28/25 at 1:48 pm, she said she went to CR #1's room to give her medication on the evening of 8/21/25. CR #1 told her she was not feeling good and could not breathe. MA D said CR #1 did not appear to have difficulty breathing because the resident was talking with her. She said CR #1 seemed like she was agitated. MA D said she went to LVN A and told her CR #1 could not breathe. MA D said she, LVN A, RN C and the Restorative Aide went to CR #1's room. She said when LVN A spoke to CR #1, LVN A's tone was not nice and asked her What's wrong with you?. MA D said she thought RN C may have gone back to check her oxygen. MA D said CR #1 was ok whenever she gave her medication, she said her pain medication may have kicked in. Interview with RN C on 10/30/25 at 4:16 pm, he said he was new to the facility during the time of the incident. He said MA D told LVN A that CR #1 was not taking her medication. LVN A told MA D she did not have to give CR #1 the medication because CR #1 had received pain medication, and it was going to take a while for the pain meds to kick in. RN C said a different nurse went into CR #1's room and he and LVN A wondered why she went in there. RN C said that nurse had received a call from the family member to check on CR #1 because she thought CR #1 was having shortness of breath. RN C said the Hospice Nurse also came to check CR #1's O2 stats and they were normal. RN C said from his perspective, he did not see CR #1 struggling to breathe or struggling to talk. RN C said that is probably why LVN A did not check CR #1's O2 stats. RN C said he thought the main issue was the medication CR #1 was supposed to receive from MA D. He said the risk to the resident if there was a lack of oxygen could be further damage to the resident. Interview with LVN A on 10/28/25 at 2:26 pm, she said she saw the family member the day of the incident and the family member was happy. LVN A said around 7 pm or 8 pm CR #1 was in pain, and she gave her pain medication. LVN A said MA D told her she was about to give medication to CR #1 and the resident said she was short of breath. LVN A said when she saw CR #1, she was not in any type of distress. LVN A said she told everyone in the room to come out of the room and let CR #1 relax. LVN A said she saw LVN B enter CR #1's room and LVN A told her Leave my patient alone. LVN B told her the family member called and told her CR #1 was short of breath and she was in distress. LVN A said the Hospice nurse came and checked on CR #1 as well. LVN A said she was suspended and then let go from the facility. LVN A said she did her job and took care of CR #1, she did not think she did anything wrong. Interview with LVN B on 10/28/25 at 2:47 pm. She said CR #1's family member called the facility that night and asked her to check on CR #1. LVN B said CR #1 was fine at the time of her assessment. LVN B said the family member would call her sometimes and if there were any concerns with CR #1, she would go to her room and CR #1 would tell her what was wrong. LVN B said the family member would always watch through the camera and made sure CR #1 was ok. LVN B said she was not in the room at the time to witness what anyone did or did not do. Interview with the DON, on 10/28/25 at 3:05 pm, he said MA D, went into CR #1's room to give her medication and CR #1 said she had shortness of breath. The DON said MA D reported this to LVN A. The DON said LVN A immediately went in CR #1's room and told her she needed to take her medications, and she did not see any shortness of breath. The DON said there may have been some confusion LVN A thought MA D was reporting the resident was refusing to take their meds. The DON said the family member showed the Administrator the video of the incident. He said LVN A was fired, and the incident was reported to the state. The DON said the risk to the resident when they are truly having respiratory distress could be detrimental. Interview with the Administrator on 10/30.25 at 9:44 am, she said the footage that she saw was CR #1 stating I can't breathe. She said MA D alerted LVN A. The Administrator said in the video, she saw LVN A tell CR # 1 I just gave you your pain medication, you have to give it time to work, just calm down and then she left the room. The Administrator said MA D stayed in the room. The Administrator said in the video CR #1 appeared to be in pain; she did not see shortness of breath. She said MA D ended up giving meds to CR #1. She said CR #1 calmed down and fell asleep. The Administrator said LVN B assessed CR #1 after the family member called her. The Administrator said LVN B alerted her of the incident. She said LVN A was terminated and did not come back after her suspension. The Administrator said LVN A should have assessed the resident. She said the risk to the resident when O2 is not checked, the resident could become non-responsive. Record review of the policy titled Nursing Service and Sufficient Staff dated 10/24/22 read in part . providing care included, but is not limited to, assessing, evaluating, planning and implementing resident care plans and responding to resident's needs .

Based on interview and record reviewed, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 (Resident #1) of 4 residents reviewed for implementing abuse policy. -The facility failed to implement their abuse policy and procedures when Nurse A did not report to the Administrator that Resident #1's family member reported to Nurse A on 08/16/25 that CNA A allegedly hit Resident #1 on his right eye, on an unknown date. This failure could place residents at risk for abuse to go undetected, to continue due to lack of identification, investigation, and reporting in accordance with policy, serious psychological and physical harm, and injury. Findings included: Record review of the facility's Abuse, Neglect and Exploitation policy, date implemented 7/11/25, revealed in part .It is the policy of this facility to provide protections for the health and welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse.Abuse.it includes physical abuse.Alleged Violation is a situation or occurrence that is observed or reported by.resident, relative.but has not yet been investigated.V. A. An immediate investigation is warranted when.reports of abuse.occur.VII. A.1. Reporting of all alleged violations to the Administrator, state agency.within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause that allegation involve abuse or result in serious bodily injury, or. Record review of Resident #1's admission Record, dated 08/19/25, revealed an [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included infrarenal abdominal aortic aneurysm (a localized dilation of the abdominal aorta below the renal arteries), without rupture, unspecified mycosis (fungal infection), malignant neoplasm of prostate (prostate cancer), and major depressive disorder, recurrent, unspecified. Record review of Resident #1's MDS Assessment, dated 06/06/25, revealed a BIMS score of 12, indicating moderately impaired cognition. Further review revealed the resident required 2 or more helpers to complete toileting. Record review of Resident #1's care plan report, undated, revealed the resident had an ADL self-care performance deficit r/t Alzheimer's and limited mobility. Interventions included assistance by (x1-2) staff for toileting. During a telephone interview on 08/19/25 at 7:39 a.m., Resident #1's family member said Resident #1 told her on Saturday, 08/16/25, that on an unknown date, CNA A had turned him to his side to change him, and it caused pain. She said Resident #1 said he grabbed her hand, and she removed his hand and put it down and then hit him with her open palm on his right eye. Resident #1's family member said she reported the allegation of abuse to Nurse A later that afternoon, 08/16/25, between 3:30 p.m. and 4:00 p.m. She said Nurse A did not say what action she was going to take. She said Nurse A received a phone call during their conversation, answered the call, and then walked away. She said she did not see any marks or bruises on the Resident #1's face. She said she called the Administrator yesterday, 08/18/25, to make sure she was aware of the allegation of abuse but said she was unable to reach her as she was already gone for the day. She said she had not heard back from anyone about her reported abuse allegation as of today, 08/19/25. During an interview on 08/19/25 at 8:14 a.m., Resident #1 said the care at the facility was not good. He said about 3 or 4 days ago (was not sure of the exact date), a nurse aide (said he did not know her name) hit him on the right side of his face in the eye. He said a nurse aide was changing him. He said the nurse aide turned him on his right side, and when she turned him, it caused him pain. He said the nurse aide had her hand on his left arm, and he told her he wanted her to lay him flat, and he tried to get her hand off him. He said that was when she hit him. He said he did not say anything to the nurse aide. He said she finished changing him and she left his room. He said he told his family member what happened, on a different day (he did not know what day). He said he did not tell anyone else. He said it made him mad when the nurse aide hit him. He said no staff had come to talk to him about the nurse aide hitting him. During a telephone interview on 08/19/25 at 9:56 a.m., Nurse A said on Saturday, 08/16/25, she was in the middle of taking care of a critical resident when Resident #1's family member came up to her and told her the CNAs were in the resident's room changing him and cleaning him up when one of the aides had hit him in the face. She said the resident's family member could not name the CNA, but the two CNAs in the room were, CNA A and CNA B. She said she asked CNA B if they had encountered anything in the room, and CNA B said Resident #1 told his family member that they had hit him in the face, but CNA B said she was by the bed with the other aide the whole time and it did not happen. She said CNA B told her they washed the resident's face with a washcloth. She said CNA B told her Resident #1 alleged she was the one who hit him in the face. She said after their conversation, she went into her critical resident's room to provide care. She said she sent out the critical resident to the hospital, stayed very late, forgot about the reported allegation of abuse from the resident's family member until this Investigator called her for this interview. She said she did not report the alleged abuse to anyone because she was juggling the allegation of abuse and the critical resident at the same time. She said when there was an alleged allegation of abuse, the Administrator, was to be called immediately. She said abuse should be reported immediately because there was alleged harm to the resident. She also said the resident would not trust staff, or could have sustained a serious injury, or their family would not trust staff. She said she did not ask Resident #1 anything about the alleged abuse because CNA A was still in the room picking up the linens off the floor. She said she received training on abuse, neglect, and exploitation. She said unfortunately she forgot to report the allegation of abuse and apologized for forgetting to report. During an interview on 08/19/25 at 12:25 p.m., the DON said when a nurse received an allegation of potential harm to a resident, they secured the resident, removed the potential harm, and notified the Administrator. He said they would notify the family/next of kin and the provider as well. He said he was not aware that Resident #1's family member reported an allegation of resident abuse to Nurse A this past Saturday, 08/16/25. He said failure to report abuse could cause a delay of treatment, if needed, and a delay of an investigation. During an interview on 08/19/25 at 1:19 p.m., the Administrator said she was not aware that Resident #1's family member reported an allegation of resident abuse to Nurse A on Saturday, 08/16/25. She said she was going to report it to the state today. She said staff members CNA A, CNA B, and Nurse A, had been suspended until the investigation was completed, and they would be in-servicing staff on Abuse/neglect and reporting.

Based on interview and record reviewed, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 (Resident #1) of 4 residents reviewed for reporting of alleged allegations. - The facility failed to ensure Nurse A reported to the facility Administrator when Resident #1's family member's reported an alleged abuse allegation. Resident #1's family member reported to Nurse A on 08/16/25 that CNA A allegedly hit Resident #1 on his right eye, on an unknown date, when changing him. This failure could place residents at risk for not having incidents reported as required and continued abuse which could result in diminished quality of life. The findings included:Record review of Resident #1's admission Record, dated 08/19/25, revealed an [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included infrarenal abdominal aortic aneurysm (a localized dilation of the abdominal aorta below the renal arteries), without rupture, unspecified mycosis (fungal infection), malignant neoplasm of prostate (prostate cancer), and major depressive disorder, recurrent, unspecified. Record review of Resident #1's MDS Assessment, dated 06/06/25, revealed a BIMS score of 12, indicating moderately impaired cognition. Further review revealed resident required 2 or more helpers to complete toileting. Record review of Resident #1's care plan report, undated, revealed the resident had an ADL self-care performance deficit r/t Alzheimer's and limited mobility. Interventions included assistance by (x1-2) staff for toileting. During a telephone interview on 08/19/25 at 7:39 a.m., Resident #1's family member said Resident #1 told her on Saturday, 08/16/25, that on an unknown date, CNA A had turned him to his side to change him and it caused pain. She said Resident #1 said he grabbed her hand, and she removed his hand and put it down and then hit him with her open palm on his right eye. Resident #1's family member said she reported the allegation of abuse to Nurse A later that afternoon, 08/16/25, between 3:30 p.m. and 4:00 p.m. She said Nurse A did not say what action she was going to take. She said Nurse A received a phone call during their conversation, answered the call, and then walked away. She said she did not see any marks or bruises on the Resident #1's face. She said she called the Administrator yesterday, 08/18/25, to make sure she was aware of the allegation of abuse, but said she was unable to reach her as she was already gone for the day. She said she had not heard back from anyone about her reported abuse allegation as of today, 08/19/25. During an interview on 08/19/25 at 8:14 a.m., Resident #1 said the care at the facility was not good. He said about 3 or 4 days ago (was not sure of the exact date), a nurse aide (said he did not know her name) hit him on the right side of his face in the eye. He said a nurse aide was changing him. He said the nurse aide turned him on his right side, and when she turned him, it caused him pain. He said the nurse aide had her hand on his left arm, and he told her he wanted her to lay him flat, and he tried to get her hand off him. He said that was when she hit him. He said he did not say anything to the nurse aide. He said she finished changing him and she left his room. He said he told his family member what happened, on a different day (he did not know what day). He said he did not tell anyone else. He said it made him mad when the nurse aide hit him. He said no staff had come to talk to him about the nurse aide hitting him. During a telephone interview on 08/19/25 at 9:56 a.m., Nurse A said on Saturday, 08/16/25, she was in the middle of taking care of a critical resident when Resident #1's family member came up to her and told her the CNAs were in the resident's room changing him and cleaning him up when one of the aides had hit him in the face. She said the resident's family member could not name the CNA, but the two CNAs in the room were, CNA A and CNA B. She said she asked CNA B if they had encountered anything in the room, and CNA B said Resident #1 told his family member that they had hit him in the face, but CNA B said she was by the bed with the other aide the whole time and it did not happen. She said CNA B told her they washed the resident's face with a washcloth. She said CNA B told her Resident #1 alleged she was the one who hit him in the face. She said after their conversation, she went into her critical resident's room to provide care. She said she sent out the critical resident to the hospital, stayed very late, forgot about the reported allegation of abuse from the resident's family member until this Investigator called her for an interview. She said she did not report the alleged abuse to anyone because she was juggling the allegation of abuse and the critical resident at the same time. She said when there was an alleged allegation of abuse, the Administrator, was to be called immediately. She said abuse should be reported immediately because there was alleged harm to the resident. She also said the resident would not trust staff, or could have sustained a serious injury, or their family would not trust staff. She said she went back and looked at the resident. She said the resident reported pain to his paralyzed left side, pointed to his arm/shoulder and leg, and requested a pain pill. She said she looked at his face, did not see any bruising or marks, and the resident said they just turned him. She said she gave him Tylenol 3 and then went to her critical care resident. She said she did not ask him anything about the alleged abuse because CNA A was still in the room picking up the linens off the floor. She said she received training on abuse, neglect, and exploitation. She said unfortunately she forgot to report the allegation of abuse and apologized for forgetting to report. During a telephone interview on 08/19/25 at 10:34 a.m., CNA A said she worked Saturday, 08/16/25. She said she worked the 2:00 p.m. to 10:00 p.m. shift. She said between 5:30 p.m. and 6:00 p.m. t Resident #1, the resident's family member, and she were in Resident #1's room. She said Resident #1's family member asked her if she could change the resident's gown and get him cleaned up. She said after Resident #1's family member asked her, she left the room and approximately 20 minutes later Resident #1's family member left the facility. She said she changed the resident after his family member left the facility. She said the family member did not mention any alleged allegations of abuse. She said she had never hit Resident #1. During an interview on 08/19/25 at 12:25 p.m., the DON said when a nurse received an allegation of potential harm to a resident, they secured the resident, remove the potential harm, and notified the Administrator. He said they would notify the family/next of kin and the provider as well. He said he was not aware that Resident #1's family member reported an allegation of resident abuse to Nurse A this past Saturday, 08/16/25. He said failure to report abuse could cause a delay of treatment, if needed, and a delay of an investigation. He said there were no reports from any staff regarding an allegation of abuse to Resident #1. During a telephone interview on 08/19/25 at 12:42 p.m., the Weekend Supervisor said he worked this past Saturday, 08/16/25 and did not receive any reports/notifications from staff, visitors, and/or family members of resident abuse. During a telephone interview on 08/19/25 at 1:06 p.m., CNA B said she worked the 2:00 p.m. to 10:00 p.m. shift on Saturday, 08/16/25. She said she was not assigned to Resident #1 but assisted CNA A with wiping him down with soap and water, changing his brief and clothes, and bed sheets because his family member complained that he smelled bad. She said she did not think she was alone in the room with the resident's family member and the resident at any point. She said when they were all in the room (Resident #1, the resident's family member, CNA A, and her) the resident at first said she hit him in the eye but then told his family member CNA A hit him, as she was walking out of his room. She said CNA A was walking out behind her. She said CNA A and she walked out of the resident's room, went to the nurse's station, and told Nurse A that Resident #1 was claiming she hit him in the eye and then changed his story and said CNA A hit him in the eye. She said she did not recall what Nurse A said but she said they laughed about it and then went their different ways. She said she had never hit Resident #1. During an interview on 08/19/25 at 1:19 p.m., the Administrator said she was not aware that Resident #1's family member reported an allegation of resident abuse to Nurse A on Saturday, 08/16/25. She said she was going to report it to the state today. She said staff members CNA A, CNA B, and Nurse A, had been suspended until the investigation was completed, and they would be in-servicing staff on Abuse/neglect and reporting. Record review of the facility's Abuse, Neglect and Exploitation policy, date implemented 7/11/25, reveled in part .It is the policy of this facility to provide protections for the health and welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse.Abuse.it includes physical abuse.Alleged Violation is a situation or occurrence that is observed or reported by.resident, relative.but has not yet been investigated.V. A. An immediate investigation is warranted when.reports of abuse.occur.VII. A.1. Reporting of all alleged violations to the Administrator, state agency.within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause that allegation involve abuse or result in serious bodily injury, or.

Based on observation, interview, and record review the facility failed to assess the resident for risk of entrapment from bed rails prior to installation, review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for 3 of 6 Residents (Resident #95, Resident #64, and Resident #356,) reviewed for the use of side rails. The facility failed to ensure nursing staff obtained physician orders and consent for the use of side rails for Residents #95, #64 and #356. This failure could place residents at risk of injury, hinder residents from getting out of bed, and/or cause a decline in resident's ability to engage in activities of daily living. Findings include: 1. Record review of Resident #95's face sheet, dated 5/20/25, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #95 had diagnoses which included unspecified trochanteric fracture of right femur (a fracture that occurs in the region of the trochanters, which are bony prominences on the thigh bone near the hip), unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning), muscle wasting and atrophy (the wasting or thinning of muscle mass), muscle weakness, unsteadiness on feet, and history of falling. Record review of Resident #95's quarterly MDS assessment, dated 4/9/25, reflected she had a BIMS score of 2, which indicated severe cognitive impairment. Resident #95 required supervision or touching assistance with rolling left and right, from sitting to lying and from lying to sitting on side of bed. Record review of Resident #95's care plan, dated 4/22/25, did not reflected she used side rails. Record review of Resident #95's physician orders for May 2025 reflected there was not an order for the use of side rails. Record review of Resident #95's EHR under the miscellaneous section reflected there was not a consent form and no assessments for the use of side rails. Observation on 5/20/25 at 1:55 PM revealed Resident #95 was lying in bed; the call light was within reach. There were half-sized bed rails up in the middle of the bed on each side, the bed was in lowest position and fall mats where on both sides of the bed. Interview with Resident #95's family member on 5/22/25 at 2:37 PM, she said she could not remember if she signed a consent for bed rails. The Family Member said Resident #95 had the bed rails the entire time she had been in the facility. 2. Record review of Resident #64's face sheet, dated 5/21/25, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #64 had diagnoses which included vascular dementia (caused by brain damage from impaired blood flow to the brain resulting in problems with, memory and other thought processes), morbid obesity (a condition in which a person has a body mass index higher than 35) , cerebral infarction (occurs when blood flow to the brain is blocked, causing brain tissue to die), muscle wasting and atrophy (the wasting or thinning of muscle mass), and muscle weakness. Record review of Resident #64's quarter MDS assessment, dated 2/16/25, reflected she had a BIMS score of 11, which indicated moderate cognitive impairment. Resident #64 required partial/moderate assistance with rolling left and right, from sitting to lying and from lying to sitting on side of bed. Record review of Resident #64's care plan, dated 4/2/25, did not reflect she used side rails. Record review of Resident #64's physician orders for May 2025, reflected an order was added on 5/21/25 for resident to use ¼ length rails for bed mobility. Record review of Resident #64's EHR under the miscellaneous section reflected there was not a consent form and no assessments for the use of side rails . Observation on 5/21/25 at 5:00 PM revealed Resident #64 was lying in bed with the head of the bed raised. There were half-sized bed rails up in the middle of the bed on each side, and a fall mat in place. 3. Record review of Resident #356's face sheet, dated 5/22/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #356 had diagnoses which included vascular dementia ( caused by brain damage from impaired blood flow to the brain resulting in problems with, memory and other thought processes), Chronic Obstructive Pulmonary Disorder (lung disease that block airflow and make it difficult to breathe), and muscle wasting and atrophy (the wasting or thinning of muscle mass). Record review of Resident #356's Quarterly MDS Assessment, dated 2/03/25, did not document a BIMS for the resident. Resident #64 required substantial/maximal assistance with rolling left and right, from sitting to lying and from lying to sitting on side of bed. Record review of Resident #356's care plan, dated May 2025, did not reflect she used side rails. Record review of Resident #356's physician orders for May 2025 reflected an order was added on 5/22/25 to use bilateral 1/4 siderails to maintain the bed perimeter related to restless movement. Record review of Resident #356's electronic medical record reflected no signed consent and no assessments for bed rails . During an interview with the Interim DON on 5/21/25 at 1:51 PM, she said rail assessments were completed upon admission. The Interim DON said she was unsure why the assessments and consents were not completed. She said the nurses were responsible for the assessments and consents and the ADON and the DON looked behind the nurses to make sure assessments and consents were completed. The Interim DON said the facility switched to a different EHR system back in December and the assessments and consents were probably in the old EHR system . She said the risk to the resident when there are no orders in place for bed rails, could cause bruises or even a choking hazard. During an interview with LVN A on 5/21/25 at 5:14 PM, she said if she saw a resident who was able to use their arms but had trouble turning, she would discuss with the DON, family, and doctor for the recommendation of bed rails. LVN A said the assessment should come first, then the consent . She said the bed rails that were in the middle of the of the bed were used for residents who were considered a fall risk. She said the risk to the resident when they were not assessed for bed rails could be they could put their arms through the bed rail and get stuck. During an interview with LVN B on 5/21/25 at 5:39 PM, she said bed rails were used for mobility. LVN B said, for example, if they provided incontinent care, the resident could hold onto the bed rail and roll over . LVN B said she did not know what the side rails located in the middle of the bed were used for. LVN B said there should be orders and assessments for bed rails, and they should be included in the care plan. LVN B said the purpose of the bed rails was for the resident to hold onto them while repositioning. She said bed rails were not to be used as a fall risk because it could be considered a restraint for the resident. During an interview with ADON A on 5/22/25 at 3:18 PM, she said bed rails should be used as assist bars, which were not normally located in the middle of the bed . There should be an order and consent for bed rails and the bed rails should be care planned. ADON A said bed rails should not be used as a restraint. She said the risk to the resident could lead to injury, trauma, or death. During an interview with the Administrator on 5/22/25 at 5:00 PM, she said if a resident needed a bed rail, the resident should have orders, and the bed rails could be included in the care plan. She said if PT recommended bed rails, they would include them in the care plan. The Administrator said the DON was responsible for obtaining consents and care planning the bed rails. She said bed rails for a resident were also reviewed in the clinical meetings. The administrator said the risk to the resident was a risk of falls. They could attempt to get out of bed and harm themselves getting across the bed rail. A policy for bed rails was requested from Interim DON on 5/22/25 at 3:45 pm and the Administrator on 5/22/25 at 5:00 PM, the facility did not have a policy for bed rails.

Based on interview, and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each residents individuality for 2 of 8 resident (Resident #36 and Resident #86) reviewed for resident rights. 1.The facility failed to ensure CNA G treated Resident #36 with respect and dignity when CNA G left Resident #36 without a brief and exposed while in the hallway after leaving her room. 2. The facility failed to ensure LVN R and CNA M treated Resident #86 with respect and dignity when LVN R and CNA M made the resident get out of bed and take a shower after she refused. These failures could place residents at risk for a diminished quality of life, loss of dignity, and self-worth. Findings included: 1. Record review of Resident #36's undated face sheet, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included Congestive Heart Failure (Condition in which the heart does not pump blood as well as it should), Metabolic Encephalopathy (brain dysfunction resulting from disruption in the body's metabolism, leading to altered mental status and cognitive impairment), and Cerebral Infarction (Blood flow to the brain is blocked leading to tissue death). Record review of Resident #36's Quarterly MDS Assessment, dated 03/03/25, reflected she had a BIMS score of 14, which indicated the resident was cognitively intact. Resident #36 required partial/moderate assistance with toileting and substantial/ maximal assistance with lower body dressing. Record review of Resident #36's revised care plan, dated 03/05/25, reflected Resident # 36 had an ADL self-care performance deficit related to muscle weakness with interventions to include required assistance by (X1) staff for toileting. Observation of video footage, dated 04/29/25, revealed: 8:00 PM: Resident #36 was in a wheelchair exiting he bathroom with a gown that covered the upper portion of her peri-area, but she did not have a brief on. 8:01 PM The resident retrieves a white towel to cover her upper legs. 8:03 PM: The resident was in a wheelchair in the hall, speaking with an unknown person . 8:05 PM: The resident was in a wheelchair in the hall speaking with an unknown person, asking for a staff member. 8:26 PM: Resident returned to her room via her wheelchair. 8:28 PM: The resident could be heard speaking to an unknown individual via the camera. 8:33 PM: CNA G left Resident #36's room across the hall and entered the room to assist Resident #36. During an interview on 05/21/25 at 09:06 AM, Resident #36 said the CNA who did not help her off the toilet on 04/29/25 still worked at the facility, and the only action the facility took was to reassign the CNA to a different hall. During an interview on 05/21/25 at 2:36 PM, CNA G said she left Resident #36 on the toilet and did not return because she was assisting another resident. She said Resident #36 could get off the toilet herself and required minimal assistance. She said she previously had spoken to the resident, and they decided to schedule her bedtime for 8:30 PM, so she proceeded to give a shower and provide incontinent care to the residents across the hall. She said after she finished incontinent care, she returned to assist Resident# 36. 2. Record review of Resident #86's, undated, face sheet, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included Dementia (the loss of cognitive functioning to such an extent that it interferes with a person's daily life and activities), and Depression (a mental health condition characterized by persistent feelings of sadness and loss of interest or pleasure in activities). Record review of Resident #86's Quarterly MDS Assessment, dated 04/22/25, reflected she had a BIMS score of 05, which indicated severe cognitive impairment. The resident required substantial/maximal assistance with toileting and showering. Record review of Resident #86's revised care plan, dated 03/29/25 , reflected Resident #86 had an ADL self-care performance deficit related to her disease process and was resistive to care and could be combative related to dementia. Her interventions included allowing the resident to make decisions about the treatment regime, providing sense of control and educating resident/family/caregivers of the possible outcome(s) of not complying with treatment or care. Observation video footage, dated 05/02/25, revealed: 8:42 AM: The resident was lying in bed and CNA M tried to get resident up and out of bed. 8:43 AM: Resident #86 could be seen resisting and telling LVN R and CNA M to leave her alone. Staff continued to assist the resident out of bed, and she was then placed in the wheelchair. During an interview on 05/22/25 at 9:22 AM, CNA M said if a resident refused a shower, she would leave the resident alone and notify the nurse. She said the resident had the right to refuse. She said the resident may experience a negative outcome if they refused care, but the staff proceeded because it would be a violation of their rights. During an interview on 05/22/25 at 9:45 AM, the interim DON said residents had a right to refuse care. She also said Resident #86 should have received assistance from the staff after toileting. During an interview on 05/22/24 at 1:44 PM, the ADON said all residents had a right to refuse care, and her expectation was for staff to notify the RP of the refusal and document it in the electronic medical record. She said they were working with staff and conducted re-education/in-serviced on resident's rights. During a telephone interview on 05/22/25 at 1:52 PM, LVN R said she was taking care of Resident #86 on 05/02/25. She said the resident refused care because she did not want to take a shower. She said the resident was soiled and had stool in her brief and she thought it was best to shower the resident instead of using wet wipes. She said the resident did have a right to refuse care; however, she did not want the resident to stay in her soiled brief and clothes because that could lead to a Urinary Tract Infection (inflammation of the bladder, caused by bacteria that enter the urinary tract and multiply) or skin breakdown. LVN R said she did not contact the RP because she thought it would be okay to shower the resident. She said she only notified the incoming nurse and the former administrator of Resident #86's refusal during morning meeting. LVN R was unable to provide a risk to the resident. During an interview on 05/22/25 at 5:10 PM, the Administrator said residents had a right to refuse. She said if the resident refused care, it was their right . Record review of the facility's, undated, policy and procedure titled, Statement of Resident Rights read in part . 10. Participate in developing a plan of care, to refuse treatment, and refuse to participate I experiment research

Based on interview, and record review, the facility failed to assist residents in obtaining routine and 24-hour emergency dental care for 1 of 6 residents (Resident #36) reviewed for dental services. The facility failed to ensure Resident #36 was referred to the dentist after she complained of tooth pain. This failure could place residents at risk of pain and decline in health. Findings included: Record review of Resident #36's, undated, face sheet, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included Congestive Heart Failure (Condition in which the heart does not pump blood as well as it should), Metabolic Encephalopathy (brain dysfunction resulting from disruption in the body's metabolism, leading to altered mental status and cognitive impairment), and Cerebral Infarction (Blood flow to the brain is blocked leading to tissue death). Record review of Resident #36's Quarterly MDS Assessment, dated 03/03/25, reflected she had a BIMS score of 14, which indicated that the resident was cognitively intact. Record review of Resident #36's nursing note dated 04/30/25 at 11:27 PM, reflected the resident had a complaint of dental pain to upper left jaw. Record review of Resident #36's nursing note dated 05/20/25 at 12:04 PM, reflected the resident had a complaint of tooth pain to the right side of mouth. Record review of Resident #36's nursing note dated 05/21/25 at 5:36 PM, reflected the social worker contacted an outside local dental group to set up an emergency appointment for the resident's complaint of tooth pain. During an interview and observation on 05/21/25 at 9:06 AM, Resident #36 said she had a toothache on the right side, and the staff had not addressed it. Pain medication was administered to the resident due to complaint of tooth pain . During an interview on 05/21/25 at 11:46 AM, the RP said her family member had a tooth abscess and had not seen a dentist since her initial complaint , which was several weeks prior. During an interview on 05/21/24 at 5:39 PM, LVN B said Resident #36 informed her she complained of tooth pain approximately 1 week ago. She said she assessed the resident, notified the RP, and administered pain medication. She said she gave the resident medication again today due to complaint of tooth pain. She said she assumed an order for dental services was already in place after speaking with the RP . She said the risk for not reporting tooth pain could lead to infection and/or sepsis. During an interview on 05/22/25 AM at 9:52 AM, the Social Worker said he started at the facility at the end of April and was not aware the resident needed urgent dental services. He said the 1st time he heard Resident #36 had dental concerns was when the state surveyor asked about it on 05/21/25 . During an interview on 05/22/25 at 3:18 PM, the ADON said the resident with constant or recurring mouth pain should require an emergency dental service. She said her expectation was for the nurses to notify the doctor and work with the social worker to arrange a dental appointment. She said Resident #36's issue should have been addressed within 24 hours of the complaint. The ADON said untreated dental problems could lead to infection, which could cause illness. During an interview on 05/22/25 at 5:00 PM, the Administrator said she was unaware of Resident #36 complaint of pain. She said the nurses should have assessed the resident and notified the social worker and the doctor for a dental consultation. She said she would notify the RP, and Resident #36 would be seen by the dentist at the next available appointment . During an interview on 05/22/25 at 5:30 PM, the DON said routine dental services were scheduled for Resident #36 in June. She said the resident had been eating without issues, and there was no change in weight, or food texture, or consumption. She said the risk of having a prolonged tooth abscess or infection could lead to complications, such as worsening of the infection or pain. Record review of the facility's Dental Services policy, dated 10/24/22, read in part, . It is the policy of this facility to assist resident in obtaining routine and emergency dental care. Emergency dental services includes services needed to treat an episode of acute pain in teeth, gums, or palate; broken, or otherwise damaged teeth, or any other problem of the oral cavity that required immediate attention by a dentist

Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 2 of 10 residents (Resident #36 and Resident #86) reviewed for infection control. 1. The facility failed to ensure CNA G followed appropriate infection control and hand hygiene procedure when providing care to Resident #36 and Resident #86 2. LVN U failed to follow appropriate Enhanced Barrier Precautions; and, failed to wash or sanitize her hands prior to, and after providing incontinent care to Resident #86. These failures could place the residents at risk for infection and cross-contamination. Findings included: 1. Record review of Resident #36's, undated, face sheet, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included Congestive Heart Failure (Condition in which the heart does not pump blood as well as it should), Metabolic Encephalopathy (brain dysfunction resulting from disruption in the body's metabolism, leading to altered mental status and cognitive impairment), and Cerebral Infarction (Blood flow to the brain is blocked leading to tissue death). Record review of Resident #36's Quarterly MDS Assessment, dated 03/03/25, reflected she had a BIMS score of 14, which indicated the resident was cognitively intact. Resident #36 required partial/moderate assistance with toileting and substantial/ maximal assistance with lower body dressing. Record review of Resident #36's revised care plan, dated 03/05/25, reflected Resident #36 had an ADL self-care performance deficit related to muscle weakness with interventions to include required assistance by (X1) staff for toileting. Record review of video footage, dated 04/29/25 at 8:33 PM, revealed: CNA G entered the room with gloves, and she dropped the dirty linen bag and trash bag from another resident's room at the entrance of the door. She removed her gloves and did not wash her hands. During an interview on 05/20/25 at 2:23 PM, LVN U said staff should wash their hands before donning gloves and wash their hands after doffing gloves. She said the risk of bringing soiled linen from one resident's room to another room could cause cross contamination. The risk of not washing hands could lead to infection to self and other residents. She said all staff should wash/sanitize hands before and after contact with residents. During an interview on 05/21/25 at 2:00 PM, the Interim DON said her expectation was for staff to remove gloves and wash their hands after dealing with soiled linen. She said the staff should not use the same gloves from one room to another. She said the gloves should be removed in the resident's room and the staff should wash/sanitize their hands before leaving that room. The Interim DON said the risk was cross contamination and infection. During an interview on 05/21/25 at 2:36 PM, CNA G said she was supposed to discard the soiled linen, gloves, and trash prior to entering another resident's room. She said she should wash /sanitize her hands before leaving and entering a resident room. She said her last in-service on infection control was last week. CNA G said the risk of using the same gloves to go to another room could start the spread of infection. 2. Record review of Resident #86's, undated, face sheet indicated reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #86 had diagnoses which included dementia (loss of cognitive functioning - thinking, remembering, and reasoning), with other behavioral disturbance, nausea with vomiting, dysphagia (difficulty of swallowing), other abnormalities of gait and mobility, type 2 diabetes mellitus without complications (diabetes where no long-term complications have yet developed), unspecified glaucoma (buildup of fluid in the eye, leading to increased pressure that can damage the optic nerve, potentially causing vision loss or blindness), essential hypertension (high blood pressure where the cause is not known or identifiable). Record review of Resident #86's MD orders, dated 2/22/25, revealed reflected an order for Accu-Check's BID in AM and HS two times a day for DM II AM and HS. Record review of general notes from intake #1005735 reflected .on 04/25/25, at 12:35 AM, LVN U entered the resident's room and grabbed gloves by the door. One of the gloves fell on the floor, but the nurse picked it up and put it on anyway. The nurse checked the resident's blood sugar. Record review of video footage, recorded on 4/24/25 at 9:40 PM, showed LVN U walked into Resident #86's room, knocked on the open door, took gloves from the box located by the door, then the gloves fell on the floor. LVN U picked the pair of gloves up from the floor, and donned (put on) the gloves on her hands. LVN U then administered water from the cup on the bedside table to Resident #86. Next, LVN U opened and assessed the resident's briefs. LVN U was not seen discarding the gloves, before and/or after leaving the resident's room. LVN U also did not wash or sanitize her hands before leaving the resident's room. In an interview with Resident #86 on 5/20/2025 at 9:48 AM, she said the nurse checked her blood sugar in the morning and before she went to bed at night. Said she could not remember if she saw the nurse drop the gloves or knew/ever saw nurses wash or sanitize their hands before or after they provided care to her. In an interview with LVN U on 05/20/25 at 2:23 PM, she said Resident #86 got her bedside blood sugar checks every morning and at bedtime. LVN U said Enhanced Barrier Precaution (EBP) signs were placed by the resident's door entrance was necessary due to the wounds on the resident's roommate's legs. She said PPE necessary for EBP was just a gown and gloves. The process she was trained to follow was to wash her hands, don gloves, provide care to the resident, and wash her hands after she doffed the gloves. She said if staff were donning gloves and the glove accidentally dropped on the floor, the glove should be discarded and another pair of gloves should be taken. She denied ever picking a pair of gloves up from the floor and put them on her hands before administering water to the resident. She said the risk of not washing her hands or using contaminated gloves could be infection to herself and other residents. She said all staff should wash/sanitize their hands before and after contact with residents. She said she received in-services on infection control last week. In an interview with the current administrator on 05/21/25 at 2:05 PM, she said the facility provided in-services to staff on different topics, like infection control, abuse/neglect and professionalism. The EBP carts were placed by the residents' doors. They were utilized to protect the residents and staff from infection. Before a staff entered a room, they were supposed to wash or sanitize their hands, and don gloves if the staff were providing care to a resident. Any staff putting on PPE, after accidentally dropping the PPE on the floor, should discard the PPE and start the process of donning PPE again. She said the risk of not washing hands or using contaminated PPE could be infection to self and other residents. She said all staff should wash/sanitize hands before and after contact with residents. Record review of the facility's policy titled Infection Prevention and Control Program, dated 05/21/23, read in part . Standard Precautions: a. all staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. b. Hand hygiene shall be performed in accordance with out facility's established hand hygiene procedures. 12. Linens: e. Soiled linen shall be collected at the bedside and placed in a bag. When the task is complete, the bag shall be closed securely and placed in the soiled utility room/ laundry barrel. 16. Staff education: b. All staff shall demonstrate competence in relevant infection control practices. c. Direct care staff shall demonstrate competence in resident care procedures established by our facility

Based on observation, interview, and record review the facility failed to provide a safe, clean and homelike environment for 1 of 8 (Resident #1) residents reviewed for resident rights in that: 1. Resident #1's linen had not been changed in 8 days, had dried fecal matter and food crumbs. This failure could have caused skin breakdown, infections and dignity issues. Findings Included: Observation on 5/7/2025 at 12:04pm, revealed Resident #1 linen was dirty due to dry fecal matter, and food crumbs. Record review of Resident #1's face sheet dated 5/7/2025 revealed he was a [AGE] year-old male that was admitted to the facility on [DATE] with diagnoses of unspecified dementia, functional quadriplegic, pain in right and left shoulders, muscle wasting and atrophy and need for assistance with personal care. Record review of Resident #1's MDS dated [DATE] revealed C0500: Brief Interview for Mental Status was coded as 00. This indicated severe cognitive impairment. Section GG 0170- revealed that Resident #1 Roll left and right was coded as (1), Sit to lying, lying to sitting on side of bed, tub/shower, toileting/hygiene were all coded as (1) which meant Resident #1 dependent and helper did all of the work. Record review of Resident #1's care plan dated 4/10/2025 revealed Resident #1 had an ADL self-care performance deficit due to weakness. Goal: The resident will maintain current level of function through the review date. Interventions: Provide sponge bath when a full bath or shower cannot be tolerated. The resident requires assistance by (X1) staff for toileting. An interview with Resident #1 on 5/7/2025 at 12:04pm, he said that his linen had not been changed in 7 or 8 days. He stated he had asked different CNA's that came in his room to please change his sheets. He said multiple times after he asked them, they said they needed to get help and did not return. He said he got bed baths on Tuesdays, Thursdays and Saturdays and he was told that the sheets were to be changed on those days. He said he would speak to the charge nurse today about it because he understood the facility no longer had a DON. An interview with Resident #1's FM on 5/7/2025 at 1:30pm, she said he often complained about his sheets not being changed. She said she would visit mostly on weekends but not every weekend. She said Resident #1 was considered a functional quadriplegic and was not capable of doing things for himself. She said she thinks he was supposed to have bed baths and linen changed a few times a week and to her knowledge these things were not being done. An interview with CNA A on 5/8/2025 at 10:37am, revealed him to state he had been employed for 2 years, worked the 6a-2pm shift and was currently working on Hall 100. He stated that he worked Halls 100, 300 or 400 wherever he was needed. He stated that he was responsible for assisting residents with showering, changing briefs, or bringing them to the restrooms, dressing, and grooming daily. He stated the residents that resided in rooms with odd numbers would have showers on morning shift. He stated that linen was usually changed on shower days. He stated that he was not working with Resident #1 today and would tell other CNA about his sheets. An interview with CNA B on 5/8/2025 at 11:17am, revealed he had been employed by their sister facility about 4 years but he had been helping at the facility since April 2025. He stated he was only PRN but worked the morning shift 6a-2p. He said he worked hall 400 and was responsible for rooms 410-417. He said all showers are to be given as ordered and that linen was supposed to be changed on shower days. He said if a resident refused any care or for their sheets to be changed, he was responsible for documenting the refusal in PCC. In a subsequent interview and observation with Resident #1 on 5/8/2025 at 3:59pm, he stated his sheets still had not been changed. The same stains and food crumbs were observed. In an interview with CNA C on 5/8/2025 at 4:00pm, she said that she was bringing Resident #1 some soup as requested. She said she had been employed for 3 weeks, worked the 6a-2p shift and was Resident #1's CNA for today. She said he had not asked her to change his sheets, but she would after he ate his food because it was his shower/bed bath day. She said as a CNA she was responsible for assisting residents with their ADL's such as bathing, grooming, changing their undergarments, feeding and transferring. An interview with LVN A on 5/8/2025 at 4:17pm, she said she asked Resident #1 to change his sheets and to have a bed bath today. She said he told her that he did not need a bed bath today as he was going to use wipes. She said she explained to him that a bed bath with soap and water would be better. She said she had been employed for 2 years and was the charge nurse on Resident #1's hall. She said she normally worked 6a-6p. She said CNAs are responsible for bathing, grooming, changing briefs or transferring residents to the restroom, feeding, and all ADL help that is needed. She said as the charge nurse she was responsible for ensuring the CNA staff provided all ADLs for the residents and changing is sheets was supposed to be done on shower days and as needed. She said not getting linen changed appropriately could cause skin irritation, infections, and dignity issues. An interview with the Interim DON on 5/9/2025 at 12:39pm she said she had been the interim DON since the second week in April. She said some of her duties were to have morning meeting/clinical meetings, follow-up with staff, direct staff, and education. She said she was no aware of nor received any complaints about sheets not being changed as needed. She said it was her understanding that staff are to change linen on shower days and as needed. She said CNAs are responsible for changing sheets, however, any nursing staff can change sheets. She said not changing the sheets regularly could cause dignity issues for residents, and skin infections. An interview with the Administrator on 5/9/2025 at 1:42pm, Administrator she had been employed for 5 days. She said her duties included management of the facility, positive outcomes, quality of life and care, each department functions, clinical and financial outcomes, advocate for residents. She said linen should be changed when residents are showered. She said it is the CNAs, DON, and floor nurses to ensure tasks are completed. She said linen not changed could cause skin infections. Record review of the facility's resident rights policy dated November 2021 revealed it to state: Residents of Texas nursing facility have the rights, benefits, responsibilities, and privileges by the Constitution of this state and the United States. They have the right to be free of interference, coercion, discrimination, and reprisal in exercising these rights as citizens of the United States. Dignity and respect: You have the right to live in a safe, decent and clean conditions.

Based on interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 1 of 8 residents (Resident #2) reviewed for Activities of Daily Living. -The facility failed to ensure Resident #2 received her bed baths on Tuesdays, Thursdays, and Saturdays on the morning shift as scheduled. This failure could have caused residents skin breakdown, discomfort, and embarrassment. Findings included: Record review of Resident #2's face sheet dated 5/8/2025 revealed she was a [AGE] year-old female with diagnoses of Alzheimer disease, and need for assistance with personal care. Record review of Resident #2 MDS dated [DATE] revealed the following: Section C- Brief Interview of Mental status was coded as 00- which represented severe mental impairment. Section GG-0130- Self Care E. Shower/bathe was coded as (02)- which meant substantial/maximal assist by helper. Section GG-0170- FF. Tub/shower transfer was coded as (01)- Dependent- which meant helper does all of the work. Section H0300- Urinary Incontinence and Bowel Incontinence (03)- represented Resident #2 was always incontinent. Record review of care plan dated 4/4/2025 revealed: Focus: Resident #2 has an ADL self-care deficit r/t Alzheimer Goal: The resident will maintain current level of function through the review date of 4/29/2025 Interventions: Bath/Shower - Provide sponge bath when full bath or shower was not tolerated, and Resident #2 required 1 staff with bathing and showering 3 times per week and as needed. Record review of Resident #2's POC (Plan of Care) for 4/10/2025-5/7/2025- revealed showers/or bed bath were to be done on Tuesdays, Thursdays, and Saturdays -There were no showers documented as she mostly had bed baths for the past 30 days. -Bed baths were not documented on the following dates: 4/10/2025 (Thursday) 4/12/2025 (Saturday) 4/17/2025-(Thursday) 4/22/2025- (Tuesday) 4/24/2025- (Thursday During an interview with Resident #2's RP on 5/8/2025 at 11:03am, revealed Resident #2 should have bed baths 3 times per week. RP stated Resident #2 was not receiving bed baths as ordered and most of the time, she was only provided a bed bath after RP or other FM asked that she was given one. FM's stated Resident #2 was visited every day and there is a camera in her room, so FMs would be aware of any bed baths given once they leave. An interview with CNA A on 5/8/2025 at 11:27am, revealed he had been employed for 2 years, worked the 6a-2pm shift and was currently working on Hall 100 today. He stated that he worked Halls 100, 300 or 400 wherever he was needed. He stated that he was responsible for assisting residents with showers, changing briefs, or bringing them to the restrooms, dressing, and grooming daily. He stated the residents that resided in rooms with odd numbers would have showers or bed baths on morning shift. He stated he was not aware of why Resident #2 was not receiving a bed bath as ordered. An interview with CNA B on 5/8/2025 at 11:33am, revealed he had been employed by their sister facility about 4 years, but he had been helping at the facility since April 2025. He stated that he was only PRN but worked the morning shift 6a-2p. He said he worked hall 400 and was responsible for rooms 410-417. He said all showers are to be given as ordered. He stated Resident #2 room was not on his side of the Hall that he was responsible for today. He said he was not sure why she had not had a bed bath as she should. He stated that he would tell CNA C since Resident #2 resided in a room that she was responsible for providing ADL's for today. An interview with CNA C on 5/8/2025 at 11:38am, revealed her to state she had been employed at the facility for about 1 month. She stated that today she was responsible for residents in rooms 401-409. She said Resident #2 should have had a bed bath on yesterday's evening shift. She said she would check on her and would be happy to give her one. She said the morning shift does A beds and evenings does B beds. Resident #2 resided in Bed B. She denied Resident #2's FM complained about her not getting bed baths. An interview with Clinical Specialist on 5/8/2025 at 12:17pm, she said she oversaw nursing, audits, and facility compliance since March 2025. She said showers are supposed to popup in POC when CNA's log in to document Resident ADL's. She said shower/bed baths should be provided three times per week and as needed. She said: Mondays, Wednesdays, and Fridays- even numbered rooms A- beds are provided showers on 6a-2p shift. B -beds are provided showers on 2-10pm shift Tuesdays, Thursdays, and Saturdays-odd numbered rooms A bed on 6a-2pm shift B beds on 2-10pm shift She said she would check with the Interim DON about any reports of showers or bed baths not given. An interview with the Interim DON on 5/9/2025 at 12:39pm she said she had been the interim DON since the second week in April. She said some of her duties were to have morning meeting/clinical meetings, follow-up with staff, direct staff, and education. She said she was not aware ofof, nor had she received any complaints about Resident #2 not getting bed baths. She said CNAs are responsible for bed baths, however, any nursing staff can help. She said not providing showers or bed baths regularly could cause dignity issues for residents, and skin infections. An interview with the Administrator on 5/9/2025 at 1:42pm, Administrator she had been employed for 5 days. She said her duties included management of the facility, positive outcomes, quality of life and care, each department functions, clinical and financial outcomes, advocate for residents. She said it was the CNAs, DON, and floor nurses who should ensure all ADL tasks are completed. She said it was her expectation was that showers are given as scheduled and documented in the electronic chart. She said she had started in-services on PCC documentation compliance, but she still had employees that needed the training. She said she learned the discrepancy in Resident#2's bed bath days were due to a lack of communication. Some staff were going by shower sheets, and they should not have been using that for shower days. They have been instructed to use PCC to determine and document the Residents ADL's. Record review of the facility's Activities of Daily Living (ADL) policy dated 5/26/2023 revealed the facility will, based on comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADL's does not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care.

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 9 residents (Resident #1) reviewed for accidents and supervision. CNA A fell asleep while feeding Resident #1 lunch on 04/18/2025 and did not wake up to evaluate Resident #1 after she began to cough. This failure placed residents who required feeding assistance at risk of aspirating food particles, pneumonia (an infection that inflames air sacs in one or both lungs), and possible death. Findings include: Record review of Resident #1's face sheet dated 04/23/2024 revealed she was a [AGE] year-old female who was initially admitted to the facility on [DATE] and recently readmitted on [DATE]. She was diagnosed with dementia (a group of symptoms affecting memory, thinking, and social abilities that interfere with daily living), severe protein-calorie malnutrition (a serious condition where the body lacks sufficient energy and protein), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), age-related osteoporosis (a condition where bones become weak and brittle due to a decrease in bone density), diabetes (a group of diseases that result in too much sugar in the blood), and essential hypertension (a chronic condition of persistently high blood pressure with no identifiable cause). Record review of Resident #1's admission MDS dated [DATE] revealed she had a BIMS score of 5 (severe cognitive impairment); Resident #1 did not exhibit behaviors related to rejection of care; Resident #1 required supervision or touching assistance for eating; and Resident #1 did not exhibit signs and symptoms of possible swallowing disorders. Record review of Resident #1's care plan revised on 04/18/2025 revealed the following care areas: * [Resident #1] has an ADL self-care performance deficit related to disease process. Goal included: [Resident #1] will maintain current level of function. Interventions included: Eating: Provide milkshakes or liquid food supplements when the resident refuses or has difficulty with solid food or provide nutritious foods that can be taken from a cup or a mug where appropriate. Eating: The resident requires set up and assistance as needed x 1 staff. * [Resident #1] is at risk for potential nutritional problems related to dementia and malnutrition. Goal included: The resident will comply with recommendation. Interventions included: Monitor/document/report PRN any s/sx of dysphagia (difficulty swallowing): pocketing (when food accumulates in the cheeks, gums, or tongue due to difficulty chewing or swallowing), choking (a situation where a person's airway is partially or completely blocked, preventing them from breathing effectively), coughing, drooling, holding food in the mouth, several attempts at swallowing, refusing to eat, or appears concerned during meals. Record review of Resident #1's hospital records revealed she was admitted to an acute care hospital from the facility on 04/15/2025 and was transferred back to the facility on [DATE]. Further review of Resident #1's hospital record revealed no documentation of speech, swallowing, or feeding concerns. Record review of Resident #1's nursing progress notes for April 2025 revealed: * On 04/17/2025 at 5:47 p.m., LVN B wrote, Received resident by private vehicle escorted by family member from [acute care hospital]. Resident was transferred extensive assist to wheelchair x 1 person. Resident confused, answering questions in Spanish . Resident was given dinner . * On 04/18/2025 at 12:48 p.m., Staff D (only Staff D's name was documented, not her credentials, such as RN or LVN. Staff D's name was not listed on the staff roster) wrote, Resident was assisted with repositioning in bed and assisted with breakfast. Resident enjoyed eating the oatmeal, half the biscuit, orange juice, and a couple of bites of scrambled eggs. Resident ate about 50%, then stated she was full. Resident was cheerful, cooperative, and readily interacted during breakfast. No s/sx of any distress. * On 04/18/2025 at 6:15 p.m., LVN C wrote, Patient has a new consult order for speech evaluation and treatment. * On 04/24/2024 at 12:31 p.m., LVN E wrote, New order per [NP] chest x-ray, 2 views - cough, one time . Record review of Resident #1's physician's orders for April 2025 revealed: * ST Clarification: ST to treat 5x's a week x's 30 days to address dysphagia treatment methods including caregiver training. One time a day 5 days on and 2 days off for 30 days. Order date: 04/18/2025. Start Date: 04/18/2025. Record review of Resident #1's Speech Therapy Evaluation and Plan of Treatment dated 04/18/2025 revealed, . Recommendations: Intake: Solids - Mechanical Soft Textures, Mechanical Soft/Ground Textures. Liquids - Thin Liquids. Supervision: Supervision for Oral Intake - Close supervision . Assessment Summary: . Risk factors: Due to the documented physical impairments and associated functional deficits, the patient is at risk for: aspiration, compromised general health, decreased ability to return to prior level of assistance, decreased participation with functional tasks . increased dependency upon caregivers, malnutrition, pneumonia, weight loss, and muscle atrophy (progressive loss of muscle mass). Impressions: Patient presents with moderate oral (difficulty with the oral phase of swallowing, which is the first stage of the swallowing process and occurs in the mouth) and mild pharyngeal phase (difficulty swallowing that specifically affects the pharynx, the area of the throat where food and liquids are transported from the mouth to the esophagus) dysphagia consisting of reduced lingual (tongue) strength and coordination along with reduced bolus propulsion and movement that results in post swallow oral residue in the left lateral sulci (the space or groove formed between the gums and cheek) . Record review of Resident #1's Radiology Interpretation dated 04/24/2025 revealed she had a 2-view chest x-ray completed on 04/24/2025. The x-ray determined that Resident #1's lungs were clear and well inflated bilaterally. Record review of the facility's staff sign-in sheet for 04/18/2025 revealed CNA A's first name was listed as the CNA assigned to Resident #1's room for the day shift (6:00 a.m. - 2:00 p.m.). Record review of the facility's staff roster revealed no staff with CNA A's first name. Further review of the record revealed Staff D was not listed. Observation of camera footage from a camera behind and above Resident #1's bed (Video #1) revealed the video was dated 04/18/2025 and time-stamped 12:38:17. In the camera's view, you could see the top of Resident #1's head, both arms/hands, and her personal belongings on the other side of the room. CNA A was sitting in a chair to the right of Resident #1 (by the window), facing the camera. There was a plate of food on the table directly in front of CNA A. The plate cover was placed at the foot of Resident #1's bed. At the beginning of the video, CNA A's eyes are closed. The video did not show if Resident #1 was chewing or that CNA A placed any food into her mouth. Resident #1 could be seen moving her head and arms/hands while CNA A was asleep. At 12:38:27, Resident #1 started to cough. CNA A moved her head from one side to the other, but she did not open her eyes. At 12:38:31, resident put her left hand over her mouth, while still coughing. CNA A's eyes fluttered, like they opened and closed at 12:38:36, while Resident #1 was still coughing. CNA A looked over at Resident #1 at 12:38:44, then quickly turned her head back towards the wall and closed her eyes again. Resident #1 stopped coughing and waived her left hand from side-to-side and said no (as if to say no more food). At 12:38:05, CNA A's head started dropped and raised as she slept. Her head rose and fell several times, and her eyes fluttered a few times. At 12:41:37, CNA A woke up and attempted to give Resident #1 more food. Resident #1 shook her head and said no. CNA A put the food down and closed her eyes again. CNA A adjusted herself slightly in the chair, chewed on whatever was in her mouth a few times, and then she closed her eyes again. Her head began to rise and fall again. The video ended at 12:42:40 with the staff still asleep. A television could be heard in the background and an inaudible voice was heard twice throughout the video. It was unknown if the voice came from inside the room or from the hallway. Observation of Video #2 revealed it was dated 04/18/2025 and time-stamped 12:46:51. The plate of food was covered from the start of the video, but CNA A was still asleep in the same chair as the first video. CNA A's head fell and raised several times until 12:47:55, when another voice inside the room (presumably Resident #2) said, You better wake up! CNA A woke up and smiled towards the direction of the voice. CNA A started chewing something in her mouth and then opened and closed the cover on the plate of food. CNA A looked at Resident #1 and then asked the other person in the room if they were done eating. CNA A got up and the video ended at 12:48:12. Observation of Resident #1 on 04/23/2025, at 11:15 a.m. revealed she was alert and wheelchair bound. In an interview with the VP of Operations on 04/23/2025, at 11:30 a.m., he stated the facility did not yet have a permanent Administrator or DON. He also stated the ADON had recently been hired and the facility lost a lot of staff in March 2025 and April 2025. He stated the facility utilized staff from their sister (other facilities owned by the same company) facilities whenever they needed to fill shifts due to vacancies or callouts. In a telephone interview with LVN C on 04/24/2024, at 10:34 a.m., she stated she worked the day shift (nurses worked 12-hour shifts. Day shift: 6:00 a.m. - 6:00 p.m.) on Friday (04/18/2025), Saturday (04/19/2025), and Sunday (04/20/2025) and she was assigned to Resident #1 on Friday, 04/18/2025. She stated Resident #1's roommate (Resident #2) said the aide who fed Resident #1 lunch on 04/18/2025 fell asleep, but nobody ever told her Resident #1 choked or coughed during the meal. She said she could not recall the CNA's name, but she confronted her about falling asleep while feeding Resident #1. She said the CNA denied that she was asleep. She said she did not want to have a confrontation in front of Resident #2, so she told Resident #2 she would educate the CNA about sleeping while providing feeding assistance. She said Resident #1 was alert and oriented x 3-4 (terms used to describe a patient's level of awareness and cognitive functioning. 3: person, place, and time. 4: person, place, time, and situation) but she was confused once-in-a-while. She said Resident #1 usually could not eat in her room because she required assistance. She said Resident #1 previously ate unassisted, but recently declined and currently needed assistance. She stated on Friday, 04/18/2025, Resident #1 was just coming back from the hospital and was weak, so she told the CNA to leave her in bed and assist with feeding. LVN C said she requested a speech therapy evaluation for Resident #1 because her family member said the hospital told her Resident #1 needed one. She said Resident #1's family member never told her Resident #1 choked or coughed during any meal. In an interview with the Interim Administrator on 04/24/2025 at 11:07 a.m., she stated Resident #1's family member had not showed her any video or informed her that a CNA fell asleep while feeding Resident #1. After watching the video, the Interim Administrator said she did not recognize the CNA who fell asleep. She stated the facility used staff from other buildings to fill shifts when they were short. She stated she would look at the facility's schedule to try and identify the staff member. She stated it was not appropriate for staff to sleep while providing care to a resident. She said if the CNA had something going on or needed a break, she should have advised the nurse. She said recently, Resident #1 had not been eating as much as she previously did and after looking at her clinical records (regarding the decrease in appetite), they wanted to get her evaluated for speech therapy. The Interim Administrator stated the negative effect of the situation was that the CNA did not assist the resident with eating while she was asleep. She also said the CNA never got up to check on the resident when she started coughing. She stated she would initiate an investigation, call in a self-report to HHSC, and decide what disciplinary action, including termination, should be issued to the CNA. She stated the facility educated all staff on how to properly assist resident with feeding if the resident was known to not eat a lot. In an interview with the Regional Clinical Specialist on 04/24/2024 at 12:04 p.m., she reviewed the video and stated it was not appropriate for the CNA to fall asleep while feeding Resident #1. She stated a negative effect would be that Resident #1 possibly did not complete her meal. She said a possible negative effect would be that the CNA would not have known if Resident #1 was in distress because she did not wake up while the resident was coughing. She stated she was going to assess Resident #1 for a COC and have her evaluated for swallowing issues. In an interview with Resident #2 on 04/24/2025 at 12:30 p.m., she stated on Friday (04/18/2025), a nurse (it was a CNA) fell asleep three times while she was feeding Resident #1. She said she did not know who the nurse was, but she had seen her working at the facility a few times. She said she could see Resident #1 when she started coughing because she usually tried to keep the privacy curtain open. She said Resident #1 looked like she was choking, and she (Resident #2) yelled for the nurse to wake up, but the nurse just looked up at her and grinned. She said she could not recall if she yelled at the nurse while Resident #1 was coughing. In an interview with Resident #1, her family member, and Resident #2 on 04/24/2025 at 12:50 p.m., Resident #1 said she once choked at the facility when someone said something funny. Resident #1 said the staff sometimes fell asleep while helping her eat. Resident #2 said the nurse asked the lady about falling asleep inside of their room and the lady said she was not asleep. Resident #2 said she told the lady she was a [expletive word] lie. Resident #2 said the lady and the nurse left the room after that. Resident #1's family member said the cameras in Resident #1's and Resident #2's room were motion activated. In an interview with Resident #1's NP on 04/24/2025 at 1:15 p.m., she stated Resident #1 did not previously have any issues with dysphagia and choking would be a new concern. She said Resident #1 recently declined and her muscles were weakening. After reviewing the video, the NP said the staff should know to not fall asleep. The NP said it looked to her like Resident #1 was coughing and not choking because if she was choking, she would have been in a lot more distress. She said if Resident #1 choked, there would be something in her lungs. She said she just ordered a chest x-ray a few minutes prior, after learning from staff that there was concern about Resident #1 choking. She said the negative result was that the CNA could have responded more quickly had she not been sleeping. In a follow-up interview with the Interim Administrator on 04/24/2025 at 2:15 p.m., she stated she was not yet able to identify the staff in the video, but once she did, she would forward her name and phone number. On 04/25/2024, at 10:59 a.m., CNA A's name and phone number were provided by the Interim Administrator. An attempt was to contact CNA A by phone on 04/25/2025 at 11:22 a.m. A voicemail message was left, but the call was not returned prior to exit. Record review of the facility's policy titled, Residents' Rights dated November 2021 revealed, . You have the right to: Receive all care necessary to have the highest possible level of health . Record review of the facility's policy titled, Activities of Daily Living dated 05/26/2023 revealed, . Policy Explanation and Compliance Guidelines: . 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene .

Based on interview and record review the facility failed to incorporate the recommendations from the PASRR level II determination and the PASRR evaluation report into a resident's assessment, care planning, and transitions of care for 4 of 4 resident's (Resident #1, #2, #3, #4) reviewed for PASRR. -The facility failed to submit authorization of PASRR Habilitative Services for Resident#1, #2, #3, #4. This failure could place residents identified at a level II for PASRR evaluation at risk for their specialized services not being provided in a timely manner. Findings included: Resident#1 Record review of Resident #1's face sheet, undated indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone) and anemia (a condition in which the blood doesn't have enough healthy red blood cells). Record review of Resident#1's Quarterly MDS assessment dated [DATE] revealed BIMS score of 03 out of 15 indicating severely impaired cognitively. She required extensive assistance from two-person physical assist with transfer, dressing, toilet use and personal hygiene. Record review of Resident#1's Care plan dated [DATE] and revised on [DATE] revealed the following: Focus: PASRR [Resident#1] is a (+) PASRR for DD. Goal: Facility will follow PASRR recommendations and monitor for any changes through next review date [DATE]. Interventions: Facility will follow the recommendations for the specialized services that [Resident#1] is eligible for. Follow up with Local Authority for any information on additional services that are available to [Resident#1] through PASRR. Record review of Resident#1's PASRR Comprehensive Service Plan (PCSP) Form dated [DATE] revealed read in part: .A3500. LA-IDD Specialized Services and Participation Confirmation: Annual SPT was held. Individual will get new assessment for Habilitative Speech Therapy and will continue with HB Coordination only. Individual had no need for other specialized services . In a telephone interview on [DATE] at 3:45p.m., with the PASRR Habilitation Coordinator (HC) (an employee of The [NAME] Center for Mental Health and IDD Authority Services), she said Resident #1 has not received authorization of PASRR habilitative speech therapy and the Resident was not receiving authorized PASRR habilitative Speech Therapy. Reisdent#1's Annual PASRR meeting was held [DATE] and new assessments to restart authorization of habilitative speech therapy was requested. Facility claimed to have been providing habilitative therapy services, last previous request was for 3 months that expired on [DATE]. The HC said she advised the facility was not authorized to provide services and educated them that requests must be inputted into the long-term portal (SIMPLE) which the facility was not doing. The HC said she also emailed the DOR and MDS nurse HHSC resources for Nursing Facility to complete requests on how to email HHSC support for assistance. The HC said facility did not attempt to submit Specialized Services that was requested in the [DATE] SPT meeting. The SPT held a update meeting on [DATE] due to facility failure to meet critical date to get specialized services request submitted within 20 business days. The HC said the facility submitted request [DATE] received denial of request on [DATE], due to wrong submission type 'new'. The HC said the facility missed the 7 day critical response time. The facility submitted 'restart' request on [DATE], and received denial on [DATE] due to no signature page and HHSC notes indicated facility had until [DATE] to submit corrections. The HC said facility missed another critical date. The HC said the facility was out of compliance with PASRR critical dates for getting authorization for services and failing to provide authorized PASRR Habilitative Speech Therapy services for Resident#1. Resident#2 Record review of Resident #2's face sheet, undated indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included Aphasia (a language disorder that affects a person's ability to communicate), Leukemia (a cancer of blood-forming tissues, hindering the body's ability to fight infection) and Major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident#2's Quarterly MDS assessment dated [DATE] revealed BIMS score of 00 out of 15 indicating severely impaired cognitively. She required extensive assistance from one-person physical assist with transfer, dressing, toilet use and personal hygiene. Record review of Resident#2's Care plan dated [DATE] and revised on [DATE] revealed the following: Focus: [Resident#2] has been identified as having PASRR positive status related to an developmental disability. Goal: [Resident#2] will maintain the highest level of practicable well-being through the review date [DATE]. Interventions: Facility will follow the recommendations for the specialized services that [Resident#2] is eligible for. Record review of Resident#2's PASRR Comprehensive Service Plan (PCSP) Form dated [DATE] revealed read in part: . A3300. Local Authority Comments: Update meeting held due to NF failed to get new assessments for habilitative PT completed and uploaded for services to be authorized and started . In a telephone interview on [DATE] at 3:45p.m., with HC, she said Resident#2's Annual PASRR meeting was held [DATE], new assessments to restart authorization of habilitative speech therapy was requested. The facility claimed to have been providing habilitative therapy services, last previous request was for 1 month that expired [DATE]. The HC said she advised the facility was not authorized to provide services and educated them that requests must be input into the long-term portal (SIMPLE) which the facility was not doing. The facility did not attempt to submit Specialized Services that was requested in the [DATE] SPT meeting. The SPT held an update meeting on [DATE] due to facility failure to meet critical date to get specialized services request submitted within 20 business days. The facility submitted request [DATE] received denial of request on [DATE], due to wrong submission type 'new'. The facility missed the 7 day critical response time. The facility submitted a 'restart' request on [DATE] and received denial on [DATE] due to invalid signature page. The HC said the facility has not submitted corrections and missed another critical date which was due by [DATE]. The HC said the facility was out of compliance with PASRR critical dates for getting authorization for services and failing to provide authorized PASRR Habilitative Speech Therapy services for Resident#2. Resident#3 Record review of Resident #3's face sheet, undated indicated he was a [AGE] year-old male, admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included Sepsis (a life-threatening complication of an infection), Cerebral palsy (a congenital disorder of movement, muscle tone, or posture) and dysphagia (difficulty swallowing foods or liquids, arising from the throat or esophagus, ranging from mild difficulty to complete and painful blockage). Record review of Resident#3's MDS assessment dated [DATE] revealed BIMS score of 03 out of 15 indicating severely impaired cognitively. He required total dependence from two-person physical assist with bed mobility, transfer, and toilet use. Record review of Resident#3's PASRR Comprehensive Service Plan (PCSP) Form dated [DATE] revealed read in part: .A3500. LA-IDD Specialized Services and Participation Confirmation- C. LA-IDD Specialized Services Comments-Annual SPT meeting was held. Individual will receive new assessment to establish OT services. Individual had no need for other services except Habilitation Coordination for ongoing monitoring. Individual will continue to be served in a NF setting . In a telephone interview on [DATE] at 3:45p.m., with HC, she said Resident#3's Annual PASRR meeting was held [DATE], new assessments to restart authorization of habilitative speech therapy was requested. Facility claimed to have been providing habilitative therapy services, last previous request was for 1 month that expired on [DATE]. HC said she advised facility not authorized to provide services and educated that requests must be input into long-term portal (SIMPLE) which the facility was not doing. HC said facility submitted request [DATE] received, received error notice made corrections then received denial of request [DATE], due to wrong submission type 'new'. Facility did not meet 7 day critical date to make corrections. Resident#3 was discharged to hospital end of September and returned on [DATE]. As of [DATE], facility failed to resubmit request for authorization as requested. HC said the facility was out of compliance with PASRR critical dates for getting authorization for services and failing to provide authorized PASRR Habilitative Speech Therapy services prior to Resident#3's hospitalization . Resident#4 Record review of Resident #3's face sheet, undated indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included multiple sclerosis(a disease in which the immune system eats away at the protective covering of nerves), schizoaffective disorder(a mental health condition including schizophrenia and mood disorder symptoms) and epilepsy (disorder in which nerve cell activity in the brain is disturbed, causing seizures). Record review of Resident#4's Quarterly MDS assessment dated [DATE] revealed BIMS score of 12 out of 15 indicating moderately impaired cognitively. He required total dependence from two-person physical assist with bed mobility, transfer, and toilet use. Record review of Resident#4's Care plan dated [DATE] revealed the following: Focus: Resident is considered PASRR positive due to a diagnosis of Mental Retardation (DD) and may require specialized services. Goal: Resident will have all identified needs met target date [DATE]. Interventions: Habilitative services as indicated by PASARR meeting. Record review of Resident#4's PASRR Comprehensive Service Plan (PCSP) Form dated [DATE] revealed read in part: .A3300. Local Authority Comments- Update meeting held because NF failed to get new assessments for habilitative OT services authorized and active. New Assessments are requested to get services implemented . In a telephone interview on [DATE] at 3:45p.m., with HC, she said Resident#4 has not received authorization of PASRR Habilitative Physical Therapy, and the individual is not receiving authorized PASRR habilitative Physical Therapy. The HC said Resident#4's IDT PASRR meeting was held [DATE], new assessments to establish authorization of habilitative occupational therapy was requested. The facility did not submit the request from the [DATE] meeting and an update meeting was held on [DATE], due to facility missed the critical date for submission of 20 business days from IDT meeting. The HC said the facility submitted request [DATE] and received denial on [DATE] due to not submitting valid assessment with request. As of [DATE] the facility has not resubmitted a request for specialized services. The HC said she had called, emailed and tried to assist this facility with getting within compliance with PASRR regulations but the facility consistently lacked follow-through measures, nor reached out to HHSC to proactively get assistance with issues or problems. The HC said this facility has a repeated cycle of lacking follow through and not taking PASRR critical dates and implementation of specialized services a priority. In an interview on [DATE] at 4:32 p.m., with the DON when asked whose responsible for ensuring the PASRR process was followed/completed at the facility the DON said the social worker, MDS Nurse and the Director of Rehab participated in the PASRR IDT meeting. She said she expected the PASRR process to be followed. She said the resident could decline as a result of not receiving her therapy services. Record review and interview on [DATE] at 11:06a.m., with RN/MDS Nurse. Surveyor reviewed Simple LTC portal (portal used to submit PASRR service requests), he said MDS in conjunction with therapy completed NFSS forms for PASRR positive residents to receive habilitative services. He said the authorization was rejected for Resident#1 because the form was submitted on the wrong side. Resident#4's was rejected because it needed more information on Section E1100. The RN/MDS nurse said it was brought to the facility's attention by PASRR HC in a meeting. RN/MDS nurse said corporate provided power point on NFSS process and created the action plan dated [DATE] because the NFSS PASRR forms were not being completed timely due to failure to identify rejections within the NFSS portal timely. In an interview on [DATE] at 1:34p.m., with Director of Rehab, she said she was responsible for the assessment portion on the NFSS form. She said Resident #1's initial submission was kicked back on [DATE] due to wrong submission type. She said a correction plan was initiated sometime in [DATE] that the MDS nurse was responsible for obtaining signature and uploading documents on Simple LTC portal. Record review and interview on [DATE] at 2:10p.m., with the RN/MDS Nurse. Surveyor reviewed Simple LTC portal (portal used to submit PASRR service requests). RN/MDS nurse said for Resident#4's authorization was submitted on [DATE]. He said on [DATE] they requested additional information on Section E1100. Facility missed the critical date for submission of 20 business days and received denial [DATE] due to not submitting valid assessment with request. RN/MDS Nurse said the facility re-submitted authorization on [DATE] and as of today ([DATE]) authorization was on pending status. He said now the process was once the completed NFSS has been submitted, he was responsible to check the online portal daily for any updates and correct/provide any missing documentation as needed. Record review of facility's Admission Criteria (Revised [DATE]) revealed read in part: .c. Upon completion of the Level II evaluation, the state PASARR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in the facility is appropriate. e. The interdisciplinary team determines whether the facility is capable of meeting the needs and services of the potential resident that are outlined in the evaluation .

Based on observation, interview and record review the facility failed to ensure allegations of abuse, neglect or mistreatment, including injuries of unknown origin was reported immediately, but not later than 2 hours after the allegation is made for 1 (CR#1) out of 4 residents reviewed for reporting alleged abuse and neglect. -The facility failed to report CR#1's right hip fracture that was discovered on 10/27/2023 to the state agency. This failure could place residents at risk for not having incidents reported as required and continued abuse and neglect which could result in diminished quality of life. Findings included: Record review CR#1's face sheet (undated) revealed CR#1 was a [AGE] year-old female admitted to the facility on [DATE] and discharged on [DATE]. Her diagnoses included dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), unsteadiness on feet ( a symptom of instability while walking), generalized muscle weakness ( commonly due to lack of exercise, ageing, muscle injury). Record review of CR#1's Quarterly MDS assessment dated [DATE] revealed BIMS score of 00 out of 15 indicating severely impaired cognitively. She required extensive assistance from one-person physical assist with bed mobility, transfer and dressing. Two-person physical assist with toilet use and personal hygiene. Staff supervision with locomotion on unit, locomotion off unit and eating. Record review of CR#1's comprehensive care plan initiated on 05/13/2022 and revised on 11/03/2023 revealed the following: Problem Start Date: 10/27/2023 [CR#1] is at risk for fractures r/t osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down) and poor safety awareness. Goal: Resident will remain free from major injury. Long Term Goal Target Date: 01/30/2024 Approach: Give resident verbal reminders not to ambulate/transfer without assistance. Keep call light in reach at all times. Keep personal items and frequently used items within reach. Provide resident an environment free of clutter. Record review of a screen shot of an email addressed to HHSC Complaint and Incident Intake, provided by Administrator B as evidence previous Administrator A attempted to report the incident revealed read in part: .Sent: Monday, October 30, 2023 10:33am I am submitting an initial reportable for our long-term care resident: [CR#1]. [CR#1] complained of right hip pain xrays were ordered and resulted on 10/27/2023 with a hip fracture . The email was sent three days after the incident. Record review of TULIP (Texas Unified Licensing Information Portal) on 11/03/23 and 11/13/23 revealed no reported alleged incidents of Abuse or Neglect, injury of unknown origin having to do with CR#1. Record review of CR#1's progress note dated 10/27/2023 at 5:02am written by LVN B revealed read in part: .Resident c/o (R)Hip pain 7/10 medicated with Tylenol 325mg 2 tabs po given for comfort. T&R, incontinent care provided. Fluids encouraged for hydration. Will continue to monitor . Record review of CR#1's progress note dated 10/27/2023 at 10:47AM written by LVN A revealed read in part: .Resident c/o right hip and knee pain, assessed resident with no noted redness or bruising to right side, noted small hematoma to left forehead, resident denies pain to forehead, no sign of distress noted. Message sent to NP, awaiting call back. VS: 135/84, 69, 18, 97.5, oxygen sat 97%. Tylenol 325 MG two tabs prn given as Ordered . Record review of CR#1's Radiology reported dated Report Date: 10/27/23 at 2:23pm revealed read in part: .Conclusion: Acute intertrochanteric RIGHT femoral fracture as noted . Electronically signed by M.D at 10/27/23 at 2:23pm Record review of CR#1's progress note dated 10/27/2023 at 3:34pm written by LVN A revealed read in part: .Spoke with resident RP and informed her of x ray results and order to send the ER, said to let her know when resident leaves for the hospital and she will meet her there . Record review of CR#1's progress note dated 10/27/2023 at 3:45pm written by LVN A revealed read in part: .X-ray was done and resulted with fracture right humorous, sent result to NP and order obtained to sent resident to RP for evaluation and treatment. RP notified, DON and ADON also notified . Record review of CR#1's progress note dated 10/27/2023 at 5:33pm written by LVN A revealed read in part: .Resident was picked up and taken to ER via stretcher, report called to Nurse . Record review of CR#1's Other Events - SBAR: Physician/NP/PA Communication Tool and Progress Note Created by LVN A revealed read in part: .When Occurred: 10/27/2023 08:40 AM. When Recorded: 10/27/2023 07:27 PM. Short Description: Reported by ongoing nurse that resident was medicated for right hip pain in am, staff reported to this writer that resident c/o pain while she was getting dress, assessed resident and noted hematoma to left forehead, no bruising to right side, informed DON and message NP . In a telephone interview on 11/03/2023 at 2:34p.m., with the complainant, she said on 10/27/23 the complainant was notified that CR#1 woke up with pain in her hip area. The facility stated that they found her in bed this way and she did not experience a fall. The facility performed x-rays and discovered the resident had a fractured right hip. Resident was transferred to the hospital. The ER performed their own x-rays of CR#1's hip and discovered the fracture. On 10/28/23, CR#1 underwent surgery on her right hip at the hospital. Observation and attempted interview on 11/03/2023 at 3:10p.m., revealed CR #1 was resting on hospital bed receiving oxygen via nasal cannula at 2 liters per minutes. Noted hematoma to left forehead. Resident mumbled for about 5 minutes while being interviewed and could not respond appropriate to the questions asked. In an interview on 11/03/23 at 3:30p.m., with RN AA, she said CR#1 was admitted to the hospital with hip fracture. CR#1 underwent surgery and was waiting to get placement. CR#1's RP did not wanted CR#1 to return to the nursing facility. In an interview on 11/3/23 at 4:16p.m., LVN K said the Administrator was facility's abuse coordinator. She said any allegations of abuse and neglect were to be reported to the DON and Administrator immediately. She said CR#1 was often seen transferring without assistance and ambulating without wheelchair. CR#1 resided in the memory care unit and had to be reminded to use her wheelchair. In an interview on 11/03/2023 at 4:32p.m., the DON said Administrator A was the facility's abuse coordinator. She said Administrator A was out of the facility today (11/03/23). She said Administrator A reported the incident via email to HHSC Complaint and Incident Intake because TULIP was not working. The DON said CR#1 resided on the memory care unit. Resident was unable to answer questions. She had a diagnosis of dementia, fall and abnormalities of gait and mobility. CR#1 had impulsive behavior of transferring without assistance and ambulating without wheelchair. The DON said it was brought to her attention that on the morning of 10/27/28 the resident was complaining of pain to right hip. Resident was further assessed for any pain or discomfort. The DON said she asked staff if the resident had a fall and the night nurse told her that when the staff were getting resident up for the morning CR#1 complained of pain. Physician was notified of pain, and orders received for x-ray to be completed. X-ray for resident resulted in right femoral fracture. New orders were given to send resident to hospital for further evaluation and treatment. In a telephone interview on 11/13/23 at 11:54p.m., with LVN A, she said CNAs brought it to her attention that CR#1 was complaining of pain. She said during shift report the night shift nurse (LVN B) reported that CR#1 was complaining of hip pain, and she had administered Tylenol. LVN A said when she assessed CR#1 there was no noted redness or bruising to the right side. She said she noted a small hematoma to left forehead, resident denied pain to the forehead. LVN A said she notified the NP and received orders for x-ray. X-ray was done and resulted with right hip fracture and CR#1 was sent to the hospital. LVN A said resident had dementia and had to be reminded to use her wheelchair when ambulating. In a telephone interview on 11/13/23 at 12:34p.m., with LVN B, she said CR#1 slept most of the night. She said towards the end of the shift when making the last rounds CR#1 complained her leg was hurting. She said she administered pain medication and notified the oncoming nurse. She said there were two staff on the memory care unit at all times. In an interview on 11/13/23 at 1:05p.m, with CNA RR and SS. CNA SS said they worked 6am-2pm shift at the facility's memory care unit. CNA SS said CR#1 assisted with all ADLs. CNA RR said in the morning of 10/27/23 CR#1 could not stand up. CR#1 was fine the day before (10/26/23). CNA RR said they got CR#1 dressed and notified LVN A. CNA SS said CR#1 was a fall risk. CR#1 had to be reminded to use her wheelchair. In an interview on 11/13/23 at 1:54p.m., with Administrator B, she said she started working last week at this facility. She said she went through previous Administrator A email and found an email that was sent on 10/30/23 to the HHSC complaint and incident intake for CR#1. When asked what was the process for ensuring ANE policy was followed and how do they ensure allegations of ANE/injuries of unknown injury were reported. Administrator B said as soon as you get the results back. Injury of unknown, sent them out and should start investigating. She said the facility investigated and submitted the 3613a on 11/06/2023 under previously reported incident on a different resident. In an interview on 11/13/23 at 2:41p.m., Surveyor reviewed email sent to HHSC Complaint and Incident intake dated 10/30/2023 with Administrator B and explained that the incident with CR#1 occurred on 10/27/23 as stated by the previous Administrator A on the email. Which was reported 3 days late and there was no follow up email/communication after the initial email sent on 10/30/23. Administrator B said TULIP had been having issue since last month. She said, but you can pick up a phone and report. Maybe the previous Administrator was a new Administrator. Record review of form 3613-A Provider Investigation Report dated 11/04/23 signed by the DON read in part: . the facility reviewed [CR #1] incident to determine contributing risk factor, evaluate continued care, and implementing interventions to include assuring bed is in lowest position, frequent reminders and rounding, fall mats at bedside. [CR#1] has been on therapy services prior to incident, OT from 8/14/23-9/18/23 and PT from 5/16/23- 7/6/23 with both disciplines showing signs of improvement. Resident to be evaluated to therapy services upon readmission. In-services for abuse and neglect, and fall prevention initiated an on-going for all staff completion . Record review of facility's Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy (Revised September 2022) read in part: .All reports of resident abuse (including injures of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulation) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Policy Interpretation and Implementation: Reporting Allegations to the Administrator and Authorities: 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law.2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; 3. :Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury .

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (DSS) of 5 staff reviewed for infection control. -The facility failed to follow policy of testing with a secondary test after a negative test with DSS. This failure placed residents at risk of exposure to COVID-19. The findings included: During an observation on 06/01/23 at 8:57 a.m., revealed an automated screening system was located at the front entrance for all staff and visitors to self-screen themselves for COVID-19 signs and symptoms. Record review of COVID-19 testing results revealed 9 residents and 1 staff memberthe DSS tested positive for COVID-19 on 05/18/23, and 1 resident on 05/20/23. During an interview on 06/01/23 at 1:50 p.m., the DSS said she left work early on Friday, 05/12/2023, because she had a fever, body aches, and a headache. She said she told the Administrator she was not feeling well. She said she did not report her symptoms that day. She said she never took a COVID-19 test on her own. She said she returned to work on Monday, 05/15/23, and answered the COVID-19 screening questions via the automated system. She said she received a message that said she needed to go home . She said she checked with the DON and ICN. She said the ICN tested her for COVID-19, and she tested negative. She said she was told she could stay and work. She said she worked on 05/15/23, 05/16/23, 05/17/23, and until approximately 11:00 a.m. on 05/18/23. She said the facility tested all staff and residents on 05/18/223 after a resident tested positive for COVID-19. She said her test result came back positive and she was sent home. She said she wore a surgical mask from 05/15/23 through 05/18/23 and interacted with staff and residents. She said she had direct contact with 2 of the 10 residents who tested positive for COVID-19. During an interview on 06/01/2023 at 2:28 p.m., the ICN said all staff members and visitors were still required to use the facility's ir automated system to screen for COVID-19 signs and symptoms. She said when someone had a positive screening, the Administrator and DON were notified. She said the individual also had to see her. She said if the individual was afebrile afebrile (without fever) and tested negative for COVID-19, they could stay if they wore a mask. She said if they tested positive or had a fever, they were sent home. She said on a Friday, 05/12/23, the DSS reported she did not feel well and went home early. She said she returned to work on Monday, 05/15/23, and answered yes when completing the screening process. She said she was not sent home and was allowed to stay at work because she did not have a fever or symptoms for 24-hours. She said she wore a mask and tested negative. She said on Thursday, 05/18/23, a resident tested positive, and the entire facility was tested . She said the DSS tested positive along with 9 other residents. She said the DSS was asymptomatic at that point. She said she was sent home and allowed to return to work on Monday, 05/22/23. She said the facility followed the CDC COVID-19 guidelines. During an interview on 06/01/2023 at 3:28 p.m., the Administrator said the DSS came to her on 05/12/23 and told her she was not feeling so good, so she went home . She said she came back to work on Monday, 05/15/23, and screened herself for COVID-19 signs and symptoms using their automated system. She said the system flagged her and she had to see the ICN. She said the DSS reported that she did not have a fever in over 24-hours. She said she was tested for COVID-19 on Monday, 05/15/23, and tested negative. She said a resident tested positive for COVID-19 on Thursday, 05/18/23, and all staff and residents were tested that day. She said the DSS tested positive along with 9 other residents. During an interview on 06/01/2023 at 4:48 p.m., the ICN said the DSS's first negative antigen test (rapid coronavirus test) was not confirmed by a second test 48 hours after the first. She said there was no potential risk of exposure to residents and/or staff unless she was symptomatic. Record review of the facility's updated version 05/15/23 Infection Control: COVID-19 Exposure Management Plan, reflectedread in part: Staff Testing If using an antigen test , a negative test result must be confirmed by either a negative PCR [viral diagnostic test for SARS-CoV-2] or second negative antigen test taken 48 hours after the first negative test.

Based on observations, interviews and record review the facility failed to implement their written policy and procedures that prohibit neglect for one of ten residents (CR #1 ) reviewed for neglect. The facility failed to provide Resident #1 with CPR (cardiopulmonary resuscitation) when she was found unresponsive and without a pulse. CR #1 died in the facility. An IJ was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility needing more time to monitor the plan of removal's effectiveness. These failures affected one resident, one who died at the facility and placed all 83 residents at risk for neglect, injury, medical decline or death. Intake #: 3 Findings Include: CR #1 Record review of face sheet for CR #1 revealed she was a [AGE] year old female with an initial admission date of [DATE] and a readmitted [DATE] to the facility. [DIAGNOSES REDACTED]. Record review of CR #1 ' s Care Plan Conference Summary dated [DATE] revealed: CR #1 ' s cognition was intact. CR #1 was receiving physical therapy and making progress. CR #1 was a fall risk and had balance problems. CR #1 is continent and toilets without assistance. Record review of CR#1 ' s clinical closed record revealed resident was a Full Code. A MDS (minimum data set assessment) for CR #1 was requested from DON for on [DATE] and [DATE]. The MDS not provided by facility. Record review of RN A ' s nurses note dated [DATE] at 12:12 am for Resident #1 read: During my midnight rounds resident in bed, respiration even and unlabored, mild crackles noted in lungs. No acute distress noted. No complain of pain offered. Will continue to monitor. Record review of RN A ' s nurses notes dated [DATE] at 2:15 am read: Around 0125 I went to 100 hall to check on resident in room [ROOM NUMBER], I came back to the med cart. I have passed this resident (CR #1) sitting in her wheelchair by the left side entrance of 100 hall. Which is very common of her. Upon my return to the med cart I asked (CR #1) if she needs anything, when I didn ' t hear any response I looked at her, she looked very pale, I went to her, upon assessment there was no pulse, I called out to my colleagues, another nurse came and assessed her too, to response noted. I called 911. (CR #1) is her own responsible party. Record review of Incident Investigation Worksheet dated [DATE] revealed CR #1 was noted by RN A, at approximately 1:25 am to have wheeled her-self into the 100 hallway and was sitting next to the medication cart. RN A approached CR #1 and asked resident if she needed anything. CR #1 did not respond. RN A assessed resident and found no pulse, respirations or blood pressure. RN A lowered CR #1 to the floor and performed a sternal chest rub 3 times and received no response from CR #1. 911 was called and a second nurse (LVN B ) then assessed Resident #1 and confirmed CR #1 did not have signs of life. Investigation Worksheet further revealed that Autopsy was not believed to take place as Resident #1 ' s body was released to Funeral Home by the facility. Record review of CR #1's physician's orders [REDACTED].#1 ' s body to county morgue. Record review of Record of Death And Mortician' s Receipt dated [DATE] at 2:50am revealed CR #1 ' s body was released to a private funeral home. Record review of RN A ' s written statement dated [DATE] at 9:30am read: I went to check my resident in room [ROOM NUMBER] upon returning to my medication cart. I said Ms. (NAME REDACTED) (CR #1) do you need anything , I didn ' t get any response I looked at her, she looked very pale. I immediately went to assess her, no pulse, no respiration noted. I lowered Resident to the floor did sternal chest rub x3 no response noted. Another nurse working with me came and assessed resident also-no sign of life noted. I called 911, Also notified Resident ' s doctor. Record review of written statement from CNA C, not dated read: At about 1:30am, RN A and I were sitting at the nurse ' s station. He got up to go check on a resident's (room [ROOM NUMBER]) feeding. CR #1 was sitting in her chair as she usually does at that time. Normally, she asks to see a nurse or just starts talking but she appeared to be asleep, which is something she had been doing lately. RN A came back from 105 (resident room [ROOM NUMBER]) and took a better look at Resident #1 and asked me to come look at her because she looked pale. I got up and checked her pulse. RNA A began rubbing her chest and calling her name. I went to look for LVN B. CNA D came down the hall and told us she had been sitting there for 30 minutes but thought nothing of it because CR #1 sits in front of the nurse ' s station every morning like that to ask for medicine. We called 911 and RN A and LVN B were standing over her. I didn ' t look closely so I ' m not sure what they were doing. We didn ' t know she was sitting there because we couldn ' t see her sitting down from over the nurse ' s station. She had been acting out of character lately and apparently had pneumonia at the time. Record review of CR #1 ' s chest x-ray dated [DATE] read in part .Impression .infiltrates are seen in the left mid and lower lung. Interview on [DATE] at 2:10pm via telephone call RN A said he found CR #1 in 100 hallway sitting in wheelchair between 1:00am and 1:30am. RN A said he called her name and she did not respond so he assessed CR #1 and found no pulse, no respirations and CR #1 was pale. RN A further revealed that he lowered CR #1 to the floor and performed a sternal rub three times without a response. When RN A was asked if he performed CPR, he stated No active CPR was started . When RN A was asked why CPR was not initiated he stated CR #1 was cool to the touch and pretty much dead . RN A did not wish to say anymore and hung up the phone. Interview on [DATE] at 1:38pm the ADON (Assistant Director of Nurses) said if a resident was found non-responsive without a pulse she would immediately call a code and she would check the residents chart for code status. She further said that if code status is not known CPR should be started until status can be verified. ADON said after code was called someone would bring the crash cart and AED. In an interview with RN E on [DATE] at 1:50pm she said, if a resident was found without a pulse and non-responsive she would go to nurses ' station, check the residents chart for code status, and would call a code if resident was a Full Code. RN E further revealed that she would grab the crash cart and another nurse on the way back to the resident ' s room. When RN E was asked where to find the AED she said that she was not sure because she normally works at another facility and was helping out today because they were short staffed. Attempted interview with LVN B on [DATE] at 2:00pm and 3:00pm. Messages left on voicemail to call surveyor. Phone calls were not returned. Attempted to interview CNA D via telephone on [DATE] at 2:20pm, no answer. Message left to call surveyor. Phone call not returned. Observation on [DATE] at 1:00 pm of facility crash cart revealed there was no list of residents who were full code versus DNR (Do not resuscitate). Observation further revealed that AED (automatic external defibrillator) was on the wall above the crash cart at the main nurses ' station and AED log book revealed that the AED had been checked daily. Interview on [DATE] at 1:00 pm the Respiratory Therapist revealed the facility does not keep a list of Full Code residents or residents who are DNR on the cart. Respiratory Therapist said that Code Status is in the residents chart or can be found in the computerized chart on the medication carts or at the nurses ' station. Respiratory Therapist said that she is responsible for maintaining the crash cart and AED and if a Full Code should occur on the day shift that respiratory services always attends but there are no respiratory therapists on the night shift, so the nurses run the code at night. In an interview on [DATE] at 2:20 pm with MA F she revealed if she found a resident unresponsive she would shout and if no one came to the resident ' s room to help, she would then run to the nurses ' station. MA F further revealed that if no one was at the nurses ' station she would run down each hall until she found someone to help her. When MA F was asked how to check residents code status she said that code status could be found in the residents chart at nurses ' station. MA F did not mention crash cart or AED. Interview on [DATE] at 2:10 pm the DON (Director of Nurses) said CPR should be initiated on all residents who are Full Code no matter how long they have been unresponsive and without a pulse. The DON said she could not understand why the two nurses (RN A and LVN B) on night shift failed to initiate CPR for Resident #1. The DON further said she asked RN A why he did not start CPR on Resident #1 when he found her to be non-responsive and without a pulse and he had responded with I just didn ' t . The DON said when she interviewed LVN B regarding not initiating CPR on Resident #1, he said he did not know. Interview with the DON further revealed the facility does not require CNA ' s (certified nurse aide) or MA ' s (medication aide) to be trained or certified in CPR and the nurses at the facility were responsible for the code. The DON said there should not be a problem for anyone to get help with CPR if they shout or holler loud enough as there were at least ,[DATE] nurses on night shift with 4 CNA ' s. The DON said that shouting is part of the CPR protocol and code status is to be checked in the residents chart at the nurses ' station or code status could be checked on the MAR (medication administration record) in the computers of the medication carts. In an interview with the DON on [DATE] at 2:55 pm she said a QA (quality assurance) meeting was not held regarding CPR but she had been doing in-services on full code versus DNR (do not resuscitate) and resident assessments with staff. Interview and observation on [DATE] at 3:20 pm, after the IJ was called, the DON and the Corporate Nurse had questions concerning the IJ. When asked concerning no QA had been done regarding CPR, the Corporate Nurse turned to the DON and said they had a QA meeting and asked the DON if she remembered. The DON did not respond. Record review of the Facility's Abuse and Neglect policy dated [DATE] (Revision date) read in part, Assessment and Recognition: 1. The nurse will assess the individual and document related findings. Assessment data will include .a. injury assessment .b. all current medications .d. vital signs .g. all active [DIAGNOSES REDACTED]. 2. The nurse will report the findings to the physician .physician will assess the resident to verify or clarify such findings, especially if the cause or the source of the problem is unclear . 3. 3b. Neglect means the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness .The facility management and staff will institute measures to address the needs of the residents and minimize the possibility of abuse and neglect . The staff and physician will monitor individuals . at least until their medical condition .have stabilized and periodically thereafter. The same policy revealed under the section Monitoring and follow-up .The Medical Director will advise facility management and staff about systems to enslure that basic medical, functional, and psychosocial needs are being met and that potentially preventable or treatable conditions affecting function and quality of life are addressed appropriately . Record review of the facility's policy Emergency Procedure-Cardiopulmonary Resuscitation dated 2001 with a revision date of [DATE] provided by facility read: If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and /or external defibrillation exists for that individual; or There are obvious signs of irreversible death (e.g., rigor mortis). Record review of the facility's policy a Change in a Resident ' s Condition or Status, dated 2001 with a revision date of [DATE] provided by facility read: The Nurse Supervisor/Charge Nurse will notify the resident ' s Attending Physician or On-Call Physician, when there has been: A significant change in the resident ' s physical/emotional/mental condition. Record review of the facility's Pulse Oximetry Policy and Procedure dated 2001 with a revision date of [DATE] read: -If SpO2 is less that 90 percent: .If SaO2 is less than acceptable level for resident ' s condition, notify the physician. - An IJ was identified on [DATE] and the DON was notified at 3:20pm. A plan to remove the IJ was submitted and accepted on [DATE]. Facility's plan of removal contained: 1. The Director of Nursing, Director of Clinical Operations, and Regional Vice President of operations was notified on 116 at approximately 3:15pm of an Immediate Jeopardy for quality of care related to delayed response of a code. The following steps are the centers plan to remove the Immediate Jeopardy. 2 a) On [DATE], Nurse Manager, licensed Nurses and director of Nursing immediately assessed all current residents in the facility to ensure every code status was correct in the residents' EMAR and hard copy chart. Confirmed 18 Residents with DNR and 65 residents with Full code Status b.) On [DATE], Social Service Director immediately assessed all current residents in the facility to ensure every care plan was Correct in the residents' EMAR and hard copy chart. C) on [DATE], Social service Director immediately assessed all current residents in the facility to ensure every code indicator was correct in the residents hard copy chart. d.) On [DATE] Human Resource audit license nurses CPR certification. 3. An Ad Hoc Quality Assurance Committee meeting was held on [DATE] with the Medical Director, Director of Nursing, Administrator, and Director of Clinical Operations the to review and discuss the plan of action of the Code Status and documented on Quality Assurance Performance Improvement Agenda form. 4. The Director of Nursing and Nurse Managers immediately began educating all staff on the following: (,[DATE] 1116) · Code Status (Cardiopulmonary Resuscitation): [MEDICAL CONDITION] is defined as inadequate cardiac contractions resulting in insufficient blood flow throughout the body Sudden [MEDICAL CONDITION] (SCA) is the leading cause of death in adults. Victims of [MEDICAL CONDITION] may initially have gasping respirations or may even appear to be having a [MEDICAL CONDITION]. The likelihood of recovering from SCA due to an acute event such as arrhythmia differs substantially from the likelihood of recovering from cardia arrest that is the end result of a multisystem failure and advanced irreversible or terminal condition. Depending on the underlying cause, the chances of surviving SCA may be increased if CPR is initiated immediately upon collapse. Any unnecessary interruptions in chest compressions (including longer than necessary pauses for rescue breathing) decreases CPR effectiveness. In potentially reversible situations, early delivery of shock with AED plus CPR within ,[DATE] minutes of collapse can further increase the chance of survival. The goal of early CPR is to try to maintain life until the emergency medical response team arrives to deliver advanced life support. If an individual ( resident, visitor, or staff member) is found unresponsive and not breathing normally, a license staff member who is certified in CPR/BLS shall initiate CPR unless: It is known that a DO NOT RESUSCITE (DNR) order that specifically prohibits CPR and /or external defibrillation exists for that individual · AED: The AED is to be used with any person in cardiopulmonary arrest as evidenced by unconsciousness; absence of nor mal breathing, absence of a pulse. If a resident is determined to be in cardiopulmonary arrest, the nurse will validate the resident's code status in the medical records prior to AED use. After assessment of the resident verifies that cardiopulmonary arrest is present, the responder assures that the 911 is called to alert the advance response team. Then CPR is begun while another responder is sent to retrieve the AED. While CPR is continued, the AED is turned on and the CPR D pads are prepared for application to the victim. CPR is discontinued while the CPR-D padz are affixed to the resident's bare chest and the cardiac rhythm is analyzed. If shock is advised, the responder ensures that all persons are cleared away from and not touching the resident and pushes the shock button. CPR is immediately resumed afterwards. If no shock is advised. CPR is resumed. Cues from the AED are followed related to depth and rate of compressions in order to optimize blood flow with CPR. AED prompts will guide the responder through further actions, until the advance response team arrives and assumes responsibility for continuing operation of the AED or transfers the victim. · How to determine a residents Code Status ( Full code or DNR) :Medication and Treatment TARS; Medical records hard copy chart · Change in condition: recognizing changes in condition (Change in a residents status; the nurse will notify the resident's attending physician and family when there has been an accident or incident involving the resident, a discovery of injury of unknown source, a reaction to medication, a significant change in the resident's physical, emotional or mental condition, a need to alter the resident's medical treatment significantly, refusal of treatment or medication, a need to transfer the resident to a hospital/treatment center, a discharge without proper medical authority, and/or instructions to notify the physician of changes in the residents change of condition. · Mock Codes: Periodic Codes (simulations of an actual arrest) for training purposes 5. The Director Of Nursing and Nurse Managers immediately began educating all staff on the following ( ,[DATE]) · Code Status (Cardiopulmonary Resuscitation): [MEDICAL CONDITION] is defined as inadequate cardiac contractions resulting in insufficient blood flow throughout the body Sudden [MEDICAL CONDITION] (SCA) is the leading cause of death in adults. Victims of [MEDICAL CONDITION] may initially have gasping respirations or may even appear to be having a [MEDICAL CONDITION]. The likelihood of recovering from SCA due to an acute event such as arrhythmia differs substantially from the likelihood of recovering from cardia arrest that is the end result of a multisystem failure and advanced irreversible or terminal condition. Depending on the underlying cause, the chances of surviving SCA may be increased if CPR is initiated immediately upon collapse. Any unnecessary interruptions in chest compressions (including longer than necessary pauses for rescue breathing) decreases CPR effectiveness. In potentially reversible situations, early delivery of shock with AED plus CPR within ,[DATE] minutes of collapse can further increase the chance of survival. The goal of early CPR is to try to maintain life until the emergency medical response team arrives to deliver advanced life support. If an individual ( resident, visitor, or staff member) is found unresponsive and not breathing normally, a license staff member who is certified in CPRIBLS shall initiate CPR unless: It is known that a DO NOT RESUSCITE (DNR) order that specifically prohibits CPR and /or external defibrillation exists for that individual · AED: The AED is to be used with any person in cardiopulmonary arrest as evidenced by unconsciousness; absence of nor mal breathing, absence of a pulse. If a resident is determined to be in cardiopulmonary arrest, the nurse will validate the resident's code status in the medical records prior to AED use. After assessment of the resident verifies that cardiopulmonary arrest is present, the responder assures that the 911 is called to alert the advance response team. Then CPR is begun while another responder is sent to retrieve the AED. While CPR is continued, the AED is turned on and the CPR D padz are prepared for application to the victim. CPR is discontinued while the CPR-D padz are affixed to the resident's bare chest and the cardiac rhythm is analyzed. If shock is advised, the responder ensures that all persons are cleared away from and not touching the resident and pushes the shock button. CPR is immediately resumed afterwards. If no shock is advised. CPR is resumed. Cues from the AED are followed related to depth and rate of compressions in order to optimize blood flow with CPR. AED prompts will guide the responder through further actions, until the advance response team arrives and assumes responsibility for continuing operation of the AED or transfers the victim. · How to determine a residents Code Status ( Full code or DNR) : Medication and Treatment TARS; Medical records hard copy chart · Change in condition: recognizing changes in condition (Change in a residents status; the nurse will notify the resident's attending physician and family when there has been an accident or incident involving the resident, a discovery of injury of unknown source, a reaction to medication, a significant change in the resident's physical, emotional or mental condition, a need to alter the resident's medical treatment significantly, refusal of treatment or medication, a need to transfer the resident to a hospital/treatment center, a discharge without proper medical authority, and/or instructions to notify the physician of changes in the residents change of condition. · Mock Codes: Periodic Codes (simulations of an actual arrest) for training purposes · Work Station Accessible on each hall (In the center) to identify code status: Each Hall has a computer in the center of the hallway. Once logged on, select the resident and the code status will appear · Computer on each medication and treatment cart and nurses station that has code status · Once Full code Status has been identified, Code Blue will be announced Education will continue each shift until I 00% of the staff is educated on the above. Those employees on FMLA or PTO will have their education completed upon arrival for the start of the next scheduled shift to work. 6. a.) To monitor the Director ofNursing/ designee started Mock Code Return demonstration on ,[DATE] and will continue. b.) Continued Review of the emergency cart and AED daily c.) DON to monitor code changes and make those reflections in the clinical record as needed 7. An Ad Hoc Quality Assurance Committee meeting was held on [DATE] with the Medical Director, Director of Nursing, Regional Vice President, and Director of Clinical Operations, and IDT the to review and discuss the plan of action of the Code Status and documented on Quality Assurance Performance Improvement Agenda form. Monitoring On [DATE] and [DATE] during all three shifts at various times staff was observed and interactions were appropriate. Staff were able to identify change in condition and to identify residents who were full code versus DNR. Record review of in-service records revealed in-services on CPR on Mock Codes were performed on [DATE], [DATE], and [DATE]. Record review of in-service records revealed in-services on Abuse and Neglect were performed on [DATE], [DATE] and [DATE]. In an interview with LVN I on [DATE] at 3:50pm, he was able to identify if a resident was full code or DNR status. LVN I was also able to demonstrate how to use AED and where the crash cart was kept. LVN I said the last in-service on CPR was [DATE] before his shift. In an interview with LVN G on [DATE] at 4:32pm, she was able to identify residents who were DNR and Full code status by the red or green sheet in the front of the residents chart. LVN G also said code status could be checked by looking in the MAR. The facility Administrator was notified on [DATE] at 4:10 pm the IJ was removed. However while the IJ was removed the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility ' s continuing need to monitor the effectiveness of the plan of removal. The facility's census listed 83 residents.

Based on observation, interview and record review the facility failed to ensure that staff provided services that met professional standards of quality for nursing care for 1 of 18 residents, Closed Record (CR) #1 who was reviewed for Advance Directives and Cardiopulmonary Resuscitation. RN A did not initiate or perform CPR on CR #1 when the resident was found unresponsive and without a pulse. CR #1 died in the facility. LVN B did not initiate or perform CPR on CR #1 when the resident was found unresponsive and without a pulse. CR #1 died in the facility. An IJ was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility needing more time to monitor the plan of removal effectiveness. This failure affected one resident and placed 65 residents with a full code status at risk of not receiving medical care and services by professionally qualified staff. Findings Include: Texas Administrative Code Title 22 Examining Boards Part 11 Texas Board of Nursing Chapter 217 Licensure, Peer Assistance and Practice Rule 217.11 Standards of nursing Practice The Texas Board of nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses, and Registered Nurses with advanced practice authorization. The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. Failure to meet these standards may result in action against the nurse ' s license even if no actual patient injury results. (1) Standards Applicable to all nurses. All vocational nurses, registered and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the boards rules and regulations as well as all federal, stated, or local laws, rules or regulations affecting the nurse ' s current area of nursing practice; . (B) Implement measures to promote a safe environment . (M) Institute appropriate nursing interventions that might be required to stabilize a client's condition and/or prevent complications . (2) Standards Specific to Vocational Nurses. The licensed vocational nurse practice is a directed scope of nursing practice under the supervision of a registered nurse, advanced practice registered nurse, physician's assistant, physician, podiatrist, or dentist. Supervision is the process of directing, guiding, and influencing the outcome of an individual's performance of an activity. The licensed vocational nurse shall assist in the determination of predictable healthcare needs of clients within healthcare settings and: (A) Shall utilize a systematic approach to provide individualized, goal-directed nursing care by . (iv) Implementing appropriate aspects of care within the LVN's scope of practice . (3) Standards Specific to Registered Nurses. The registered nurse shall assist in the determination of healthcare needs of clients and shall: (A) Utilize a systematic approach to provide individualized, goal-directed, nursing care by . (iv) Implementing nursing care . CR #1 Record review of face sheet for CR #1 revealed she was a [AGE] year old female with an initial admission date of [DATE] and a readmitted [DATE] to the facility. [DIAGNOSES REDACTED]. Record review of CR #1 ' s Care Plan Conference Summary dated [DATE] revealed: CR #1 ' s cognition was intact. CR #1 was receiving physical therapy and making progress. CR #1 was a fall risk and had balance problems. CR #1 is continent and toilets without assistance. Records review of CR #1 ' s clinical closed record revealed resident was a Full Code. MDS (minimum data set) for CR #1 was requested from DON on [DATE] and [DATE]. MDS not provided by facility. Record review of RN A ' s nurses note dated [DATE] at 12:12 am for CR #1 read: During my midnight rounds resident in bed, respiration even and unlabored, mild crackles noted in lungs. No acute distress noted. No complain of pain offered. Will continue to monitor. Record review of RN A ' s nurse ' s notes dated [DATE] at 2:15 am read: Around 0125 I went to 100 hall to check on resident in room [ROOM NUMBER], I came back to the med cart. I have passed this resident (CR #1) sitting in her wheelchair by the left side entrance of 100 hall. Which is very common of her. Upon my return to the med cart I asked CR #1 if she needs anything, when I didn ' t ' t hear any response I looked at her, she looked very pale, I went to her, upon assessment there was no pulse, I called out to my colleagues, another nurse came and assessed her too, to response noted. I called 911. CR #1 is her own responsible party. Record review of Incident Investigation Worksheet dated [DATE] revealed CR #1 was noted by RN A, at approximately 1:25 am to have wheeled her-self into the 100 hallway and was sitting next to the medication cart. RN A approached CR #1 and asked resident if she needed anything. CR #1 did not respond. RN A assessed resident and found no pulse, respirations or blood pressure. RN A lowered CR #1 to the floor and performed a sternal chest rub 3 times and received no response from CR #1. 911 was called and a second nurse (LVN B) then assessed CR #1 and confirmed CR #1 did not have signs of life. Investigation Worksheet further revealed that Autopsy was not believed to take place as CR #1 ' s body was released to Funeral Home by the facility. Record review of physician order [REDACTED].#1 ' s body to county morgue. Record review of Record of Death And Mortician ' s Receipt dated [DATE] at 2:50am revealed CR #1 ' s body was released to a private funeral home. Record review of RN A ' s written statement dated [DATE] at 9:30am read: I went to check my resident in room [ROOM NUMBER] upon returning to my medication cart. I said Ms. (NAME REDACTED) (Resident #1) do you need anything , I didn ' t get any response I looked at her, she looked very pale. I immediately went to assess her, no pulse, no respiration noted. I lowered Resident to the floor did sternell (sic) chest rub x3 no response noted. Another nurse working with me came and assessed resident also-no sign of life noted. I called 911, also notified Resident ' s doctor. Record review of written statement from CNA C, not dated read: At about 1:30am, RN A and I were sitting at the nurse ' s station. He got up to go check on a resident's (room [ROOM NUMBER]) feeding. CR #1 was sitting in her chair as she usually does at that time. Normally, she asks to see a nurse or just starts talking but she appeared to be asleep, which is something she had been doing lately. RN A came back from 105 (resident room [ROOM NUMBER]) and took a better look at CR #1 and asked me to come look at her because she looked pale. I got up and checked her pulse. RNA A began rubbing her chest and calling her name. I went to look for LVN B. CNA D came down the hall and told us she had been sitting there for 30 minutes but thought nothing of it because Resident #1 sits in front of the nurse ' s station every morning like that to ask for medicine. We called 911 and RN A and LVN B were standing over her. I did not look closely so I 'm not sure what they were doing. We didn ' t know she was sitting there because we couldn ' t ' t see her sitting down from over the nurse ' s station. She had been acting out of character lately and apparently had pneumonia at the time. Record review of CR #1 ' s chest x-ray dated [DATE] read in part .Impression .infiltrates are seen in the left mid and lower lung. Interview on [DATE] at 2:10pm via telephone call RN A said he found CR #1 in 100 hallway sitting in wheelchair between 1:00am and 1:30am. RN A said he called her name and she did not respond so he assessed CR #1 and found no pulse, no respirations and CR #1 was pale. RN A further revealed that he lowered CR #1 to the floor and performed a sternal rub three times without a response. When RN A was asked if he performed CPR, he stated No active CPR was started . When RN A was asked why CPR was not initiated he stated CR #1 was cool to the touch and pretty much dead . RN A did not wish to say anymore and hung up the phone. Interview on [DATE] at 1:38pm the ADON (Assistant Director of Nurses) said if a resident was found non-responsive without a pulse she would immediately call a code and she would check the residents chart for code status. She further said that if code status is not known CPR should be started until status can be verified. ADON said after code was called someone would bring the crash cart and AED. In an interview with RN E on [DATE] at 1:50pm she said, if a resident was found without a pulse and non-responsive she would go to nurses ' station, check the residents chart for code status, and would call a code if resident was a Full Code. RN E further revealed that she would grab the crash cart and another nurse on the way back to the resident ' s room. When RN E was asked where to find the AED she said that she was not sure because she normally works at another facility and was helping out today because they were short staffed. Attempted interview with LVN B on [DATE] at 2:00pm and 3:00pm. Messages left on voicemail to call surveyor. Phone calls were not returned. Attempted to interview CNA D via telephone on [DATE] at 2:20pm, no answer. Message left to call surveyor. Phone call not returned. In an interview with MA H on [DATE] at 10:30 am she revealed if she found a resident non-responsive without a pulse she would start CPR immediately and call a code by shouting for help. MA H further revealed that code status could be checked in the residents chart at the nurses ' station and also in the computer on the medication cart. MA H revealed she was CPR certified and identified where the crash cart and AED was kept. MA H demonstrated how to use AED with hand gestures and said the AED talks you through each step with voice commands. Observation on [DATE] at 1:00 pm of facility crash cart revealed there was no list of residents who were full code versus DNR (Do not resuscitate). Observation further revealed that AED (automatic external defibrillator) was on the wall above the crash cart at the main nurses ' station and AED log book revealed that the AED had been checked daily. Interview on [DATE] at 1:00 pm the Respiratory Therapist revealed the facility does not keep a list of Full Code residents or residents who are DNR on the cart. Respiratory Therapist said that Code Status is in the residents chart or can be found in the computerized chart on the medication carts or at the nurses ' station. Respiratory Therapist said that she is responsible for maintaining the crash cart and AED and if a Full Code should occur on the day shift that respiratory services always attends but there are no respiratory therapists on the night shift, so the nurses run the code at night. In an interview on [DATE] at 2:20 pm with MA F she revealed if she found a resident unresponsive she would shout and if no one came to the resident ' s room to help, she would then run to the nurses ' station. MA F further revealed that if no one was at the nurses ' station she would run down each hall until she found someone to help her. When MA F was asked how to check residents code status she said that code status could be found in the residents chart at nurses ' station. MA F did not mention crash cart or AED. Interview on [DATE] at 2:10 pm the DON (Director of Nurses) said CPR should be initiated on all residents who are Full Code no matter how long they have been unresponsive and without a pulse. The DON said she could not understand why the two nurses (RN A and LVN B) on night shift failed to initiate CPR for Resident #1. The DON further said she asked RN A why he did not start CPR on Resident #1 when he found her to be non-responsive and without a pulse and he had responded with I just didn ' t . The DON further said when she interviewed LVN B regarding not initiating CPR on Resident #1, he said he did not know. Interview with the DON further revealed the facility does not require CNA ' s (certified nurse aide) or MA ' s (medication aide) to be trained or certified in CPR and the nurses at the facility were responsible for the code. The DON said there should not be a problem for anyone to get help with CPR if they shout or holler loud enough as there were at least ,[DATE] nurses on night shift with 4 CNA ' s. DON further said that shouting is part of the CPR protocol and code status is to be checked in the residents chart at the nurses ' station or code status could be checked on the MAR (medication administration record) in the computers of the medication carts. In an interview with DON on [DATE] at 2:55 pm she said that a QA (quality assurance) meeting was not held regarding CPR but she had been doing in-services on full code versus DNR (do not resuscitate) and resident assessments with staff. Interview and observation on [DATE] at 3:20pm after the IJ had been called the DON and the Corporate Nurse had questions concerning the IJ. When asked concerning no QA had been done regarding CPR, the Corporate Nurse turned to the DON and said they had a QA meeting and asked the DON if she remembered. The DON did not respond. An IJ was identified on [DATE] and the DON was notified at 3:20pm. A plan to remove the IJ was submitted and accepted on [DATE]. Facility's plan of removal contained: 1. The Director of Nursing, Director of Clinical Operations, and Regional Vice President of operations was notified on 116 at approximately 3:15pm of an Immediate Jeopardy for quality of care related to delayed response of a code. The following steps are the centers plan to remove the Immediate Jeopardy. 2. a) On ,[DATE], Nurse Managers, Licensed Nurses, and the Director of Nursing immediately assessed all current residents in the facility to ensure every code status was correct in the residents' EMAR and hard copy chart. Confirmed 18 Residents with DNR and 65 residents with Full code Status b.) On [DATE], Social Service Director immediately assessed all current residents in the facility to ensure every care plan was correct in the residents' EMAR and hard copy chart. c.) On [DATE], Social Service Director immediately assessed all current residents in the facility to ensure every code indicator was correct in the residents hard copy chart. d.) On [DATE] Human Resource audit license nurses CPR certification. 3. An Ad Hoc Quality Assurance Committee meeting was held on [DATE] with the Medical Director, Director of Nursing, Administrator, and Director of Clinical Operations the to review and discuss the plan of action of the Code Status and documented on Quality Assurance Performance Improvement Agenda form. 4. The Director of Nursing and Nurse Managers immediately began educating all staff on the following: (,[DATE] 1116) · Code Status (Cardiopulmonary Resuscitation): [MEDICAL CONDITION] is defined as inadequate cardiac contractions resulting in insufficient blood flow throughout the body Sudden [MEDICAL CONDITION] (SCA) is the leading cause of death in adults. Victims of [MEDICAL CONDITION] may initially have gasping respirations or may even appear to be having a [MEDICAL CONDITION]. The likelihood of recovering from SCA due to an acute event such as arrhythmia differs substantially from the likelihood of recovering from [MEDICAL CONDITION] that is the end result of a multisystem failure and advanced irreversible or terminal condition. Depending on the underlying cause, the chances of surviving SCA may be increased if CPR is initiated immediately upon collapse. Any unnecessary interruptions in chest compressions (including longer than necessary pauses for rescue breathing) decreases CPR effectiveness. In potentially reversible situations, early delivery of shock with AED plus CPR within ,[DATE] minutes of collapse can further increase the chance of survival. The goal of early CPR is to try to maintain life until the emergency medical response team arrives to deliver advanced life support. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a license staff member who is certified in CPR/BLS shall initiate CPR unless: It is known that a DO NOT RESUSCITE (DNR) order that specifically prohibits CPR and /or external defibrillation exists for that individual · AED: The AED is to be used with any person in cardiopulmonary arrest as evidenced by unconsciousness; absence of nor mal breathing, absence of a pulse. If a resident is determined to be in cardiopulmonary arrest, the nurse will validate the resident's code status in the medical records prior to AED use. After assessment of the resident verifies that cardiopulmonary arrest is present, the responder assures that the 911 is called to alert the advance response team. Then CPR is begun while another responder is sent to retrieve the AED. While CPR is continued, the AED is turned on and the CPR D pads are prepared for application to the victim. CPR is discontinued while the CPR-D pads are affixed to the resident's bare chest and the cardiac rhythm is analyzed. If shock is advised, the responder ensures that all persons are cleared away from and not touching the resident and pushes the shock button. CPR is immediately resumed afterwards. If no shock is advised. CPR is resumed. Cues from the AED are followed related to depth and rate of compressions in order to optimize blood flow with CPR. AED prompts will guide the responder through further actions, until the advance response team arrives and assumes responsibility for continuing operation of the AED or transfers the victim. · How to determine a residents Code Status (Full code or DNR): Medication and Treatment TARS; Medical records hard copy chart · Change in condition: recognizing changes in condition (Change in a residents status; the nurse will notify the resident's attending physician and family when there has been an accident or incident involving the resident, a discovery of injury of unknown source, a reaction to medication, a significant change in the resident's physical, emotional or mental condition, a need to alter the resident's medical treatment significantly, refusal of treatment or medication, a need to transfer the resident to a hospital/treatment center, a discharge without proper medical authority, and/or instructions to notify the physician of changes in the residents change of condition. · Mock Codes: Periodic Codes (simulations of an actual arrest) for training purposes 5. The Director Of Nursing and Nurse Managers immediately began educating all staff on the following (,[DATE]) · Code Status (Cardiopulmonary Resuscitation): [MEDICAL CONDITION] is defined as inadequate cardiac contractions resulting in insufficient blood flow throughout the body Sudden [MEDICAL CONDITION] (SCA) is the leading cause of death in adults. Victims of [MEDICAL CONDITION] may initially have gasping respirations or may even appear to be having a [MEDICAL CONDITION]. The likelihood of recovering from SCA due to an acute event such as arrhythmia differs substantially from the likelihood of recovering from [MEDICAL CONDITION] that is the end result of a multisystem failure and advanced irreversible or terminal condition. Depending on the underlying cause, the chances of surviving SCA may be increased if CPR is initiated immediately upon collapse. Any unnecessary interruptions in chest compressions (including longer than necessary pauses for rescue breathing) decreases CPR effectiveness. In potentially reversible situations, early delivery of shock with AED plus CPR within ,[DATE] minutes of collapse can further increase the chance of survival. The goal of early CPR is to try to maintain life until the emergency medical response team arrives to deliver advanced life support. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a license staff member who is certified in CPRIBLS shall initiate CPR unless: It is known that a DO NOT RESUSCITE (DNR) order that specifically prohibits CPR and /or external defibrillation exists for that individual · AED: The AED is to be used with any person in cardiopulmonary arrest as evidenced by unconsciousness; absence of nor mal breathing, absence of a pulse. If a resident is determined to be in cardiopulmonary arrest, the nurse will validate the resident's code status in the medical records prior to AED use. After assessment of the resident verifies that cardiopulmonary arrest is present, the responder assures that the 911 is called to alert the advance response team. Then CPR is begun while another responder is sent to retrieve the AED. While CPR is continued, the AED is turned on and the CPR D pads are prepared for application to the victim. CPR is discontinued while the CPR-D pads are affixed to the resident's bare chest and the cardiac rhythm is analyzed. If shock is advised, the responder ensures that all persons are cleared away from and not touching the resident and pushes the shock button. CPR is immediately resumed afterwards. If no shock is advised. CPR is resumed. Cues from the AED are followed related to depth and rate of compressions in order to optimize blood flow with CPR. AED prompts will guide the responder through further actions, until the advance response team arrives and assumes responsibility for continuing operation of the AED or transfers the victim. · How to determine a residents Code Status (Full code or DNR): Medication and Treatment TARS; Medical records hard copy chart · Change in condition: recognizing changes in condition (Change in a residents status; the nurse will notify the resident's attending physician and family when there has been an accident or incident involving the resident, a discovery of injury of unknown source, a reaction to medication, a significant change in the resident's physical, emotional or mental condition, a need to alter the resident's medical treatment significantly, refusal of treatment or medication, a need to transfer the resident to a hospital/treatment center, a discharge without proper medical authority, and/or instructions to notify the physician of changes in the residents change of condition. · Mock Codes: Periodic Codes (simulations of an actual arrest) for training purposes · Work Station Accessible on each hall (In the center) to identify code status: Each Hall has a computer in the center of the hallway. Once logged on, select the resident and the code status will appear · Computer on each medication and treatment cart and nurses ' station that has code status · Once Full code Status has been identified, Code Blue will be announced Education will continue each shift until I 00% of the staff is educated on the above. Those employees on FMLA or PTO will have their education completed upon arrival for the start of the next scheduled shift to work. 6. a.) To monitor the Director of Nursing/ designee started Mock Code Return demonstration on ,[DATE] and will continue. b.) Continued Review of the emergency cart and AED daily c.) DON to monitor code changes and make those reflections in the clinical record as needed 7. An Ad Hoc Quality Assurance Committee meeting was held on [DATE] with the Medical Director, Director of Nursing, Regional Vice President, and Director of Clinical Operations, and IDT the to review and discuss the plan of action of the Code Status and documented on Quality Assurance Performance Improvement Agenda form. Monitoring During interviews with nursing staff on [DATE] and [DATE] during all three shifts at various times revealed staff was able to identify residents with change in condition and residents who were full code versus DNR. Observations on [DATE] and [DATE] during all three shifts at various times revealed staff informed physician of change in resident condition per facility policy. Record review of in-service records revealed in-services on CPR on Mock Codes were performed on [DATE], [DATE], and [DATE]. Record review of in-service records revealed in-services on Abuse and Neglect were performed on [DATE], [DATE] and [DATE]. In an interview with LVN I on [DATE] at 3:50pm, he was able to identify if a resident was full code or DNR status. LVN I was also able to demonstrate how to use AED and where the crash cart was kept. LVN I said the last in-service on CPR was [DATE] before his shift. In an interview with LVN G on [DATE] at 4:32pm, she was able to identify residents who were DNR and Full code status by the red or green sheet in the front of the residents chart. LVN G also said code status could be checked by looking in the MAR. The facility Administrator was notified on [DATE] at 4:10 pm the IJ was removed. However while the IJ was removed the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility ' s continuing need to monitor the effectiveness of the plan of removal. The facility's census was 83 residents.

Based on observation, interviews and record review, the facility failed to ensure one of eight residents (CR #1 ) reviewed for quality of care received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. -CR #1 had a full code status and the facility failed to ensure she received CPR (cardiopulmonary resuscitation) when she was found non-responsive and without a pulse. CR #1 died in the facility. An IJ was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility needing more time to monitor the plan of removal effectiveness. These deficient practices affected one resident one who died in the facility and placed 83 residents at risk for neglect, injury and death. Intake #: 3 Findings Include: CR #1 Record review of face sheet for CR #1 revealed she was a [AGE] year old female with an initial admission date of [DATE] and a readmitted [DATE] to the facility. [DIAGNOSES REDACTED]. Record review of CR #1 ' s Care Plan Conference Summary dated [DATE] revealed: CR #1 ' s cognition was intact. CR #1 was receiving physical therapy and making progress. CR #1 was a fall risk and had balance problems. CR #1 is continent and toilets without assistance. Records review of CR #1 ' s clinical closed record revealed resident was a Full Code. MDS (minimum data set) for CR #1 was requested from DON on [DATE] and [DATE]. MDS not provided by facility. Record review of RN A ' s nurses note dated [DATE] at 12:12 am for CR #1 read: During my midnight rounds resident in bed, respiration even and unlabored, mild crackles noted in lungs. No acute distress noted. No complain of pain offered. Will continue to monitor. Record review of RN A ' s nurse ' s notes dated [DATE] at 2:15 am read: Around 0125 I went to 100 hall to check on resident in room [ROOM NUMBER], I came back to the med cart. I have passed this resident (CR #1) sitting in her wheelchair by the left side entrance of 100 hall. Which is very common of her. Upon my return to the med cart I asked CR #1 if she needs anything, when I didn ' t ' t hear any response I looked at her, she looked very pale, I went to her, upon assessment there was no pulse, I called out to my colleagues, another nurse came and assessed her too, to response noted. I called 911. CR #1 is her own responsible party. Record review of Incident Investigation Worksheet dated [DATE] revealed CR #1 was noted by RN A, at approximately 1:25 am to have wheeled her-self into the 100 hallway and was sitting next to the medication cart. RN A approached CR #1 and asked resident if she needed anything. CR #1 did not respond. RN A assessed resident and found no pulse, respirations or blood pressure. RN A lowered CR #1 to the floor and performed a sternal chest rub 3 times and received no response from CR #1. 911 was called and a second nurse (LVN B) then assessed CR #1 and confirmed CR #1 did not have signs of life. Investigation Worksheet further revealed that Autopsy was not believed to take place as CR #1 ' s body was released to Funeral Home by the facility. Record review of physician order [REDACTED].#1 ' s body to county morgue. Record review of Record of Death And Mortician ' s Receipt dated [DATE] at 2:50am revealed CR #1 ' s body was released to a private funeral home. Record review of RN A ' s written statement dated [DATE] at 9:30am read: I went to check my resident in room [ROOM NUMBER] upon returning to my medication cart. I said Ms. (NAME REDACTED) (Resident #1) do you need anything , I didn ' t get any response I looked at her, she looked very pale. I immediately went to assess her, no pulse, no respiration noted. I lowered Resident to the floor did sternell (sic) chest rub x3 no response noted. Another nurse working with me came and assessed resident also-no sign of life noted. I called 911, also notified Resident ' s doctor. Record review of written statement from CNA C, not dated read: At about 1:30am, RN A and I were sitting at the nurse ' s station. He got up to go check on a resident's (room [ROOM NUMBER]) feeding. CR #1 was sitting in her chair as she usually does at that time. Normally, she asks to see a nurse or just starts talking but she appeared to be asleep, which is something she had been doing lately. RN A came back from 105 (resident room [ROOM NUMBER]) and took a better look at CR #1 and asked me to come look at her because she looked pale. I got up and checked her pulse. RNA A began rubbing her chest and calling her name. I went to look for LVN B. CNA D came down the hall and told us she had been sitting there for 30 minutes but thought nothing of it because Resident #1 sits in front of the nurse ' s station every morning like that to ask for medicine. We called 911 and RN A and LVN B were standing over her. I did not look closely so I 'm not sure what they were doing. We didn ' t know she was sitting there because we couldn ' t ' t see her sitting down from over the nurse ' s station. She had been acting out of character lately and apparently had pneumonia at the time. Record review of CR #1 ' s chest x-ray dated [DATE] read in part .Impression .infiltrates are seen in the left mid and lower lung. Interview on [DATE] at 2:10pm via telephone call RN A said he found CR #1 in 100 hallway sitting in wheelchair between 1:00am and 1:30am. RN A said he called her name and she did not respond so he assessed CR #1 and found no pulse, no respirations and CR #1 was pale. RN A further revealed that he lowered CR #1 to the floor and performed a sternal rub three times without a response. When RN A was asked if he performed CPR, he stated No active CPR was started . When RN A was asked why CPR was not initiated he stated CR #1 was cool to the touch and pretty much dead . RN A did not wish to say anymore and hung up the phone. Interview on [DATE] at 1:38pm the ADON (Assistant Director of Nurses) said if a resident was found non-responsive without a pulse she would immediately call a code and she would check the residents chart for code status. She further said that if code status is not known CPR should be started until status can be verified. ADON said after code was called someone would bring the crash cart and AED. In an interview with RN E on [DATE] at 1:50pm she said, if a resident was found without a pulse and non-responsive she would go to nurses ' station, check the residents chart for code status, and would call a code if resident was a Full Code. RN E further revealed that she would grab the crash cart and another nurse on the way back to the resident ' s room. When RN E was asked where to find the AED she said that she was not sure because she normally works at another facility and was helping out today because they were short staffed. Attempted interview with LVN B on [DATE] at 2:00pm and 3:00pm. Messages left on voicemail to call surveyor. Phone calls were not returned. Attempted to interview CNA D via telephone on [DATE] at 2:20pm, no answer. Message left to call surveyor. Phone call not returned. In an interview with MA H on [DATE] at 10:30 am she revealed if she found a resident non-responsive without a pulse she would start CPR immediately and call a code by shouting for help. MA H further revealed that code status could be checked in the residents chart at the nurses ' station and also in the computer on the medication cart. MA H revealed she was CPR certified and identified where the crash cart and AED was kept. MA H demonstrated how to use AED with hand gestures and said the AED talks you through each step with voice commands. Observation on [DATE] at 1:00 pm of facility crash cart revealed there was no list of residents who were full code versus DNR (Do not resuscitate). Observation further revealed that AED (automatic external defibrillator) was on the wall above the crash cart at the main nurses ' station and AED log book revealed that the AED had been checked daily. Interview on [DATE] at 1:00 pm the Respiratory Therapist revealed the facility does not keep a list of Full Code residents or residents who are DNR on the cart. Respiratory Therapist said that Code Status is in the residents chart or can be found in the computerized chart on the medication carts or at the nurses ' station. Respiratory Therapist said that she is responsible for maintaining the crash cart and AED and if a Full Code should occur on the day shift that respiratory services always attends but there are no respiratory therapists on the night shift, so the nurses run the code at night. In an interview on [DATE] at 2:20 pm with MA F she revealed if she found a resident unresponsive she would shout and if no one came to the resident ' s room to help, she would then run to the nurses ' station. MA F further revealed that if no one was at the nurses ' station she would run down each hall until she found someone to help her. When MA F was asked how to check residents code status she said that code status could be found in the residents chart at nurses ' station. MA F did not mention crash cart or AED. Interview on [DATE] at 2:10 pm the DON (Director of Nurses) said CPR should be initiated on all residents who are Full Code no matter how long they have been unresponsive and without a pulse. The DON said she could not understand why the two nurses (RN A and LVN B) on night shift failed to initiate CPR for Resident #1. The DON further said she asked RN A why he did not start CPR on Resident #1 when he found her to be non-responsive and without a pulse and he had responded with I just didn ' t . The DON further said when she interviewed LVN B regarding not initiating CPR on Resident #1, he said he did not know. Interview with the DON further revealed the facility does not require CNA ' s (certified nurse aide) or MA ' s (medication aide) to be trained or certified in CPR and the nurses at the facility were responsible for the code. The DON said there should not be a problem for anyone to get help with CPR if they shout or holler loud enough as there were at least ,[DATE] nurses on night shift with 4 CNA ' s. DON further said that shouting is part of the CPR protocol and code status is to be checked in the residents chart at the nurses ' station or code status could be checked on the MAR (medication administration record) in the computers of the medication carts. In an interview with DON on [DATE] at 2:55 pm she said that a QA (quality assurance) meeting was not held regarding CPR but she had been doing in-services on full code versus DNR (do not resuscitate) and resident assessments with staff. Interview and observation on [DATE] at 3:20pm after the IJ had been called the DON and the Corporate Nurse had questions concerning the IJ. When asked concerning no QA had been done regarding CPR, the Corporate Nurse turned to the DON and said they had a QA meeting and asked the DON if she remembered. The DON did not respond. Record review of in-service records revealed in-services on SBAR Communication were done on [DATE] with nursing staff. Record review of the facility's policy Emergency Procedure-Cardiopulmonary Resuscitation dated 2001 with a revision date of [DATE] provided by facility read: If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and /or external defibrillation exists for that individual; or There are obvious signs of irreversible death (e.g., rigor mortis). Record review of the facility's policy a Change in a Resident ' s Condition or Status, dated 2001 with a revision date of [DATE] provided by facility read: The Nurse Supervisor/Charge Nurse will notify the resident ' s Attending Physician or On-Call Physician, when there has been: A significant change in the resident ' s physical/emotional/mental condition. Record review of the facility's Pulse Oximetry Policy and Procedure dated 2001 with a revision date of [DATE] read: -If SpO2 is less that 90 percent: .If SaO2 is less than acceptable level for resident ' s condition, notify the physician. - An IJ was identified on [DATE] and the DON was notified at 3:20pm. A plan to remove the IJ was submitted and accepted on [DATE]. Facility's plan of removal contained: 1. The Director of Nursing, Director of Clinical Operations, and Regional Vice President of operations was notified on 116 at approximately 3:15pm of an Immediate Jeopardy for quality of care related to delayed response of a code. The following steps are the centers plan to remove the Immediate Jeopardy. 2. a) On [DATE], Nurse Managers, Licensed Nurses, and the Director of Nursing immediately assessed all current residents in the facility to ensure every code status was correct in the residents' EMAR and hard copy chart. Confirmed 18 Residents with DNR and 65 residents with Full code Status b.) On [DATE], Social Service Director immediately assessed all current residents in the facility to ensure every care plan was correct in the residents' EMAR and hard copy chart. c.) On [DATE], Social Service Director immediately assessed all current residents in the facility to ensure every code indicator was correct in the residents hard copy chart. d.) On [DATE] Human Resource audit license nurses CPR certification. 3. An Ad Hoc Quality Assurance Committee meeting was held on [DATE] with the Medical Director, Director of Nursing, Administrator, and Director of Clinical Operations the to review and discuss the plan of action of the Code Status and documented on Quality Assurance Performance Improvement Agenda form. 4. The Director of Nursing and Nurse Managers immediately began educating all staff on the following: (,[DATE] ,[DATE]) · Code Status (Cardiopulmonary Resuscitation): [MEDICAL CONDITION] is defined as inadequate cardiac contractions resulting in insufficient blood flow throughout the body Sudden [MEDICAL CONDITION] (SCA) is the leading cause of death in adults. Victims of [MEDICAL CONDITION] may initially have gasping respirations or may even appear to be having a [MEDICAL CONDITION]. The likelihood of recovering from SCA due to an acute event such as arrhythmia differs substantially from the likelihood of recovering from [MEDICAL CONDITION] that is the end result of a multisystem failure and advanced irreversible or terminal condition. Depending on the underlying cause, the chances of surviving SCA may be increased if CPR is initiated immediately upon collapse. Any unnecessary interruptions in chest compressions (including longer than necessary pauses for rescue breathing) decreases CPR effectiveness. In potentially reversible situations, early delivery of shock with AED plus CPR within ,[DATE] minutes of collapse can further increase the chance of survival. The goal of early CPR is to try to maintain life until the emergency medical response team arrives to deliver advanced life support. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a license staff member who is certified in CPR/BLS shall initiate CPR unless: It is known that a DO NOT RESUSCITE (DNR) order that specifically prohibits CPR and /or external defibrillation exists for that individual · AED: The AED is to be used with any person in cardiopulmonary arrest as evidenced by unconsciousness; absence of nor mal breathing, absence of a pulse. If a resident is determined to be in cardiopulmonary arrest, the nurse will validate the resident's code status in the medical records prior to AED use. After assessment of the resident verifies that cardiopulmonary arrest is present, the responder assures that the 911 is called to alert the advance response team. Then CPR is begun while another responder is sent to retrieve the AED. While CPR is continued, the AED is turned on and the CPR D pads are prepared for application to the victim. CPR is discontinued while the CPR-D pads are affixed to the resident's bare chest and the cardiac rhythm is analyzed. If shock is advised, the responder ensures that all persons are cleared away from and not touching the resident and pushes the shock button. CPR is immediately resumed afterwards. If no shock is advised. CPR is resumed. Cues from the AED are followed related to depth and rate of compressions in order to optimize blood flow with CPR. AED prompts will guide the responder through further actions, until the advance response team arrives and assumes responsibility for continuing operation of the AED or transfers the victim. · How to determine a residents Code Status (Full code or DNR): Medication and Treatment TARS; Medical records hard copy chart · Change in condition: recognizing changes in condition (Change in a residents status; the nurse will notify the resident's attending physician and family when there has been an accident or incident involving the resident, a discovery of injury of unknown source, a reaction to medication, a significant change in the resident's physical, emotional or mental condition, a need to alter the resident's medical treatment significantly, refusal of treatment or medication, a need to transfer the resident to a hospital/treatment center, a discharge without proper medical authority, and/or instructions to notify the physician of changes in the residents change of condition. · Mock Codes: Periodic Codes (simulations of an actual arrest) for training purposes 5. The Director Of Nursing and Nurse Managers immediately began educating all staff on the following ([DATE]) · Code Status (Cardiopulmonary Resuscitation): [MEDICAL CONDITION] is defined as inadequate cardiac contractions resulting in insufficient blood flow throughout the body Sudden [MEDICAL CONDITION] (SCA) is the leading cause of death in adults. Victims of [MEDICAL CONDITION] may initially have gasping respirations or may even appear to be having a [MEDICAL CONDITION]. The likelihood of recovering from SCA due to an acute event such as arrhythmia differs substantially from the likelihood of recovering from [MEDICAL CONDITION] that is the end result of a multisystem failure and advanced irreversible or terminal condition. Depending on the underlying cause, the chances of surviving SCA may be increased if CPR is initiated immediately upon collapse. Any unnecessary interruptions in chest compressions (including longer than necessary pauses for rescue breathing) decreases CPR effectiveness. In potentially reversible situations, early delivery of shock with AED plus CPR within ,[DATE] minutes of collapse can further increase the chance of survival. The goal of early CPR is to try to maintain life until the emergency medical response team arrives to deliver advanced life support. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a license staff member who is certified in CPRIBLS shall initiate CPR unless: It is known that a DO NOT RESUSCITE (DNR) order that specifically prohibits CPR and /or external defibrillation exists for that individual · AED: The AED is to be used with any person in cardiopulmonary arrest as evidenced by unconsciousness; absence of nor mal breathing, absence of a pulse. If a resident is determined to be in cardiopulmonary arrest, the nurse will validate the resident's code status in the medical records prior to AED use. After assessment of the resident verifies that cardiopulmonary arrest is present, the responder assures that the 911 is called to alert the advance response team. Then CPR is begun while another responder is sent to retrieve the AED. While CPR is continued, the AED is turned on and the CPR D pads are prepared for application to the victim. CPR is discontinued while the CPR-D pads are affixed to the resident's bare chest and the cardiac rhythm is analyzed. If shock is advised, the responder ensures that all persons are cleared away from and not touching the resident and pushes the shock button. CPR is immediately resumed afterwards. If no shock is advised. CPR is resumed. Cues from the AED are followed related to depth and rate of compressions in order to optimize blood flow with CPR. AED prompts will guide the responder through further actions, until the advance response team arrives and assumes responsibility for continuing operation of the AED or transfers the victim. · How to determine a residents Code Status (Full code or DNR): Medication and Treatment TARS; Medical records hard copy chart · Change in condition: recognizing changes in condition (Change in a residents status; the nurse will notify the resident's attending physician and family when there has been an accident or incident involving the resident, a discovery of injury of unknown source, a reaction to medication, a significant change in the resident's physical, emotional or mental condition, a need to alter the resident's medical treatment significantly, refusal of treatment or medication, a need to transfer the resident to a hospital/treatment center, a discharge without proper medical authority, and/or instructions to notify the physician of changes in the residents change of condition. · Mock Codes: Periodic Codes (simulations of an actual arrest) for training purposes · Work Station Accessible on each hall (In the center) to identify code status: Each Hall has a computer in the center of the hallway. Once logged on, select the resident and the code status will appear · Computer on each medication and treatment cart and nurses ' station that has code status · Once Full code Status has been identified, Code Blue will be announced Education will continue each shift until I 00% of the staff is educated on the above. Those employees on FMLA or PTO will have their education completed upon arrival for the start of the next scheduled shift to work. 6. a.) To monitor the Director of Nursing/ designee started Mock Code Return demonstration on ,[DATE] and will continue. b.) Continued Review of the emergency cart and AED daily c.) DON to monitor code changes and make those reflections in the clinical record as needed 7. An Ad Hoc Quality Assurance Committee meeting was held on [DATE] with the Medical Director, Director of Nursing, Regional Vice President, and Director of Clinical Operations, and IDT the to review and discuss the plan of action of the Code Status and documented on Quality Assurance Performance Improvement Agenda form. Monitoring During interviews with nursing staff on [DATE] and [DATE] during all three shifts at various times revealed staff was able to identify residents with change in condition and residents who were full code versus DNR. Observations on [DATE] and [DATE] during all three shifts at various times revealed staff informed physician of change in resident condition per facility policy. Record review of in-service records revealed in-services on CPR on Mock Codes were performed on [DATE], [DATE], and [DATE]. Record review of in-service records revealed in-services on Abuse and Neglect were performed on [DATE], [DATE] and [DATE]. In an interview with LVN I on [DATE] at 3:50pm, he was able to identify if a resident was full code or DNR status. LVN I was also able to demonstrate how to use AED and where the crash cart was kept. LVN I said the last in-service on CPR was [DATE] before his shift. In an interview with LVN G on [DATE] at 4:32pm, she was able to identify residents who were DNR and Full code status by the red or green sheet in the front of the residents chart. LVN G also said code status could be checked by looking in the MAR. The facility Administrator was notified on [DATE] at 4:10 pm the IJ was removed. However while the IJ was removed the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility ' s continuing need to monitor the effectiveness of the plan of removal. The facility's census was 83 residents.

Based on observation, interview and record review the Facility Administration failed to administer the facility in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practical physical, mental and psychosocial well-being for one of ten residents (CR #1 ) reviewed for quality of care. The Administrator failed to: -To implement the facility's policy and procedure on Advance Directives and CPR. -Supervise the DON to ensure nursing staff performed CPR (cardiopulmonary resuscitation) on unresponsive, pulseless residents who were Full Code. -Supervise the DON to ensure nursing staff conducted accurate assessments of residents, when they had a change in condition. -Supervise the DON to ensure nursing staff monitor and notify physician and document resident's assessment of residents when they had a change in condition. The DON failed to: -Train and monitor the staff on CPR implementation. -Train and monitor the staff on assessments of Residents when they had a change in condition. -Train and monitor the staff on monitoring residents condition when they had a change in condition. -Train and monitor the staff on notifying resident's physician when they had a change in condition. These failures affected one residents, one who died in the facility and placed 83 residents at risk for neglect, injury, medical decline or death. An IJ was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility needing more time to monitor the plan of removal's effectiveness. Findings Include: Intake #: 3 CR #1 Record review of face sheet for CR #1 revealed she was a [AGE] year old female with an initial admission date of [DATE] and a readmitted [DATE] to the facility. Diagnoses: [REDACTED]. Record review of CR #1 ' s clinical closed record revealed a green code status alert sheet in the front of the medical record that indicated the resident was Full Code and for staff to proceed with cardiopulmonary resuscitation. Record review of Incident Investigation Worksheet dated [DATE] revealed that Resident #1 was noted by RN A, at approximately 1:25am to have wheeled her-self into the 100 hallway and was sitting next to the medication cart. RN A approached Resident #1 and asked resident if she needed anything. Resident #1 did not respond. RN A assessed resident and found no pulse, respirations or blood pressure. RN A lowered Resident #1 to the floor and performed a sternal chest rub 3 times and received no response from Resident #1. 911 was called and a second nurse (LVN B )then assessed Resident #1 and confirmed Resident #1 did not have signs of life. Investigation Worksheet further revealed that Autopsy was not believed to take place as Resident #1 ' s body was released to Funeral Home by the facility. In an interview on [DATE] at 2:10 pm via telephone call with RN A, he said he found Resident #1 in 100 hallway sitting in wheelchair between 1:00am and 1:30am. RN A said he called her name and she did not respond so he assessed Resident #1 and found no pulse, no respirations and Resident #1 was pale. RN A further revealed that he lowered Resident #1 to the floor and performed a sterna rub 3 times without a response. When RN A was asked if he performed CPR, he stated No active CPR was started . When RN A was asked why CPR was not initiated he stated Resident #1 was cool to the touch and pretty much dead . RN A did not wish to say anymore and hung up the phone. In an interview on [DATE] at 3:15 pm with LVN B, he was questioned by surveyor on what occurred and said he was called to nurses station by RN A and informed that Resident #1 had expired. When asked about policies and procedures regarding use of AED and CPR, he stated I guess I should have started CPR. In an interview with RN E on [DATE] at 1:50 pm she said, if a resident was found without a pulse and non-responsive she would go to nurses ' station, check the residents chart for code status, and would call a code if resident was a Full Code. RN E further revealed she would grab the crash cart and another nurse on the way back to the resident ' s room. When RN E was asked where to find the AED she said that she was not sure because she normally worked at another facility and was helping out today because they were short staffed. RN E said she had not received in-service on Abuse, neglect or CPR at this facility as she normally worked at another facility. In an interview on [DATE] at 2:20pm with MA F she revealed that if she found a resident unresponsive she would shout and if no one came to the resident ' s room to help, she would then run to the nurses ' station. MA F further revealed that if no one was at the nurses ' station she would run down each hall until she found someone to help her. When MA F was asked how to check residents code status she said that code status could be found in the residents chart at nurses ' station. MA F did not mention crash cart or AED. In an interview the DON (Director of Nurses) on [DATE] at 2:10 pm she said CPR should be initiated on all residents who were Full Code no matter how long they have been unresponsive and without a pulse. She stated every resident's chart had either a green (full code) sheet or a red (DNR) Do Not Resuscitate sheet. In an interview on [DATE] at 2:55 pm the DON said a QA (quality assurance) meeting was not held regarding CPR but she had been doing in-services on full code versus DNR (do not resuscitate) and resident assessments with staff. Interview and observation on [DATE] at 3:30 pm the DON and the Corporate Nurse questions about the IJ were answered. When the Corporate Nurse was asked why there was no QA done regarding CPR, the Corporate Nurse turned to DON and said they had a QA meeting and asked the DON if she remembered. The DON did not respond. In an interview on [DATE] at 10:55am the Administrator said he monitored the DON by the in-services of the staff and monitoring her performance. Administrator said he was aware of the incident where CPR was not provided to a Full Code status resident. The Administrator said he was the interim Administrator for the facility as a new Administrator would be starting [DATE]. Record review of Pulse Oximetry Policy and Procedure dated 2001 with a revision date of [DATE] read: -Review the physician's order [REDACTED]. -Review the resident ' s care plan to assess for any special needs of the resident. -Refer to the manufacturer ' s instructions for pulse oximetry placement and alarm settings. -Assemble the equipment and supplies needed. -If SpO2 is less that 90 percent: -Reposition the probe and re-evaluate readings. -If SaO2 is less than acceptable level for resident ' s condition, notify the physician. -Position the resident in semi or high-Fowler ' s position. Record review of Change in a Resident ' s Condition or Status, dated 2001 with a revision date of [DATE] provided by facility read: The Nurse Supervisor/Charge Nurse will notify the resident ' s Attending Physician or On-Call Physician, when there has been: A significant change in the resident ' s physical/emotional/mental condition. Record review of Emergency Procedure-Cardiopulmonary Resuscitation dated 2001 with a revision date of [DATE] provided by facility read: .If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and /or external defibrillation exists for that individual; or There are obvious signs of irreversible death (e.g., rigor mortis) . Record review of facility Abuse and Neglect Policy, date not able to be read, revealed Policy Statement: Our residents have the right to be free from abuse, neglect and misappropriation of resident property, corporal punishment and involuntary seclusion. In an interview with DON on [DATE] at 3:00pm she said In-services have been provided frequently on abuse, neglect, CPR and assessments. DON said staff are monitored when performing MOCK codes and assessments to make sure staff understands content. An IJ was identified on [DATE] and the DON was notified at 3:20pm. A plan to remove the IJ was submitted and accepted on [DATE]. Facility's plan of removal contained: 1. The Director of Nursing, Director of Clinical Operations, and Regional Vice President of operations was notified on 116 at approximately 3:15pm of an Immediate Jeopardy for quality of care related to delayed response of a code. The following steps are the centers plan to remove the Immediate Jeopardy. 2. a) On ,[DATE], Nurse Managers, Licensed Nurses, and the Director of Nursing immediately assessed all current residents in the facility to ensure every code status was correct in the residents' EMAR and hard copy chart. Confmned 18 Residents with DNR and 65 residents with Full code Status b.) On [DATE], Social Service Director immediately assessed all current residents in the facility to ensure every care plan was correct in the residents' EMAR and hard copy chart. c.) On [DATE], Social Service Director immediately assessed all current residents in the facility to ensure every code indicator was correct in the residents hard copy chart. d.) On [DATE] Human Resource audit license nurses CPR certification. 3. An Ad Hoc Quality Assurance Committee meeting was held on [DATE] with the Medical Director, Director of Nursing, Administrator, and Director of Clinical Operations the to review and discuss the plan of action of the Code Status and documented on Quality Assurance Performance Improvement Agenda form. 4. The Director of Nursing and Nurse Managers immediately began educating all staff on the following: (,[DATE] 1116) · Code Status (Cardiopulmonary Resuscitation): [MEDICAL CONDITION] is defined as inadequate cardiac contractions resulting in insufficient blood flow throughout the body Sudden [MEDICAL CONDITION] (SCA) is the leading cause of death in adults. Victims of [MEDICAL CONDITION] may initially have gasping respirations or may even appear to be having a [MEDICAL CONDITION]. The likelihood of recovering from SCA due to an acute event such as arrhythmia differs substantially from the likelihood of recovering from cardia arrest that is the end result of a multisystem failure and advanced irreversible or terminal condition. Depending on the underlying cause, the chances of surviving SCA may be increased if CPR is initiated immediately upon collapse. Any unnecessary interruptions in chest compressions (including longer than necessary pauses for rescue breathing) decreases CPR effectiveness. In potentially reversible situations, early delivery of shock with AED plus CPR within ,[DATE] minutes of collapse can further increase the chance of survival. The goal of early CPR is to try to maintain life until the emergency medical response team arrives to deliver advanced life support. If an individual ( resident, visitor, or staff member) is found unresponsive and not breathing normally, a license staff member who is certified in CPR/BLS shall initiate CPR unless: It is known that a DO NOT RESUSCITE (DNR) order that specifically prohibits CPR and /or external defibrillation exists for that individual · AED: The AED is to be used with any person in cardiopulmonary arrest as evidenced by unconsciousness; absence of nor mal breathing, absence of a pulse. If a resident is determined to be in cardiopulmonary arrest, the nurse will validate the resident's code status in the medical records prior to AED use. After assessment of the resident verifies that cardiopulmonary arrest is present, the responder assures that the 911 is called to alert the advance response team. Then CPR is begun while another responder is sent to retrieve the AED. While CPR is continued, the AED is turned on and the CPR D pads are prepared for application to the victim. CPR is discontinued while the CPR-D padz are affixed to the resident's bare chest and the cardiac rhythm is analyzed. If shock is advised, the responder ensures that all persons are cleared away from and not touching the resident and pushes the shock button. CPR is immediately resumed afterwards. If no shock is advised. CPR is resumed. Cues from the AED are followed related to depth and rate of compressions in order to optimize blood flow with CPR. AED prompts will guide the responder through further actions, until the advance response team arrives and assumes responsibility for continuing operation of the AED or transfers the victim. · How to determine a residents Code Status ( Full code or DNR) :Medication and Treatment TARS; Medical records hard copy chart · Change in condition: recognizing changes in condition (Change in a residents status; the nurse will notify the resident's attending physician and family when there has been an accident or incident involving the resident, a discovery of injury of unknown source, a reaction to medication, a significant change in the resident's physical, emotional or mental condition, a need to alter the resident's medical treatment significantly, refusal of treatment or medication, a need to transfer the resident to a hospital/treatment center, a discharge without proper medical authority, and/or instructions to notify the physician of changes in the residents change of condition. · Mock Codes: Periodic Codes (simulations of an actual arrest) for training purposes 5. The Director Of Nursing and Nurse Managers immediately began educating all staff on the following ( ,[DATE]) · Code Status (Cardiopulmonary Resuscitation): [MEDICAL CONDITION] is defined as inadequate cardiac contractions resulting in insufficient blood flow throughout the body Sudden [MEDICAL CONDITION] (SCA) is the leading cause of death in adults. Victims of [MEDICAL CONDITION] may initially have gasping respirations or may even appear to be having a [MEDICAL CONDITION]. The likelihood of recovering from SCA due to an acute event such as arrhythmia differs substantially from the likelihood of recovering from cardia arrest that is the end result of a multisystem failure and advanced irreversible or terminal condition. Depending on the underlying cause, the chances of surviving SCA may be increased if CPR is initiated immediately upon collapse. Any unnecessary interruptions in chest compressions (including longer than necessary pauses for rescue breathing) decreases CPR effectiveness. In potentially reversible situations, early delivery of shock with AED plus CPR within ,[DATE] minutes of collapse can further increase the chance of survival. The goal of early CPR is to try to maintain life until the emergency medical response team arrives to deliver advanced life support. If an individual ( resident, visitor, or staff member) is found unresponsive and not breathing normally, a license staff member who is certified in CPRIBLS shall initiate CPR unless: It is known that a DO NOT RESUSCITE (DNR) order that specifically prohibits CPR and /or external defibrillation exists for that individual · AED: The AED is to be used with any person in cardiopulmonary arrest as evidenced by unconsciousness; absence of nor mal breathing, absence of a pulse. If a resident is determined to be in cardiopulmonary arrest, the nurse will validate the resident's code status in the medical records prior to AED use. After assessment of the resident verifies that cardiopulmonary arrest is present, the responder assures that the 911 is called to alert the advance response team. Then CPR is begun while another responder is sent to retrieve the AED. While CPR is continued, the AED is turned on and the CPR D padz are prepared for application to the victim. CPR is discontinued while the CPR-D padz are affixed to the resident's bare chest and the cardiac rhythm is analyzed. If shock is advised, the responder ensures that all persons are cleared away from and not touching the resident and pushes the shock button. CPR is immediately resumed afterwards. If no shock is advised. CPR is resumed. Cues from the AED are followed related to depth and rate of compressions in order to optimize blood flow with CPR. AED prompts will guide the responder through further actions, until the advance response team arrives and assumes responsibility for continuing operation of the AED or transfers the victim. · How to determine a residents Code Status ( Full code or DNR) : Medication and Treatment TARS; Medical records hard copy chart · Change in condition: recognizing changes in condition (Change in a residents status; the nurse will notify the resident's attending physician and family when there has been an accident or incident involving the resident, a discovery of injury of unknown source, a reaction to medication, a significant change in the resident's physical, emotional or mental condition, a need to alter the resident's medical treatment significantly, refusal of treatment or medication, a need to transfer the resident to a hospital/treatment center, a discharge without proper medical authority, and/or instructions to notify the physician of changes in the residents change of condition. · Mock Codes: Periodic Codes (simulations of an actual arrest) for training purposes · Work Station Accessible on each hall (In the center) to identify code status: Each Hall has a computer in the center of the hallway. Once logged on, select the resident and the code status will appear · Computer on each medication and treatment cart and nurses station that has code status · Once Full code Status has been identified, Code Blue will be announced Education will continue each shift until I 00% of the staff is educated on the above. Those employees on FMLA or PTO will have their education completed upon arrival for the start of the next scheduled shift to work. 6. a.) To monitor the Director ofNursing/ designee started Mock Code Return demonstration on ,[DATE] and will continue. b.) Continued Review of the emergency cart and AED daily c.) DON to monitor code changes and make those reflections in the clinical record as needed 7. An Ad Hoc Quality Assurance Committee meeting was held on [DATE] with the Medical Director, Director of Nursing, Regional Vice President, and Director of Clinical Operations, and IDT the to review and discuss the plan of action of the Code Status and documented on Quality Assurance Performance Improvement Agenda form. Monitoring of the plan of removal: Record review of in-service records revealed in-services on CPR on Mock Codes were performed on [DATE], [DATE], and [DATE]. Record review of in-service records revealed in-services on Abuse and Neglect were performed on [DATE], [DATE] and [DATE]. In an interview with LVN I on [DATE] at 3:50pm, he was able to identify if a resident was full code or DNR status. LVN I was also able to demonstrate how to use AED and where the crash cart was kept. LVN I said the last in-service on CPR was [DATE] before his shift. In an interview with LVN G on [DATE] at 4:32pm, she was able to identify residents who were DNR and Full code status by the red or green sheet in the front of the residents chart. LVN G also said code status could be checked by looking in the MAR. The facility Administrator was notified on [DATE] at 4:10 pm the IJ was removed. However while the IJ was removed the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility ' s continuing need to monitor the effectiveness of the plan of removal. The facility census was 83.

Based on observation, interview and record review the facility failed to ensure the right to formulate advance directives for one of ten residents (CR #1) reviewed for advance directives. The facility failed to follow the advance directives of CR #1 ' s full code status when she was found non-responsive and without a pulse. Staff failed to initiate Cardio [MEDICAL CONDITION] Resuscitation (CPR). This failure affected one resident who died in the facility and placed 65 additional residents in the facility who had requested a Full Code status to not be provided resuscitation, which would result in death. An IJ was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of actual harm due to the facility needing more time to monitor the plan of removal effectiveness. Intake #: 3 Findings Include: CR #1 Record review of face sheet for CR #1 revealed she was a [AGE] year old female with an initial admission date of [DATE] and a readmitted [DATE] to the facility. Diagnoses: [REDACTED]. Record review of CR #1 ' s clinical closed record revealed a green code status alert sheet in the front of the medical record that indicated the resident was Full Code and for staff to proceed with cardiopulmonary resuscitation. Record review of Quarterly Social Service Review notes dated [DATE] revealed an X next to FULL Code, indicating CR #1 was a Full Code. Quarterly Social Service Review notes further revealed CR #1 (CR #1) is her own RP-social worker assists as needed and had Resident #1 had no cognitive deficits . Record review of CR #1's Care Plan Conference Summary dated [DATE] revealed: CR #1 ' s cognition was intact. CR #1 was receiving physical therapy and making progress. CR #1 was a fall risk and had balance problems. CR #1 is continent and toilets without assistance. Record review of CR #1 ' s Care Plan Conference Summary dated [DATE] revealed: Special Requests/Choices/Conditions; Full Code. MDS (minimum data set assessment) for CR #1 was requested from the DON on [DATE] at 11:00 am and on [DATE] at 11:06 am. An MDS was not provided by the facility prior to exit. Record review of RN A 's nurses note dated [DATE] at 12:12 am for CR #1 read in part: During my midnight rounds resident in bed, respiration even and unlabored, mild crackles noted in lungs. No acute distress noted. No complain of pain offered. Will continue to monitor. Record review of the facility Incident Investigation Worksheet dated [DATE] revealed CR #1 was noted by RN A, at approximately 1:25 am to have wheeled her-self into the 100 hallway and was sitting next to the medication cart. RN A approached CR#1 and asked the resident if she needed anything. CR #1 did not respond. RN A assessed the resident and found no pulse, respirations or blood pressure. RN A lowered CR #1 to the floor and performed a sternal chest rub three times and received no response from CR #1. At this time 911 was called and a second nurse (LVN B ) then assessed CR #1 and confirmed CR #1 did not have any signs of life. The Investigation Worksheet further revealed that an autopsy was not believed to take place as CR#1 ' s body was released to a funeral home by the facility. Record review of RN A ' s nurses notes dated [DATE] at 2:15 am read: Around 0125 (1:25 am) I went to 100 hall to check on resident in room [ROOM NUMBER], I came back to the med cart. I have passed this resident (CR #1) sitting in her wheelchair by the left side entrance of 100 hall. Which is very common of her. Upon my return to the med cart I asked CR #1 if she needs anything, when I didn ' t hear any response I looked at her, she looked very pale, I went to her, upon assessment there was no pulse, I called out to my colleagues, another nurse came and assessed her too, no response noted. I called 911. Resident (CR #1) is her own responsible party. Record review of CR #1's physician's orders [REDACTED].#1 ' s body to the county morgue. Record review of Record of Death And Mortician ' s Receipt dated [DATE] at 2:50 am revealed CR #1 ' s body was released to a private funeral home. Interview on [DATE] at 3:15 pm via telephone LVN B said he was called to nurses station on [DATE] by RN A who informed him that CR #1 had expired. When LVN B was asked about policies and procedures regarding use of AED and CPR, he stated I guess I should have started CPR. Interview on [DATE] at 2:10 pm via telephone RN A said he found CR #1 on the 100 hallway sitting in wheelchair between 1:00 am and 1:30 am. RN A said he called her name and she did not respond so he assessed CR #1 and found no pulse, no respirations and CR #1 was pale. RN A said he lowered CR #1 to the floor and performed a sternal rub three times without a response. When RN A was asked if he performed CPR, he stated No active CPR was started. When RN A was asked why CPR was not initiated he stated CR #1 was cold to the touch and pretty much dead. RN A did not wish to say anymore and hung up the phone. In an interview on [DATE] at 2:10 pm the Director of Nurses (DON) said CPR should be initiated on all residents who are Full Code no matter how long they had been unresponsive and without a pulse. The DON said she could not understand why the nurses (RN A and LVN B) on the night shift failed to initiate CPR for CR #1. The DON further said she asked RN A why he did not start CPR on CR #1 when he found her to be non-responsive and without a pulse. RN A had responded with I just didn ' t . The DON said when she interviewed LVN B regarding why there was no initiating of CPR for CR #1, he said he did not know. Interview with the DON further revealed the facility does not require certified nurse aides (CNA) or medication aides (MA) to be trained or certified in CPR and the nurses at the facility were responsible for performing the code. The DON said there should not be a problem for anyone to get help with CPR if they shout or holler loud enough as there were at least two to three nurses on night shift with four CNAs. The DON further said shouting was part of the CPR protocol and code status was to be checked in the residents chart at the nurses ' station or code status could be checked on the medication administration record (MAR) in the computers on the medication carts. Record review of RN A ' s written statement dated [DATE] at 9:30 am read: I went to check my Resident in room [ROOM NUMBER] upon returning to my medication cart. I said Ms (CR #1) do you need anything , I didn ' t ' t get any response I looked at her, she looked very pale. I immediately went to assess her, no pulse, no respiration noted. I lowered Resident to the floor did sternal chest rub x3 no response noted. Another nurse working with me came and assessed resident also-no sign of life noted. I called 911. Also notified Resident ' s doctor. Record review of written statement from CNA C, not dated read: At about 1:30 am, (RN A) and I were sitting at the nurse ' s station. He got up to go check a Resident's (room [ROOM NUMBER]) feeding. (CR #1) was sitting in her chair as she usually does at that time. Normally, she asks to see a nurse or just starts talking but she appeared to be asleep, which is something she had been doing lately. ( RN A ) came back from 105 (resident room [ROOM NUMBER]) and took a better look at (CR #1) and asked me to come look at her because she looked pale. I got up and checked her pulse. RNA A began rubbing her chest and calling her name. I went to look for (LVN B). (CNA D) came down the hall and told us she had been sitting there for 30 minutes but thought nothing of it because (CR #1) sits in front of the nurse ' s station every morning like that to ask for medicine. We called 911 and (RN A) and (LVN B) were standing over her. I didn ' t look closely so I ' m not sure what they were doing. We didn ' t know she was sitting there because we couldn ' t see her sitting down from over the nurses station. She had been acting out of character lately and apparently had pneumonia at the time. Record review of CR #1 ' s chest x-ray dated [DATE] read in part .Impression .infiltrates are seen in the left mid and lower lung. Attempted to interview CNA D via telephone on [DATE] at 2:20 pm, no answer. Message left to call surveyor. Phone call not returned. Interview on [DATE] at 1:38 pm the Assistant Director of Nurses (ADON) said if a resident was found non-responsive without a pulse she would immediately call a code and she would check the residents chart for code status. She further said if the code status was not known CPR should be started until status can be verified. The ADON said after the code was called someone would bring the crash cart and AED. Interview on [DATE] at 1:50 pm RN E said, if a resident was found without a pulse and non-responsive she would go to the nurses ' station, check the residents chart for a code status, and would call a code if the resident was a Full Code. RN E further revealed she would grab the crash cart and another nurse on the way back to the resident ' s room. When RN E was asked where to find the AED she said that she was not sure because she normally worked at another facility and was helping out today because the facility was short staffed. In an interview on [DATE] at 2:20 pm with MA F said if she found a resident unresponsive she would shout and if no one came to the resident ' s room to help, she would then run to the nurses ' station. MA F further revealed if no one was at the nurses ' station she would run down each hall until she found someone to help her. When MA F was asked how to check residents code status she said the resident's code status could be found in the residents chart at nurses ' station. MA F did not mention crash cart or AED. Further observation revealed there was an automatic external defibrillator (AED) on the wall above the crash cart at the main nurses ' station. Interview on [DATE] at 1:00 pm the Respiratory Therapist stated the facility did not keep a list of Full Code residents or residents who were DNR on the cart. The Respiratory Therapist said the resident's Code Status was in the residents chart or could be found in the computerized chart on the medication carts or at the nurses ' station. The Respiratory Therapist said she was responsible for maintaining the crash cart and the AED. If a Full Code should occur on the day shift, respiratory services always attended but there were no respiratory therapists on the night shift, so the nurses would actually run the code at night. Interview on [DATE] at 2:55 pm the DON said a QA (quality assurance) meeting was not held regarding CPR but she had been doing in-services on full code versus do not resuscitate (DNR) and resident assessments with staff. Interview and observation on [DATE] at 3:20pm with the DON and the Corporate Nurse after the IJ was called, the Corporate Nurse had questions concerning the IJ that was identified. When questioned concerning that no QA had been done regarding CPR, the Corporate Nurse turned to the DON and stated they had a QA meeting and asked the DON if she remembered the meeting. The DON did not respond. Interview on [DATE] at 4:32 pm LVN G said if she found a resident non-responsive without a pulse or respirations she would immediately call a code, have someone check the residents chart or check on medication cart for code status. LVN G further said she would have someone get the crash cart. When LVN G was asked what if no one responds to the code she said call light in room and emergency call light in residents bathroom would be pulled and she would continue to call for help. LVN G said the facility had an in-service on CPR on [DATE]. Record review of the policy: Emergency Procedure-Cardiopulmonary Resuscitation dated 2001 with a revision date of [DATE] provided by facility read: .-The goal of delivery of CPR is to try to maintain life until the emergency medical response team arrives to deliver Advanced Life Support (ALS). -If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and /or external defibrillation exists for that individual; or There are obvious signs of irreversible death (e.g., rigor mortis). On [DATE] at 3:20pm an IJ was identified and the information was. The IJ was removed on [DATE] at 4:10 P.M. A plan of removal of the IJ was submitted and accepted on [DATE]. The plan included: 1. The Director of Nursing, Director of Clinical Operations, and Regional Vice President of operations was notified on 116 at approximately 3:15pm of an Immediate Jeopardy for quality of care related to delayed response of a code. The following steps are the centers plan to remove the Immediate Jeopardy. 2. a) On ,[DATE], Nurse Managers, Licensed Nurses, and the Director of Nursing immediately assessed all current residents in the facility to ensure every code status was correct in the residents' EMAR and hard copy chart. Confmned 18 Residents with DNR and 65 residents with Full code Status b.) On [DATE], Social Service Director immediately assessed all current residents in the facility to ensure every care plan was correct in the residents' EMAR and hard copy chart. c.) On [DATE], Social Service Director immediately assessed all current residents in the facility to ensure every code indicator was correct in the residents hard copy chart. d.) On [DATE] Human Resource audit license nurses CPR certification. 3. An Ad Hoc Quality Assurance Committee meeting was held on [DATE] with the Medical Director, Director of Nursing, Administrator, and Director of Clinical Operations the to review and discuss the plan of action of the Code Status and documented on Quality Assurance Performance Improvement Agenda form. 4. The Director of Nursing and Nurse Managers immediately began educating all staff on the following: (,[DATE] 1116). Code Status (Cardiopulmonary Resuscitation): [MEDICAL CONDITION] is defined as inadequate cardiac contractions resulting in insufficient blood flow throughout the body Sudden [MEDICAL CONDITION] (SCA) is the leading cause of death in adults. Victims of [MEDICAL CONDITION] may initially have gasping respirations or may even appear to be having a [MEDICAL CONDITION]. The likelihood of recovering from SCA due to an acute event such as arrhythmia differs substantially from the likelihood of recovering from cardia arrest that is the end result of a multisystem failure and advanced irreversible or terminal condition. Depending on the underlying cause, the chances of surviving SCA may be increased if CPR is initiated immediately upon collapse. Any unnecessary interruptions in chest compressions (including longer than necessary pauses for rescue breathing) decreases CPR effectiveness. In potentially reversible situations, early delivery of shock with AED plus CPR within ,[DATE] minutes of collapse can further increase the chance of survival. The goal of early CPR is to try to maintain life until the emergency medical response team arrives to deliver advanced life support. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a license staff member who is certified in CPR/BLS shall initiate CPR unless: It is known that a DO NOT RESUSCITE (DNR) order that specifically prohibits CPR and /or external defibrillation exists for that individual. AED: The AED is to be used with any person in cardiopulmonary arrest as evidenced by unconsciousness; absence of nor mal breathing, absence of a pulse. If a resident is determined to be in cardiopulmonary arrest, the nurse will validate the resident's code status in the medical records prior to AED use. After assessment of the resident verifies that cardiopulmonary arrest is present, the responder assures that the 911 is called to alert the advance response team. Then CPR is begun while another responder is sent to retrieve the AED. While CPR is continued, the AED is turned on and the CPR D pads are prepared for application to the victim. CPR is discontinued while the CPR-D padz are affixed to the resident's bare chest and the cardiac rhythm is analyzed. If shock is advised, the responder ensures that all persons are cleared away from and not touching the resident and pushes the shock button. CPR is immediately resumed afterwards. If no shock is advised. CPR is resumed. Cues from the AED are followed related to depth and rate of compressions in order to optimize blood flow with CPR. AED prompts will guide the responder through further actions, until the advance response team arrives and assumes responsibility for continuing operation of the AED or transfers the victim. · How to determine a residents Code Status ( Full code or DNR) :Medication and Treatment TARS; Medical records hard copy chart · Change in condition: recognizing changes in condition (Change in a residents status; the nurse will notify the resident's attending physician and family when there has been an accident or incident involving the resident, a discovery of injury of unknown source, a reaction to medication, a significant change in the resident's physical, emotional or mental condition, a need to alter the resident's medical treatment significantly, refusal of treatment or medication, a need to transfer the resident to a hospital/treatment center, a discharge without proper medical authority, and/or instructions to notify the physician of changes in the residents change of condition. · Mock Codes: Periodic Codes (simulations of an actual arrest) for training purposes. 5. The Director Of Nursing and Nurse Managers immediately began educating all staff on the following ( ,[DATE]) · Code Status (Cardiopulmonary Resuscitation): [MEDICAL CONDITION] is defined as inadequate cardiac contractions resulting in insufficient blood flow throughout the body Sudden [MEDICAL CONDITION] (SCA) is the leading cause of death in adults. Victims of [MEDICAL CONDITION] may initially have gasping respirations or may even appear to be having a [MEDICAL CONDITION]. The likelihood of recovering from SCA due to an acute event such as arrhythmia differs substantially from the likelihood of recovering from cardia arrest that is the end result of a multisystem failure and advanced irreversible or terminal condition. Depending on the underlying cause, the chances of surviving SCA may be increased if CPR is initiated immediately upon collapse. Any unnecessary interruptions in chest compressions (including longer than necessary pauses for rescue breathing) decreases CPR effectiveness. In potentially reversible situations, early delivery of shock with AED plus CPR within ,[DATE] minutes of collapse can further increase the chance of survival. The goal of early CPR is to try to maintain life until the emergency medical response team arrives to deliver advanced life support. If an individual ( resident, visitor, or staff member) is found unresponsive and not breathing normally, a license staff member who is certified in CPRIBLS shall initiate CPR unless: It is known that a DO NOT RESUSCITE (DNR) order that specifically prohibits CPR and /or external defibrillation exists for that individual · AED: The AED is to be used with any person in cardiopulmonary arrest as evidenced by unconsciousness; absence of nor mal breathing, absence of a pulse. If a resident is determined to be in cardiopulmonary arrest, the nurse will validate the resident's code status in the medical records prior to AED use. After assessment of the resident verifies that cardiopulmonary arrest is present, the responder assures that the 911 is called to alert the advance response team. Then CPR is begun while another responder is sent to retrieve the AED. While CPR is continued, the AED is turned on and the CPR D padz are prepared for application to the victim. CPR is discontinued while the CPR-D padz are affixed to the resident's bare chest and the cardiac rhythm is analyzed. If shock is advised, the responder ensures that all persons are cleared away from and not touching the resident and pushes the shock button. CPR is immediately resumed afterwards. If no shock is advised. CPR is resumed. Cues from the AED are followed related to depth and rate of compressions in order to optimize blood flow with CPR. AED prompts will guide the responder through further actions, until the advance response team arrives and assumes responsibility for continuing operation of the AED or transfers the victim. · How to determine a residents Code Status ( Full code or DNR) : Medication and Treatment TARS; Medical records hard copy chart · Change in condition: recognizing changes in condition (Change in a residents status; the nurse will notify the resident's attending physician and family when there has been an accident or incident involving the resident, a discovery of injury of unknown source, a reaction to medication, a significant change in the resident's physical, emotional or mental condition, a need to alter the resident's medical treatment significantly, refusal of treatment or medication, a need to transfer the resident to a hospital/treatment center, a discharge without proper medical authority, and/or instructions to notify the physician of changes in the residents change of condition. · Mock Codes: Periodic Codes (simulations of an actual arrest) for training purposes · Work Station Accessible on each hall (In the center) to identify code status: Each Hall has a computer in the center of the hallway. Once logged on, select the resident and the code status will appear · Computer on each medication and treatment cart and nurses station that has code status · Once Full code Status has been identified, Code Blue will be announced Education will continue each shift until I 00% of the staff is educated on the above. Those employees on FMLA or PTO will have their education completed upon arrival for the start of the next scheduled shift to work. 6. a.) To monitor the Director ofNursing/ designee started Mock Code Return demonstration on ,[DATE] and will continue. b.) Continued Review of the emergency cart and AED daily c.) DON to monitor code changes and make those reflections in the clinical record as needed 7. An Ad Hoc Quality Assurance Committee meeting was held on [DATE] with the Medical Director, Director of Nursing, Regional Vice President, and Director of Clinical Operations, and IDT the to review and discuss the plan of action of the Code Status and documented on Quality Assurance Performance Improvement Agenda form. The plan was monitored by evidence of: Record review of in-service records revealed in-services on CPR on Mock Codes were performed on [DATE], [DATE], and [DATE]. Record review of the In-Service sign-in sheet revealed that staff from the nursing department representing all three shifts had been in-serviced from [DATE]-[DATE] on CPR, Code Status, and when to initiate CPR. Record review of the In-Service sign in sheet revealed that staff from the nursing department representing all three shifts had been in-serviced on [DATE] for Change in Resident Condition and SBAR. Record reviews of current resident's charts revealed current code status noted on each chart. Staff interview Interviews with staff members of all shifts revealed understanding of in-service trainings on CPR, code status and change in condition. On [DATE] and [DATE] during all three shifts at various times staff was observed and interactions were appropriate. Staff were able to identify change in condition and to identify residents who were full code versus DNR. Record review of in-service records revealed in-services on CPR on Mock Codes were performed on [DATE], [DATE], and [DATE]. Record review of in-service records revealed in-services on Abuse and Neglect were performed on [DATE], [DATE] and [DATE]. In an interview with LVN I on [DATE] at 3:50pm, he was able to identify if a resident was full code or DNR status. LVN I was also able to demonstrate how to use AED and where the crash cart was kept. LVN I said the last in-service on CPR was [DATE] before his shift. In an interview with RN A at 11:20am and LVN G on [DATE], both said they identify residents who were DNR and Full code status by the red or green sheet in the front of the residents chart and proceed from there. They said if Resident is full code they would initiate CPR and use the AED until EMS arrived Further interview with LVN G on [DATE] at 4:32pm; LVB B at 4:38pm on both said they would also identify residents who were DNR and Full code status by the red or green sheet in the front of the residents chart. LVN G also said code status could be checked by looking in the MAR. The facility Administrator was notified on [DATE] at 4:10 pm the IJ was removed. However while the IJ was removed the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility ' s continuing need to monitor the effectiveness of the plan of removal. The facility's census listed 83 residents, and identified 65 residents who had requested full code status.

Based on observation, interview and record review the Administrator and DON failed to administer the facility in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practical physical, mental and psychosocial well-being for 8 of 23 residents reviewed for quality of care. (CR #16 and CR #13, Residents #17, #18, #21, #20, #23, Residents #5) The Administrator failed to: -- implement the facility Neglect, and Exploitation (NE) Policy to prevent neglect. --supervise the DON to ensure nursing staff completed accurate care and treatment for [REDACTED]. --supervise the DON to ensure that nursing staff were trained on documentation of care and treatment provided to residents during a change of condition. --supervise the DON to ensure that nursing staff put into place effective interventions for all Residents with when a change of condition occurs. --ensure staff was trained and able to follow physician orders. The DON failed to: train staff to identify residents' risk factor for change of condition. train and monitor the staff on quality of care being provided. These failures affected 8 residents and placed 94 residents at risk for inadequate care and miss medication and diminishing health conditions. Findings include: Interview on [DATE] at 2:50 p.m. the Administrator said he had been at the facility for only a month. He said that he was in the process of monitoring and working on the the facility's processes and procedures to ensure that the residents' needs were being met. He said most of the staff including the DON were new to the facility and he was making some changes to improve Residents quality of care. He said he monitored staff, including the DON, by using community liaison which he explained as each staff has assigned residents to observed and monitor for quality of care and concerns. He said during morning all issues identified are discussed and evaluated for follow up. When asked why he thought this Substandard Quality of Care happened he said Nurses had a set of guidelines that need to be followed and were paid for the work that they were assigned. He said Nurses failed to document care and treatment provided to residents. Interview on [DATE] at 3:00 p.m., the Director of Nurses (DON) said she was new to the facility. She said she expected all nurses to have all required training regarding documenting on residents with change of condition and following physician's orders [REDACTED]. The DON said SQC happened due to staff failed to provide and document care and treatment that was provided to residents. CR#16 Record review of Resident #16's clinical records face sheet revealed she was [AGE] years old and was admitted to the facility initially on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of 24 hours report book kept at the nurse's station revealed no documentation on resident CR #16. In an interview with Director of Nurses (DON) on [DATE] at 10:00 a.m., she said she was at the nurses' station on [DATE] at 7:05am when she heard a nurse call code blue. She said she got the crash cart to CR #16's room and continued Cardio [MEDICAL CONDITION] Resuscitation (CPR). She assisted with CPR until the ambulance arrived. She said Paramedics took over CPR. She then left the room. She said by the time she came back to the room the Paramedics had already left the facility with the resident. The DON said she did not investigate what happened to CR #16. She said the 10 p.m. to 6 a.m. shift did not document what happened to CR #16. She said she did not contact LVN J who works the night shift regarding CR#16. She said the 2:00 p.m. to 10:00 p.m. shift said she notified the Responsible Party (RP) with orders for new medication. She said she was not present during the night shift and did not know what happened. In an interview with Licensed Vocational Nurse (LVN) M on [DATE] at 4:40 p.m., who worked the 2:00 p.m.-10:00 p.m. shift on [DATE] she said she informed CR #16's RP about the medication and told her that CR #16 was vomiting. She said at the end of her shift she told the 10 p.m. to 6 a.m. nurse about CR #16's new orders. Interviews with the Assistant Director of Nursing (ADON) on [DATE] at 2:00 p.m., she said she came to work at about 8:00 a.m. and the CR #16 was already out of the facility. She said LVN J, who worked the 10:00 p.m.-6:00 a.m. shift on [DATE], no longer worked at the facility. She said LVN J was scheduled to work on [DATE] but did not show up and did not call. She said an attempt was made to contact LVN J and there was no answer. Interview on [DATE] at 4:00 p.m. with the ADON she said LVN J was on the phone and would like to answer the Surveyor's questions. An attempt was made to communicate with LVN J but failed. LVN J answered, said hello and a television was heard in the background. Several attempts were made on [DATE] at 10:00 a.m., 2:00 p.m. and at 5:00 p.m., [DATE] at 9:00 a.m. 1:00 p.m. and 3:00 p.m. Several messages were left for LVN J to call but none were returned. Prior to exit on [DATE] the DON said LVN J did not return the facility's phone calls. Staff administered medications in the dining room and hallways to five of twenty three residents reviewed (Residents #17, #18, #21, #20, #23). Staff failed to change [MEDICAL CONDITION] bags and follow physician orders [REDACTED].#5, CR #13, #21). The CMS 670 listed a census of 100 residents.

Based on observation, interview and record review the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing for 4 of 23 residents (CR #16,CR #13 Resident #5 and Resident #21) reviewed for pain management and [MEDICAL CONDITION] care. CR #16 had a change of condition, she began vomiting on [DATE] during the 2:00pm-10:00pm shift. She was found on [DATE] at 6:50am not responding and not breathing. She was pronounced dead at the hospital at 7:37am. CR #13 complained of pain for 5 days without receiving pain medication ([MEDICATION NAME]) scheduled or as needed. CR #13 was sent to the hospital at her request and was found to be in [MEDICAL CONDITION] and have a renal mass. She also had a [MEDICAL CONDITION] bag that was not changed and would come off and leak stool all over resident attracting flies. Staff failed to change [MEDICAL CONDITION] bags as ordered for Residents #5 and #21. This caused the bags to leak stool onto the residents and to cause a foul odor. This failure affected one resident and placed 42 residents on pain management and four residents that required ostomy care at risk of not receiving assessments, medical care and services, which could have a negative impact on their medical health and wellbeing. Findings Include: CR #16 Record review of Resident #16's clinical records face sheet revealed she was a [AGE] year old female admitted to the facility initially on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of CR #16's hospital records dated [DATE] read in part Clinical Report .time seen 7:30am arrrived by ambulance .patient unsresponsive .Chief complaint: [MEDICAL CONDITION] .7:37am not able to obtain vital signs (blood pressure and pulse or respirations) .Appearance: Unresponsive. (Pt has yellow vomit on clothes) .Chest compressions performed. No spontaneous pulse. No heart sounds .No spontaneous respirations .Skin: (Mottled) . Time of death called at 7:37am .Family notified of pts death at 8:13am .Clinical Impression: [MEDICAL CONDITION]. Record review of CR #16's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 09 to indicate moderate cognitive imapirment. She required extensive assist of one to two people for her activities of daily living (ADLs) except for eating she required supervision and setup help only. She had listed [DIAGNOSES REDACTED]. CR #16 was not assessed to have had fever or vomiting. Record review of CR #16's Quarterly MDS assessment dated [DATE] revealed the following: she had a BIMS score of 09. She required limited to extensive assist of one to two people for her ADLs, except for eating she required supervision and setup help only. She had listed [DIAGNOSES REDACTED]. She was not assessed as having shortnes of breath, fever, or vomiting. Record review of Nurses notes dated [DATE] 15:25 revealed, Called to resident (CR #16's) room, resident vomiting and complaining of diarrhea. Vital sign ,[DATE], 85, 18, 97. 6. Resident continues [MEDICATION NAME] 500mg PO (by mouth) for ESBL (Extended spectrum beta-lactamase) of urine. Notified MD, and received orders for stool sample to be collected for [MEDICAL CONDITION], [MEDICATION NAME] 25 mg (milligrams) IM (intramuscular) Q6 (every six) hour as needed for nausea and vomiting, notify responsible party of new orders. Will continue to monitor. Record review of CR #16's physician's orders [REDACTED]. Record review of CR #16's Medication Administration Record [REDACTED]. Record review of CR #16's Nurse's note dated [DATE] at 6:12pm by LVN M revealed checked on CR #16 and the [MEDICATION NAME] was effective. CR #16 stated she had not vomited in the past 25 minutes. Stated she felt a little better, vital sign revealed she was afebrile; will continue to monitor. Record review of CR #16's clinical record revealed no documentation of follow-up or monitoring of CR #16 on the 10:00pm-6:00am shift. In an interview with Director of Nurses (DON) on [DATE] at 10:00am, she said she was at the nurse ' s station when she heard a nurse call code blue. She got the crash cart to CR #16's room and Cardio [MEDICAL CONDITION] Resuscitation (CPR) was continued. She assisted with CPR until the ambulance arrived. She said the Paramedics took over performing CPR. She then left the room. She said by the time she came back to the room the Paramedics had already left the facility with the CR #16. The DON said she did not investigate what happened to CR #16 because she was already gone to the hospital. She said the 10pm to 6 am shift did not document what happened to CR #16. She said she did not contact LVN J that worked the night shift regarding CR#16. She said the 2:00pm to 10:00Pm shift Nurse said she notified CR #16's RP with orders for new medication. She said she was not present during the night shift and did not know what happened. Interview with LVN N on [DATE] at 11:30am that worked 6am to 2 pm shift on [DATE] said she entered CR #16's room at about 6:50am and found CR #16 not breathing and not responsive and pulseless. She called 911 and began chest compressions. She rechecked for a pulse and it was absent she then placed CR #16 on a 100% non-rebreather oxygen mask. LVN N said at about 7:04 am the EMS arrived and took over CPR. She said the night nurse LVN J notified resident ' s responsible party to report to the local emergency room where resident was being transferred. Record review of CR #16's nurse's note dated [DATE] at 4:33pm read, Late entry at 6:50am CR #16 was fond unresponsive, not breathing and pulseless. 911 was activated. Pulse rechecked and was absent. Chest compression started and CR #16 was placed on a 100% nonrebreather oxgen mask. EMS arrived at 7:04am and took over chest compressions and intubated CR #16. Interviews with the Assistant Director of Nursing (ADON) on [DATE] at 2:00pm, she said she came to work at about 8:00am and the resident was already out of the facility. She said LVN J no longer work at the facility. She said LVN J was scheduled to work on [DATE] but did not show up and did not call. She said an attempt was made to contact LVN J and there was no answer. Further interview at 4:00pm she said LVN J was on the phone and would like to answer surveyor ' s questions. Attempt was made to communicate with LVN J but failed. LVN J answered, said hello and television was heard talking. Several attempts were made on [DATE] at 10:00am, 2:00pm and at 5:00pm, [DATE] at 9:00am 1:00pm and 3:00pm. Several messages were left no returned phone from LVN J. In an interview with LVN M on [DATE] at 4:40 pm, she said at about 3:00pm on [DATE], CR # 16 was in her wheel chair with a trash can vomiting into the trash can and it was yellowish in color. She asked CR #16 if she had eaten anything and she said no. She called CR #16's physician to inform him of CR #16's condition. LVN M said as CR #16 continued vomiting she called the physician back who ordered [MEDICATION NAME] 25mg intramuscular every 6 hours as needed, a chest X-ray and stool test. She said [MEDICATION NAME] 25 mg IM was given and she continued to monitor resident ' s condition during her shift. She said at about 8:30pm all vital signs were normal. She said at the end of her shift she told the 10pm to 6am nurse of Resident ' s new orders. Record review of written statement from CNA O on [DATE] revealed that she had worked the 10:00pm-6:00am shift on [DATE]. She said that she rarely saw LVN J check on CR #16 but she checked on her at 12:00pm when she was just lying down, at 3:30am CR #16 was sleeping and at 5:12am she checked to see if CR #16 was wet or dry and that was her last round. There was a request made for further information for CR #16 including CNA documentation. No further information was provided. CR #13 Record review of CR #13 ' s Admission's Record revealed the [AGE] year old female was admitted to the facility on [DATE]. She had the following Diagnoses: [REDACTED]. Record review of CR #13's quarterly MDS asessment dated [DATE] revealed she had a BIMS score of 13 which indicated she was cognitively intact. She required limited assistance of one person for most ADLs to inclde transfers, locomotion, dressing and toilet use. For bed mobility she neede supervision of one person, eating and personal hygiene she only required supervision and set-up help. She was assessed as having an ostomy under bowel continence. She had a [DIAGNOSES REDACTED]. Undere the section for pain assessment it was marked as CR #13 received schedule pain medication but that she had not received PRN pain medication or non-medication interventions for pain. The rest of the pain assesment was blank as it was marked CR #13 had not pain at any time in the last five days prior to the assessment date. Record review of Care plan with revision date of [DATE] revealed that Nursing Staff will change [MEDICAL CONDITION] bag as needed and as resident allows. Provide stoma care daily as instructed and prn. Report any abnormalities to MD and LP. Education with resident on how to properly change bag. provide equipment needed for resident to provide [MEDICAL CONDITION] care. Record review of CR #13's Medication Review Report dated Sep 2, 2015 revealed the following orders: --Asper-Flex Cream 10%-apply to right shoulder topically every 12 hours as needed for mild to moderate pain. Start date of [DATE]. --Change colotsomy appliance daily and as needed for dislodgement and leaking. Start date was [DATE]. --[MEDICAL CONDITION] care every shift and as needed for dislodgement and leaking. Start date was [DATE]. --Monitor stoma for proper functioning and skin around stoma for irritation every shift. Start date was [DATE]. --[MEDICATION NAME]-Acetamnophen tablet ,[DATE]mg one time a day for pain. Start date was [DATE]. --[MEDICATION NAME] tablet 200mg- give one tablet by mouth twice daily as needed for pain. Start date was [DATE]. --[MEDICATION NAME] 50mg- give one tablet by mouth at bedtime for pain. Start date was [DATE]. --[MEDICATION NAME] 50mg- give one tablet by every six hours as needed for pain. Start date was [DATE]. --[MEDICATION NAME]- give 4mg by mouth every 8 hours as needed for nausea. Record review of CR #13's MAR indicated [REDACTED] --Change [MEDICAL CONDITION] appliance daily and [MEDICAL CONDITION] care every shift (start date [DATE]) was checked and initialed to indicate that the appliance had been changed everyday from [DATE]-[DATE]. --Monitor for pain every shift and document pain using ,[DATE] scale was checked and initialed to indicate that it was completed. CR #13 complained of pain as follows: --[DATE]-2 out of 10 on the evening and night shift --[DATE] - 4 out of 10 on the day shift, 6 out of 10 on the evening shift. --[DATE]- 5 out of 10 on day and evening shift. --[DATE]- 1 out of 10 on the day shift. --[DATE]- 2 out of 10 on the day shift and 4 out of 10 on the evening and night shift. --[DATE]- 4 out of 10 on the day shift and 2 out of 10 on the evening and night shift. --[DATE]- 2 out of 10 on the day and evening shift. --[DATE]- 5 out of 10 on the day shift, 4 out of 10 on the evening shift and 1 out of 10 on the night shift. --[DATE]-1 out of 10 on the day and evening shifts. --For [DATE]-[DATE] the document reflected a 0 out of 10 for all shifts to indicate CR #13 had not complained of pain. Further review of the MAR for [DATE] revealed [MEDICATION NAME] 50mg was given on [DATE] at 7:42pm and [DATE] at 9:43pm for pain and documented with an E to indicate the medication was effective. The [MEDICATION NAME]-[MEDICATION NAME] Tablet ,[DATE]mg and [MEDICATION NAME] 50mg every night listed for administration per physician orders [REDACTED]. --[DATE]- 5 out of 10 on day and evening shift. --[DATE]- 1 out of 10 on the day shift. --[DATE]- 2 out of 10 on the day shift and 4 out of 10 on the evening and night shift. --[DATE]- 4 out of 10 on the day shift and 2 out of 10 on the evening and night shift. --[DATE]- 2 out of 10 on the day and evening shift. --[DATE]- 5 out of 10 on the day shift, 4 out of 10 on the evening shift and 1 out of 10 on the night shift. --[DATE]-1 out of 10 on the day and evening shifts. Interview on [DATE] at 4:15pm with CR #13's RP revealed that CR #13 had complained of pain from [DATE] until she was sent to the hospital on [DATE]. been found with a large amount of feces on her shirt, pants and on her bed from a [MEDICAL CONDITION] bag not being changed. The RP further said that she has taken pictures of CR #13 covered in feces and flies because it has happened on more than one occasion. CR #13's RP said that she was always soiled with feces when she arrived. She further revealed that she would even call ahead to the facility to let them know she was on her way and that her mom still was soiled. In an interview on [DATE] with CR #13 she said when she used her call light for help staff came in the room and would take the call light away and they said, That's Ok and would close the door. She said staff would not wait to see what she needed and this happened all the time. CR #13 said she had been in severe pain for several days prior to being transferred to the hospital. She also said the facility had not treated the pain. In an interview with DON on [DATE] at 10:45am, she revealed that she is unfamiliar with CR #13 and her medications and orders. In an interview with CR #13 (RP) she said that her mom was always soiled with feces when she arrived. She further revealed that she would even call ahead to the facility to let them know she was on her way and that her mom still was soiled. Record Review of Medication Administration Record [REDACTED]. Resident #5 Record review of Resident #5's clinical record revealed a [AGE] year old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident #5 ' s quarterly MDS dated [DATE] revealed the following: he had a BIMS score of 05, which indicated severe cognitive impairment. He was dependent on two staff members for transfers and dressing, dependent on one staff for locomotion, eating, toilet use, personal hygiene and bathing. For bowel incontinence he was assessed as having an osotomy. Record review of Resident #5 ' s care plan dated [DATE] read in part . the Resident had a [MEDICAL CONDITION] .monitor daily put (SIC) daily, nursing staff will change [MEDICAL CONDITION] bag as needed and provide stoma care daily as instructed and as needed. Record review of Resident #5 ' s physician's order [REDACTED]. Record review of Resident #5 ' s MAR indicated [REDACTED]. The start date was [DATE]. There was a check mark for each day and initials of staff to indicate that it had been changed. Observation on [DATE] at 11:00am revealed Resident #5 was in bed wearing a hospital gown. The room smelled of stool. His [MEDICAL CONDITION] bag was full of greenish brown stool and air. In an interview on [DATE] at 11:05am with LVN H she admitted that Resident #5 ' s [MEDICAL CONDITION] bag was full of stool and air and needed to be emptied. Observation on [DATE] at 11:15am revealed LVN H removing stool from [MEDICAL CONDITION] bag by squeezing stool out of bag. Stool leaked on Resident #5 ' s gown and on the sheet. LVN H said she would just change the bag instead of emptying it. Record review of Resident #5 ' s Medication Review Report for [DATE] revealed an order to Change [MEDICAL CONDITION] Appliance Daily and As Needed Every Shift. Observation on [DATE] at 12:45pm of Resident #5 ' s [MEDICAL CONDITION] bag revealed the [MEDICAL CONDITION] bag was full of greenish brown stool and air. Room smelled of stool. In an interview on [DATE] at 12:45pm with CNA L she said she would change his [MEDICAL CONDITION] bag at the end of the shift. Resident # 21 Record review of Resident #21 ' s clinical record revealed the [AGE] year old female was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #21 ' s Medication Administration Record [REDACTED]. Observation and Interview on [DATE] at 3:30pm with Resident #21 revealed her [MEDICAL CONDITION] bag was not dated to indicated last time it was changed. She said that they did not change her [MEDICAL CONDITION] bag when needed and they only changed it weekly . She stated Sometimes my bag is so full it runs down my leg when I am up using my walker . Resident #21 said she had asked staff to change her [MEDICAL CONDITION] bag on several occasions and one time it took 8 hours before it was changed and on another occasion it was changed 12 hours later by the next shift. She said that she was routinely stopped in the hall for medication administration and she finds it unprofessional and embarrassing. In an interivew on [DATE] at 10:05am with ADON she said she would provide surveyor with policy and procedure for [MEDICAL CONDITION] care. In an interview on [DATE] at 11:15am with LVN H she said [MEDICAL CONDITION] care is provided as ordered and as needed. CMS 672 listed a Census of 100

Based on observations, interview and record review the facility failed to implement their policy and procedures that prohibit mistreatment and neglect and abuse for 1 of 23 residents (CR #16 ) reviewed for neglect. This was evidenced by: CR #16 had a change of condition, she began vomiting on [DATE] during the 2:00pm-10:00pm shift. She was found on [DATE] at 6:50am not responding and not breathing. She was pronounced dead at the hospital at 7:37am. This failure affected 1 residents and placed 100 residents at risk of injury from lack of proper care and adequate supervision. Intake ID # 9, # 2 and # 7 Findings Include: CR #16 Record review of Resident #16's clinical records face sheet revealed she was a [AGE] year old female admitted to the facility initially on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of CR #16's hospital records dated [DATE] read in part Clinical Report .time seen 7:30am arrrived by ambulance .patient unsresponsive .Chief complaint: [MEDICAL CONDITION] .7:37am not able to obtain vital signs (blood pressure and pulse or respirations) .Appearance: Unresponsive. (Pt has yellow vomit on clothes) .Chest compressions performed. No spontaneous pulse. No heart sounds .No spontaneous respirations .Skin: (Mottled) . Time of death called at 7:37am .Family notified of pts death at 8:13am .Clinical Impression: [MEDICAL CONDITION]. Record review of CR #16's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 09 to indicate moderate cognitive imapirment. She required extensive assist of one to two people for her activities of daily living (ADLs) except for eating she required supervision and setup help only. She had listed [DIAGNOSES REDACTED]. CR #16 was not assessed to have had fever or vomiting. Record review of CR #16's Quarterly MDS assessment dated [DATE] revealed the following: she had a BIMS score of 09. She required limited to extensive assist of one to two people for her ADLs, except for eating she required supervision and setup help only. She had listed [DIAGNOSES REDACTED]. She was not assessed as having shortnes of breath, fever, or vomiting. Record review of Nurses notes dated [DATE] 15:25 revealed, Called to resident (CR #16's) room, resident vomiting and complaining of diarrhea. Vital sign ,[DATE], 85, 18, 97. 6. Resident continues [MEDICATION NAME] 500mg PO (by mouth) for ESBL (Extended spectrum beta-lactamase) of urine. Notified MD, and received orders for stool sample to be collected for [MEDICAL CONDITION], [MEDICATION NAME] 25 mg (milligrams) IM (intramuscular) Q6 (every six) hour as needed for nausea and vomiting, notify responsible party of new orders. Will continue to monitor. Record review of CR #16's physician's orders [REDACTED]. Record review of CR #16's Medication Administration Record [REDACTED]. Record review of CR #16's Nurse's note dated [DATE] at 6:12pm by LVN M revealed checked on CR #16 and the [MEDICATION NAME] was effective. CR #16 stated she had not vomited in the past 25 minutes. Stated she felt a little better, vital sign revealed she was afebrile; will continue to monitor. Record review of CR #16's clinical record revealed no documentation of follow-up or monitoring of CR #16 on the 10:00pm-6:00am shift. In an interview with Director of Nurses (DON) on [DATE] at 10:00am, she said she was at the nurse ' s station when she heard a nurse call code blue. She got the crash cart to CR #16's room and Cardio [MEDICAL CONDITION] Resuscitation (CPR) was continued. She assisted with CPR until the ambulance arrived. She said the Paramedics took over performing CPR. She then left the room. She said by the time she came back to the room the Paramedics had already left the facility with the CR #16. The DON said she did not investigate what happened to CR #16 because she was already gone to the hospital. She said the 10pm to 6 am shift did not document what happened to CR #16. She said she did not contact LVN J that worked the night shift regarding CR#16. She said the 2:00pm to 10:00Pm shift Nurse said she notified CR #16's RP with orders for new medication. She said she was not present during the night shift and did not know what happened. Interview with LVN N on [DATE] at 11:30am that worked 6am to 2 pm shift on [DATE] said she entered CR #16's room at about 6:50am and found CR #16 not breathing and not responsive and pulseless. She called 911 and began chest compressions. She rechecked for a pulse and it was absent she then placed CR #16 on a 100% non-rebreather oxygen mask. LVN N said at about 7:04 am the EMS arrived and took over CPR. She said the night nurse LVN J notified resident ' s responsible party to report to the local emergency room where resident was being transferred. Record review of CR #16's nurse's note dated [DATE] at 4:33pm read, Late entry at 6:50am CR #16 was fond unresponsive, not breathing and pulseless. 911 was activated. Pulse rechecked and was absent. Chest compression started and CR #16 was placed on a 100% nonrebreather oxgen mask. EMS arrived at 7:04am and took over chest compressions and intubated CR #16. Interviews with the Assistant Director of Nursing (ADON) on [DATE] at 2:00pm, she said she came to work at about 8:00am and the resident was already out of the facility. She said LVN J no longer work at the facility. She said LVN J was scheduled to work on [DATE] but did not show up and did not call. She said an attempt was made to contact LVN J and there was no answer. Further interview at 4:00pm she said LVN J was on the phone and would like to answer surveyor ' s questions. Attempt was made to communicate with LVN J but failed. LVN J answered, said hello and television was heard talking. Several attempts were made on [DATE] at 10:00am, 2:00pm and at 5:00pm, [DATE] at 9:00am 1:00pm and 3:00pm. Several messages were left no returned phone from LVN J. In an interview with LVN M on [DATE] at 4:40 pm, she said at about 3:00pm on [DATE], CR # 16 was in her wheel chair with a trash can vomiting into the trash can and it was yellowish in color. She asked CR #16 if she had eaten anything and she said no. She called CR #16's physician to inform him of CR #16's condition. LVN M said as CR #16 continued vomiting she called the physician back who ordered [MEDICATION NAME] 25mg intramuscular every 6 hours as needed, a chest X-ray and stool test. She said [MEDICATION NAME] 25 mg IM was given and she continued to monitor resident ' s condition during her shift. She said at about 8:30pm all vital signs were normal. She said at the end of her shift she told the 10pm to 6am nurse of Resident ' s new orders. Record review of written statement from CNA O on [DATE] revealed that she had worked the 10:00pm-6:00am shift on [DATE]. She said that she rarely saw LVN J check on CR #16 but she checked on her at 12:00pm when she was just lying down, at 3:30am CR #16 was sleeping and at 5:12am she checked to see if CR #16 was wet or dry and that was her last round. There was a request made for further information for CR #16 including CNA documentation. No further information was provided. Record review of the Facility's Abuse and Neglect policy dated [DATE] (Revision date) read in part, Assessment and Recognition: 1. The nurse will assess the individual and document related findings. Assessment data will include .a. injury assessment .b. all current medications .d. vital signs .g. all active [DIAGNOSES REDACTED]. 2, The nurse will report the findings to the physician .physician will assess the resident to verify or clarify such findings , especially if the cause or the source of the problem is unclear .3b. Neglect means the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness .The facility management and staff will institute measures to address the needs of the residents and minimize the possibility of abuse and neglect . The staff and physician will monitor individuals . at least until their medical condition .have stabilized and periodically thereafter. Facility 672 dated [DATE] revealed a census of 100 residents.

Based on observation, interview and record review the facility failed to provide the necessary treatment and services to promote healing and prevent infections for 1 of 3 Residents reviewed for pressure ulcers (Resident #1) by: -Resident #1 was admitted with a stage II sacral pressure ulcer now had a stage IV. The facility failed to conduct pressure ulcer assessments and follow the resident care plan (RCP). Resident #1 was hosptalized on [DATE] with an infected sacral pressure ulcer. The failure affected 1 resident and placed 12 residents with pressure sores at risk for worsening pressure ulcers, infection and pain. Complaint # 7 The findings include: Record review of the facility history and physical dated 04/23/13 for Resident #1 revealed he was [AGE] years old and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the significant change assessment MDS for Resident #1 with assessment reference date of 08/12/13 under the skin condition assessment section revealed resident was assessed as being at risk for pressure ulcer development and had a stage IV pressure ulcer with length of 7.0 cm by 4.0 cm wide and 0.5 cm depth with slough yellow or white tissue adheres to ulcer bed. The pressure ulcer was present on prior assessment and no other skin problems were assessed. The assessment revealed resident had a pressure ulcer reducing device for the chair/bed, pressure ulcer care and application of dressings and medications. Observation on 08/29/13 at 7:20 a.m. revealed of Resident #1 in bed on his back with a thin pillow at his left hip and the head of his bed was elevated at 30 degrees. On the wall at the head of his bed were signs to off-load his sacral area. Observation on 08/29/13 at 8:50 a.m. revealed Resident #1 in bed on his back with a thin pillow positioned at left hip and the head of his bed elevated at 30 degrees. A mattress pump was at the foot board of the bed. On the wall at the head of his bed were signs to off-load his sacral area. In an interview at that time, the Resident was asked if the staff turned and repositioned him and he said he was often on his back for long periods of time. He said the last time they repositioned him was at 6:30 a.m. and they had not been back. Observation on 08/29/13 at 9:00 a.m. revealed Resident #1 in bed on his back with a thin pillow positioned at his left hip and the head of his bed elevated at 30 degrees. A mattress pump was on the foot board of the bed. On the wall at the head of his bed were signs to off-load his sacral area. Observation on 08/29/13 at 12:30 p.m. revealed LVN A administering pressure ulcer treatment to Resident #1 with LVN B assisting with positioning. LVN A took a saline soaked gauze and patted multiple times in the sacral pressure ulcer from the outer wound bed edge to the inner wound bed edge and across the wound bed without using a new gauze or changing position of the gauze until the last pat in the pressure ulcer. LVN A measured the pressure ulcer with a paper tape measure as 12.5 cm (L) by 10.0 cm (W) and measured the depth by placing the end of the soiled paper tape measure directly into the wound bed and (D) was 5.0 cm. LVN A de-gloved, conducted hand hygiene, applied new gloves, took moistened gauze and directly pushed the gauze into the pressure ulcer. LVN A de-gloved and without conducting hand hygiene applied new gloves and applied the new dressing to sacral ulcer. In an interview on 08/30/13 at 11:50 a.m. with Resident # 1 about his sacral pressure ulcer, he said he came from the hospital a few months ago and the opening on his bottom (sacral) was the size of a quarter. He said it was now large enough hold 2 adult hands/fists and it hurt most of the time. The resident was asked how did the pressure ulcer increase in size and he said the facility staff left him dirty in stool throughout many nights, he said he was frequently not repositioned many days. In continued interview at that time, Resident #1 stated at [MEDICAL TREATMENT] on Monday, Wednesday and Friday afternoons, he said he sat in the [MEDICAL TREATMENT] chair in stool for long periods of time. He said the [MEDICAL TREATMENT] staff would get upset with him when he needed to leave [MEDICAL TREATMENT]. Resident #1 said the facility staff had recently blamed him for refusing care and refusing to attend [MEDICAL TREATMENT]. Resident #1 said he recently refused to attend [MEDICAL TREATMENT] because he knew he would sit in stool and wet for about 10 hours. He then said he couldn't refuse to be cleaned and repositioned when in the facility as he was Quadriplegic, couldn't do anything and was totally dependent on the staff for everything. At this time the resident started to sob and cry saying, "I'm scared I will never heal". Record review of the RCP revealed a problem for alteration in skin integrity related to multiple pressure ulcers and risk for infection dated 05/08/13. The goal was documented as resident's skin will remain clean and dry and wounds will decrease in size or heal during the assessment period. The target date was documented as 08/06/13. The approaches included; turn and reposition every 2 hours, treatment as ordered, provide pressure relieving devices for bed /chair, adhere to good infection control when providing treatment to wounds. Record review of the RCP revealed a problem dated 06/18/13 of Resident is at risk for skin breakdown related to incontinence, impaired bed mobility, history of pressure ulcer, fragile skin, Braden score of 11 and diabetes mellitus. The goal was skin will remain clean, dry and intact without evidence of breakdown over the next 90 days. The approaches included; 1.-monitor for incontinence every 2 hours and PRN, change promptly, 2.-assist with repositioning as needed, using padding between pressure area, 5.-monitor for skin break down, report to MD and RP, 6.-provide pressure relieving and positioning devices as needed, 7.- assess skin weekly and record findings, 8.-turn and reposition every 2 hours. No approaches related to [MEDICAL TREATMENT] treatment and the prolonged period resident is positioned in [MEDICAL TREATMENT] chair without repositioning on Monday, Wednesday and Friday. Record review of the facility's Treatment record dated for the month of 07/13 for Resident #1 revealed the sacral pressure wound to be treated daily was blank/undocumented on 07/13/13 and 07/14/13. Weekly skin assessments were not documented. Record review of physician telephone orders dated 07/23/13 for Resident #1 revealed: send to hospital through emergency for wounds. Record review of the facility ' s weekly skin/ body assessments dated for month of 07/13 for Resident #1 revealed sacral ulcer assessments were conducted on 07/02/13 and 07/12/13 and revealed documentation of a sacral ulcer. Record review of the facility's weekly pressure ulcer assessments dated for month of 07/13 for Resident #1 revealed the resident was admitted with a stage II sacral pressure ulcer on 04/22/13. The assessments for the sacral pressure ulcer were conducted on; - 07/04/13 of 6.0 cm(L) by 4.0 cm (W) by 0.5 cm (D) with serous discharge, 0% slough and stage III, - 07/11/13 of 6.0 cm(L) by 4.0 cm (W) by 0.5 cm (D) with green-serous discharge, 80% slough and stage III, - 07/17/13 of 6.0 cm(L) by 4.0 cm (W) by 0.5 cm (D) with green-yellow discharge, 100% slough and stage III. Record review of the physician telephone orders for the month of 08/13 revealed: -08/17/13 send to hospital to evaluate and treat -08/22/13 admit to facility -08/22/13, Consult wound physician for wound care -08/23/13, sacral stage IV, 90% slough, 10% necrotic apply Santyl, wet to dry, cover with 4 by 4 gauze abdominal pad and tape every day signed by NP for primary physician. -08/29/13 clean sacral wound with Dakins ... cover to protect every day, signed by Wound consultant. Further review of the physician orders [REDACTED]. -Turn and reposition every 2 hours while in bed -Cefepimine HCL 2 gm/100 ml (antibiotic) intravenous, over 30 minutes every 48 hours on Monday, Wednesday and Friday after [MEDICAL TREATMENT] for 4 weeks. Treatment discontinued on 08/30/13. Further review of the orders dated for the month of 8/13 revealed there was no order for pressure ulcer treatment indicated. Record review of the RCP for Resident #1 revealed a problem with start date 08/22/13 for resident is on Antibiotics and is at risk for adverse reactions ... related to wound infection. The goal was infection will be resolved ...The approaches included give medications per order, follow universal/standard precaution to prevent cross contamination and spread of infection. Record review of the facility's Treatment record dated for the month of 08/13 for Resident #1 revealed the sacral pressure ulcer was to be treated daily. Resident #1 was hospitalized [DATE] and returned to facility on 08/22/13 at 9:30 pm and sacral pressure ulcer treatment on 08/23/13 the record was blank/undocumented. Weekly skin assessments were not documented. Record review of the facility's weekly skin/ body assessments dated for month of 08/13 for Resident #1 revealed no documentation for skin/body assessments. Record review of the facility's weekly pressure ulcer assessments dated for month of 08/13 for Resident #1 revealed assessment for a sacral pressure ulcer on; - 08/16/13 of 8.0 cm(L) by 7.5 cm (W) and no depth measurement with 20% slough , no odor and stage III, - 08/23/13 of 13.0 cm (L) by 13.0 cm(W) by 5.5 cm (D) with 0% slough, no odor and stage IV. Record review of the hospital physician report dated 08/17/13 at 2:12 p.m. for Resident #1 revealed sacral wound stage IV size approximately 18 cm (L) by 16 cm (W) by 4 cm (D) and 60% slough and 40% red. Right leg, right foot wound on the ankle size 2 cm by 2 cm black necrotic foot lateral aspect 2 cm by 2 cm necrotic. Record review of the hospital wound consultant operative report dated 08/19/13 for Resident #1 revealed pre-operative [DIAGNOSES REDACTED]. Wound classification was documented as dirty, infected. The wound bed was inspected and the wound was debrided. Record review of the clinical record for Resident #1 revealed a refusal for wound/sacral pressure ulcer treatment was documented on 07/31/13 as the resident wanted to wait on the wound treatment nurse to conduct the treatment. In an interview on 08/30/13 at 1:10 p.m. with the DON about care and services for the management and prevention of pressure ulcers revealed staff are to reposition residents at least every 2 hours and use pressure relieving devices such as off-load heels . The DON further said nutritional supplements are provided and weekly skin assessments conducted and documented on the proper pages in the treatment book. The DON was asked about Pressure and non-pressure area assessments and she said they are to be conducted weekly and documented on the Pressure and non-pressure forms. In continued interview at that time, the DON was asked why were there missing documents for residents skin problems, weekly skin assessments and weekly pressure and non pressure ulcers. At that time, the DON stated the WTN suddenly left and they have had several other WTN sine then. She stated the WTN needed re-enforcement about the job responsibilities. In interview on 08/30/13 at 3:10 p.m., LVN A said she had not had any in-service or skill proficiency checks since she was hired by the facility. LVN A was asked if she was the WTN and she said "no, we don't have one, she left". In an interview on 08/30/13 at 3:20 p.m. with UM G about care and services for Resident #1 she said the Resident had refused to be bathed and repositioned as well as refusing to go to [MEDICAL TREATMENT]. UM G was asked what was the nurse to do if Resident refused care/services. UM G said if a resident refused care/service, the nurse was to talk/resolve the refusal situation and document it in the nurses notes. UM G was requested to provide copies of the nurses note which demonstrated where Resident #1 refused care/services. The requested documentation was not provided prior to facility exit. In an interview on 08/30/13 at 5:25 p.m. with the primary physician responsible for Resident #1 and sacral pressure ulcer development revealed Resident was recently sent to hospital for an infected sacral wound. He stated the resident was susceptible to pressure ulcer development related to [DIAGNOSES REDACTED]. The physician said the resident needed to go to an LTAC to heal the sacral pressure ulcer. The physician said he recently referred Resident #1 for a wound consult on 08/22/13. Record review of the Personnel file for LVN A revealed the date of hire was 03/26/13. Further review revealed no documentation of skill proficiency or In-service on pressure ulcers/infection control/ wound treatment had been provided to LVN A. Record review of the facility's In service binder dated for 2013 revealed the only In services for Wound treatment/wound care were dated 04/12/13 and 05/09/13 and were given to the Wound care nurse and revealed the Wound care/treatment duties and expectations. The treatment nurse duties weekly included; -prepare weekly pressure and non-pressure reports ... -make sure nurses are educated on new orders and treatments ... -Get measurements and record ... -follow-up with MD, RP and residents with any new orders, changes, improvements or lack of improvement ... -make at least weekly notations regarding wound on all residents with wounds, -make sure all nursing staff are educated on wound care -initiate and update care plans as needed, -weekly skin assessments on all residents per established schedules -administer daily treatments ... -ensure proper turning and repositioning on the residents with wounds, Record review of the facility's policy and procedure on prevention of pressure ulcers dated 10/2010 revealed purpose was to provide information regarding identification of pressure ulcer risk factors and interventions for specific risk factors. General guidelines: 1. Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure and decreased of circulation to that area and subsequent destruction of tissue, 2. ... if pressure ulcers are not treated ...they get quickly larger, become very painful, and often become infected. 3. Pressure ulcers are often made worse by continual pressure, heat, irritating substances on the skin ... General Preventative Measures: 2. For a person in bed: a. Change position at least every 2 hours or more frequently as needed ... 5. Once a pressure ulcer develops it can be extremely difficult to heal ... 6. The facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated , reported to physician, RP, family and addressed. 9. Routinely assess and document the condition of the resident ' s skin per the facility wound and skin care program. Record review of the facility's policy and procedure on Wound care dated 10/10, revealed: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. 1. Wash and dry hands thoroughly, 2. Put on gloves ...remove tape and dressing 3. Pull glove over dressing and discard ....wash and dry your hands 4. Put on gloves Documentation: The following information should be recorded in the resident ' s medical record: 1. The type of wound care given 2. The date and time the wound care was given 7. All assessment data (i.e., wound bed color, size, drainage etc.) 8. If Resident refused the treatment and the reason(s ) why. Reporting: 1. Notify the supervisor if the resident refuses the wound care. 2. Report other information in accordance with facility policy and professional standards of practice. Record review of the facility's policy and procedure on Hand hygiene, dated 04/12, read: Policy statement: This facility considers hand hygiene the primary means to prevent the spread of infections: In most situations the preferred way of hand hygiene is with alcohol based hand rub ...of the following situations: a. Before and after direct contact with residents b. Before donning sterile gloves c. Before handling clean or soiled dressings, gauze pads etc. d. After contact with objects in the immediate vicinity of the resident e. After removing gloves. The CMS form 672 revealed 13 residents with pressure sores.

Based on observation, interview, and record review, the facility failed to notify the physician in a timely manner when one resident (Closed Record (CR #1)) of four residents reviewed for a change of condition exhibited a discolored and cool-to-the touch foot. The resident was sent to the hospital around 4:30 p.m. CR #1's left foot was discolored and had a reported difference in temperature (cool) at around 8:00 a.m. on 7/22/13. The facility did not notify the physician until around 1:30 p.m. There was no evidence they attempted to re-notify the physician before his arrival at the facility near 4:00 p.m. The delay in treatment contributed to the resident having to have his leg amputated. This failure affected one resident and placed 89 residents at risk of not having changes in conditions treated in a timely manner. # 7 Findings included: Record review of CR #1's Face Sheet dated 07/22/13, reflected he was [AGE] years of age, and was admitted to the facility on [DATE]. The Face Sheet reflected the resident had [DIAGNOSES REDACTED]. The resident resided on the 200 Hall. Record review of a Daily Skilled Nurses' Note (NN) dated 07/22/13 at 1:00 p.m. reflected, "Therapist requested this nurse to assess pt BLE rt (patient's bilateral lower extremities related to) new onset discoloration. Purpleish (sic) discoloration noted to bottom of L (left) foot and toes. Areas of discoloration blanchable. 0 (zero) palpable pulses to bilateral feet. Communicated with charge nurse to contact MD (physician) for STAT (immediate) imaging diagnostic to determine cause of discoloration." The note was signed by the Director of Nurses (DON). The subsequent NN, at 2:00 p.m., reflected the DON requested Registered Nurse (RN) A to assess the resident. The NN reflected "feet were discolored, poor cap (capillary) refill in left foot, legs WNL (within normal limits) to mid calf where skin turned cool and abnormal in color." The NN reflected the physician was paged at that time. Record review of CR #1's Physician's Telephone Order (TO) dated 07/22/13 at 2:00 p.m. reflected an order for [REDACTED]. Record review view of CR #1's Physician's Progress Note (PN) dated 07/22/13 at 4:00 p.m. reflected "Called by nurse earlier today at 1:30 p.m. c/o (Complained of) patient with foot pain and discoloration. Pt c/o foot pain. Daughter at bedside. Acute change with L foot ischemia L > R (decreased oxygenation, left ischemia greater than right ischemia). Decreased pulses ..." The PN reflected "Impression: Acute Ischemic foot." The PN reflected the physician called the hospital to ensure the resident was evaluated "STAT." Record review of CR #1's TO dated 07/22/13 at 4:15 p.m. reflected he was to be sent to the emergency room (ER) "now". Record review of CR #1's hospital ER records reflected the Triage time of 4:54 p.m. The assessment reflected the resident's left foot was purple, and the left dorsal pedal pulse was absent. The hospital notes reflected the family of the resident refused the Vascular Surgeon's Consult upon arrival, and again at 9:00 p.m. The surgeon did evaluate the resident at 1:00 a.m. on 07/23/13. The Impression reflected, "His left foot has been insensate and has rigor mortise from more than 17 hours of ischemia. Based on this advanced ischemia the foot is non-salvageable." The consult reflected the family requested transfer to a different hospital. In an interview with CR #1's facility physician on 07/31/13 at 5:15 p.m., he stated that on 07/22/13 he received a message from the facility between 1:30 p.m. to 1:45 p.m. He stated he arrived at the facility at 4:00 p.m. specifically to assess Resident #1. He stated that he observed the resident's left foot to be cyanotic, and that in his opinion it was an acute condition, and he gave an order for [REDACTED]. In an interview with CR #1's family member on 07/31/13 at 5:50 p.m., she stated that a staff member had mentioned the resident's foot was observed to be discolored as early as 8:00 a.m. on 07/22/13. The family member informed the surveyor that the resident's left leg was amputated above the knee at the hospital. Record review of the facility Daily Nursing sign-in sheet dated 07/22/13 revealed the staff working the day of CR #1's change in condition. The surveyor interviewed staff assigned to the 200 Hall for the 6:00 a.m. to 2:00 p.m. (morning) shift. The Treatment Nurse had since changed to an "as needed" role, and was not available for interview. The sheet reflected that the 200 Hall nurse "WNBI (will not be in)." The three remaining nurses were: RN A, Licensed Vocational Nurse (LVN) C, and LVN D. In an interview Certified Nurse Aide (CNA) B on 08/01/13 at 10:25 a.m., she stated that she worked the morning shift on the day CR #1 was sent to the hospital. She stated that shortly after breakfast she was in the resident's room, when one of the Therapy Department staff informed her that "his feet did not look right." CNA B stated, "I went straight out and told the nurse." The surveyor asked which nurse CNA B told. CNA B stated that LVN C and LVN D were together, and both were informed. CNA B Stated "I made sure I told both of them". CNA B could not recall the name of the therapy staff, but did recall the staff was female. CNA B again stated that the time was "shortly after breakfast". In an interview with the DON on 08/01/13 at 10:58 a.m., she stated that she was made aware of CR #1's foot discoloration at around 1:00 p.m. She stated she observed it to be "purplish, not dark purple" at that time. The DON stated that the feet did blanche when she palpated with her thumb. During an interview with the Therapy Director (TD F) on 08/01/13 at 12:00 noon, she provided the surveyor with the Daily Interaction Form for Certified Occupational Therapy Assistant (COTA) E. The form reflected COTA E worked with CR #1 from 7:15 a.m. to 8:27 a.m. on 07/22/13. In an interview with COTA E on 08/01/13 at 12:45 p.m., she confirmed that she worked with CR #1. She stated that she primarily worked with the resident's upper portions of the body but did assist with dressing. The surveyor asked COTA E if she had observed CR #1's feet. COTA E stated, "They were a little different. I told _____ (T D F). They were a little darker than they normally were." She stated that she observed the resident at 7:30 a.m. COTA E stated, "My immediate thought was to let my Supervisor know". COTA E stated she informed her supervisor before 8:00 a.m. She stated that TD F "checked it out right away". In an interview on 08/01/13 at 1:05 p.m., TD F stated that COTA E had informed her about CR #1's feet. TD stated, "She had concerns that morning secondary to his feet were more discolored. I probably went in about 8:00 (a.m.). They were not purple. Blue. Darker than they were on Friday (07/19/13). I checked for pulse. I couldn't find one so I told _____ (COTA E) to tell the nurse or PT (Physical Therapist). PT was _____ (PT G). She (COTA E) said she told _____ (PT G). Not sure if she told any of the nurses. _____ (PT G) said he could hardly feel a pulse." In an interview on 08/01/13 at 1:08 p.m., PT G stated, "I don't remember someone telling me to look at him (CR#1). I was aware that there was a problem with his feet. As far as skin integrity I didn't assess him." In an interview with LVN D on 08/01/13 at 1:22 p.m., she stated that she did not remember CR #1, and that no one had informed her of any issues with his feet. In an interview with RN A on 08/01/13 at 1:43 p.m., she stated that on 07/22/13 she was assigned to the 300 Hall. She stated that "close to the end of the first shift", the DON asked her to look at CR #1's feet. RN A stated she thought the resident exhibited "Lack of circulation. One (foot) worse than the other. Capillary refill, better in one (foot) than the other. Five to six seconds. Could not locate pedal pulses. Mid-shin down cool." RN A stated she did not recall which nurse was assigned to CR #1. On 08/01/13 at 2:05 p.m. the surveyor attempted to interview LVN C via telephone, but was unsuccessful contacting the nurse. An internet article (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC 69/> ) from the British Medical Journal dated 03/18/2000, entitled Acute Limb Ischaemia, reflected "Complete acute ischaemia will lead to extensive tissue necrosis within six hours unless the limb is surgically revascularised. Incomplete acute ischaemia can usually be treated in the first instance. Patients with irreversible ischaemia require urgent amputation unless it is too extensive or the patient is too ill to survive. The Article reflected, "When a patient is suspected to have an acutely ischaemic limb the case must be discussed immediately with a vascular surgeon. A few hours can make a difference between death or amputation and complete recovery of limb function." The facility's CMS 672 listed a census of 89 residents.

Based on observation, interview, and record review, the facility failed to implement their policy and procedures that prohibit neglect of one resident (Closed Record (CR #1)) of four residents reviewed for a change of condition exhibited a discolored and cool-to-the touch foot. CR #1's left foot was discolored and had a reported difference in temperature at around 8:00 a.m. The facility did not notify the physician until around 1:30 p.m. The resident was sent to the hospital around 4:30 p.m. The delay in treatment contributed to the resident having to have his leg amputated. This failure affected one resident and placed 89 residents at risk of not having changes in conditions treated in a timely manner. # 7 Findings included: Record review of CR #1's Face Sheet dated 07/22/13, reflected he was [AGE] years of age, and was admitted to the facility on [DATE]. The Face Sheet reflected the resident had [DIAGNOSES REDACTED]. The resident resided on the 200 Hall. Record review of a Daily Skilled Nurse's Note (NN) dated 07/22/13 at 1:00 p.m. reflected "Therapist requested this nurse to assess pt BLE rt (patient's bilateral lower extremities related to) new onset discoloration. Purpleish (sic) discoloration noted to bottom of L (left) foot and toes. Areas of discoloration blanchable. 0 (zero) palpable pulses to bilateral feet. Communicated with charge nurse to contact MD (physician) for STAT (immediate) imaging diagnostic to determine cause of discoloration." The note was signed by the Director of Nurses (DON). The subsequent NN, at 2:00 p.m., reflected the DON requested Registered Nurse (RN) A to assess the resident. The NN reflected "feet were discolored, poor cap (capillary) refill in left foot, legs WNL (within normal limits) to mid calf where skin turned cool and abnormal in color." The NN reflected the physician was paged at that time. There were not additional notes indicating additional calls to the physician. Record review of CR #1's Physician's Telephone Order (TO) dated 07/22/13 at 2:00 p.m. reflected an order for [REDACTED]. Record review view of CR #1's Physician's Progress Note (PN) dated 07/22/13 at 4:00 p.m. reflected "Called by nurse earlier today at 1:30 p.m. c/o (Complained of) patient with foot pain and discoloration. Pt c/o foot pain. Daughter at bedside. Acute change with L foot ischemia L > R (decreased oxygenation, left ischemia greater than right ischemia). Decreased pulses ..." The PN reflected "Impression: Acute Ischemic foot." The PN reflected the physician called the hospital to ensure the resident was evaluated "STAT." Record review of CR #1's TO dated 07/22/13 at 4:15 p.m. reflected he was to be sent to the emergency room (ER) "now". Record review of CR #1's hospital ER records reflected the Triage time of 4:54 p.m. The assessment reflected the resident's left foot was purple, and the left dorsal pedal pulse was absent. The hospital notes reflected the family of the resident refused the Vascular Surgeon's Consult upon arrival, and again at 9:00 p.m. The surgeon did evaluate the resident at 1:00 a.m. on 07/23/13. The Impression reflected, "His left foot has been insensate and has rigor mortise from more than 17 hours of ischemia. Based on this advanced ischemia the foot is non-salvageable." The consult reflected the family requested transfer to a different hospital. In an interview with CR #1's facility physician on 07/31/13 at 5:15 p.m., he stated that on 07/22/13 he received a message from the facility between 1:30 p.m. to 1:45 p.m. He stated he arrived at the facility at 4:00 p.m. specifically to assess CR #1. He stated that he observed the resident's left foot to be cyanotic, and that in his opinion it was an acute condition, and he gave an order for [REDACTED]. In an interview with CR #1's family member on 07/31/13 at 5:50 p.m., she stated that a staff member had mentioned the resident's foot was observed to be discolored as early as 8:00 a.m. on 07/22/13. The family member informed the surveyor that the resident's left leg was amputated above the knee at the hospital. Record review of the facility Daily Nursing sign-in sheet dated 07/22/13 revealed the staff working the day of CR #1's change in condition. The surveyor interviewed staff assigned to the 200 Hall for the 6:00 a.m. to 2:00 p.m. (morning) shift. The Treatment Nurse had since changed to an "as needed" role, and was not available for interview. The sheet reflected that the 200 Hall nurse "WNBI (will not be in)." The three remaining nurses were: RN A, Licensed Vocational Nurse (LVN) C, and LVN D. In an interview Certified Nurse Aide (CNA) B on 08/01/13 at 10:25 a.m., she stated that she worked the morning shift on the day CR#1 was sent to the hospital. She stated that shortly after breakfast she was in the resident's room, when one of the Therapy Department staff informed her that "his feet did not look right." CNA B stated, "I went straight out and told the nurse." The surveyor asked which nurse CNA B told. CNA B stated that LVN C and LVN D were together, and both were informed. CNA B Stated "I made sure I told both of them". CNA B could not recall the name of the therapy staff, but did recall the staff was female. CNA B again stated that the time was "shortly after breakfast". In an interview with the DON on 08/01/13 at 10:58 a.m., she stated that she was made aware of CR #1's foot discoloration at around 1:00 p.m. She stated she observed it to be "purplish, not dark purple" at that time. The DON stated that the feet did blanche when she palpated with her thumb. During an interview with the Therapy Director (TD F) on 08/01/13 at 12:00 noon, she provided the surveyor with the Daily Interaction Form for Certified Occupational Therapy Assistant (COTA) E. The form reflected COTA E worked with CR #1 from 7:15 a.m. to 8:27 a.m. on 07/22/13. In an interview with COTA E on 08/01/13 at 12:45 p.m., she confirmed that she worked with CR #1. She stated that she primarily worked with the resident's upper portions of the body but did assist with dressing. The surveyor asked COTA E if she had observed CR #1's feet. COTA E stated, "They were a little different. I told _____ (T D F). They were a little darker than they normally were." She stated that she observed the resident at 7:30 a.m. COTA E stated, "My immediate thought was to let my Supervisor know". COTA E stated she informed her supervisor before 8:00 a.m. She stated that TD F "checked it out right away". In an interview on 08/01/13 at 1:05 p.m., TD F stated that COTA E had informed her about CR #1's feet. TD stated, "She had concerns that morning secondary to his feet were more discolored. I probably went in about 8:00 (a.m.). They were not purple. Blue. Darker than they were on Friday (07/19/13). I checked for pulse. I couldn't find one so I told _____ (COTA E) to tell the nurse or PT (Physical Therapist). PT was _____ (PT G). She (COTA E) said she told _____ (PT G). Not sure if she told any of the nurses. _____ (PT G) said he could hardly feel a pulse." In an interview on 08/01/13 at 1:08 p.m., PT G stated, "I don't remember someone telling me to look at him (CR #1). I was aware that there was a problem with his feet. As far as skin integrity I didn't assess him." In an interview with LVN D on 08/01/13 at 1:22 p.m., she stated that she did not remember CR #1, and that no one had informed her of any issues with his feet. In an interview with RN A on 08/01/13 at 1:43 p.m., she stated that on 07/22/13 she was assigned to the 300 Hall. She stated that "close to the end of the first shift", the DON asked her to look at CR #1's feet. RN A stated she thought the resident exhibited "Lack of circulation. One (foot) worse than the other. Capillary refill, better in one (foot) than the other. Five to six seconds. Could not locate pedal pulses. Mid-shin down cool." RN A stated she did not recall which nurse was assigned to CR #1. There was no evidence of any additional attempts to notify the physician prior to the physician's arrival at 4:00 p.m. On 08/01/13 at 2:05 p.m. the surveyor attempted to interview LVN C via telephone, but was unsuccessful contacting the nurse. An internet article (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC 69/> ) from the British Medical Journal dated 03/18/2000, entitled Acute Limb Ischaemia, reflected " Complete acute ischaemia will lead to extensive tissue necrosis within six hours unless the limb is surgically revascularised. Incomplete acute ischaemia can usually be treated in the first instance. Patients with irreversible ischaemia require urgent amputation unless it is too extensive or the patient is too ill to survive. The Article reflected " When a patient is suspected to have an acutely ischaemic limb the case must be discussed immediately with a vascular surgeon. A few hours can make a difference between death or amputation and complete recovery of limb function. " The facility's CMS 672 listed a census of 89 residents.