Every finding on record at Memorial City Nursing and Rehabilitation Center

Based on interview, and record review, the facility failed to ensure resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 13 residents (Resident #21) reviewed for abuse. The facility failed to ensure Resident #21 remained free from abuse when LVN A removed the resident's property (cell phone) as a way to restrict the resident's communication (preventing calls to 911). These failures could place residents at risk of an unsafe environment and unprotected from mistreatment. The findings included: Record review of Resident #21's face sheet dated 04/23/2026 reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included systemic lupus erythematosus (a chronic, autoimmune disease where the immune system attacks healthy tissues, causing widespread inflammation and damage to organs), unspecified, epilepsy (chronic brain disorder characterized by recurrent, unprovoked seizures caused by electrical disturbances), anxiety disorder (mental health conditions characterized by excessive, persistent fear or worry that interferes with daily life), obesity (excess calories), pain in unspecified joint, stiffness of unspecified joint, muscle wasting and atrophy (reduced in size of boy tissues, muscles and organs), cognitive communication deficit (a communication impairment causing memory, or executive function deficits), and need for assistance with personal care. Record review of Resident #21's Comprehensive MDS, dated [DATE], reflected the resident had a BIMS score of 15 which indicated the resident had intact mental cognition. The resident had impairment on one side of her lower extremities and was dependent (helper does all of the effort and resident does none of the effort to complete the activity or the assistance of 2 or more helpers was required) for toileting, shower/bathe self, upper/lower body dressing, putting on/taking off footwear, and personal hygiene. According to the assessment Resident #21 was always incontinent of bowel and bladder. Record review of Resident #21's care plan reflected the resident had an ADL, self-care performance deficit r/t CHF, lupus date intuited 01/21/2026 and revised 02/05/2026. Intervention: The resident requires assistance by staff with bathing/showering 3 x weekly & as needed. The resident requires assistance by staff to turn and reposition in bed as needed. The resident requires assistance by staff to dress. The resident requires assistance by staff to eat. The resident requires assistance by staff with personal hygiene and oral care. The resident requires assistance by staff for toileting. The resident requires assistance by staff to move between surfaces as needed. The resident discussed feelings about self-care deficit. Encourage the resident to participate to the fullest extent possible with each interaction. Encourage the resident to use bell to call for assistance. Monitor/document/report PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. Praise all efforts at self-care. Record review of Resident #21's progress notes dated 03/4/2026 at 04:28 a.m., reflected LVN A noted resident had called 911, 2-times tonight. While making rounds LVN A walked into resident's room on the phone with the police. Police requested to speak to LVN A, police asked LVN A if the resident was okay. LVN A stated to the police the resident was okay. CNA A was called to assist LVN A get the resident out of the bed for the morning. Resident #21 being monitored. Record review of Resident #21's progress notes dated 03/04/2026 at 07:06 a.m., reflected LVN A noted Resident #21 attempted to pull the Fire Alarm. Record review of Resident #21's order dated 03/04/2026 at 02:13 p.m., reflected MD seen the resident and prescribed a new order for a psychological consultant for behavior. Record review of Resident #21's change of condition dated 03/04/2026 at 02:26 p.m., reflected change in mental status was noted as new or worsening behavioral symptoms. Vitals checked and noted within range. ADON A received the resident at the nurse's station as resident was up having behavior and making 911 calls. Resident was then taken to her room at the resident's request and was placed to bed. ADON A, called Family A to inform him of the resident's behavior with no response. Record review of Resident #21's behavior monitoring assessment dated [DATE] reflected, resident had the following antidepressants behaviors noted: No behaviors noted. During an interview on 04/22/2026 at 10:52 a.m., Resident #21 stated she had a diagnosis of lupus, and the symptoms caused her chronic pain in her joints and back, that required frequent repositioning. She stated she relied on staff for that repositioning. She stated all too often, when she pressed the call light for assistance with repositioning, there would be a delay in staff responses and staff would be mad with her, responding with attitudes, disrespect, and unfriendly tones such as What do you need now? She stated that she was sick and needed staff to answer her call light. She stated she had been a nurse and knew the staff's task responsibilities and need for having great customer service. She stated the staff needed refresher training on customer services and resident rights. During an interview on 04/23/2026 at 02:25 p.m., Resident #40 stated that her roommate was Resident #21. She stated on 03/04/2026 at 4:00 a.m., Resident #21 woke up crying, pressed the call light, yelled out for help, and then called the facility's front desk from her cellphone for assistance with no response. She stated then Resident #21 called 911 when LVN A entered the room and asked why Resident #21 had called 911 as EMT had responded to the call at the facility. She stated Resident #21 told LVN A she was in pain, but LVN A left the room. She stated Resident #21 called 911 trying to recall the facility's address, when LVN A reentered the room and Resident #21 asked LVN A for the address. LVN A told Resident 21's she did not know address, took the resident's phone and told the 911 operator that everything was okay with the resident, and hung up the phone, and left the room with Resident #21's cellphone. She stated at 5 a.m., LVN A and CNA A got Resident #21 out of bed, into a wheelchair for LVN A to monitor the resident from the nurse's station. She stated from the room, she could hear Resident 21 yelling and saying nurse, nurse, nurse, can you help me. She stated sometime later, she heard the fire alarm go off and then CNA B and CNA C brought Resident #21 back into room and into the bed. She stated that Resident #21 had a lupus diagnosis that required her to be repositioned often, which meant the resident pushed the call light often for assistance. During an interview on 04/23/2026 at 04:26 p.m., SW A stated on 03/09/2026, she followed up with Resident #21 after a behavior of calling 911 twice on 03/04/2026. She stated the resident stated a call was placed to Family B who lived out of town, expressing the need to go to the hospital. She stated the resident stated Family B had not felt the resident needed to go to the hospital. She stated she felt the resident called 911 in an attempt to get Family B's attention on the resident's wellbeing. She stated which was accomplished when the resident made the 911 calls. She stated that nursing staff responded when the resident called 911 on 03/04/2026 and found that the resident had no changes in condition that required emergency services. She stated the resident had not expressed concerns with her cellphone taken by LVN A or being unavailable to hindering her need to call anyone including 911. She stated as the SW it was her responsibility to ensure the resident had not experienced any adverse social issues after the incident. She stated her evaluation found the resident had no adverse effects from the incident and was safe and felt safe. She stated the resident had a psychosocial evaluation on 03/04/2026, that found the resident had no psychosocial changes or need for medication changes. She stated from her evaluation of the resident she only found neurological issues that limited the resident's ability to remember details of the 911 event, date, and time. She stated the resident provided no reason for wanting to go to the hospital, other than she wanted to go and wanted to go to another facility at that time. She stated the resident stated she no longer felt the need to go to another facility. She stated that she had a recent care plan meeting with Family A who expressed issues with the resident making frequent calls to him with feelings of abandonment, with no mention of staff removing the use of her cellphone. She stated that it had been her expectations that staff do not take a resident's personal property for any reason, specifically a cellphone to prevent a resident from calling 911. She stated doing so could hinder the resident's need to call for emergency services and delay higher level care. She stated the ADM was the abuse coordinator who all abuse and neglect allegations were reported to. She stated the facility provided in-service training and ANE routinely and after incidents occur. She stated the last in-service was last week and covered ANE and resident rights. She stated in the event that the abuse coordinator was the perpetrator, she would report the abuse to the DON, corporate's compliance line and/or the state. She named the 5-forms of abuse as: physical, emotional, verbal, sexual, and misappropriation of property. During an interview on 04/23/2026 at 05:33 p.m., ADON A stated she was aware Resident #21 had called 911 and pulled the fire alarm but was not on shift. She was not aware that LVN A had taken the resident's phone. She stated that CNAs made reports that the resident had behaviors when she first admitted in January 2026, but none relating to calling 911, pulling the fire alarm, of from the removal of her cellphone. She stated in the event that a resident reported a nursing staff had taken her cellphone or any personal property, she would report that the ADM immediately as misappropriation of property. She stated taking a resident's cellphone could keep the resident from calling for help, reaching their family, or hinder their need to call 911. She stated if a resident requested to go to the hospital even if there were no obvious changes in the resident's condition, she would immediately notify the resident's MD and report the resident's concerns to the DON. She stated if the MD did no provide a new order to transfer the resident to the hospital, yet the resident insisted on going out, she would not attempt to stop the resident and assist with that transfer. She stated that the ADM was the abuse coordinator. She noted the following as forms of abuse: physical, psychological, mental, verbal, financial, and sexual. She stated the facility provided in-service training on ANE and resident rights every month. During an interview on 04/23/2026 at 05:49 p.m., the DON stated she was aware Resident #21's cellphone had been charged at the nursing station on 03/04/2026. She stated that there was an issue with the cellphone not being charged when it was returned back to the resident, she was not aware the resident had an issue with cellphone being charged at the nurse's station. She stated it had been a common practice for staff to charge resident's cellphones at the nurse's station if the resident did not have a charger in their room. She stated the facility since discontinued that practice to avoid any incidences of a cellphone not being returned. She stated the ADM purchased additional chargers for residents to have in their rooms. She stated she had not been made aware that the resident had any pain issues on 03/04/2026. She stated had the resident had pain issues she would have expected a call from LVN A during that shift. She stated when the resident first admitted in January 2026, the resident was heavy on the call light to the point her previous roommate complained about her using it so much and staff would not respond when the roommate pressed it. She stated they moved Resident #21 to a different room and was not aware there were any issues since. She stated LVN A quit without notice unrelated to Resident #21 incident. She stated that ADM was the abuse coordinator and named the following forms as abuse: physical, mental, financial, verbal, and sexual. She stated the facility provided staff in-service training on ANE, resident rights, and pain management, quarterly, monthly and as needed. During an interview on 04/23/2026 at 09:00 p.m., LVN A stated on 03/03/2026, her shift began at 07:00 p.m. and ended on 03/04/2026 at 07:00 a.m., and Resident #21 was under her care. She stated while making rounds, she went to resident's room when the resident passed her a cellphone saying a family member wanted to speak to her. She stated on the phone there was a 911 operator asking what emergency services the resident needed. She stated she told 911 that the resident was fine and hung up the call. She stated a short time later; CNA A brought her the resident's phone after answering the resident's call light requesting to speak to someone. She stated she took the phone and again, 911 was on the line asking what emergency services the resident needed. She stated again, she told 911 that the resident was fine. She stated at 07:00 a.m. as an intervention to prevent the resident's 911 calling behaviors, her and CNA A got the resident out of bed. She stated as an additional intervention, took the resident's cellphone and placed it at the nurse's station to prevent further 911 calls. She stated when the ADM came on shift at 07:00 a.m., she informed him of the 911 incident and that the resident's cellphone was at the nurse's station to prevent further calls to 911. She stated she asked the ADM were they allowed to take a resident's phone, and the ADM told her they really could not do that. She stated that she told the ADM she would return the phone, but the ADM stated he would handle it. She stated while in the tv area, the resident wheeled her over the wall near the fire alarm. She stated the SC tried to stop the resident from pulling the alarm but was too late. She stated she asked the resident why she pulled the alarm, and the resident stated that she wanted to go home. She stated that CNA B was asked to put the resident back to bed. She stated that the facility provided in-service training on ANE all the time, but she was unaware that she could not take the resident's cell phone, because she thought she was doing the right thing. She stated she quit working for the facility unrelated to the incident with no disciplinary actions ever taken against her. She stated that the ADM was the abuse coordinator who all incidents were reported. During an interview on 04/24/2026 at 10:51 a.m., Resident #21's MD stated that on 03/04/2026 at 11:00 a.m., she was making her routine rounds at the facility and was informed by nursing staff Resident #21 had experienced evaluated anxiety behavior and attention seeking behavior that triggered the resident placing repeated calls to 911 early that morning. She stated the resident had an order for Prozac for anxiety and depression, and Clonazepam for anxiety. She stated nursing staff were monitored the resident's vitals, and she noted the vitals were tracked within range. She stated that the resident had chronic pain, and chronic inflammation due to a Lupus diagnosis and would expect that if the resident was calling 911 and EMS arrived at the facility, the EMTs would evaluate and the nursing staff would lean on the EMT's evaluation to determine if a hospital transfer was necessary. She stated she would not expect the facility staff to turn the EMTs away without evaluating the residents. She stated it was also her expectation that if a resident insisted on being transferred to the hospital that the facility staff assist with that transfer and notify MD and family of the transfer. She would not expect the staff to take the resident's phone as an intervene to avoid the resident making 911 calls. She stated that she could not recall being informed that LVN A had taken the resident's phone. She stated she had not been made aware that the resident had pulled the fire alarm and that the fire department had responded at the facility. She stated again, it was her expectation that if the fire department made the scene, that EMTs would have evaluated the resident before departing the facility. She stated it was not typical that EMS transported residents to the hospital for behaviors, but if the resident was crying, complaining of discomfort, and insisting on transfer it was possible. She stated she had not been informed by the facility of the resident's behavior prior to making her routine rounds. She stated she spoke with Family member A last week and made adjustments to the resident's psych medication at the request of Family member A. During an interview on 04/24/2026 at 01:42 p.m., the DON stated on 03/05/2026, Resident #21 had a positive UTI lab culture with antibiotics that began on 03/06/2026. She stated that confusion and sudden changes in behavior were associated with UTI symptoms. She stated the UTI symptoms could have contributed to the resident exhibiting abnormal and confused behavior She stated during the 03/04/2026 she had not received a call from staff regarding the resident's calls to 911. She stated she reviewed the resident's clinical notes and found that on 03/04/2026, MD assessed the resident and ordered a psychological consultation. She stated she was not made aware that the resident's cellphone was taking away, or was being changed at the nurse's station, nor that the resident was upset about her phone being taken. During an interview on 04/24/2026 at 01:51 p.m., the ADM stated he was on shift on 03/04/2026 when the resident pulled the fire alarm after a behavior to symptoms contributed to her positive UTI. He stated the fire department arrived at that the facility and were informed that it was a false alarm, pulled in error. He stated he came in early before LVN A had left shifted and learned that the resident's phone would not charge. He stated that he went to the resident's room and the resident told him that her phone was not charging by the charger she had and LVN A had tried charging it for the resident. He stated he retrieved 2 or 3 chargers from his office and attempted to plug them into the resident's cellphone, but none of them fit. He stated that the resident began stating that her phone had a colored design on the back of her phone. He stated that he took the resident's cellphone to the nurse's station trying to fit other chargers when he noticed there were several other phones at the desk. He stated one of the phones had a colored design on the back as previously described by the resident. He stated he took that designed phone to the resident's room and plugged it into her charge and realized that the resident had been given the wrong phone. He stated the resident was appreciative and had no complaints. He stated during his morning rounds, Resident #21 told him her charger would not work in her phone. He stated he took about 15 minutes looking for a new charger, when he saw multiple cellphones at the nurse's station, one with a colored design. He stated he took that phone to the resident, plugged in her charger, and the phone worked perfectly. He stated that LVN A was a nice night nurse that lacked confidence. He stated LVN A had a no call, no show and never returned to work for the facility. He stated LVN A had no disciplinary actions write-ups on her. He stated that night shift staff received in-serviced training on ANE, resident rights and customer service. He stated he was the abuse coordinator. During an interview on 04/24/2026 at 02:07 p.m., the DON stated that Resident #21 had two cellphones, one worked and the other did not. She stated that the resident gave LVN A permission to take one of the phones to the nurse's station for charging, but when phone was returned, it was the wrong phone. She stated that ADM learned about the phone mix-up when making morning rounds. She stated the ADM located the resident's phone at the nurse's station charging and the ADM returned the phone to the resident. She stated she was not made aware there was a problem with the phone being at the nurse's station until this date. During an interview on 04/24/2026 at 02:32 p.m., the DON stated on 03/04/2026, it was communicated during the morning meeting by ADON A after a pass off report during shift change from LVN A that resident's phone was being charged at the nurse's station. It was never stated that the phone was taken from the resident, only with permission. She stated had she known the phone was taken without permission, she would have addressed it at that time. She stated she would never advise a staff to take a resident phone. She stated taking a resident's phone could be considered a form of abuse and interrupt the need for the resident to reach out during issues or distress and hinder a resident's ability to call 911. She stated she was made aware of the resident's 911 calling behavior and addressed the behavior and the pain concerns were evaluated. She stated at the time of the incident she was focused on trying to figure out what caused the resident to have a behavior. She stated staff never communicated with her at the time the resident had begun calling 911, otherwise, she would have addressed the behavior immediately. She stated the facility provides in-services training on ANE, resident rights, and customer service monthly, and off cycles as needed due to incidents. During an interview on 04/24/2026 at 05:25 p.m., Resident #21 stated that when the staff took her phone to prevent her from calling 911 and would not address her pain, she had anxiety, felt horrible, and mistreated. During an interview on 04/25/2026 at 02:00 p.m., ADM stated he was not made aware that LVN A had taken the Resident #21's phone without permission. He stated that LVN A was disgruntled employee who made a false allegation against the facility. During an interview on 04/26/2026 at 01:26 p.m., CNA D stated she worked for the facility on the 3:00 p.m. to 11:00 p.m., shift. She stated that on this date she received an in-service training on ANE, and resident rights that covered the resident's right to call 911, answering call-lights as soon as possible, and reporting changes in a resident's behavior to the charge nurse as soon as possible. She stated she was to document all behaviors in POC the clinical part of a resident's charge that CNAs document. She stated that staff had previously charged resident's phones at the nurse's station, but because a resident could accuse the staff of taking the phones without permission, they were no longer allowed. She stated staff were to provide a resident with a phone charger in the resident's room. She stated that the facility and purchased new phone chargers for resident's use. She stated the ADM was the abuse coordinated that all forms of abuse were to be reported. She stated in the event the ADM was unavailable or the perpetrator of abuse, she would report the abuse to the charge nurse, and DON. She named the following as forms of abuse: misappropriation of property, neglect, verbal, physical, seclusion, sexual, and mental/emotion. During an interview on 04/26/2026 at 01:36 p.m., LVN B stated she worked 7:00 a.m. to 7:00 p.m. on a rotating day shift. She stated she received in-service training on 04/25/2026 on ANE and not taking resident's cellphones to charge, that all phone charging was to take place in a resident's room. She stated that the ADM was the abuse coordinator and in the event that the ADM was the preparator she would report the abuse to the DON, HR, and the company's compliance hot line. She stated the following were forms of abuse to report: physical, mental, emotional misappropriation, and sexual. During an interview on 04/26/2026 at 01:41 p.m., LVN D stated she worked 7:00 a.m. to 7:00 p.m. on a rotating day shift. She stated she received in-service training on 04/25/2026 ANE, not taking personal belongings, and answering call lights timely. She stated staff were not to take any personal belongings from a resident including their cellphone even for charging purposes. She stated staff could provide the residents a charger to use in their room. She stated if she witnessed abuse or exploitation, she would make sure the resident was safe and notify the ADM who was the abuse coordinator, nurse supervisor, residents RP, MD, and DON immediately. She stated she would then complete a change of condition report, documenting the abuse and or misappropriated items, her witnessed observation, and notes from the resident's statement. She stated in the event that the ADM was the preparator she would report the abuse to the corporate's compliance hot line anonymously if she feared retaliation. She stated the following were forms of abuse to report to the abuse coordinator immediately: physical, verbal, sexual, misappropriation, neglect, and emotional. During an interview on 04/26/2026 at 01:49 p.m., ADON A stated she worked for the facility on a rotating shift. She stated she received in-service training on 04/25/2026 covering ANE, not taking a residents possession including their phone even for charging, provide the a resident with a charger to use in the resident's room, and reporting all changes of a resident's behavior to the MD, RP, and DON. She stated in the event that a resident made repeated calls to 911 to be sent to the hospital, she would complete a behavioral assessment, notify the MD and RP and send the resident to the hospital. She stated once transferred she would follow up with the hospital on the resident's condition and update the resident's MD, RP, and the DON. She stated the following were forms of abuse that were to be reported to the ADM who was the abuse coordinator: physical, financial, emotional, psychological, verbal, and sexual. She stated if the ADM was the abuser or she feared retaliation from reporting, she would report to the corporate compliance line and the state anonymously. During an interview on 04/26/2026 at 01:55 p.m., LVN E stated she worked for the facility on a rotating shift from 07:00 a.m. to 07:00 p.m. She stated she received in-services on 04/25/2026 on resident rights, right to be free from ANE, right to call 911, right to have their phone in their room, change of condition and reporting to the resident's MD, RP, and the DON, completing pain and behavioral assessment, not charging resident's phones outside of the resident's room, and bringing chargers to the resident in the room, and comply with the resident's request and right to go to the hospital. She stated if a resident wants to go to the hospital, it was the staff's responsibility to assist with the transfer even if the resident will not share what was wrong. She stated that the ADM was the abuse coordinator and named the following as forms of abuse: verbal, physical, psychosocial, restraining, financial, seclusion, and sexual. She stated if abuse was reported to her, she would first stop and intervene to ensure the resident was safe and identify who, what and where the abuse took place. She stated and in the event that the ADM was the abuse coordinator, she would report the abuse to the DON, contact the police, call the compliance line, and any department manager. She stated if she feared retaliation from reporting abuse, she would call the compliance line anonymously. During an interview on 04/26/2026 at 8:27 p.m., CNA B stated she worked the from 7:00 a.m. to 07:00 p.m. and from 7:00 p.m. to 07:00 a.m. on a rotating shift. She stated she received in-service training on 04/25/2026 on ANE and stated the following were forms of abuse: verbal, misappropriation of funds, physical, mental, seclusion, and sexual that were to be reported to the ADM who was the abuse coordinator. She stated she received in-service training the same day on resident rights, not taking a cellphone outside of the residents' room to charge, and reporting changes of a resident's condition to include behavior reports. She stated if she feared retaliation from reporting abuse, she would call the compliance line and report to her on call manager. During an interview on 04/27/2026 at 10:24 a.m., CNA B stated she worked on 03/04/2026 beginning her shift at 07:00 a.m. She stated ADON A instructed her to transfer Resident #21 who was sitting in a wheelchair across from the nurse's station into bed. She stated she asked CNA C to assist and the transfer. She stated she had not recalled anything out the ordinary with the resident. She stated she could not recall any more details from that morning, but stated the resident exhibited tearfulness or complaints or desire of wanting her cellphone. She stated had she, she would have reported those behaviors immediately to the resident's nurse. She stated she was not made aware on 03/04/2026, the resident pulled the fire alarm and called 911 repeatedly and heard comments from other staff this week the behavior was contributed by the resident's anxiety. During an interview on 04/27/2026 at 03:35 p.m., CNA A stated she worked on 03/03/2026 from 7:00 p.m. to 7:00 a.m. on 03/04/2026 and was responsible for Resident #21's care. She stated at 04:00 a.m., she responded to the residents' call light when the resident asked for snacks and drinks. She stated the resident pushed the call light again and the resident asked to get out of bed. She stated she informed LVN A and LVN A told her it was too early for the resident to get up. She stated that the resident insisted on getting up and she informed LVN A again. She stated LVN A assisted her get the resident out of the bed and into a wheelchair. She stated that LVN A rolled the resident into the hallway so that LVN A could have eyes on the resident while the staff made their final round of the shift. She stated the resident made no requests to go to the hospital or no complaints about her cellphone. She stated had she been aware, she would have reported the events to the nurse in charge. She stated she was not aware that the resident had called 911 repeatedly and had pulled the fire alarm. She stated she received in-service training on ANE and stated that following were forms of abuse: verbal, sexual, physical, seclusion, financial, and mental. She stated that the ADM was the abuse coordinator of which all forms of abuse were reported to. She stated in the event that the ADM was unavailable or the perpetrator, he would report the abuse to the nurse in charge, and the compliance line. She stated she also received in-service training on the resident's right to have the cellphone and call whoever they want. She stated staff were not to take any resident's property including a resident's cellphone and all resident phones were to be charged in a resident's room and nowhere else by staff. During an interview on 04/27/2026 at 6:38 p.m., CNA E stated on 03/03/2026 she came on shift at 11:00 p.m. until 7:00 a.m. on 03/04/3036. She stated on 03/04/2026, she answered Resident #21's call light and the resident was on the phone, and they individual was asking the resident questions and the resident was complaining about something, but she does not recall what the complaint was or who the resident was talking to because the resident asked the nurse to speak to the person on the phone. She stated she took the resident's phone to LVN A at the nurse's station and went back to work. She stated then LVN A asked her to assist in getting the resident out of the bed and into the wheelchair. She stated during the transfer the resident made no complaints and was not in pain. She stated when she left her shift at 07:00 a.m., the resident was sitting in front of the television calm. She stated she had not seen the resident crying or complaining of pain, or of not having or wanting her cellphone. She stated she was not aware when and when or if LVN A returned the resident's phone to her after speaking to the caller on the resident's phone. She stated she was not aware if the resident's phone was at the nurse's station or if it was being charged while at the station. She stated she had not seen or known if EMT or the fire department responded to 911 calls made by the resident or the pulling of the fire alarm. She stated she

Based on interviews, and record reviews, the facility failed to ensure that pain management was provided to Resident #21's who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. The facility failed to monitor and address Resident #21's pain on 03/04/2026 from 3:00 a.m. to 11:00 a.m., when Resident #21 pressed her call light, cried out in pain, called 911 twice, and pulled the fire alarm requesting to go to the hospital. This failure had the potential to place residents at risk for delayed treatment, pain, and actual harm. The findings included: Record review of Resident #21's face sheet dated 04/23/2026 reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included systemic lupus erythematosus, epilepsy, anxiety disorder, obesity, pain in unspecified joint, stiffness of unspecified joint, muscle wasting and atrophy, cognitive communication deficit, and need for assistance with personal care. Record review of Resident #21's Comprehensive MDS, dated [DATE], reflected the resident had a BIMS score of 15 which indicated the resident had intact mental cognition. Record review of Resident #21's care plan reflected, the resident was risk for pain and discomfort r/t lupus date initiated 01/21/2026 and revised on 02/05/2026. Record review of Resident #21's order dated 01/22/2026 at 08:00 a.m., reflected MD ordered Hydroxychloroquine sulfate oral table 200 mg by mouth one time a day for lupus. Record review of Resident #21's order dated 02/18/2026 at 05:00 p.m., reflected MD ordered Acetaminophen-Codeine Oral Tablet by mouth two times a day for pain (D/C 04/20/2026). Record review of Resident #21's order dated 03/04/2026 at 02:13 p.m., reflected MD ordered Gabapentin 300 mg TID for pain. Record review of Resident #21's order dated 03/04/2026 at 02:13 p.m., reflected MD ordered 2-view x-ray of lumbar spine r/t pain. Record review of Resident #21's order dated 03/04/2026 at 02:18 p.m., reflected a MD ordered a two view lumber spine x-ray, performed a complete pain assessment, resident denied any pain or discomfort at that moment, and resident was to continue with her scheduled pain medications. Record review of Resident #21's pain evaluation dated 03/04/2026 at 02:35 p.m., revealed ADON A completed an evaluation finding the resident had complaints of pain in her back and pain medication administered to alleviate pain. Record review of Resident #21's March 2026 MAR reflected resident received, Acetaminophen-Codeine Oral Tablet 300-30 mg 1 tablet given by mouth two times a day for pain and degenerative joint disease beginning 02/18/2026 at 05:00 p.m. and D/C on 04/20/2026 at 01:24 p.m. check and note pain levels at 09:00 a.m. and 05:00 p.m. administration. No pain levels were recorded on 03/03/2026 and 03/04/2026. Record review of Resident #21's March 2026 MAR reflected resident received, Gabapentin Capsule 300 mg capsule to be given by mouth three times a day for Pain beginning, 03/04/2026 at 05:00 p.m. To be administered at 09:00 a.m., 05:00 p.m. and 09:00 p.m. Resident received her first dose on 03/04/2026 05:00 p.m. Record review of Resident #21's March 2026 MAR reflected resident to have pain monitored every shift use 0-10 scale, (a) for alert residents use pain and (b) for confused. Document which pain scale used to assess residents pain rating. every shift starting 01/21/2026 at 07:00 a.m. No pain levels were recorded on 03/03/2026 and 03/04/2026. Record review of Resident #21's change of condition dated 03/04/2026 at 02:26 p.m., reflected the resident reported pain that started on 03/04/2026. Vitals checked and noted within range. Change in mental status was noted as new or worsening behavioral symptoms and pain medication administered. Suggested request for lab work and x-ray. New order for Gabapentin 200 mg TID. ADON A received the resident at the nurse's station as resident was up having behavior and making 911 calls. Resident was then taken to her room at the resident's request and was placed to bed. ADON A, called Family Member A to inform him of the resident's behavior with no response. During an interview on 04/22/2026 at 10:52 a.m., Resident #21 stated at she had a diagnosis of Lupus, and the symptoms caused her chronic pain in her joints and back, and the need for frequent repositioning. She stated she relied on staff for that repositing and to provide her with her PRN pain medication. She stated all too often, when she pressed the call light for assistance with repositioning there was a delay in staff responds and sometimes that would not come at all until meals were passed. She stated because she frequently pressed the light for assistance, the staff often were mad with her, responding with attitudes, disrespect, and unfriendly tones. She stated staff would respond with, What do you need now? She stated that she was sick and needed staff to answer her call light. She stated she was a nurse and knew the staff's task responsibilities and need for great customer service. She stated the facility staff needed refresher training on customer services and resident rights. She stated she had concerns that there were only 2-CNAs for 50-residents on hall she resided. She stated she had not reported the incident to the staff or the ADM who was the abuse coordinator because they were all aware of the incident. During an interview on 04/23/2026 at 2:25 p.m., Resident #40 stated that her roommate was Resident #21. She stated on 03/04/2026 at 4:00 a.m., Resident #21 woke up crying in pain, pressed the call light, yelled out for help, and then called the facility's front desk from her cellphone, with no response. She stated then Resident #21 called 911 when LVN A came into the room and asked Resident #21 why she had called 911 as EMS had responded to her call as was at the facility. She stated Resident #21 told LVN A she was in pain, but LVN A then left the room. She stated again, Resident #21 dialed 911 who asked for the address to the facility. She stated Resident #21 was only able to provide the street name, when LVN A reentered the room. She stated Resident #21 asked LVN A for the facility's address, but LVN A told Resident 21's she did not know the address, took the resident's phone to tell the 911 operator that everything was okay with the resident, and hung up the call. She stated that LVN A then left the room with Resident #21's cellphone. She stated that Resident #21 yelled out for assistance until 5 a.m., when LVN A and CNA A entered the room and got Resident #21 out of bed and into a wheelchair. She stated LVN A stated she would monitor the resident from the nurse's station. She stated that while Resident #21 was in the hall, she could hear the resident saying nurse, nurse, nurse, can you help me. She stated sometime later, she heard the fire alarm go off and then CNA B and CNA C brought the resident back to the room and put her into the bed. She stated that Resident #21 required a lot of care, specifically repositing due to the resident's Lupas diagnosis that caused the resident severe pain. She stated that Resident #21 pushed her call light frequently for assistance due to pain and the need for pain medication. She stated anything longer than an hour of Resident #21 sitting in a wheelchair caused the resident increased pain. She stated on 03/04/2026, the staff had the resident sitting in her wheelchair for more than an hour. She stated she had not reported the incident to any staff or the ADM because they were all aware. She stated the ADM was the abuse coordinator, but she would not report abuse to him because he was a liar and could not be trusted to do what was best for the residents. During an interview on 04/23/2026 at 04:26 p.m., SW A stated on 03/09/2026, she followed up with Resident #21 after a behavior of calling 911 twice on 03/04/2026. She stated Resident #21 had neurological issues that limited her ability to remember the 911 event, date, and times. She stated the resident explained to her on 03/04/2026, she wanted to go to the hospital and called Family Member B's who had not agreed with the resident's need to go to the hospital. She stated the resident told her she wanted to go to the hospital and go to another facility, but the resident could not provide a reason why. SW A stated she believed, the resident called 911 in an attempt to get Family B's attention on her wellbeing. SW A stated which was accomplished and with the focus on the resident, the resident felt better. She stated that LVN A responded to the resident's need to call 911 but found that the resident had no changes in condition that required hospital transfer. She stated she had not heard the resident had concerns with back pain or any pain on 03/04/2026 as the reasoning for calling 911. She stated it had been her expectations had the nursing staff been made aware of any pain concerns, they would have assessed the resident and made a decision how to proceed thereafter. She stated it had also been her expectation that staff not to hinder a resident's request to be transferred to the hospital. She stated failure hinders hospital transfer could delay a resident's need for higher levels of care. She stated she was not aware that the resident had also pulled the fire alarm nor that the fire department had responded. She stated at a recent care plan meeting with the resident and Family A, neither made mention of any pain management issues. She stated after speaking to the resident, the resident told her she no longer wanted to go to another facility and was safe and felt safe. She stated the facility provided in-service training on reporting a change of condition related to pain management to the resident's nurse, DON, and the resident's MD. During an interview on 04/23/2026 at 05:33 p.m., ADON A stated she was aware Resident #21 had called 911 and pulled the fire alarm, but she had not been on shift. She stated that CNAs had reported to her that the resident had behaviors when the resident first admitted in January 2026 but had not called out for the need to go to the hospital. She stated the resident had often complained of pain due to her diagnosis, but the resident could not specify the exact location, only that pain was present. She stated on 4/20/2026, MD D/C the resident's scheduled medication due to the resident experiencing nauseous and a new PRN medication was ordered. She stated she never knew the resident to cry out in pain. She stated that when the resident received pain focused assessments, the resident denied pain or denied the assessments all together. She stated if the nurse insisted on completing the pain assessments, the resident would insult the nurse. She stated in the event that a resident reported pain, she would immediately notify the resident's MD and contact the DON. If the resident insisted on going to the hospital, she would not attempt to stop the resident. She stated the facility provided in-service training on resident rights and properly caring for a resident which covered pain management, every month. During an interview on 04/23/2026 at 05:49 p.m., the DON stated LVN A quit without notice after a casual conversation unrelated to the 911 calls with Resident #21. She stated the facility provided staff in-service training on pain management quarterly, monthly and as needed. During an interview on 04/23/2026 at 09:00 p.m., LVN A stated on 03/03/2026, her shift began at 07:00 p.m. and ended on 03/04/2026 at 07:00 a.m. and she was assigned to care for Resident #21's on that shift. She stated while making rounds check in on the resident to find she wanting to pass her a cellphone. She stated when she got on the phone, a 911 operator asked what type of emergency assistance the resident had needed. She stated she told 911 that the resident was fine before disconnecting the call. She stated the resident had normal vitals and there was nothing voiced by the resident to be concerned nor was there anything visibly wrong with the resident. She stated a short time later; CNA A brought her the resident's phone answering the resident's call light. She stated she took the phone saying hello, and again, 911 was on the line asking what emergency services the resident needed and again she told 911 that the resident was fine. She stated at 07:00 a.m. her and CNA A got the resident out of bed as an intervention to the resident's behaviors. She stated she also took the resident's cellphone and placed it at the nurse's station as an intervention to keep the resident from calling 911. She stated when the ADM came on shift at 07:00 a.m., she told him she had taken the resident's phone and asked if they were allowed to do that. She stated the ADM told her they really could not do that, and she said OKAY she would return the phone, but the ADM stated he would handle it. She stated while in the tv area, the resident wheeled her over the wall near the fire alarm. She stated the SC tried to stop the resident from pulling the alarm but was too late. She stated she asked the resident why she pulled the alarm, and the resident stated that she wanted to go home. She stated that CNA B was asked to put the resident back to bed. She stated at no time had the resident complained of pain, cried out, or expressed any discomfort. She stated she had heard nothing further on the incident, was unaware if the resident received a pain assessment or a new order for pain medication. She stated that the facility provided in-service training on pain management all the time. She stated she quit working for the facility unrelated to the incident and had no disciplinary actions taken against while with the facility. During an interview on 04/24/2026 at 10:51 a.m., the MD stated that on 03/04/2026 at 11 a.m. she visited Resident 21's during routine rounds at the facility. She stated she learned from staff that the resident had placed repeated calls to 911 early that morning after experiencing evaluated anxiety and attention seeking behavior. She stated that the resident had chronic pain and inflammation associated with the Lupus diagnosis, along with chronic pain from a compression fracture and surgery to the resident's lower back. She stated during that visit, the resident expressed having severe and sharp pain that was more than usual. The MD stated she ordered new labs, a lumbar x-ray, and added Gabapentin to accompany the existing scheduled pain medication of Tylenol with codeine. She stated labs and x-rays confirmed existing inflammation and previous fractures that contributed to the resident's ongoing pain, but no new/acute issues. She stated the resident called 911 due to chronic pain. The MD stated the nursing staff had tracked and monitored the resident's vitals during that time frame, noting all were within range. She stated she was not aware when the resident called 911 that EMS had arrived at the facility and had been turned away without evaluating the resident. She stated it was her expectation if EMS made the scene, that the resident should have been evaluated and the staff should have relied on the EMT's evaluation to determine if resident had pain that justified a hospital transfer. She stated it was also her expectation that if a resident insisted on being transferred to the hospital that the facility would assist with that transfer, notify MD, and the resident's family. She stated it was her expectations that the nursing staff do not minimize residents' pain. She stated she had not been made aware staff transferred the resident from her bed to a wheelchair as an intervention and deterrent from calling 911. She stated sitting the resident up could elevate pain. She stated she had not been made aware that the resident had also pulled the fire alarm and that the fire department had responded at the facility. She stated she would have also expected the facility staff to allow the fire department's EMTs to evaluate the resident before departing the facility. She stated she had not received a call prior to making rounds of the incidents with the resident. She stated had any of the physician staff been made aware that the resident had called 911 due to the pain, crying in pain, and insisting to be sent to the hospital they would have immediately ordered a hospital transfer. She stated on stated that on 04/20/2026, the resident's Tylenol order was D/C and replaced with Tramadol a stronger pain medication. During an interview on 04/24/2026 at 01:42 p.m., the DON stated on 03/04/2026, she had not received a call from staff regarding Resident #21 calling 911 repeatedly due to pain. She stated at the morning meeting on 03/04/2026 she learned the resident had behaviors during the night shift and called 911 and pulled the fire alarm. She stated there was no mention of pain during the meeting. She stated after reviewing the resident's clinical notes she found that on 03/04/2026, the MD completed a pain assessment, ordered x-rays of the resident's spinal lumbar, and added a new order of Gabapentin 3-times a day. During an interview on 04/24/2026 at 01:51 p.m., the ADM stated he was on shift on 03/04/2026 before LVN A's shift ended at 07:00 a.m. He stated he was on shift and when Resident #21 pulled the fire alarm and called 911 repeatedly after behaviors contributed to the resident's UTI diagnosis. He stated the fire department arrived at the facility and were informed that it was a false alarm. He stated that he was not made aware that the resident had reported pain to LVN A. He stated that LVN A was a nice night nurse that lacked confidence. He stated LVN A had no calls, no show and never returned to work at the facility. He stated LVN A had no disciplinary actions write-ups on her. He stated that night shift staff received in-serviced training on notifying physicians of change in a resident's condition. During an interview on 04/24/2026 at 2:32 p.m., the DON stated on 03/04/2026, she was made aware of the resident's 911 calling behavior and addressed the behavior and the pain concerns were evaluated. She stated at the time of the incident she was focused on trying to figure out what caused the resident to have the behavior. She stated staff never communicated with her in the moment that the resident was calling 911, otherwise, she would have addressed the behavior immediately. She stated the facility provides in-services training on changes of condition that addresses pain management monthly, and off cycles as needed due to events. During an interview on 04/24/2026 at 5:25 p.m., Resident #21 stated when the staff prevent her from calling 911 and would not address her pain, she had anxiety, felt horrible, and mistreated. She stated she was currently receiving tramadol to manage the pain. During an interview on 04/26/2026 at 01:26 p.m., CNA D stated she worked the 03:00 p.m. to 11:00 p.m., shift at the facility. She stated that on this date she received an in-service training on reporting changes of condition to the charge nurse including resident's voicing pain or exhibiting pain like behavior as soon as possible. She stated she was to document the changes POC noting what abnormal conditions were observed and what was known that could have caused the changes. She stated the ADM was the abuse coordinator that all forms of abuse were to be reported. She stated in the event the ADM was unavailable or the perpetrator of abuse, she would report the abuse to the charge nurse, and DON. She named the following as forms of abuse: misappropriation of property, neglect, verbal, physical, seclusion, sexual, and mental/emotion. During an interview on 04/26/2026 at 01:36 p.m., LVN B stated she worked 7:00 a.m. to 7:00 p.m. on a rotating day shift. She stated she received in-service training on 04/25/2026 on reporting changes of condition and of pain to the charge nurse, resident's MD and RP, and the DON immediately. She stated the in-service also covered if a resident insists on going to the hospital sent the resident and inform the MD, RP, and DON, and complete all required transfer documentation in the resident's clinical chart. She stated that the ADM was the abuse coordinator and in the event that the ADM was the preparator she would report the abuse to the DON, HR, and the company's compliance hot line. She stated the following were forms of abuse to report: physical, mental, emotional misappropriation, and sexual. During an interview on 04/26/2026 at 01:41 p.m., LVN D stated she worked 7:00 a.m. to 7:00 p.m. on a rotating day shift. She stated she received in-service training on 04/25/2026 ANE, answering call lights timely, reporting change of condition, and pain immediately. She stated if she witnessed abuse, she would make sure the resident was safe and notify the abuse coordinator immediately, perform skin and pain assessment, notify the nurse supervisor, family, MD, ADM, and DON. She stated she would then complete the change of condition document noting finding from her assessments, witnessed observation, and interview from the resident. She stated that the ADM was the abuse coordinator who all allegations of abuse were reported. She stated in the event that the ADM was the preparator she would report the abuse to the corporate's compliance hot line anonymously if she feared retaliation. She stated the following were forms of abuse to report to the abuse coordinator immediately: physical, verbal, sexual, misappropriation, neglect, and emotional. She stated if a resident insisted on going to the hospital despite the lack of MD orders, she was to notify the MD, RP, and DON of the transfer and complete the required transfer documentation. During an interview on 04/26/2026 at 01:49 p.m., ADON A stated she worked for the facility on a rotating shift. She stated she received in-service training on 04/25/2026 covering changes in a resident's pain. She stated she would administer any PRN medication, report the pain the MD, RP, and DON, complete a pain assessment, and send the resident to the hospital. She stated once transfer was complete, follow up with the hospital and report the resident's status to the resident's MD, RP, and the DON. She stated the following were forms of abuse that were to be reported to the ADM who was the abuse coordinator: physical, financial, emotional, psychological, verbal, and sexual. She stated if the ADM was the abuser or she feared retaliation from reporting abuse, she would report the abuse to the facility's corporate compliance line and the state anonymously. During an interview on 04/26/2026 at 01:55 p.m., LVN E stated she worked for the facility on a rotating shift from 07:00 a.m. to 07:00 p.m. She stated she received in-services on 04/25/2026 on resident rights to call 911 and comply with the resident's request and right to go to the hospital, reporting the resident's pain change of condition to the resident's MD, RP, and the DON, completing pain assessments, and the staff's responsibility to assist with hospital transfers even if the resident will not share the need to go to the hospital. She stated that the ADM was the abuse coordinator and named the following as forms of abuse: verbal, physical, psychosocial, restraining, financial, seclusion, and sexual. She stated if abuse was reported to her, she would first stop and intervene to ensure the resident was safe and identify who, what and where the abuse took place. She stated and in the event that the ADM was the abuse coordinator, she would report the abuse to the DON, contact the police, call the compliance line, and any department manager. She stated if she feared retaliation from reporting abuse, she would call the compliance line anonymously. During an interview on 04/26/2026 at 8:27 p.m., CNA B stated she worked shifts that covered 7:00 a.m. to 07:00 p.m. and 7:00 p.m. to 07:00 a.m. She stated she received in-service training on 04/25/2026 on She stated she was to report changes to a resident's condition to include reporting a resident's pain to the unit manager immediately. She stated she also had ANE in-service training and stated the following were forms of abuse: verbal, misappropriation of funds, physical, mental, seclusion, and sexual that were to be reported to the ADM who was the abuse coordinator. She stated if she feared retaliation from reporting abuse, she would call the compliance line and report to her on call manager. During an interview on 04/27/2026 at 10:24 a.m., CNA B stated she worked on 03/04/2026 beginning her shift at 07:00 a.m. She stated Resident #21 who was sitting in a wheelchair across from the nurse's station with no events out the ordinary. She stated ADON A instructed her to transfer the resident to the bed and CNA C assisted with that transfer. She stated she could not recall any more details from event, but had the resident exhibited tearfulness, pain, discomfort, or complaints or desires to go to the hospital, she would have reported those behaviors immediately to the resident's nurse. She stated she was not made aware on 03/04/2026, the resident pulled the fire alarm and called 911. During an interview on 04/27/2026 at 03:35 p.m., CNA A stated on 03/03/2026 she worked from 7:00 p.m. to 7:00 a.m. on 03/04/2026. She stated she was responsible for Resident #21's care and at 04:00 a.m., she responded to the resident's call light who wanted a snack and drink. She stated again she responded to the resident's call-light and the resident asked to get out of bed. She stated LVN A was informed and LVN A responded it was too early for the resident to get up. She stated that the resident insisted on getting up LVN A assisted her transferring the resident into a wheelchair. She stated LVN A rolled the resident into the hallway for LVN A to keep a closer eye on the resident. She stated the resident made no requests to go to the hospital or complaints of pain. She stated had she been aware, she would have reported the events to the nurse in charge. She stated she was not aware that the resident had called 911 repeatedly and had pulled the fire alarm. She stated she received in-service training on pain management, reporting changes of condition to the charge nurse immediately, and residents had the right to go to the hospital. She stated she also received in-service training on ANE and stated that following were forms of abuse: verbal, sexual, physical, seclusion, financial, and mental. She stated that the ADM was the abuse coordinator of which all forms of abuse were reported to. In the event that the ADM was unavailable or the perpetrator, he would report the abuse to the nurse in charge, and the compliance line. During an interview on 04/27/2026 at 6:38 p.m., CNA E stated on 03/03/2026 she started her shift at 11:00 p.m. and came off shift on 03/04/3036 at 7:00 a.m. She stated on 03/04/2026, she answered Resident #21's call light and found the resident on a cellphone being asked questions and complaining about something. She stated the resident handed her the cellphone stating the individual wanted to speak to a nurse. She stated she took the resident's phone to LVN A at the nurse's station and went back to work. She stated then LVN A asked her to assist in getting the resident out of the bed and into the wheelchair. She stated during the transfer the resident had not made any complaints of pain. She stated she left her shift at 07:00 a.m., and the resident was sitting in front of the television calm. She stated she had not seen the resident crying or complaining of pain. She stated she had not seen or known if EMT or the fire department responded to 911 calls made by the resident due to pain and was not aware the resident pulled the fire alarm. She stated she later learned those incidents occurred. She stated she received in-service training a few days ago on residents were allowed to call 911 and be sent to the hospital, and to report a resident's pain to their nurse immediately. She stated she received ANE in-service training and all reports of abuse were to be reported to the ADM who was the abuse coordinator. She stated the following were forms of abuse to be reported to the ADM immediately: verbal, mental, sexual, financial, and physical. She stated in the absence of the abuse coordinator she would report the abuse to the DON and the compliance hotline. During an interview on 04/28/2026 at 10:33 a.m., CNA C stated she worked on 03/04/2026 and began shift at 07:00 a.m. She stated she found it strange to see Resident #21 sitting in the television area across from the nurse's station that early in the morning. She stated the resident requested to be transferred from the wheelchair to bed. She stated she assisted CNA B with the transfer with the use of a gait belt, without incident. She stated that the resident had not cried, whined, or complained of pain that required reporting to the resident's nurse. She stated she learned this week that the resident pulled the fire alarm and called 911 repeatedly on 03/04/2026. She stated it was normal for the resident to cry and whine from knee and back pain, which she reported to the nurse. She stated that the resident sometimes wanted to get out of bed into a wheelchair but could not sit for long periods of time due to what the resident noted as cement in her back that caused pain. She stated that she received ANE in-service training on 04/27/2026, that covered reporting change of condition and reporting a resident's pain immediately to the resident's nurse and documenting the pain in POC. She stated in the event that the resident's nurse had not responded to the report of pain immediately she would report the pain to the ADON and the DON, and double back to ensure the pain was assessed. She stated the following were forms of abuse to report to ADM who was the abuse coordinator: verbal, mental exploitation, sexual, and physical. She stated in the absence of the abuse coordinator she would report the abuse to the compliance hotline and the state. During an interview on 04/28/2026 at 10:24 a.m., with the ADM and the DON, the DON stated the negative effects of not addressing Resident 21's pain, could have caused the resident increased pain and pain that was not addressed. She stated had she been made aware the resident's pain had not been addressed by LVN A, she would have terminated LVN A that day. The DON stated it had been her expectation that if a resident made a report of pain, the resident's nurse would perform a pain assessment, notify the manager on duty, and the resident's MD, check orders for pain medication, and administer the medication. She stated if no pain medication was ordered or the order the pain medication order was not effective, she expected that the MD would be further informed a new order for pain received, and complete further pain evaluations to document any changes in the resident's pain. She stated to post the pain report, the residents received quarterly pain assessment. The ADM agreed with the DON's statements on pain and stated he would have reported the incident as abuse, and suspended LVN A pending an investigation of the allegations. Record review of policy titled Notification of Changes dated 10/24/2022, reflected: Policy. The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Compliance Guidelines: The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification. Record review of in-service training dated 04/24/2026 titled: Responding to Call lights/Cellphones was conducted by DON and presented to all the facility staff reflected: All changes in condition must be reported to the MD/NP, DON and RP. Non-clinical staff report any noticeable changes to the charge nurse and then the manager on duty if the charge nurse was not available. Record review of in-service training dated 04/25/2026 titled: Addendum: All changes in a resident's condition must include a documented pain assessment. If a resident calls 911 or the fire department, they have the right to receive evaluation and treatment. The resident has the right to be transferred out for treatment per their request. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status.

Based on record reviews and interviews, the facility failed to ensure each resident is offered the COVID-19 (infectious respiratory illness caused by the corona virus) vaccine unless the immunization is medically contraindicated, or the resident has already been immunized for all residents.The facility failed to offer COVID vaccine to its residents upon admission to the facility. This failure could place residents at risk of COVID. The findings are: During an interview on 04/24/2026 at 10:13 a.m., the ICPN stated the facility did not offer COVID vaccines to its residents. She stated residents and residents' representatives always declined the COVID vaccination, so the facility stopped offering the vaccine. She stated she was unaware the facility should have offered the vaccine to its residents and they could accept or refuse to receive it. She stated she did not recall when the facility stopped offering the vaccine to its residents. She stated if the facility did not offer the vaccine to residents, they could be at a higher risk of COVID disease. During an interview on 04/24/2026 at 10:25 a.m., The DON stated she was unaware the facility should have offered the COVID vaccine to its residents and they could accept or refuse to receive it. She stated she did not recall when the facility stopped offering the vaccine to its residents. She stated if the facility did not offer the vaccine to residents, they could be at risk of COVID. During an interview on 04/24/2026 at 10:29 a.m., The MD stated he was unaware the facility should have offered the COVID vaccine to its residents and they could accept or refuse to receive it. He stated if the facility did not offer the vaccine to residents, they could be at a higher risk of COVID disease. During an interview on 04/24/2026 at 1:20 p.m., The administrator stated he was unaware the facility should have offered the COVID vaccine to its residents. He stated he did not recall when the facility stopped offering the vaccine to its residents. He stated if the facility did not offer the vaccine to residents, they could be at risk of COVID disease. Record review of the facility's Infection Control Policy, dated 05/13/2023, reflected, Policy: This facility has established and maintains 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 as per accepted national standards and guidelines.Policy Explanation and Compliance Guidelines: 8. COVID-19 Immunization:a. Residents and staff will be offered the COVID-19 vaccine when vaccine supplies are available to the facility.b. Residents and staff will be screened prior to offering the vaccination for prior immunization, medical precautions and contraindications to determine candidacy for the vaccination.c. Education about the vaccine, risks, benefits, and potential side effects will be given to residents or resident representatives and staff prior to offering the vaccine.d. Residents or resident representatives will have the opportunity to accept or refuse a COVID-19 vaccination, and change their decision based on current guidance. Record review of CDC (U.S. government agency responsible for protecting public health) ACIP (a CDC-chartered group of medical experts that develops recommendations for vaccine use in the U.S. civilian population) recommendations, dated October 2024, revealed .In October 2024, ACIP recommended that all persons aged 65 years receive a second 2024-2025 COVID-19 vaccine dose 6 months after their last dose. What are the implications for public health practice?Adults aged 65 years should receive 2 doses of 2024-2025 COVID-19 vaccine Record review of CDC COVID Recommendations, dated 11/19/2025, revealed, .The COVID-19 vaccine helps protect you from severe illness, hospitalization, and death.It is especially important to get your 2025-2026 COVID-19 vaccine if you are ages 65 and older.Vaccine protection decreases over time, so it is important to get your 2025-2026 COVID-19 vaccine.

Based on observation, interview and record reviews, the facility failed to ensure the resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 8 residents (Resident #38) reviewed for call light placement. The facility failed to ensure Resident #38's call light was within reach on 04/24/2026, while he was lying in bed. These failures could place residents at risk of not receiving immediate assistance when needed. Findings include: Record review of Resident #38's Face Sheet, dated 04/24/2026, reflected, a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #38 had diagnoses which included cerebral infarction (when blood flow to part of the brain is blocked), muscle weakness and history of falling. Record review of Resident #38's admission MDS (a standardized, mandatory assessment tool used by nursing homes to evaluate the health, functional status, and care needs of residents), dated 04/08/2026, reflected, the resident had a BIMS of 0, which indicated the resident had severe cognitive impairment. He used a wheelchair for mobility. He was dependent on staff with personal hygiene, toileting hygiene, showering, upper body dressing and lower body dressing. He was always incontinent with bladder and bowel. Record review of Resident #38's Care Plan dated 04/03/2026, reflected the resident had an ADL self-care performance deficit r/t cerebral infarction. The resident was at risk for falls r/t cerebral infarction and muscle weakness. Record review of Resident #38' Progress Note, dated 04/03/2026, reflected the resident incontinent of bowel and bladder, bed to be in lowest position and call light within reach. During an observation and an interview on 04/24/2026 at 9:54 a.m., revealed Resident #38 was lying in his bed with the call light out of reach, on the head of his bed. Resident #38 said he could not reach his call light. The resident said his call light was out of his reach most of the time. The resident stated he was doing okay and was not aware as to when or who placed his call light on the head of his bed. During an interview on 04/24/2026 at 10:00 a.m., CNA Q stated he was unaware of how Resident #38's call light was placed out of reach, on the head of his bed. He stated in the morning the resident's call light was close to the resident. He stated he checked residents call lights placement every morning at the beginning of his shift and whenever he went to residents' rooms when they needed help. He stated the call light needed to always be within reach in the event the resident needed to call for help. He stated he received in-service training on call lights last week. During an interview on 04/24/2026 at 10:12 a.m., RN Q stated she was unaware of why Resident #38's call light was not within his reach. She stated she checked residents' call lights when she provided care to them. She said Resident #38's call light not being within his reach could increase his chances of falling on the floor if he needed to reach out to something and was not able to. She stated she received in-service training on call lights last week. During an interview on 04/24/2026 at 01:07p.m., the DON stated residents' call lights were to always be within reach for residents to call for assistance. She stated a resident could fall at any moment reaching for an item they may need. She stated failure to place a call light within reach could result in a resident experiencing a fall. She stated she expected CNAs and nurses to round on residents every 2 hours and ensure call lights were within reach. She stated she checked residents call lights placement weekly.She stated the facility provided call light positioning, answering, and personal items within reach at bedside in-service training last week. Record review of in-service training, dated 03/21/2026 and 04/24/2026, titled Call Lights reflected All staff members are responsible for answering call lights. If you answer a light and it's not in your scope or field. Notify the nurse in charge and a unit nursing manager. Direct care staff, after providing care make sure the call light is attached to the patient or in reach, whichever is the patient's preference. Call lights should be answered timely. Communication is key if you can't provide care at that moment let the patient know when to expect you back. If you're overwhelmed or too busy notify your charge nurse or team member so they assist where needed. If a clamp is missing put it in TELS (digital maintenance request platform) so maintenance can replace it. Signed by multiple facility staff, conducted by DON The in-service included the staff identified to care for Resident #38. Record review of the facility's Call Lights: Accessibility and Timely Response policy. dated 10/13/2022 reflected, Policy: The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response.Policy Explanation and Compliance Guidelines.6. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room.9. Ensure the call system alerts staff members directly or goes to a centralized staff work area.10. All staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified.

Based on interview and record review, the facility failed to transmit encoded, accurate, and complete MDS data to the Center for Medicaid/Medicare System (CMS) System for 1 of 6 closed records (CR #154) reviewed for Minimum Data Set (MDS) transmission. - The facility failed to complete and retransmit CR #154's MDS discharge assessment within 14-days of CR #154's discharge when the anticipated return had not resulted in a readmission. This failure could place residents at risk of not having assessments completed and submitted in a timely manner as required. The findings were: Record review of CR #154's face sheet dated 04/23/2026, reflected, CR admitted to the facility on [DATE] and discharged on 01/23/2026. CR's had diagnoses which included pain in right shoulder, unspecified fall, pain in unspecified joint, muscle wasting and atrophy, multiple sites, cognitive communication deficit, need: assistance with personal care, dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Record Review of CR #154's Comprehensive MDS assessment dated [DATE] reflected, CR had a BIMS score of 08 which reflected CR had moderate impaired cognition. Record Review of CR #154's Discharge MDS assessment dated [DATE] reflected, CR had unplanned discharge with anticipated return due to a short-term hospital transfer. Record Review of CR #154's Change of Condition Communication Form dated 01/20/2026 at 02:13 p.m., reflected CR had s/sx of a reported cough that started on 01/20/2026. Since the start of the condition, the symptoms stayed the same with medication making the symptoms better. Vitals: pulse 83 (regular), respiration 18, most recent temperature 97.3, most recent weight 135 mm, and most recent O2 sats 97. Family D had a concern with CR coughing and wanted to talk to the doctor to send CR to the hospital. NP was notified and a new order was given for stat CXR Guaifenesin (an over-the-counter (expectorant used to thin and loosen mucus in the airways, making coughs more productive and clearing chest congestion)100ml q 4hr PRN and DuoNeb inhalation solution used to treat airway narrowing) q 4hrs PRN. Record Review of CR #154's progress notes created by LVN F and dated 01/23/2026 at 12:30 a.m., reflected Family C requested CR's hospital transfer r/t a cough. The DON informed. Record Review of CR #154's progress notes created by LVN F and dated 01/23/2026 at 01:12 p.m., reflected CR was transported by EMS to hospital. CR's face sheet and medication sheet were given to EMS. Record Review of CR #154's progress notes created by LVN G dated 01/23/2026 at 01:29 p.m., reflected that CR's NOMNC issued 01/09/2026 was received and sent to Family C. Per Family C, he continued to maintain that CR had covered Medicare benefits, the insurance made a mistake, and CR won her last appeal. LVN G reiterated that the NOMNC was issued and coverage ending notice stayed as is (01/09/2026) and CR had been private pay as of 01/10/2026. Family became upset and asked for more time to fix issues. Family was instructed to talk with BOM and SW to finalize financial obligation and discharge plan. Record Review of CR #154's progress notes created by CMA dated 01/24/2026 at 01:43 p.m., reflected, CR out on pass. Record Review of CR #154's progress notes created by CMA dated 01/25/2026 at 01:15 p.m., reflected CR was at the hospital. Record Review of the facility's admission, transfer, discharge log reflected CR #154 was admitted on [DATE] and discharging on 01/23/2026. Record Review on 04/23/2026 at 10:58 a.m., reflected CR #154's quarterly/annual MDS was 77-days overdue. During an interview on 04/25/2026 at 12:54 a.m., the MDS Nurse stated that she was responsible for transmitting the MDS discharges for the facility. She stated CR #154 discharged on 01/23/2026 with an anticipated return and she completed CR's discharge MDS assessment on 01/23/2026. She stated the care plan was to be closed out if CR had not returned with 30-days. She stated that the dashboard should have shown a notification at the end of that 30-days to close out CR's care plan. She stated because the care plan was not closed, the care plan remained open and the MDS quarterly/annual review showed 79-days overdue. She stated without the notification the only way anyone would have known the care plan was still opened would have been to simply go into CR's clinicals. She stated she ran a report to show any open care plans and MDS's but CR had not reflected on the report as open or incomplete. She stated she was not sure how the discharge was missed. She stated because CR was no longer an active resident, no adverse effects would transpire from the care plan remaining open. She stated with CR no longer in the facility, the system would not allow anyone to add or reduce information on the care plan. She stated she was not aware of a written policy on MDS and discharges. She stated she was trained by corporate over a year ago. During an interview on 04/28/2026 at 11:29 a.m., RRN A stated that when a resident discharges from the facility with an anticipated return that does not result in a readmission, the facility must manually complete a discharge deletion so that the care plan closes out and no further MDS tasks trigger for completion. He stated it was the facility's responsibility to track CR #154's progress after discharging to the hospital to determine where the resident when once released. He stated he could not see in the CR's progress notes where the resident was once discharged from the hospital. He stated since it appears that tracking had not occurred, it explained why CR's discharge was not manually changed from anticipated returned to returned not anticipated. He stated it was his understanding that the facility as well as RRN should have been triggered after CR had not readmitted within 30 days. He stated he was not aware why no triggers were initiated. He stated that there were no negative or financial effects from the lack of correcting the discharge assessment, only paper compliance with CMS. Record review of policy titled Policy Assessment Frequency/Timeliness Date Implemented: and dated 10/24/2022 reflected, Policy: The purpose of this policy is to provide a system to complete standardized assessments in a timely manner, according to the current RAI Manual. 9. A significant correction assessment will be completed no later than the 14th calendar day after determination that a significant error in a prior OBRA assessment occurred. 11. Part A PPS discharge assessment must be completed within 14 days after the end date of the most recent Medicare stay (14 calendar days). If combined with an OBRA discharge assessment, it must be completed 14 days after the ARD of the OBRA discharge date .

Based on observations, interviews and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 of 10 residents (Resident #30, Resident #41) reviewed for medication storage and labeling.The facility failed to ensure nurses dated Residents #30 and 41's opened insulin glargine (a medication prescribed to help the body manage blood sugar levels) pens and discarded them within 28 days of opening, on 04/24/2026.This failure could place residents at risk of receiving medications that were less effective or expired and the risk of contamination or chemical degradation (change of a substance into something else, often making it weaker, useless, or harmful).Findings included: Record review of Resident #30's Provider Orders dated 04/09/2026, revealed an active order to receive insulin glargine 100 units/ml multiple-dose pen. Inject 20 units SQ (under the skin) one time a day for diabetes (a disease in which the body cannot make or properly use insulin).Record review of Resident #41's Provider Orders dated 03/11/2026, revealed an active order to receive insulin glargine 100 units/ml multiple-dose pen. Inject 30 units SQ one time a day for diabetes.During an observation of Hall 100's medication cart and interview on 04/24/2026 at 12:08 p.m., revealed, staff opened and dated 2 insulin glargine, 100 units/ml multiple-dose pens and kept them in the medication cart beyond 28 days of the opening date. The insulin pens belonged to Resident #30 and #41. Staff opened and dated both insulin pens on 03/23/2026.RN Q stated she should have checked the insulin pens opening dates before each administration and discarded them after 28 days of opening. RN Q added if nurses kept using the insulin pens after 28 days of opening, residents could receive insulin that was less effective in controlling their blood sugar levels, RN Q stated she was unaware the insulin pens were expired.During an interview on 04/24/2026 at 1:04 p.m., the DON stated she expected all nurses to check insulin pens for opening dates before each administration and discard them after 28 days of opening. The DON stated she spot checked insulin pens for expiration dates weekly. The DON stated she spot checked the facility's medication carts for expired medications last week. The DON added if nurses kept using the insulin pens after 28 days of opening, residents could receive insulin that did not work as prescribed.Record review of the facility's Insulin Pen Policy dated 07/03/2023, revealed .Policy: It is the policy of this facility to use insulin pens in order to improve the accuracy of insulin dosing, provide increased resident comfort, and serve as a teaching aid to prepare residents for self-administration of insulin therapy upon discharge.Policy Explanation and Compliance Guidelines:9. Insulin pens should be disposed of after 28 days or according to manufacturer's recommendation.Procedure:e. Check the expiration date on the pen. Discard if expired.Record review of the most current manufacturer's guide for insulin glargine pens dated August 2022, revealed staff must throw away all opened pens after 28 days of first use, even if there is insulin left in the pen.

Based on record review and interview, the facility failed to ensure that a written notice of transfer or discharge, was provided to the resident and/or their representative contained all federally mandated elements for 1 of 4 residents (Resident #40) reviewed for discharge notices. The facility failed to ensure that Resident #40's written notice of transfer or discharge, including a safe discharge location. The facility failed to ensure that Resident #40's written notice of transfer or discharge, contained the Ombudsman's name and email address. These failures could place the residents at significant risk by bypassing critical safeguards meant to ensure their safety and continuity of care.Findings included: Record review of Resident #40's face sheet dated 04/26/2026, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included, lesion of radial (dysfunction in the arm, leading to symptoms like wrist drop, weak triceps, and numbness on the back of the hand) of left upper limb. Record review of Resident #40's MDS dated [DATE] reflected the had a BIMS score of 00 indicating the resident had sever impaired cognition. Record review of Resident #40's progress Notes dated 06/12/2025 at 10:11 a.m., created by SW B reflected, SW B called several hotels and found Resident #40 had resided at one and the owner confirmed he had the resident's belongings. The owner confirmed that they had no first floor availability at that time for the resident to return, when asked. SW B would go see the resident to ascertain if there were other hotel room availabilities for the resident to discharge. Record review of Resident #40's progress Notes dated 10/16/2025 at 09:24 a.m., created by SW B reflected, while making safety check rounds was told by Resident #40 said she had a vacate notice about and up and coming in a PCH. SW B inquired about the PCH choice for the pending discharge, as SW B wanted to assist the resident in locating a PCH. The resident said it was early; she had just woken up, and asked SW B to come back in the afternoon. Record review of Resident #40's progress notes dated 10/20/2025 at 04:52 p.m., created by SW B reflected, resident assured SW the resident would notify staff of any concerns regarding the pending 30-day notice for discharge and hearing notification. None noted. Record review of Resident #40's progress notes dated 11/12/2025 at 02:30 p.m., created by MD B, reflected, resident seen laying in the bed. Staff reported the resident would not cooperate in discharge planning. Resident would not cooperate with exam when asked to raise her legs, stated that I am working on it. When asked to raise her upper left upper extremity, resident claimed it is better. When encouraged to get out of the room, the resident said she was working on some things in the room. MD B noted the resident provided vague responses to MD B's questions. Resident denied any pain during the evaluation. Resident was on Tylenol, PRN for pain. Previously, the resident had been difficult to work with in terms of finding placement. The resident had been resistant to taking gabapentin despite recommendations. Resident had complained of wearing splint on left wrist and forearm and had reported feeling better with pain managed by Tylenol as needed. Social History: Resident was living in hotel, no family support. Vacate notice imminent. Planned discharge to a PCH; SW B assisting with placement. Ongoing challenges with discharge planning and placement. Staff reported the resident had not been cooperating with discharge planning, placement efforts, and had been difficult to place. SW B had previously engaged regarding housing and PCH options; patient requested a later return for further discussion. Record review of Resident #40's progress notes dated 11/20/2025 at 09:30 a.m., created by PA-C, reflected, resident had ongoing challenges with discharge planning and placement; not cooperating with SW B regarding facility's needs and potential discharge/placement planning. Psychiatric: Normal appearance and behavior, calm during examination, not agreeable to leaving room with discharge planning. Resident noncompliance with other medical treatment and regimen. Will continue to work with nursing staff and social services to address placement issues. All medications, allergies and problems discontinued on this date. Record review of Resident #40's progress notes dated 01/28/2026 at 04:34 p.m., created by SW A reflected, resident acknowledged receipt of 30 notice of discharge for non-payment for services. Resident was adamant of not needing assistance; that resident understood the rights relative to discharge notice. Resident very verbal relative to not trusting others; stated plan of not being able to walk out of here. SW A to follow up with referral to APS regarding the resident's 30-day notice of discharge and lack of plans and cooperation for assistance. Record review of Resident #40's progress notes dated 1/30/2026 at 11:08 a.m., created by SW A reflected, contact to APS regarding resident with 30-day notice of discharge; unknown status as to resident's discharge plans; failure to comply with facility staff assistance with access to services. Case will be referred to local ombudsman office. Record review of Resident #40's progress notes dated 04/10/2026 at 08:00 a.m., created by PA-C reflected, resident declined follow-up visit. Hospital Course: Resident was a [AGE] year-old female with history of sciatica (uses crutches) sustained a mechanical fall resulting in an open left distal humerus fracture, a left femoral neck (hip) fracture, and bilateral displaced superior pubic rami fractures. Orthopedic surgery performed irrigation and debridement with ORIF of the left distal humerus, with subsequent removal/revision of prior ORIF on 05/06/2025 and application of a wound vacuum with low suction. Radial nerve injury was noted; preoperative integrity was unclear. Resident elected non-operative management for the femoral neck and pelvic fractures. Resident was stabilized and transferred from the hospital to the facility for rehabilitation. Resident declined her follow-up on 04/07/2026 and again on this date. Resident stated she was fine and does not need to be checked. The resident was not assessed on this date due to her refusal of the visit. Previously, the patient had demonstrated an ongoing pattern of noncompliance with medical treatment and refusal of assessments, including refusal of right shoulder evaluation, treatment options, and diagnostic imaging. Resident had been managing chronic pain with Tylenol 650 mg every 6 hours as needed. Resident had a history of right shoulder pain, left femoral neck fracture and left pubic fracture both healing with conservative management, and left radial nerve injury with splint. Resident had been difficult to work with regarding discharge and placement planning, and has been resistant to gabapentin despite recommendations. Record review of Resident #40's discharge notice titled Nursing Home Transfer and Discharge Notice reflected, the resident was not receiving Medicare, the resident was her own RP, with an out of state address, with an anticipated discharge date of 02/27/2026. The reason for discharged listed: Your bill, for services at this facility, has not be pained after reasonable and appropriate notice to pay. The following reasons require either this form be signed by a physician or a physician's written order for discharge or transfer be attached. The signing physician may be the resident's attending or treating physician, the facility medical director, or a nurse practitioner or physician's assistant as a physician designee. Your health has improved sufficiently so that you no longer need the services provided by this facility. The notice failed to outline the Ombudsman's name and email address. During an interview on 04/23/2026 at 2:25 p.m., Resident #40 stated when she admitted to the facility she came for OT and PT services to assist with walking and mobility strength. She stated during therapy services she was encouraged to walk, but the attempts caused her too much pain and added new sciatic nerve pain. She stated she cannot walk, nor get into a shower chair due to pain from the bone break. She stated that the facility staff thought she was being difficult because she refused care, but it had been due to fear of pain and reactivating pain. She stated she can feed herself and she was able to give herself a bed bath with the assistance of staff providing her soap and water. She stated that the staff change her bedding daily, provider her with incontinent care, and repositing assistance. She stated she does not take medication because the MD discontinued the pain order. She stated because she had refused nursing care due to pain the facility had labeled her difficult. She stated that she had no trust of the ADM, DON, BOM, SW, Ombudsman, and others she had not named because they had lied on her saying she was difficult and refused because she could not pay for her stay in advance. She stated that she refused nursing care due to pain and pain fears, not to be difficult. She stated that since the facility staff labeled her difficult, she does not share information or communicate with them. She stated that she had not applied for Medicare services, but she may and did not want the help of facility because they had all lied on her. Email received from Resident #40's on 04/23/2026 at 02:52 p.m., Resident #40 stated she received a 30-day notice of involuntary discharge in January 2026 from the facility that she stated was defective and invalid because the facility could not show a safe discharge location for her to transfer. She stated instead of exhausting all administrative remedies including correcting the invalid discharge notice, the ESQ. filed an eviction notice in the Justice of the Peace court. During an interview on 04/23/2026 at 04:26 p.m., SW stated in or around May 2025, Resident #40 was living in a hotel room, got out of the shower, and was already using crutches, and one of the crutches slipped and the resident fell and fractured her hip. She stated the resident went to the hospital for surgery and was sent to the facility under a LOA program where the hospital paid 6-weeks of the resident's short-term care for the resident to obtain therapy services. She stated since that time, the resident had been living at the facility for free. She stated that the resident will not provide any family, financial earning information, or apply for financial benefits to cover the resident's financial obligation for the care provided by the facility. She stated the facility suggested referring the resident's case to the guardianship program to see assign someone to get involved applying for financial services for the benefit. She stated that she does not believe that the resident will qualify under the programs guidelines because the resident was cognitively intact. She stated that the resident refuses all care services, had no active medication orders, and refused to allow staff to get her out of bed and get her well. She stated the resident would also not participate in psychological services or assessments as the facility thought the resident's refusals and failure to provide family and financial information could have been psych related. She stated that the resident was simply comfortable being in the bed. She stated 2-weeks ago, the ADM participated in a facility indicated court hearing in eviction court receiving an eviction ruling in the favor of the facility to evict Resident #40. She stated that the constables would be to the facility any day to remove the resident from the facility. She stated at the end of the day, the resident had not provided the facility with enough information for the resident to have a safe discharge. She stated the facility had been in contact with APS who they were assuming will step in once the resident's eviction was complete to ensure that the resident found a safe placement. During an interview on 04/25/2026 at 02:36 p.m., RRN B stated that the IDT met to discuss and determine Resident #40's need for discharge. She stated that the IDT attempted to discuss with the resident her ideal discharge plans, but the resident refused to take part in the planning by refusing to share information for a safe discharge location. She stated the BOM attempted to obtain financial information and the resident's participation in applying for Medicaid benefits, but the resident refused to provide information and assist in the application process. She stated the IDT reviewed the resident's nurse's notes, medications, progress notes, and ADLs and determined the resident no longer required skilled or long term care services. She stated the resident was not taking any medications, refused therapy, activates, and psychology services. She stated the resident was only accepting meals and incontinent care at times. She stated as a result, the IDT determined the resident was ready for discharge and the discharge notice was sent to the resident on 01/27/2026 with an anticipated discharge on or before 02/27/2026. She stated she reviewed the resident's progress notice after the discharge notice was sent and found that the facility had not made contact with any family or individual who lived at the out of state address listed on the discharge notice. She stated the facility had not confirm as to whom the resident would receive care and support from if discharged to the out of state location. She stated based on having no contact with the individuals at that out of state address, she could not consider the out of state address as a safe discharge location. She stated she was not aware of the name of the Ombudsman or if the Ombudsman was aware or involved in supporting the resident thought the discharge process. She stated after reviewing the discharge notice she found that there was no Ombudsman name or email address listed on the notice and the facility was in the process reinitiating a new discharge notice that would give them additional time to find the resident a safe discharge location. Email received from Resident #40's on 04/26/2026 at 10:22 a.m., Resident #40 stated she came to the facility after a fall, fracture to her pelvis in two locations, hip, and arm. She stated after 3-surgeries she was discharged from the hospital after 3 weeks to the facility. She stated at the hospital that she received rehabilitation services, but after the second week, it was extremely difficult to push up with all her weight on uninjured leg without causing pelvic and sciatic nerve pain. She stated at the end of the 3-weeks, she was in no condition to leave the facility, but the ADM was trying to force her to for lack of insurance. She stated she tried to set up a payment plan, but the ADM wanted all money up front a month in advance, which she could not do. She stated shortly thereafter she received a 30-day notice of discharge. She stated that the notice lacked an address for a safe discharge location and the Ombudsman's contact name and email address. She stated, ESQ. who specialized in nursing home defense, filed an eviction in the Justice of the Peace court for her removal from the facility. During an interview on 04/26/2026 at 03:30 p.m., the ESQ. stated that she was outside counsel for the facility. She stated Resident #40's was admitted to the facility from the hospital with a 30-days LOA for the hospital to pay for that 30-day stay. She stated the resident refused to provide the facility with information to assist in applying for Medicaid benefits or offering any financial information to pay for her stay. She stated the facility had been trying to figure out where the resident could discharge since the resident's MD medically cleared the resident for discharge. She stated the facility submitted their 30-days discharge notice to the resident on 01/27/2026 to be effective on 02/27/2025. She stated the resident was from out of state and that address used on the discharge notice was addressed to the out of state address. She stated the discharge notice provided the resident with an opportunity to appeal the decision. She stated that the resident had not appealed, and with no appeal, the facility assured the out of state address was a safe discharge location. She stated that the facility had given the resident plenty of time to discharge on her own. She stated the facility had done everything they needed to do administratively to discharge the resident, and with no corporation from the resident, and decided to evict the resident through eviction court proceedings. She stated the court ruled in the facility's favor to evict the resident. She stated the resident attempted to appeal, but the court denied the resident's appeal. She stated that she had issued a wit to possess (summons to notify the resident of her eviction timeframe) with the constable's office, and the constables office would be placing a notice on the resident's room door this week. She stated once the notice was placed, the resident had 24-hours to vacate before the constables physically removed the resident from the facility. She stated the facility had made contact with APS informing them of their decisions to remove the resident. She stated that APS could not step in and assist with placement until the resident was out of the facility. She stated once the resident was officially out of the facility, the facility would call APS in hopes that they would step in immediately with a safe placement for the resident. During an interview on 04/27/2026 at 08:59 a.m., the Ombudsman stated that she visited the facility residents every Monday morning and had a few attempts to visit with Resident #40 who had refused to communicate with the Ombudsman. She stated she knows that the resident came from out of state, fell while in a hotel, and came to the facility for rehabilitation services. She stated the resident had not engaged with staff, nor shared family or financial information to assist with paying for the stay, and refused to assist with the facility in completing a Medicare application. She stated that the facility had not provided her with a copy of the resident's discharge notice and the Ombudsman's office had not received the notice either. She stated the facility was supposed to send an email to the main Ombudsman's email address and the Ombudsman's secretary was to forward the notice to her. She stated once an email was received from a facility, the notice was usually forwarded the same day, directly to her email. She stated she had never received a discharge notice from this facility for any of the residents. She stated had she received the resident's discharge notice, she would review the notice to ensure that it was properly initiated, check with the BOM, discharge manager, resident, and ADM to discuss the improper notice and discharge plans for resident. Email received from Resident #40's on 04/27/2026 at 11:06 a.m., Resident stated ESQ. obtained a court order to physically remove her on 04/28/2026 or 04/29/2026, even though the facility's 30-day notice of involuntary discharge was invalid. During an interview on 04/27/2026 at 11:41 a.m., the ESQ. stated she was the facility's outside legal counsel. She stated that she sent Resident #40 a new discharge notice and that the facility would hold off on the resident's eviction for at least 40-days. She stated even though the out of state address listed on the resident's discharge notice was assumed to be a safe discharge location, because the resident had not appealed, the ADM had made contact with a group home in the area to assure the resident had a safe discharge from the facility. She stated a new discharge notice was reinitiated and planned to be send out on this date to the resident. Record review of policy titled Transfer and Discharge (including AMA) dated 03/05/2025, reflected: Policy: It is the policy of this facility to permit each resident to remain in the facility and not transfer or discharge the resident from the facility, except in limited circumstances. This policy applies to all residents regardless of their payment source. Policy Explanation and Compliance Guidelines:1. The facility will evaluate and determine the level of care needed for the resident prior to admission to ensure the facility's ability to meet the resident's need.2. Once admitted , the resident has the right to remain at the facility unless their transfer or discharge meets one of the following specified exemptions:a. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility.b. The transfer or discharge is appropriate because the resident's health has improved sufficiently so that the resident no longer needs the service provided by the facility.c. The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident.d. The health of individuals in the facility would otherwise be endangered.e. The resident has failed, after reasonable and appropriate notice, to pay or have paid under Medicare or Medicaid for his or her stay at the facility. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay.3. The facility's transfer/discharge notice will be provided to the resident and resident's representative in a language and manner in which they can understand. The notice will include all of the following at the time it is provided:a. The specific reason and basis for transfer or discharge.b. The effective date of transfer or discharge.c. The specific location (such as the name of the new provider or description and/or address if the location is a residence) to which the resident is to be transferred or discharged .d. An explanation of the right to appeal the transfer or discharge to the State.e. The name, address (mailing and email) and telephone number of the State entity which receives such appeal hearing requests.f. Information on how to obtain an appeal form.g Information on obtaining assistance in completing and submitting the appeal hearing request.h. The name, address (mailing and email), and phone number of the representative of the Office of the State Long-Term Care Ombudsman.4. Generally, the notice must be provided at least 30 days prior to a transfer or discharge of the resident. Exceptions to the 30-day requirement apply when the transfer or discharge is affected because:a. The health and/or safety of individuals in the facility would be endangered due to the clinical or behavioral status of the resident;.

Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain grooming and personal hygiene for 3 out of 8 residents (Resident #22, Resident #17, and Resident #24) reviewed for ADLs.1. The facility failed to provide scheduled showers and/or bed baths on M/W/F to Resident #22 on 9/17/25, 9/19/25, 9/22/25, 9/26/25, 10/1/25, 10/3/25, 10/6/25, 10/8/25, 10/10/25, 10/13/25, and 10/15/25.2. The facility failed to provide scheduled showers and/or bed baths on M/W/F to Resident #17 on 9/17/25, 9/19/25, 9/22/25, 9/24/25, 9/26/25, 9/29/25, 10/1/25, 10/3/25, 10/6/25, 10/8/25, and 10/10/25.3. The facility failed to provide scheduled showers and/or bed baths on M/W/F to Resident #24 on 9/17/25, 9/19/25, 9/22/25, 9/24/25, 9/26/25, 10/1/25, 10/3/25, 10/6/25, 10/8/25, 10/10/25, 10/13/25, and 10/15/25.This failure could place residents at risk of skin breakdown, infection, and reduced feelings of self-worth.Findings included:1. Record review of Resident #22's undated face sheet revealed she was a [AGE] year-old female, who admitted on [DATE] with diagnoses of fracture of pubis (pelvis), iron deficiency anemia (not enough iron in the blood), and left upper limb radial nerve lesion (left upper arm, nerve problems).Record review of Resident #22's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15, which indicated normal cognition. Per the MDS, the resident did not reject care (e.g., bloodwork, taking medications, ADL assistance) that was necessary to achieve the resident's goals for health and wellbeing. The resident had impairment on one side of her upper and lower extremity and was bed bound. The resident required substantial/maximal assistance (helper does more than half the effort) with showers/baths. Resident #22 was frequently incontinent of bowel and bladder.Record review of Resident #22's Care Plan dated 5/14/25 revealed a Focus: Resident had an ADL self-care performance deficit r/t fracture of unspecified pubis (Initiated: 5/14/25). The goal was to improve the level of function in ADLs through the review date (Target Date: 11/23/25). Interventions included: Bath/Showering- The resident required assistance by staff with bathing/showering 3 times per week and as needed. The Care Plan did not mention any refusals of showers/baths.Record review of Resident #22's Progress Notes from 9/18/25-10/13/25 revealed no notes about refusing a bath/shower.Record review of Resident #22's ADL - Bathing MWF Task, printed on 10/15/25 for the past 30 days revealed 1 bath/shower on 9/24/25 and 1 refusal on 9/29/25. She missed a bath on 9/17/25, 9/19/25, 9/22/25, 9/26/25, 10/1/25, 10/3/25, 10/6/25, 10/8/25, 10/10/25, 10/13/25, and 10/15/25.In an interview and observation on 10/14/25 at 9:43am, Resident #22 was sitting up in bed. She said that she had only had 4-5 baths since she got there in May. She said the staff did not even come in and offer her a bath and if she asked for one, they were rude to her. 2. Record review of Resident #17's undated face sheet revealed he was a 61year-old male admitted on [DATE] with diagnoses of heart failure (heart is not pumping effectively), COPD (lung diseases that cause airflow obstruction and breathing problems), need for assistance with personal care, cognitive communication deficit, functional quadriplegia (inability to move the limbs due to severe disability or frailty), afib (heart beat is irregular), polyosteoarthritis (inflammatory joint disease in multiple joints), chronic pain, bilateral cataracts (clouding over both eyes), and muscle wasting and atrophy.Record review of Resident #17's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 12 out of 15, which indicated the resident had moderately impaired cognition. Per the MDS, the resident did not reject care (e.g., bloodwork, taking medications, ADL assistance) that was necessary to achieve the resident's goals for health and wellbeing. The resident had impairment on both sides of his lower extremities and used a wheelchair for mobility. According to the assessment the resident was dependent (helper did all of the effort, resident did none of the effort to complete the activity) for showers/baths. Resident #17 was always incontinent of bowel and bladder. The resident had shortness of breath or trouble breathing with exertion (walking, bathing, transferring), when sitting at rest, and when lying flat, and was on oxygen.Record review of Resident #17's Care Plan dated 10/1/24 revealed the focus: The resident had an ADL self-care performance deficit r/t recent hospitalization for COPD exacerbation, generalized weakness, and afib (Initiated: 10/1/24, Revised: 10/8/24). The goal was to improve his level of function in ADLs through the review date (Target: 11/2/25). The interventions included: bathing/showering- The resident required assistance by staff with showering and as necessary.Record review of Resident #17's Progress Notes from 9/17/25-10/15/25 revealed 2 notes that he refused a bath/shower, on 10/13/25 and 10/15/25.Record review of Resident #17's ADL - Bathing MWF Task, printed on 10/15/25 for the past 30 days revealed No Data Found. The task did not note any refusals. He missed a bath on 9/17/25, 9/19/25, 9/22/25, 9/24/25, 9/26/25, 9/29/25, 10/1/25, 10/3/25, 10/6/25, 10/8/25, and 10/10/25.In an observation and interview on 10/14/25 at 9:14am, Resident #17 was sitting up in bed. He said he did not get showers/baths often and was supposed to get one on Friday 10/10/25 but didn't. He said the staff would not offer it and say they were too busy. Record review of Resident #24's undated face sheet revealed she was a [AGE] year-old female admitted [DATE] with diagnoses of multiple sclerosis (chronic autoimmune disease that affects the brain and spinal cord), osteoarthritis, need for assistance with personal care, cognitive communication deficit, glaucoma (increased pressure in eye), neuromuscular dysfunction of bladder (bladder will not release urine), and muscle wasting and atrophy.Record review of Resident #24's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 13 out of 15, which indicated normal cognition. Per the MDS, the resident did not reject care (e.g., bloodwork, taking medications, ADL assistance) that was necessary to achieve the resident's goals for health and wellbeing. The resident had impairment on both sides of her lower extremities and used a wheelchair for mobility. The assessment revealed the resident was dependent for showers/baths. Resident #24 had an indwelling catheter (tube into bladder to drain urine) and was always incontinent of bowel. The resident had shortness of breath when lying flat and had 1 Stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcer.Record review of Resident #24's Care Plan dated 10/24/24, had a Focus: Resident has an ADL self-care performance deficit r/t impaired mobility and needs assistance with personal care (Initiated: 5/28/25). The goal was that the resident would improve her level of function in ADLs through the review date (Initiated: 10/24/24, Revised: 10/30/24, Target: 12/2/25). The interventions included: The resident was totally dependent on staff for repositioning and turning in bed, the resident was bedfast all or most of the time, the resident was totally dependent on staff for personal hygiene and oral care.Record review of Resident #24's Progress Notes from 9/17/25-10/15/25, revealed 1 note from 9/22/25 stating she received a bed bath. There were no refusals noted in any of the Progress Notes.Record review of Resident #24's ADL - Bathing MWF Task, printed on 10/15/25 for the past 30 days revealed 1 bed bath on 9/29/25. The task did not note any refusals. She missed a bath on 9/17/25, 9/19/25, 9/24/25, 9/26/25, 10/1/25, 10/3/25, 10/6/25, 10/8/25, 10/10/25, 10/13/25, and 10/15/25.In an interview and observation on 10/14/25 at 9:41am, Resident #24 was sitting up in bed. She said she got maybe 2 baths a week, if that. She could not remember when her last bath was.In an interview on 10/15/25 at 11:13am, the SW said Resident #17 told her before that he was not receiving showers/baths. She said she would report it to the nurse.In an interview on 10/15/25 at 12:38pm, LVN H and LVN T, who worked the resident's hall, said the showers/baths were documented in the EMR, under tasks. Both LVNs gave the names of 2 different residents as the only residents they could think of who refused showers/baths, and not Resident #22, Resident #17, or Resident #24. LVN H and LVN T said the CNAs in the morning gave the baths/showers to the A beds and the CNAs at night gave the showers/baths to the B beds.In an interview on 10/15/25 at 12:54pm, CNA O said showers/baths were given to the even numbered rooms on MWF and odd numbered rooms on TTS. A beds were given their shower/bath in the morning and B beds were given theirs at night. She said they documented the shower/bath in the EMR, and they documented the refusal in the system as well. CNA O said if a resident refused, she told the nurse, and the nurse would talk to the resident.In an interview on 10/15/25 at 2:14pm, LVN F said she had received complaints from residents about not getting showers/baths. She said the only resident who refused showers/baths was a different resident than Resident #22, Resident #17, or Resident #24. She said she felt the CNAs had enough time for showers/baths and providing care. LVN F said the baths/showers were documented in the EMR, along with refusals. She said if residents did not get showers/baths, they could develop skin issues and body odor, and the residents would feel horrible if they did not get them.In an interview on 10/15/25 at 2:39pm, CNA R, who worked the resident's hall, said she had enough time to provide showers/baths and care to residents. She said she had received complaints from residents about not getting showers/baths, and one of the residents was Resident #17. She said she would report it to the nurse when he would report it to her. CNA R said the showers/baths were documented in the EMR, and the refusals were documented there also. She said if residents did not get showers/baths they could get skin breakdown or scabies.In an interview on 10/15/25 at 3:33pm, the DON said the baths/showers should be documented in the EMR in the tasks, along with the refusals. She said if the resident refused, the CNA should have informed the nurse and then the nurse documented the refusal. She said, then the nurse would call the family and see if they could convince the resident, or they would try other interventions. The DON said if residents did not receive baths/showers they could get skin infections.In an interview on 10/16/25 at 9:20am, Resident #22 said she had never refused a bath/shower.In an interview on 10/16/25 at 9:22am, Resident #24 said she had not gotten a bath/shower in the last few days, and she wanted a bed bath. She said no one had come in and offered her one.Record review of the facility's policy and procedure on Activities of Daily Living (ADLs) dated 5/26/23 read in part: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure the resident's abilities in ADLs do 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.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.Documentation shall be completed at the time of service, but no later than the shift in which care service occurred.

Based on observation, interview, and record review, the facility failed to adequately equip to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside for 1 (Residents #35) of 6 residents reviewed for call lights.-Residents #35 did not have her call light within reach while she was in bed.This failure could lead to residents not being able to request and receive prompt medical care and result in injury and harm.Record review of Resident #35's face sheet dated 10/16/2025, she was a [AGE] year-old female originally admitted on [DATE] with medical diagnoses including vascular dementia, bipolar disorder, generalized anxiety disorder, Alzheimer's Disease, hypertension, cognitive communication deficit and other abnormalities of gait and mobility.Record review of Resident #35's Quarterly MDS assessment dated [DATE], she had a BIMS score of 3 out of 15, indicating severe cognitive deficit related to memory and thinking. Resident #35 was coded for having a walker. Resident #35 required set-up/cleanup assistance with tasks such as toileting, oral hygiene and dressing, and mobility in bed.Record review of Resident #35's care plan dated 10/16/2025, she had an ADL self-care performance deficit r/t impaired mobility with resident requiring staff assistance for toileting, turning and re-positioning in bed as necessary. Resident #35 was at risk for falls r/t confusion, gait/balance problems with interventions including being sure the resident's call light was within reach and encouraging the resident to use it as needed, the resident needed prompt response to all requests for assistance. Observation and interview with Resident #35 on 10/14/2025 at 9:48am, revealed she was in bed and appeared well-groomed and in no distress. Resident #35 said staff took her call light out of her room a couple of days ago, and told her they removed it because she used it too much. The call light was observed on the floor in the middle of the room between two dressers, out of reach of the resident in bed. LVN M was called to the room, and she put on gloves and took the call light off the floor and gave it back to Resident #35 who wrapped it around her bedrail. LVN M said that she was the nurse for the hall on 10/14/2025 and had been at the facility for ten months. LVN M said everyone was responsible for putting call lights close to the residents. LVN M said Resident #35 was confused at baseline and did not use her call light, but the light should be near her. If residents did not have call lights nearby, then they could not call for help. LVM M said she would remind her aides to put call lights on beds. In an interview with the DON on 10/15/2025 at 3:33pm, she said that she did monthly in-services on call lights with staff. The DON said call lights should not be on the floor. If the lights were on the floor, residents would not be able to call for help and residents should always have access to staff. It was a safety concern so residents could tell staff what they needed. The DON said everyone was responsible for ensuring call lights were within residents' reach and to answer them. A call light policy was requested by email on 10/16/2025 at 9:36am with the DON who said the facility did not have a specific call light policy.

During observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility is free of pests for the 300 and 400 halls, in that: The facility continues had an infestation of roaches in Residents' rooms as observed in the following: 317,321,323, 327 and 405. This failure could expose Residents to infection and decreased quality of life. During observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility is free of pests for the 300 and 400 halls, in that: The facility continues had an infestation of roaches in Residents' rooms as observed in the following: 317,321,323, 327 and 405. This failure could expose Residents to infection and decreased quality of life. Facility's record review shows, Resident # 4 was a [AGE] year-old male who was admitted to the facility on [DATE]. He was admitted with the following diagnoses: Cerebral infarction unspecified, Type 2 diabetes, Morbid obesity, Hyperlipidemia, Recurrent depression, Hypertension, Aphasia, Hemiplegia and Hemiparesis related to cerebral infarction affecting the left dominant side, Abnormality of gait and mobility, Lack of coordination, Retention of urine, Cognitive communication deficit, Dysarthria and anarthria, Obstructive and reflux uropathy. Facility's record review show, Resident #1 was a [AGE] year old male, admitted to the facility on [DATE], with the following comorbid factors: Muscle wasting and atrophy, Atrial flutter, Gait and mobility abnormalities, Cognitive communication deficit, Hypertension, Protein malnutrition, Chronic kidney disease, Non-pressure chronic ulcer of the right lower leg, Atherosclerotic heart disease, Ulcer of the right foot, Hyperlipidemia, Unspecified dementia without behavior, Presence of cardiac pacemaker, Chronic Obstructive pulmonary disease and Pulmonary edema. Facility's record review shows Resident # 2 was a [AGE] year-old male, admitted on [DATE] with the following diagnoses: Alcoholic cirrhosis f the liver with ascites, Diabetes mellitus, Recurrent depressive disorder, Benign prostatic hyperplasia, and Transient ischemic attack Observation, and interview with Resident # 2 on 07/01/2025 at 08:10 am in his room, he stated there are always roaches running around in his restroom. He has a BIM's score of 14. Resident # 2 said, come with me, and I will show you where most of the roaches are. Investigator and Resident # 2 saw two roaches crawling on the restroom floor. Resident #2 stated, they come out like this all the time. Both at night and during the day. The roaches disappeared into the cracks on the floor. Resident stated: They don't clean good around here. In an interview with Resident # 4's family on 06/30/2025 at 11:00 am at his bedside at the hospital, she said she and her family saw roaches at different instances when their dad, Resident # 4 was at the facility prior to hospitalization. She vividly remembered two dates: On 06/01/2025, my family member killed a roach. On 06/02/2025 my other family member killed another roach. I cannot remember the other dates. In an interview on 06/30/2025 at 3:20 pm with Resident # 1 in his room, he pointed to a hole where he said, the roaches come out and goes back in all the time. He sees them from his bed. Yes, I see roaches. I saw one yesterday running around the toilet bowl. I did not tell anyone. I see roaches that crawl on the wall, behind the television into a hole on the wall next to the bathroom door. In an interview with Housekeeper A on 06/30/2025 at 04:15 pm, who stated: Last month I saw roaches coming from outside, entering the building through the main entrance. I told my boss. Interview with Housekeeper B, on 06/30/2025 at 04:30 pm. Stated: I see roaches sometimes. I saw them last on hallway 400. They were babies. I saw them in a room, but I cannot recall the room number. I told the unit Manager. In an interview with CNA A on 06/30/2025 at 04:43 pm. CNA A stated: I see roaches all the time. I last saw roaches today in the following rooms: 321,323, and 327. I did not report to any one because everybody knows about them. This is not anything new to the facility. The maintenance Director was not available for interview on this day. In an interview with Resident # 3 on 07/01/2025 at 08:17 am in the Resident's room, she attests, she sees roaches on a weekly basis. I see roaches. Last week I saw roaches. This week, more precisely yesterday. Roaches are common. Record review on 07/02/2025 at 07:14 pm. Resident # 4's family shared a video with a roach crawling on the floor of Resident # 4's bedroom floor. Resident # 4's family member stated: this is not the first time. We have killed some in the past. Record review of pest control binder on 07/01/2025, shows Service Report presented by the facility. The Administrator stated pest control provider comes in twice a month. On 06/12/2025, inspection order # 777033, inspected the following rooms: 212,315,318,319,323,324,325 and 327. These rooms were vacuumed, dusted and applied liquid application accordingly. Upon arrival at the facility, Service Report shows: Upon arrival, inspected logbook. No activity reported in the pest sighting log at this time. On 06/26/2025, the general comment stated both interior and exterior areas of the building were inspected. Offices, restrooms, common areas, cafe bistro and kitchen. Small roaches were targeted for interior building. The report did not show that any roaches were exterminated. Rats were partially consumed by the mechanical catch trap outside the building. The Director of Nursing was unavailable for interview. She was out for a family medical appointment. Record review of text message on 07/01/2025 at 10'44 am from the Director of Nursing: Running to drop my son off for surgery of his gum his dad will stay. I'll be right bac. You can still. The Director of Nursing wrote this in a text message she sent to the investigator. Interview was not conducted with the maintenance manager because he was not in the building. Interview with the Administrator on 07/01/222025. He stated the pest control provider comes in twice a month. He said, they might have to increase the frequency to weekly. He said, there is no pest control policy. This was also in an email which stated: I was able to verify there is no pest control policy. We work from an agreement with pest control company and processes we follow to minimize risk.

Based on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 5 (Residents #21 #22, #44, #51 and #108) of 16 residents reviewed for cleanliness and sanitization. 1. The facility failed to address damaged and unclean walls in Residents #22, #44, and 51's room. 2. Resident #21's headboard was loose and moving back and forth. 3. Resident #108's wash basin on the nightstand that was not labeled and there was another wash pan in the bathroom that was not labeled or bagged. These deficient practices could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life. The findings include: Observation on 2/11/2025 at 9:41am in Resident #51's room revealed the wall at the head of bed had missing paint. Observation on 2/11/2025 at 10:07am in Resident #44's room revealed the room had a hole in the wall with a TV plug hanging out. The wall facing the resident's bed also had several areas of chipped wall paint and appeared dirty. Later interview with Resident #44 on 2/11/2025 at 2:27pm, she said she wanted to go back to her old room because the room she was currently in was [NAME], and she pointed at the markings and holes in the wall in front of her bed. Observation on 2/11/2025 at 1:59pm of Resident #22's room revealed paint chipped off along all of the baseboard by his bed. Resident #22 was not interviewable. Observation on 02/11/25 at 2:27PM of Resident #21's headboard revealed it was not attached securely to the bed (moving back and forward). The wall on the left side of the bed had brown stains. There was a hole in the wall on the right side of bed near the head of bed with wiring exposed. Interview on 02/11/25 at 2:30PM with the DON after she observed the Resident #21's and #22's rooms said she would have to call maintenance to make the necessary repairs in the resident room. The DON said any environmental issues in the facility, the staff were supposed to communicate with the maintenance department in the computer system. The DON said it was the responsibility of the staff (CNAs, nurses, unit managers, and the ambassadors) to make rounds on the resident rooms and when they saw any abnormalities, they were to report to maintenance or housekeeping to go and resolve the problem. The DON said housekeeping was notified verbally. Interview on 02/11/24 at 2:40PM ADON K said she was the Unit Manager for the hall where Resident #21 resided. ADON K said she was not aware of Resident #21's room having a hole in the wall with wires exposed or the resident's wall not being clean. ADON K said she was also not aware of the resident's headboard being broken. ADON K said it was very important to keep the resident rooms and their environment presentable because it was their home. ADON K said if that was not done, it could place the resident at risk for infections and not feeling good about their environment. ADON K said because residents had visitors, it was important to make the resident space presentable. ADON K said she would take care of the matter right away. Interview on 02/11/25 at 2:48PM with the Housekeeping Supervisor said the residents' rooms were to be cleaned daily and as needed. When the Housekeeping supervisor observed the walls in Resident #21's room, he said the wall needed to be cleaned. The Housekeeping supervisor said when Housekeeping cleaned the resident room, they were supposed to pay attention to the resident walls to see if it needed to be cleaned for infection control. The supervisor said the Housekeeper for Resident #21's room had gone home for the day. Interview on 02/11/25 at 3:00PM CNA T said she was the CNA for Resident #21. CNA T said a CNA who name she could not remember said she had reported to the maintenance department about Resident #21's headboard being broken approximately a week ago, but nothing had been done about it. CNA T said she was aware of the walls in the resident's room being dirty and informed Housekeeper U about it. CNA T said Resident #21's walls had been dirty for a while. CNA T said it was important to keep the residents' rooms clean for appearance. CNA T said if the resident room was not cleaned and maintained properly, it placed the resident at risk for infections or mold. CNA T said a broken headboard could place the resident a risk for injuries. Interview 02/11/25 at 3:16PM with the Maintenance Director said he had been working at the NF approximately five to six months. The Maintenance Director said he was responsible for work orders communicated to him in the computer system regarding the environment of the facility. The Director said he checked work orders daily and was not aware of Resident #21's room having a hole in his wall with visible wiring inside of it or the resident's headboard being broken until the present time. The Director said the issues were being taken care of at present time. The Director said the hole in resident's room wall was a communication line and should be covered. The Director said the ambassadors were supposed to communicate with him if they saw any environmental issues in the residents' rooms. The Director said the ambassadors were supposed to make daily rounds in the resident rooms. The Director said with the open hole in Resident #21's wall and broken headboard put the resident in danger. Further interview, the Director said after speaking with the Regional Maintenance Director , the loose headboard placed the resident at risk of falling if not repaired. The Director said the hole in the wall put the resident at risk of allowing pests to enter in the room. He said that he receives work orders through the computer which he checked daily, which included pests and room maintenance such as holes in the wall and open wiring. He said some staff are referred to as ambassadors and they are to make rounds each morning and throughout the day and are to report any environmental issues they observed. He said that he did not have any concerns regarding pests recently but saw a concern in the system today related to a spider earlier in the day. The Maintenance Director said he went into that particular room but did not find anyone else but he called pest control who will come on 2/12/2025. Interview on 02/13/25 at 8:40AM with the DON and the Regional Nurse after reviewing the Ambassador Round Assignment reflected that the Maintenance Director was Resident #21's ambassador. Resident #108 Record review of Resident #108's face sheet dated 02/11/25 revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. The resident's diagnoses included: cerebral infarction (blood flow to the brain is interrupted), muscle atrophy (a condition that causes muscle tissue to thin or waste away), and aphasia (disorder that affects a person ability to communicate effectively). Record review of Resident #108's admission MDS dated [DATE] reflected a BIMS score of 3 indicating the resident's cognition was severely impaired. Observation on 02/11/25 at 9:11AM of Resident #108's room revealed there was of a gray wash basin sitting on top of nightstand by Resident #108's bed on the left side. The wash basin was not labeled or inside of a bag. Further observation was made of a wheelchair leg rest sitting on top of the gray wash basin. Observation was made of another gray wash basin inside of the bathroom sitting on top of a rolling walker that was not dated or inside of a bag. Further observation of Resident #108's room revealed she was not in the room. Observation on 02/11/25 at 1:55PM in Resident #108's room revealed there was a gray wash basin in same areas of the room with no label and was not bagged. Interview on 02/11/25 at 2:02PM with CN R said she was the CNA for Resident #108. CNA R said when a resident's personal care equipment (wash basin) was not in use, the equipment should be labeled and bagged for infection control. CNA R said that was done to distinguish who the personal care item belonged too. CNA R said if this was not done, it placed the resident at risk for cross contamination. Interview on 02/11/25 at 2:20PM the DON said resident personal care items including wash pans were to be labeled with the room number or the resident name and bagged when done using for infection control. The DON said the CNAs were responsible for making sure it was done. Record review of the facility's policy on General Housekeeping, undated, reflected in part, the facility provides sufficient housekeeping and maintenance personnel, equipment, and supplies to maintain the interior and exterior of the facility in a safe, clean, orderly, and attractive manner. Record Review of facility's November 2021 Policy titled Resident Rights revealed: Residents of Texas nursing facilities have all the rights, benefits, responsibilities, and privileges granted by the Constitution and laws 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 safe, decent and clean conditions.

Based on observation, interview, and record review, the facility failed to ensure that a resident needing respiratory care, including tracheostomy care, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 6 of 8 (Residents #14, #21, #11, #17, #43 and #86) reviewed for oxygen. Resident #14's continuous oxygen was observed set at 8L/min on 02/11/2025 when he had a physician order for continuous oxygen at 6L/min. Resident #21's nebulizer machine was on the floor on the left side of his bed. The resident had respiratory tubing that was attached to a mask hanging on wheelchair at the bedside. Resident #11's nebulizer tubing and mask was not dated and placed inside of plastic bag when not in use. Resident #17's oxygen tubing was lying on the floor and nebulizer tubing and mask was not dated and placed inside of plastic bag when not in use. Resident #43's and #86's oxygen (O2) tubing was not stored off the floor in a clean and sanitary location. The failures placed residents at risk for respiratory infections and inadequate repiratory care. Findings Included: Resident #14 Record review of Resident #14's face sheet last captured 02/13/2025 revealed a [AGE] year-old male originally admitted on [DATE]. His medical diagnoses included anoxic brain damage (brain damage from lack of oxygen), muscle wasting and atrophy, cognitive communication deficit, tracheostomy status, chronic congestive heart failure, and pneumonia (infection of the lungs). Record review of Resident #14's Comprehensive MDS dated [DATE] revealed that he was receiving oxygen therapy at the facility. Record review of Resident #14's baseline care plan dated 02/09/2025 revealed he was receiving oxygen therapy, with interventions including monitoring for s/sx of respiratory distress and report to MD PRN. Record review of Resident #14's Physician's Orders last updated 02/11/2025 at 3:36pm revealed he had an order with a start date of 02/08/2025 for Oxygen at 6LPM (liters per minute) via trach every shift for hypoxia. Record review of Resident #14's care plan last updated 02/10/2025 revealed he was had a focus area of having oxygen therapy r/t ARF and trach (tracheostomy, a surgical procedure that creates an opening in the windpipe to provide an airway for breathing) placement with a last revised date of 02/11/2025. Interventions included O2 via as ordered and position resident to facilitate ventilation. Record review of Resident #14's BIMS (a short assessment to determine a person's cognitive intactness) assessment dated [DATE] revealed a score of 0, indicating Resident #14 had severe cognitive impairment. He was marked as rarely or never understood and that he was severely impaired in making decisions regarding tasks of daily life. Observation and interview on 02/11/2025 at 11:49am, revealed Resident #14 was in bed. His oxygenator reflected 8L/min and he was receiving a respiratory treatment at the time. He was on oxygen through his trach. Resident #14 appeared comfortable and without distress. Later observation on 02/11/2025 at 3:48pm, revealed Resident #14's oxygenator reflected 8L/min. LVN A came into the room and confirmed that Resident #14's oxygenator reflected 8L/min and said she was going out of the room to confirm Resident #14's oxygen orders with LVN B who was his nurse. LVN A came back and confirmed Resident #14 was supposed to be on 6L/min and adjusted his oxygen level. Resident #14 appeared comfortable and without distress during the observation. Interview with RN C and LVN B on 02/11/2025 at 3:48pm, LVN B said she was Resident #14's nurse. She said the oxygenator might've jumped up due to the machine's compressor shaking but that nothing was wrong with the machine. RN C said that Resident #14 had normal oxygen saturation and that Resident #14's oxygenator reflected 6L/min when she checked on him two hours ago. LVN B said as nurses they had to follow physician's orders and that exceeding physician's orders for oxygen could place residents at risk of distress. She said she received training on oxygen since working at the facility. Resident #43 Record reviewed of Resident #43's Facesheet captured date of 02/12/2025 revealed Resident was a [AGE] year-old male who admitted to the facility on [DATE]. Resident's diagnosis included but were not limited to obstructive sleep apnea (disorder characterized by repeated episodes of complete or partial blockage of the upper airway, leading to disrupted breathing patterns during sleep), acute on chronic diastolic (congestive) heart failure (heart muscle's difficulty relaxing), cerebrovascular disease (disruptions in blood flow and oxygen supply to the brain), peripheral vascular disease (narrowed or blockage, reduced blood flow to the limbs), emphysema (shortness of breath), dementia, and acute cough. Record review of Resident #43's Care Plan captured date of 02/13/2025 revealed resident had an activities of daily living (ADL) self-care performance deficit with weakness, decreased mobility due to and chronic heart failure are all conditions that can affect the heart and lungs, and chronic obstructive pulmonary disease, peripheral arterial disease, and dementia with poor safety awareness. Date Initiated: 05/04/2023. Revision on: 10/17/2023. Resident was resistive to care, on compliant with oxygen tubing to be laces in bag after use and stored properly. Resident wraps tubing to bed post. Date Initiated: 02/11/2025. Revision on: 02/11/2025. Record review of Resident #43's MDS dated [DATE] revealed Resident had a BIMS of 14 suggesting that the resident's cognition was intact. Record review of Resident #43's Order Entry dated 07/06/2023 revealed Prescriber written/ordered by MD G. Description: Change Tubing: by way of (via) (Nebulizer tubing). Order Summary: Change Tubing: via (Nebulizer tubing) at bedtime every Thursday for maintenance after use detach, rinse, and allow to dry, and place in a bag. And, every 24-hours as needed for maintenance After use detach, rinse, and allow to dry, and PLACE IN A BAG. Observation/Interview on 02/11/2025 at 09:50 a.m., revealed O2 tubing on floor near garbage and bed of Resident #43. Resident #43 sat at bedside in wheelchair, oxygen was not in use. Observation/Interview on 02/11/2025 at 10:44 a.m. Family #1 stated that Resident #43's used PRN oxygen. Observed tubing on the floor, unlabeled. Observation/Interview on 02/11/2025 at 01:03 p.m. O2 tubing on floor in Resident #43's room. Resident #43 stated that he used oxygen all the time but could not provide a date and time of last use. Resident #86 Record reviewed of Resident #86's Facesheet captured date of 02/13/2025 revealed Resident was a [AGE] year-old male who admitted to the facility on [DATE]. Resident's diagnosis included but were not limited to aortic aneurysm (balloon-like bulges that occur in the aorta) of unspecified site, without rupture (balloon-like bulges that occur in the aorta. Aorta is the main blood vessel through which oxygen and nutrients travel from the heart to organs throughout your body), spinal stenosis (the space within the spine that houses the spinal cord and nerve roots, becomes narrowed), cervical region, and dementia, unspecified severity, without behavioral disturbance. Record review of Resident #86's MDS dated [DATE] revealed Resident had a BIMS of 03 suggesting that the resident's cognition was severely impaired. Record review of Resident #86's Order Summary dated 02/08/2025 revealed: Oxygen at 2-liters per minute (LPM) via (nasal cannula) every 4-hours as needed for shortness of breath (SOB). Verbal order received from medical doctor (MD) G. Record review of Resident #86's Progress Notes dated 02/08/2025 at 06:42 p.m. Change of Condition Signs/Symptoms Details: SOB, started 02/08/2025, since started it has gotten: Things that make the condition worse: Things that make the condition better: History: Primary Diagnosis Vitals: Blood Pressure: 134/68 Lying down 02/08/2025 Pulse: 77 Regular 02/08/2025 Resp: 20 02/08/2025 Temp: 97.9 02/08/2025 . O2 Sat: 93 02/08/2025 2. Functional Status: Functional Status Changes: 1 Mentals Status: Mental Status Changes:1 Respiratory: 01, Cough: 00. Describe signs and symptoms (S/S): Assessment/Suggestion: Nebulizer (Neb) treatment every (q) 6 hours times (X) 3-days, as needed (PRN) oxygen at 2-LPM. Record review of Resident #86's Progress Notes dated 02/08/2025 06:55 p.m. Resident observed SOB, 02 sat 93% Nurse .received order for PRN oxygen at 2 liters (L) of Neb treatment (q) 6hr X 3 days. Record review of Resident #86's Progress Notes dated 02/09/2025 at 05:46 p.m. Resident is stable, no acute distress noted, Day 3/3 Phenol Aerosol related to (r/t) cough, no adverse reactions noted, no respiratory distress noted, Resident is currently on oxygen 2 L for SOB. no complaints of (c/o) pain or discomfort, will continue to monitor. In an observation on 02/11/2025 at 10:33 a.m. Resident #86 lying in bed not able to be aroused by voice. Oxygen tubing observed on the floor near bed. In an observation on 02/11/2025 at 01:16 p.m. Resident #86 was sitting at bedside in wheelchair. Oxygen tank on, facemask on bed and tubing on the floor. Resident picking at his meal tray food. Resident spoke words that were not understood. In an observation/interview on 02/11/2025 at 03:19 p.m. Registered Nurse (RN) H, stated that the resident's oxygen tubing should be bagged and placed away when not in use to prevent infections. She stated that it was also to be labeled with the date it was last changed. She stated it was hers and the certified nursing aids (CNA)'s responsibility to ensure that tubing was off the floor, labeled and bagged when not in use. RN H was observed labeling bags for Resident #43 and Resident #86's oxygen tubing. Record review of the facility's Monitoring of Medication Administration last revised 10/01/2019 reflected in part, procedures, personnel, and techniques are monitored, and that medications are administered at the frequency and times indicated in the prescriber orders. Record review of Resident #21's face sheet dated 02/11/25 revealed a [AGE] year-old admitted to the facility on [DATE] and again on 12/12/24. The resident's diagnoses included the following: dementia (memory loss and judgment), cerebral palsy (abnormal brain development often before birth that causes disorder of movement, muscle tone, or posture), epilepsy (uncontrolled jerking, loss of consciousness, blank stare), and dysphagia (difficulty swallowing). Record review of Resident #21'quarterly MDS dated [DATE] reflected a BIMS score of 9 which indicated the resident's cognition was moderately impaired. Review of section O (special treatment program) of the MDS reflected that the resident was receiving respiratory treatment. Record review of Resident #21's care plan dated 02/07/25 reflected the resident was care planned for infection of the respiratory tract with the intervention to administer antibiotics as ordered by the MD. Record review of Resident #21's Physician's Order Summary Report for the month of February 2025 reflected the following orders: -Dated 02/05/25 Ipratropium-Albuterol (medication used to treat respiratory disease by relaxing the muscles around the airways to open up and bake breathing easier) solution 0.5-2.5 (3) mg/3ml, 3ml inhale orally every 4 hours as needed for SOB or wheezing for 7 days via nebulizer (a small machine that turns liquid medicine into a mist that can easily be inhaled). -Dated 02/06/25 Doxycycline (medication used to treat bacterial infections in many parts of the body) oral tablet 100mg give 1 tablet by mouth twice a day for PNA (respiratory infection) for 7 days. Record review of Resident #21's MAR and TAR for the month of February 2025 reflected that the facility was following physician's orders. Observation on 2/11/25 at 10:05AM revealed Resident #21 resting in bed. The resident had a wheelchair in the room on the left side of bed with clear tubing hanging on the back of the wheelchair with a mask attached to the tubing. Observation was made of the nebulizer machine sitting on the floor on the left side of the resident's bed at the head of bed. Resident #17 Record review of Resident #17's face sheet dated 02/11/15 revealed an [AGE] year-old female admitted to the facility on [DATE]. Resident #17's diagnoses included the following: dementia (memory loss and judgment), Alzheimer's Disease (progressive disease that destroys the memory and other mental functions), mild intermittent asthma (when a person's airway becomes irritated, narrow and swell, producing extra mucus, which makes it hard to breathe), and chronic obstructive pulmonary disease (a group of lung disease that block airflow making it hard to breathe). Record review of Resident #17's quarterly MDS dated [DATE] reflected a BIMS score of 1 indicating the resident's cognition was severely impaired. Further review revealed the resident was receiving special treatment that consisted of respiratory treatments oxygen: continuous and non-invasive mechanical ventilator: breathing support device that uses a mask to deliver air to a patient's lungs to help breathe better. Record review of Resident #17's care plan dated 02/10/25 reflected the resident was care planned for a respiratory infection with the intervention to administer antibiotic as order by the MD. Record review of Resident #17's Physician's Order Summary Report for the month of February 2025 reflected the following orders: -Dated 02/10/25 Amoxicillin (medication used to treat bacterial infections, such as chest infections including pneumonia) 500-125mg give 1tablet by mouth three time a day for PNA (respiratory infection). -Dated 02/10/25 Ipratropium-Albuterol solution (medication used to treat respiratory disease) 0.5-2.5 (3) mg/3ml, 3 ml inhale orally every 4 hours as needed for SOB or wheezing via nebulizer (a small machine that turns liquid medicine into a mist that can easily be inhaled). Record review of Resident #17's MAR and TAR for the month of February 2025 reflected that the facility was following physician's orders for the above orders. Observation on 02/11/25 at 10:35AM revealed Resident #17 awake in bed coughing. The resident said she had bronchitis. The resident had an oxygen machine on the right side of bed with undated oxygen tubing connected to the machine that was lying on the floor on the right side of the resident's bed There was a nebulizer machine on the nightstand on the right side of the resident's bed with tubing connected to a nebulizer machine with a mask attached. The mask and tubing were not dated but the mask was inside of plastic bag. Observation on 02/11/25 at 11:15AM revealed Resident #17 in bed with oxygen tubing still on floor. LVN Z was asked to go to resident's room to assess the resident. LVN Z went to Resident #17's room to check her oxygen saturation (the percentage of oxygen carried by red blood cells in the body). The resident's oxygen saturation was 94% on room air. LVN Z left the resident's room with the oxygen tubing still on the floor. The resident said she was okay and was not experiencing any difficulty breathing. Resident #11 Record review of Resident #11's face sheet dated 02/11/25 revealed an [AGE] year-old male admitted to the NF on 08/14/24. Resident diagnoses included Type 2 diabetes mellitus (too much sugar in the blood), polyosteoarthritis (arthritis affecting five or more joints at the same time), glaucoma (eye condition that can cause blindness), hypertension (high blood pressure), and difficulty walking. Record review of Resident #11's quarterly MDS dated [DATE] reflected a BIMS score of 11 indicating the resident cognition was intact. Further review revealed the resident was on specialized treatment for respiratory care (non-invasive mechanical ventilator: breathing support device that uses a mask to deliver air to a patient's lungs to help breathe better). Record review of Resident #11's care plan dated 08/14/24 did not reflect a care plan for respiratory treatments. Record review of Resident #11's Physician Order Summary Report for the month of February 2025 reflected the following order: -Dated 02/10/25 Ipratropium-Albuterol (medication used to treat respiratory disease) 0.5-2.5 (3) mg/3ml, 3 ml inhale orally every 4 hr as needed for SOB or wheezing via nebulizer (a small machine that turns liquid medicine into a mist that can easily be inhaled). Record review of Resident #11's MAR and TAR for the month of February 2025 revealed that the facility was administering the medication Ipratropium-Albuterol 0.5-2.5 (3) mg/3ml, 3ml as ordered. Observation on 02/11/25 at 10:40 AM revealed Resident #11 had a rolling walker on the left side of his bed. Further observation revealed a mask connected to tubing lying on the rolling walker. The tubing and mask were not dated or inside of a plastic bag. Interview on 02/11/25 at 10:46 AM LVN Z said she was the nurse for Resident #11, Resident #17, and Resident #21. LVN Z said she had given Resident #17 a breathing treatment between 8:30AM or 9:00AM and that Resident #17 received breathing treatments three times a day. LVN Z said she worked from 7am-7pm. Interview and observation on 02/11/25 at 2:05 PM with LVN Z,, regarding respiratory equipment (tubing, mask, etc.) said the respiratory equipment should be dated to signify when the last time the equipment had been changed for infection control. LVN Z said she believed respiratory equipment should be changed every seven days on the night shift; at least that was the way it was done at other facilities but was not for certain how it was done at the present facility. LVN Z said she worked at the NF PRN. LVN Z said because she worked at the present facility on a PRN basis, it did not give an excuse as to why respiratory equipment was not being labeled and placed in a plastic bag when not in use. LVN Z said she was the nurse for Residents #11, #17, and #21 and she must have overlooked the residents' respiratory equipment. LVN Z went to Resident #11 and Resident #17's room where she observed Resident #17's oxygen tubing still on the floor and Resident #11's nebulizer tubing with the mask sitting on the resident's rolling walker at the bedside. LVN Z placed on gloves and began to dispose of respiratory equipment by placing inside of a plastic bag and removing from the room of Resident #11's room. LVN Z said she would replace the respiratory equipment with new equipment, which she did including Resident #21. Interview on 02/11/25 at 2:20PM the DON said all respiratory equipment such as masks were supposed to be inside of zip top bag when not in use. The DON said the equipment should be dated and changed weekly usually on the night shift and as needed for infection control. The DON said the nurses were responsible in changing respiratory equipment. The DON said the unit managers and ambassadors assigned to certain rooms were to follow-up to ensure that this was being done. Review of the facility provided policy on Oxygen Safety dated 01/26/24 reflected in part: .It is the policy of this facility to provide a safe environment for residents, staff, and the public . The policy did not reflect oxygen supplies when to be dated and bagged when not in use. 44669

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 disease and infections and follow standard and transmission-based precautions to be followed to prevent spread of infections for 1 of 24 (Resident #14) residents reviewed for infection control. During tracheostomy care for Resident #14, RN A and LVN B failed to properly dispose of used materials in a biohazard bag after completing care. This failure could put residents at risk of exposure to infection and cross contamination. Findings included: Record review of Resident #14's face sheet last captured 02/13/2025 revealed a [AGE] year-old male originally admitted on [DATE]. His medical diagnoses included anoxic brain damage (brain damage from lack of oxygen), muscle wasting and atrophy, cognitive communication deficit, tracheostomy status, chronic congestive heart failure, and pneumonia (infection of the lungs). Record review of Resident #14's Comprehensive MDS dated [DATE] revealed that he was receiving oxygen therapy at the facility. Record review of Resident #14's BIMS (a short assessment to determine a person's cognitive intactness) assessment dated [DATE] revealed a score of 0, indicating Resident #14 had severe cognitive impairment. He was marked as rarely or never understood and that he was severely impaired in making decisions regarding tasks of daily life. Record review of Resident #14's baseline care plan dated 02/09/2025 revealed he was receiving oxygen therapy, with interventions including monitoring for s/sx of respiratory distress and report to MD PRN. Record review of Resident #14's care plan last updated 02/10/2025 revealed he was had a focus area of having oxygen therapy r/t ARF and trach (tracheostomy, a surgical procedure that creates an opening in the windpipe to provide an airway for breathing) placement with a last revised date of 02/11/2025. Interventions included o2 via as ordered and position resident to facilitate ventilation. Record review of Resident #14's Physicians Orders last updated 02/11/2025 at 3:36pm revealed he had an order with a start date of 02/08/2025 for Oxygen at 6LPM (liters per minute) via trach every shift for hypoxia. Observation on 2/13/2025 at 8:53am of Resident #14 revealed RN A and LVN B completed tracheostomy suctioning. RN A exited Resident #14's room. LVN B brought a clear trash bag, placed supplies used for suctioning including gauze, sterile and non-sterile gloves, and a tracheostomy inner tube, with bodily fluids on them in the bag, tied it and placed it in a large, yellow container used for linen located in Resident #14's restroom. Interview on 2/13/2025 at 11:42am with LVN B, she said that Resident #14's body fluids should have been put in her biohazard bag and disposed of immediately. If it was in a regular bag, LVN B said that staff or residents would not know how to properly handle biohazard material since they did not know what it contained. That could cause infection control issues because it was infectious to leave a room with fluids in a regular bag instead of a biohazard bag. Interview on 2/13/2025 at 2:36 with RN A, she said she was going to double-bag Resident #14's trash with a clear bag and then place it in a biohazard bag and take it to the biohazard room in the soiled utility room. RN A said the bag contained body fluid and sputum which would have been in the biohazard bag. She said not doing placing biohazard supplies in a biohazard bag before exiting a resident's room could have caused exposure to a respiratory illness. Record review of the facility's Equipment Protocol policy undated reflected in part, reusable items potentially contaminated with infectious materials shall be placed in an impervious clear plastic bag. Label bag as CONTAIMINATED and place in the soiled utility room for pickup and processing. 44669

Based on observation, interview and record review, the facility failed to maintain an effective pest control program so that the facility is free of pests and rodents for 2 of 2 (Residents #23, #50) resident rooms reviewed for environment. Resident #23 had a live roach in their bed during medication pass Resident #50 had a spider on the wall in their room near the bed . This failure could lead to spread of disease and a decline in resident health from preventable pest control. Findings included: Observation of medication pass on 2/12/2025 at 8:00am in Resident #23's room, a live roach crawled on the side of their bed. LVN G was observed using the face towel to brush the roach away during G-tube (gastric tube for nutrition and medication) medication administration. Observation and interview on 2/11/2025 at 9:31am in Resident #50's room, there was a spider on the wall by the right corner of Resident #50's bed. CNA B put on gloves and took a white towel and pressed on the spider. CNA B said that she will report this and that reports about pests are to be reported in the facility's computer system. She said the facility has spiders did appear and the facility gets pests when it's raining. Interview with the DON on 2/11/2025 at 3:09pm, she said she was made aware of the roach on Resident #23's bed during patient care and said that pest control did rounds and did not have any recent concerns with pests. Interview with the Maintenance Director on 2/11/2025 at 3:16pm, he said that he received work orders through the computer which he checked daily, which included pests. He said some staff are referred to as ambassadors and they made rounds each morning and throughout the day and are to report any environmental issues they observed. He said that he did not have any concerns regarding pests recently but saw a concern in the system today related to a spider seen in a resident's room earlier on 02/11/2025. The Maintenance Director said he went into that particular room but did not observe any pests but he called pest control who will come on 2/12/2025. Record review of the facility's Pest Control binder revealed Pest Control visited on 1/9/2025, 1/23/25 and 2/12/2025. There were no sightings of roaches or spiders. There were some light ant activity and small and large flies found in 5 of 5 light traps at the facility. Record review of the facility's policy on General Housekeeping, undated, reflected in part, the facility provides sufficient housekeeping and maintenance personnel, equipment, and supplies to maintain the interior and exterior of the facility in a safe, clean, orderly, and attractive manner.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment in one (right side) of two shower rooms on Hall 400. -The facility failed to clean the shower room on the right side of Hall 400 that was observed with soiled towels, gloves, empty containers of personal care items, hair on the floor, and the floor had brown and black stain marks. This failure placed residents at risk for receiving showers in an unclean and uncomfortable environment. Findings included: Observation on 01/24/25 at 10:38AM of the shower room on the right side of Hall of 400 with CNA S. The shower room had large, soiled towels on the floor, wood shelving, and shower bed. Further observation was made of used empty containers of personal care items (shower gel, etc.) sitting on wood shelving. CNA S immediately started placing the soiled towels inside of a plastic bag. CNA S proceeded throwing used resident care supplies inside of plastic bag and picking gloves up off the floor. Further observation was made of the shower room floor being dirty with brown and black stains on the floor. There was debris on the floor behind the wood shelving. Further observation was made of a ball of white hair on the floor. Interview on 01/24/25 at 10:40AM with CNA S said the floors were dirty and she did not know when the last time the shower room floors had been cleaned. CNA S said when the CNAs finish providing a shower to a resident, the CNA was not to leave anything behind such as towels or resident personal care items due to germs and infection control. CNA S said it was the resident's home and that it was important to keep the shower room clean and tidy. CNA S said the nursing staff and housekeeping were responsible in making sure that the shower rooms were being cleaned for resident use. CNA S said when the shower room needed to be clean the staff would write in the communication book at the nurse desk. When CNA S went to find the shower book at the nurse station, she could not locate the book. CNA S proceeded to say the way they communicate with housekeeping was in the computer but did not show the surveyor where in the computer the staff was communicating with housekeeping regarding cleaning the showers. Interview on 01/24/25 at 10:40AM with Housekeeper T after observing the shower room on the right side of Hall 400 said the shower room floor was dirty and needed to be . Housekeeper T said she did not work at the facility on 01/23/25. Housekeeper T said she was working Hall 400 and was responsible for cleaning the resident rooms and keeping the shower room clean. Housekeeper T said she worked from 6AM-2PM. Housekeeper T said housekeeping was supposed to clean the shower room at least once a day and as needed. Housekeeper T said it was important to keep the resident's shower room clean and disinfected to reduce the risk of infections and cross contamination. Housekeeper T said whoever was assigned to the shower room on 01/23/25, did not clean the floors. Housekeeper T said she was going to clean the shower floor right away. Interview on 01/24/25 at 11:05AM with Hall 400 LVN/ADON U said it was the responsibility of the Nursing staff and the Housekeeping Department to ensure the resident shower room was being clean and disinfected for infection control. LVN/ADON U said the ambassador was also assigned to do rounds on the halls to make sure everything was going well. Interview on 01/24/25 at 11:15AM with the Administrator said the ambassador uses a check list on what things to look at on the Halls assigned to them, and the shower room was not one of them. The Administrator said it was the floor techs under the direction of the supervisor of housekeeping that were responsible for ensuring the floors were clean including the shower rooms. Interview on 01/24/25 at 11:20AM with the DON said after the CNAs provided a shower for a resident, that CNA was supposed to make sure the shower room was clean for the next resident to be showered. The DON said housekeeping was responsible for mopping and disinfecting the floors after each shower use. The DON said the floor techs were responsible for deep cleaning the floors and the grout. The DON said the shower rooms should be mopped after each use to prevent cross contamination. The DON said whenever the CNA gave a resident a shower, the CNA is supposed to reach out to housekeeping verbally or on a group text that the shower room needed to be mopped. The DON said she would have to see if the NF had a policy on maintaining the NF shower rooms. The DON did not provide a policy on maintenance of shower rooms. Interview on 01/24/2025 at 11:37AM with the NF Environmental Service Department said he was also over housekeeping and the floor techs. The Environmental Service Department said he was assigned to Hall 400 shower rooms. He said he cleaned the shower rooms on 01/23/2025 and had not gotten to cleaning the shower room on 01/24/2025. He said it was important to clean the shower rooms in between use for infection control reasons. Record review of the NF policy on Infection Prevention and Control Program dated 05/13/23 reflected in part: .This facility has established and maintains, and infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to prevent the development and transmission of communicable disease and infections as per accepted national standards and guidelines . Record review of the NF policy on General Housekeeping Policy not dated reflected in part: .The facility provides sufficient housekeeping and maintenance personnel, equipment, and supplies to maintain the interior and exterior of the facility in a safe, clen , orderly, and attractive manner .All housekeeping personnel utilize the accepted practices and procedures to keep the facility free from offensive odor, accumulation of dirt, rubbish, dust, and hazards . Record review of the NF policy on Resident Rights dated November 2021 reflected in part: .Residents of Texas Nursing Facilities have all the rights, benefits, responsibilities, and privileges granted by the constitution and laws of this state and the United States. They have the rights to be free of interference, coercion, discrimination, and reprisal in exercising these right as citizens of the United States .Dignity and Respect .Residents have the right to live in a safe, decent, and clean conditions .

Based on record review and interview, the facility failed to maintain medical records on each resident that are accurately documented for 1 of 5 (Resident #50) residents reviewed for care plans. The facility failed to have accurate Physician Orders for Resident #50 when anticoagulant medication monitoring was ordered without an order for an anticoagulant. This deficiency could put residents at risk of improper medication administration and inaccurate documentation and tracking of residents' condition and treatment. Findings include: Record review of Resident #50's face sheet last captured 1/24/25 revealed an [AGE] year-old female originally admitted on [DATE] and last readmitted on [DATE]. Her medical diagnoses included muscle wasting and atrophy (loss of muscle mass and function), Chronic Obstructive Pulmonary Disease (a lung condition characterized by lung damage such as inflammation and restricted airflow), Dementia (loss of cognitive function such as memory and thinking which affects daily life), Hypertension (high blood pressure), Chronic Pain Syndrome, Polyosteoarthritis (inflammation that affects five or more joints), and cognitive communication deficit. Record review of Resident #50's Quarterly MDS (a resident assessment) dated 10/18/2024 revealed Resident #50 was able to make herself understood by others some of the time and had the ability to understand others some of the time. Her BIMS score (an assessment to test cognitive function and memory) was a 03 out of 15, indicating severe cognitive dysfunction. Resident #50 was fully dependent on others for toileting, showering, and footwear and required partial to moderate assistance with eating, upper body dressing, oral hygiene and personal hygiene. Record review of Resident #50's care plan last revised 01/14/2025, revealed Resident #50 had hypertension r/t lifestyle choices with a start date of 04/10/2023, with interventions including educating the resident/family/caregiver about the importance of maintaining a normal weight for height, the value of regular exercise, limiting salt intake, give anti-hypertensive [sic] medications as ordered, and monitor/document/report PRN any s/sx of malignant hypertension, headache, lethargy, nausea and vomiting and difficulty breathing. Resident #50 also had a problem with skin integrity with a start date of 1/23/2025 related to her rash on the chest resulting to severe itching, scratching and interventions including administering medications as ordered to address medical diagnosis and conditions and cream twice a day for her rash. Record review of Resident #50's Physician Orders revealed the following: -Start date: 08/10/2024 Anticoagulant medication - monitor for discolored urine, N&V (nausea and vomiting), bruising, sudden changes in mental status, nose bleeds every 12 hours for ASA (Aspirin) 325. This order was discontinued on 01/23/25 at 5:55pm -Start date 01/23/2025 Anticoagulant medication - monitor for discolored urine, N&V (nausea and vomiting), bruising, sudden changes in mental status, nose bleeds every 12 hours for ASA (Aspirin) 81. This order was active. -Start date 1/24/2025 Hypertension medication - Aspirin EC (enteric-coated, meaning the tablet had a protective coat that allows the medication to be released in the intestines rather than the stomach) 325 MG (Aspirin) Give 1 tablet by mouth one time a day related to Essential (Primary) Hypertension. Further review revealed Resident #50 had no active orders for anticoagulant medication. Record review of Resident #50's January 2025 [DATE] revealed Resident #50 had received anticoagulant medication monitoring every twelve hours for aspirin 325 (mg) with a start date of 08/10/2024 and a discontinued date of 01/23/2025. Resident #50 also received anticoagulant medication monitoring every twelve hours for aspirin 81 (mg) with a start date of 01/23/2025. Interview with the DON on 1/24/2025 at 2:47pm, she said that Resident #50 was ordered aspirin for her cardiovascular issues, from what Resident #50's physician told her. The DON said at 325 mg the aspirin can be used as an anticoagulant, but that for Resident #50 the medication acts more like an antiplatelet medication. She said she would update and clarify the aspirin's purpose for Resident #50. A later interview on 1/24/2025 at 4:10pm, the DON said that Resident #50 had some reddish areas on her skin that were being monitored, so she kept in the order to monitor for the rash, not the anticoagulant. Resident #50 had bruising and the DON had called her physician to cancel the aspirin but the physician told her that Resident #50 needed it for her heart condition. Interview with the MDS Nurse on 1/24/2025 at 4:19pm, she said that she did not work with Resident #50. The MDS Nurse said when a resident admits to the facility, she looks at their clinicals and determines their medical diagnoses. The MDS Nurse said that medications and the treatment plan should match with diagnoses. Interview with NP A on 1/24/2025 at 5:14pm, she returned a call and said she was no longer associated with Resident #50 and the physician's group associated with the facility and declined to answer more questions. Record review of the facility's Medication Administration policy implemented on 10/24/2022 read in part, Medications are administered by licensed nurses, or other staff legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice . 20. Correct any discrepancies and report to nurse manager.

Based on observation, interviews, and record review the facility failed to ensure based on the comprehensive assessment of a resident, residents received care, consistent with professional standards of practice, to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable; and a resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (CR#1) of five residents reviewed for pressure ulcers . The facility failed to ensure CR #1 did not acquire an unstageable pressure ulcer to her bilateral buttock. This failure could place residents at risk for developing pressure wounds, Cellulitis (skin infection), Sepsis (infection of the blood) and severe pain. Findings included: Record review of CR#1's face sheet dated 01/11/2025, reflected a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE]. CR #1 had a diagnosis which included Alzheimer's disease (a neurological disorder that causes irreversible changes in memory, thinking, and behavior, leading to a gradual decline in cognitive abilities and daily functioning). Review of CR#1's annual MDS, dated [DATE], reflected CR#1's was assessed to require ADL assistance for movement in bed. CR#1 was at risk for pressure ulcers. Record review of CR#1''s, undated, comprehensive care plan reflected a focus area initiated on 06/20/2022 and revised on 10/09/2024, CR#1 has Potential/Actual Skin Issue related to weakness. Goal: CR #1 skin will remain intact without signs of breakdown. Interventions: turn and reposition frequently to decrease pressure; skin checks weekly per facility protocol, document findings. The comprehensive care plan did not address minimizing risks of pressure ulcer/injury prior to CR#1's discharge to the hospital on [DATE]. Record review of clinical record reveled that skin assessments were completed by WCN weekly and there was no documented finding of skin breakdown prior to 01/08/2025. There was no found documentation of turning and repositioning CR #1 to decrease pressure. Record review of progress notes reflected CR #1 had a change in condition, diagnosed with pneumonia and was being monitored by the NP and physician. Record review of Physician's Order for CR#1 reflected no wound care orders. Record review of the skin assessment for CR#1, dated 01/08/2025, read in part, 3 x 2.5ins shear wound to sacrum, 6 x 4.5ins shear wound to right buttock and 5 x 3.5ins shear wound to left buttock with scant serous drainage. Record review of skin assessment in the 30-day look period of 12/01/2025 - 01/01/2025 reflected no pressure injury or skin breakdown to CR #1 sacrum. Record review of the hospital skin assessment dated [DATE], reflected CR #1 was admitted to hospital from the facility on 01/08/2025 with an unstageable pressure wound to her bilateral buttock. There was no evidence the wound was contributing to the sepsis and the resident was receiving treatment for pneumonia and UTI. Observation on 01/13/2025 at 6:25 p.m. revealed CR # 1 was seen at the hospital, lying in bed on a low airflow mattress and repositioning wedges. CR #1 was lethargic at the time of observation. Observation of the sacrum revealed an open wound with dark purple skin discoloration with moderate drainage. The State Surveyor was unable to interview CR # 1 due to orientation status of CR #1. In an interview on 01/13/2025 at 4:00 p.m. the DON stated the facility policy required everyone who provided direct care for the residents were responsible for ensuring the prevention of acquired pressure wounds at the facility. The DON stated that the policy required pressure wound risk to be identified and addressed in the resident's comprehensive care plan. The DON stated the facility nurses and CNA were responsible for repositioning residents and timely incontinent care was provided for residents requiring assistance. The DON stated the WCN was responsible for completing skin assessments on all facility residents. The DON stated the facility's policy required skin observations to be completed by the CNA when residents' showers were provided. The DON stated if skin breakdown was identified the primary nurse should be notified. She stated the primary nurse was responsible for notifying the physician and responsible party. The DON stated the care team was responsible for the accuracy of the resident's care plan and intervention. The DON stated she was responsible for ensuring the needs of the resident were addressed and intervention were implemented by the facility staff. The DON was able not a to explain how she ensured the intervention were implemented. The DON stated wound care prevention training had been provided to all direct care staff. The State surveyor requested the wound care policy and documentation of training provided. In a telephone interview on 01/13/2025 at 5:00 p.m., the WCN stated she was responsible for completing weekly skin assessments. She stated when she identified a wound, she would notify the resident's primary assigned nurse. She stated the facility police required nurses to contact the resident's physician to obtain a wound consult and wound care orders. In a telephone interview on 01/13/2025 at 5:30 p.m., the family member stated on 01/08/2025 at approximately 3:30 p.m. the family was informed CR #1 had a little sore on her bottom and cream was applied to CR #1's bottom. The Family member stated she arrived in the facility approximately an hour later and found CR #1 did not appear well. She stated she requested to CR#1's bottom and noted the wound was a dark black color and the skin was not intact. She stated she feared CR #1 was septic because the wound was draining and appeared to have a foul odor. She stated she requested to have CR #1 transferred to the hospital as she had concerns of CR #1 being septic. She stated she also notified the DON of the concerns, but the DON stated the facility was aware of the wound, but the wound would not make CR #1 septic. The Family member stated a picture of the wound was captured and sent to the DON. The Family member stated CR #1 was admitted to a local hospital and diagnosed with Sepsis and the wound was unstageable on admission to the hospital from the facility. In an interview on 01/13/2025 at 6:15 p.m., Hospital Nurse T stated CR #1 was admitted to the hospital critical care unit on 01/08/2025. On admission CR #1 was lethargic and found to have Sepsis and an unstageable pressure injury to CR #1 bilateral buttock. She stated CR #1 was started on antibiotic treatment and the wound care team was following CR #1 for maintenance of the wound. Nurse T stated it was unknown if Sepsis was caused by the wound. An interview on 01/15/2024 at 10:30 a.m., CNA V stated she cared for CR#1. She stated CR # 1 required assistance to be turned in bed. She stated when CR #1 was turned, she went back on her back. She stated CR #1 had not been getting out of bed for several days prior to her being sent to the hospital on [DATE]. CNA V stated that she did not know how often CR #1 was turned. She could not recall the last time CR #1 was out of bed in a chair or wheelchair. She stated she did not know why CR # 1 was not get up out bed. She stated CR # 1 would did not require much assistance. She said she assisted the WCN with wound care if she needed help for other residents, but was not aware CR #1 had a pressure wound. She said CR#1's did not seemed to be herself, but she could not provide a timeline. She stated CNAs round every 2 hours for incontinent care and re-positioning. She stated CR #1 would usually be out of bed and did not require frequent turning. She CR #1 could have developed a pressure injury from not be re-positioned frequently because CR #1 usually would be up in her wheelchair. In an interview on 01/15/2025 at 11:00 a.m., the WCD, stated she had not been consulted for CR#1 and was not consulted for all facility identified wounds. The WCD stated shear wounds were caused by the sliding or pulling of the skin and tissue in opposite directions, while pressure wounds were caused by prolonged, constant pressure on an area of skin that restricted blood flow. The WCD stated an unstageable wound referred to a wound where the depth could not be determined because the wound bed was covered by necrotic tissue (dead tissue), slough (yellowish tissue), or eschar (black, hard tissue). She stated it was possible for an unstageable wound to develop in a short period (such as two days), particularly if the wound was caused by prolonged pressure (such as in pressure ulcers) or severe shear forces and inadequate or delayed treatment. She stated without proper offloading (relieving pressure), repositioning, or wound care, what started as a minor injury could progress to deeper tissue damage in a matter of days. She stated proper assessment and care were critical in preventing an unstageable wound and pressure wound progression. In an interview on 01/15/2025 at 12:00 p.m., the WCN stated she was notified by the primary assigned nurse, Nurse G that CR #1 had a wound on 01/08/2025. She stated a wound consult was submitted by Nurse G for CR#1 on 01/08/2025, she stated an assessment of the wound was completed by her and verified by the DON. She stated at the time of her assessment on 01/08/2025 she observed a shear wound to CR#1 sacrum and the skin was intact. She stated the wound was acquired at the facility. She stated the skin surrounding the wound was pink. She stated the family was at the bedside. She stated CR #1's primary care provider was notified and new orders for zinc oxide cream daily and as needed was provided. In interview on 01/15/2025 at 12:30 p.m., Nurse G stated on 01/08/2025 attention was called to CR# 1's room, as CNA T was cleaning her when she heard CR #1 screaming. Nurse G assessed resident and observed an open area on the sacrum. Nurse G stated she was unsure if the wound was infected but there was drainage, the skin in the area was a dark color and was not intact. Nurse G stated pictures of the wound was captured. Nurse G stated she had cared for CR #1 a couple of days prior on 01/06/2025 and did not assess the area and was not sure if the wound was present on 01/06/2025. Nurse G stated CR #1 had experienced generalized weakness since Saturday, 01/04/2025, and not been her usual self. Nurse G stated CR #1 was not able to turn and reposition independently in bed, which may have contributed to the development of the pressure injury. Nurse G stated the wound was a pressure injury, but she was not sure of the stage. Nurse G stated that the wound was acquired at the facility and could have been prevented with frequent repositioning. She stated the facility nurses and CNAs was responsible for repositioning the residents. Nurse G stated wound care was consulted, and the primary care provider coordinator and CR #1 family was notified. The State surveyor was unable to interview CNA T prior to exiting the facility. In interview on 01/15/2025 at 3:30p.m., the DON stated there was gaps in both the prevention and management of pressure wounds at the facility. She stated she did not believe the gaps contributed to the development of Sepsis for CR #1. She stated that the wound was acquired at the facility. She stated that CR #1 should have been turned and repositioned timely to prevent the pressure wound. The DON stated she did not have a system in place to monitor that CR #1 was being turned frequently to prevent the pressure wound. The DON stated by not following the facility policy, turning, and repositioning residents it placed residents at risk for skin breakdown and pressure injuries. In interview on 01/15/2025 at 3:35 p.m., the unit manager, ADON T stated if the facility failed to properly assess, address, and document wound care and prevention needs it could constitute a violation of care standard and cause the residents to stuffer. She stated the facility policy required stated to prevent facility acquired pressure injury when possible. She stated pressure injuries could be prevented by turning and repositioning residents. She stated that CR #1 developed pressure injury was acquired at the facility and could have been prevented.

Based on observations, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident medical, nursing, mental, and psychosocial needs for 1 (Resident #1) of 3 residents reviewed for care plans in that: The facility failed to ensure Resident #1 bed was in the lowest position per care plan while he was in the bed. The facility failed to update falls and interventions for Resident #1's care plan after his last 3 falls. This failure placed facility residents who were fall risk at risk of serious harm and injury. An Immediate Jeopardy (IJ) was identified on 9/18/2024. The IJ template was provided to the Administrator In-Training and DON on 9/18/2024 at 12:46 p.m. While the IJ was removed on 9/20/2024 at 12:30 p.m., the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of pattern, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at an increased risk of decline, and diminished quality of life. Findings included: Record review of Resident #1's face sheet dated 9/17/2024 revealed a [AGE] year-old male who admitted to the facility originally on 2/9/2021 and readmitted on [DATE] with the following diagnoses: Fragile X syndrome (genetic disorder and one of the most common causes of inherited intellectual disability), muscle weakness, unspecified falls, lack of coordination and cognitive communication deficit. Record review of Resident #1's Annual MDS dated [DATE] revealed he had a BIMS score of 0 which indicated severe cognitive impairment. He used a wheelchair for mobility. Resident #1 requires total assistance (helper does all the support) for sit to stand and bed transfers. Section J1900 - Number of Falls since admission/entry or reentry or prior assessment was left balnk. Record review of Resident #1's care plan revised 4/18/2024 revealed the following care areas: Problem: [Resident #1] receives anticoagulant/antiplatelet (medications that help reduce blood clotting) therapy (Plavix medication) Date initiated: 2/2021. Revision: 4/18/2024 Goal: [Resident #1] will be free from discomfort or adverse reactions related to anticoagulant use through the review date. Date initiated: 2/10/2021. Revision on: 6/20/2024. Target date 11/3/2024. Interventions: Administer anticoagulant medications as ordered by physician .Daily skin inspection. Document any abnormalities .Observe/document/report PRN adverse reactions of anticoagulant therapy: .bruising. Revision on 8/6/2023, Resident/family /caregiver teaching to include the following: . avoid activities that could result in injury, take precautions to avoid falls . Problem: [Resident #1] is high risk for falls r/t impaired mobility. Date initiated 2/11/2021. Revision on: 4/18/2024. Goal: [Resident #1] risks and injury potential will be minimized through the next review date. Date initiated: 2/11/2021. Revision on: 6/20/2021. Target date: 11/3/2024. Interventions: Anticipate and meet the resident's needs. Dated initiated: 2/11/2021. Follow facility fall protocol. Date initiated 2/19/2021. PT evaluate and treat as ordered or PRN. The resident needs a safe environment with: (even floors free from spills and/or clutter, adequate glare-free light; a working and reachable call light, the bed in low position at night; side rails as ordered, handrails on walls, person items within reach. Date initiated 2/19/2021. Revision on 8/7/2023. Problem: [Resident #1] has had an actual fall with (Specify: no injury, On 12/28/2022) Poor Balance, Unsteady gait [the way a person walks]. 7/12/2023: actual fall, no injury. Date initiated: 1/9/2023. Revision on: 7/12/2023. Interventions: Continue interventions on the at-risk plan. Date initiated: 1/9/2023. PT consult for strength and mobility. Date initiated: 1/9/2023 .Staff will round frequently and try to anticipate his needs. Date initiated: 7/21/2024. Staff will start offering [Resident #1] to stand and relieve pressure throughout the day. Date initiated 4/1/2024. Record review of facility Incidents by Resident fall report dated 9/17/2024 revealed the following in part: o [Resident #1] - Fall on 7/21/2024 at 9:40 p.m. o [Resident #1] - Fall on 9/14/2024 at 7:34 p.m. o [Resident #1] - Fall on 9/15/2024 at 12:15 p.m. Record review of Resident #1's Fall Risk Evaluations dated 7/21/2024 - 9/14/2024 revealed the following: *Effective Date: 7/21/2024 - Score 13. Category High Risk. Scoring: If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. A prevention protocol should be initiated immediately and documented on the care plan. *Effective Date: 9/14/2024 - Score 15. Category High Risk. Scoring: If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. A prevention protocol should be initiated immediately and documented on the care plan. *Effective Date: 9/15/2024 - Score 16. Category High Risk. Scoring: If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. A prevention protocol should be initiated immediately and documented on the care plan. Record review of Resident #1's Order Summary Report dated 9/17/2024 revealed the following in part: orders: *May transfer to [Hospital] and clinical ER for CT of head r/t witness fall with head injury (order date 9/15/2024). *Transfer to .ER for CT of head and X-ray of L [left] shoulder r/t fall (order date 7/22/2024). *Clopidogrel Bisulfate oral tablet 75 mg - Give 1 tablet by mouth one time a day for blood thinner (order date 2/10/2021). Record review of facility nursing notes dated 9/14/2024 at 10:06 p.m. written by LVN B revealed Change of Condition: Signs/Symptoms Details: witnessed fal [sic], started 09/14/2024 . Record review of Resident #1's hospital discharge summary dated 9/14/2024 revealed Visit Summary - discharge diagnoses: tear of skin - primary, closed injury of head - primary, contusion (bruise) of right elbow - primary . Record review of facility nursing notes dated 9/15/2024 at 2:00 a.m. written by LVN B indicated Res arrived back to facility via . Ambulance transport. x2 assist by city ambulance personnel to transfer res from stretcher to bed via slide method. Res arrived back to facility a&o x1 with 0 s/s of distress or discomfort. CT scan of head negative of any new/acute findings. No new orders received with res discharge paperwork from hospital. [name of on call service] on call contact and notified of situation and res return to facility; spoke with NP. NP ordered to hold Plavix [keeps blood from coagulating (clotting)] until Monday; order implemented. POC conts [sic] as ordered. Res in bed with bed in lowest position, call light in place and all safety measures in place at this time. Interview on 9/19/2024 at 7:30 p.m. LVN B, said CNA C notified her Resident #1 was in his room, fell forward out of his wheelchair, fell on the floor and hit his head (on 9/14/2024). LVN B said she went to the Resident #1's room and he had a tear on his right elbow, skin tear to his fifth digit, an abrasion to his right thigh and top of his head. LVN B said the DON told her to fill out the incident report, fall assessment and treat his injuries. LVN B said she was not instructed to update Resident #1's care plan. LVN B said the DON instructed her to complete additional rounding (q 4 hours) and add a fall mat. She said she did not update Resident #1's interventions. LVN B said care management (MDS nurses) was responsible for updating the care plans. Interview on 9/19/2024 at 7:52 p.m. CNA C said he took Resident #1 to his room. CNA C said he turned to adjust the bed and Resident #1 fell out of his wheelchair onto the floor on 9/14/2024. CNA C said Resident #1 fell face first and did not make a sound. CNA C said Resident #1 was sent the hospital. CNA C said when the resident returned, he was told to sit with the resident while he laid in bed. He said he was not aware of new interventions for Resident #1. Record review of facility nursing note dated 9/15/2024 12:15 p.m. written by LVN A indicated Res in Bistro area in WC eating lunch and witnessed falling on floor r/t leaning forward in WC after numerous attempts of assistance from staff to reposition him in WC so that res can sit back comfortably. Upon assessment SN (LVN A) noted bleeding and swelling from previous head injury to res forehead. res states it hurts but unable to give pain scale rating . Record review of Resident #1's hospital discharge summary dated 9/15/2024 revealed Visit Summary - discharge diagnoses: Scalp injury, Fall. CT head without contrast. Findings: Right frontal scalp swelling is demonstrated. Interview on 9/18/2024 at 2:40 p.m. LVN A said she worked with Resident #1 while he ate lunch on 9/15/2024. She said Resident #1 leaned forward and pushed back from the table, which was his normal behaviors. She said Resident #1 pushed back from the table, while in the wheelchair, leaned forward, fell to the floor and hit his head. She said Resident #1 yelled out his head hurts. She said she was not told to update Resident #1's care plan. She said she was told by the DON keep a closer eye on him, which meant to keep him in our eyesight. She said Resident #1's leaning was not new, but it was more exaggerated. She said she was aware Resident #1 had a fall the day prior but was not told about new or updated interventions in his care plan. She said his normal interventions were to anticipate his needs and follow the fall protocol. She said the ADON said we needed to update his care plan because this behavior was not new, but it was more frequent. LVN A said the DON and ADON was responsible for updating the care plans. Interview on 9/18/2024 at 3:12 p.m. Resident #1's PCP said she was notified Resident #1 had a fall on 9/14 and he was in his wheelchair, had a hematoma to his head and the nurse [LVN B] said the hematoma was expanding. The PCP said she was at the facility when Resident #1 had the second fall on 9/15/2024 around lunch time. She said he had a raised bump on his head. She said he had tears rolled down his face. She said she observed him today (9/18/2024) in his wheelchair trying to get up using the hand railing. She said she was not sure who updated the care plans but said it was important to include behaviors that caused a risk to the resident's safety and to implement interventions to help to prevent injuries. An attempted Interview and observation on 9/17/2024 at 9:12 a.m. Resident #1 did not respond to questions asked. Resident #1 was lying in bed on a pressure reducing air mattress. Resident #1 had on a brief, no shirt and no pants, glasses and a baseball style cap. The floor on both sides of Resident #1's bed did not have a mat . The Residents bed was in a low position. Interview on 9/17/2024 at 11:46 a.m. the Activity Dir. said, Resident #1 liked to be placed against the wall next to the handrails. She said he pulls himself forward out of Resident #1's wheelchair . She said she was not updated on new interventions for Resident #1. She said she was in the morning meeting on 9/16/2024 but was not present for the full meeting and was not sure if new fall interventions were discussed for Resident #1. Interview on 9/17/2024 at 1:17 p.m. MDS A, said one of her responsibilities was to update care plans quarterly for residents with Medicare and without a payer source. She said a MDS nurse that quit the previous week. MDS A said she could not remember if it was last Wednesday or Thursday [9/11/24 or 9/12/24]. She said the former MDS nurse was responsible for updating the care plans for the long-term care residents that included Resident #1. MDS A said the DON, ADON or unit manager should update the care plans when there was an acute issue like a new fall. MDS A said she was not aware of Resident #1's last two falls. Interview on 9/17/2024 at 1:35 pm the ADON said Resident #1 had two witnessed falls on 9/14/2024 and 9/15/2024. She said after the fall on 9/14/2024 they were instructed by the DON to make more frequent rounding and make sure he was visible. She said she did not update Resident #1's care plan after the last two falls. She said care plans should be updated to ensure interventions are documented and put in place. The ADON said the MDS nurses take the workload and update the care plans and the ADMIN said a Corp. MDS nurse would update care plans since a MDS nurse quit last week (9/11/24 or 9/12/24). She said it was her understanding MDS A and MDS B would update care plans. She said she was not told it was her responsibility to update the care plan. She said Resident #1's last two falls were discussed in the morning meeting on 9/16/2024 with the IDT. The ADON said MDS A, MDS B and DON were in the morning meeting held on 9/16/2024. She said interventions were discussed related to Resident #1 with the IDT. She said she expected MDS A and MDS B to update Resident #1's care plan interventions. She said care plan interventions for Resident #1 should have been updated to address his recent falls and Resident #1's behavior of pulling up on handrails. She said the interventions are carried over to the cna's plan of care after the care plan is updated. Interview on 9/17/2024 at 2:06 p.m. with the DON, said the care plan for Resident #1 should have been updated by any nurse and care management (MDS nurses). She said the MDS nurse who was responsible for Resident #1's care plan quit last week on Thursday or Friday (9/11/24 or 9/12/24). She said she was told by the Admin. the Corp. MDS would monitor after the MDS nurse quit. She said Resident #1's fall interventions should have been update by care management (MDS A and MDS B). She said after a fall the IDT, which consisted of nurses, MDS nurses, DON and ADON, should discuss if interventions should be modified or new ones implemented. She said interventions were discussed in the morning meeting (9/16/2024) and the care management team was present. The DON said the care plan interventions should be updated so they can be seen in the cna's point of care. She said the care plan interventions should have been specific to Resident #1's needs after his two recent falls. She said Resident #1's care plan was not updated after the falls or the morning meeting (9/16/2024) where his falls were discussed. She said Resident #1 was at risk of injury because his interventions were not available to facility staff. She said the interventions she gave to LVN A and LVN B after Resident #1's falls were to monitor him closer and frequently. Interview on 9/17/2024 at 2:23 p.m. the ADMIN said the Corp. MDS was supposed to take over for the MDS nurse that quit. She said the Corp. MDS kept in contact with the care management team (MDS A and MDS B) by email. The ADMIN said she was at a conference and was not a part of the morning meeting (9/16/2024) after Resident #1's falls. Interview on 9/17/2024 at 3:08 p.m. with CNA A (via contracted Spanish interpreter) said she was Resident #1's aide. She said she was not told he had two falls during the past weekend. She said she was not informed of any updates to Resident #1's interventions. She said there was not a mat placed at the bedside earlier in the morning when the resident was in the bed. She said a mat was placed at Resident #1 bedside today at approximately 2:00 p.m. She checked the POC for any new updates related to resident interventions and she did not see new fall interventions for Resident #1. Interview on 9/18/2024 at 12:36 p.m. the ADMIN said there was not a time frame to update the care plan. She said she was not able to answer when an intervention needed to be updated and that would be a question for the DON and nursing staff. She said the issue with Resident #1 happened over the past weekend and they were not able to update the care plan. She said Resident #1's care plan was not updated after his fall, but the staff should have verbally communicated any new interventions put in place after the falls. Interview on 9/18/2024 at 1:22 p.m. with the Corp. MDS A nurse said she reviewed Resident #1's care plan. She said resident care plans should be a working document to mitigate what happened. She said Resident #1's care plan should be individualized to address his falls in his room and outside of his room. She said she was not the responsible for taking over for the MDS nurse that quit. Interview on 9/18/2024 at 1:51 p.m. with the Corp. MDS B said she was a traveling MDS nurse and helped out 1 to 2 days a week when needed at a facility. She said care plans are blueprints of what the resident needs. She said an acute issue, like a recent fall, should have been updated by the facility MDS nurses. She said her responsibility was to help update quarterly and annual care plans. Observation and Interview on 9/18/2024 at 3:45 p.m. revealed Resident #1 was lying in bed and his bed was not in the low position. CNA B said she was not sure why the bed was not in the low position. She said Resident #1 may have used the remote control for the bed. She removed the bed remote that was wedged between the mattress and bed frame. She said Resident #1 has used the remote before, but she had not notified a nurse of this behavior. She said the bed should be in the low position because Resident #1 is a high fall risk. Interview on 9/19/2024 at 12:34 p.m. the DON said Resident #1 was discussed in the morning meeting on 9/16/2024. She said a different wheelchair was discussed but was ruled it out because it would have been restrictive. She said a helmet was discussed but ruled out because they felt he would not wear it. She said they had not tried deterring him from pulling up on the handrails by not sitting him on the hall next to the handrails. She said the care management team (MDS nurses) should have updated the care plan right there in the meeting, but it was missed. She said she thought the failure happened over the weekend and she was not on her computer, so she provided verbal interventions. She said she told staff to monitor Resident #1 more frequently and that meant more rounding than the normal every 2 hours. She said the care plan was not updated timely for the interventions to care over to the CNAs POC, which would have made them aware of fall interventions for Resident #1. Interview on 9/19/2024 at 7:30 p.m. with LVN B, said CNA C notified her Resident #1 was in his room, fell forward out of his wheelchair, fell on the floor and hit his head (on 9/14/2024). LVN B said she went to the Resident #1's room and he had a tear on his right elbow, skin tear to his fifth digit, an abrasion to his right thigh and top of his head. LVN B said the DON told her to fill out the incident report, fall assessment and treat his injuries. LVN B said she was not instructed to update Resident #1's care plan. LVN B said the DON instructed her to complete additional rounding (q 4 hours) and add a fall mat. She said she did not update Resident #1's interventions. LVN B said care management (MDS nurses) was responsible for updating the care plans. Interview on 9/19/2024 at 12:47 a.m. with MDS A said Resident #1's care plan was not updated until 9/18/2024 after surveyor intervention. She said the care plan interventions are carried over to the POC for CNAs to have access as to what the interventions were. She said the intervention was to keep Resident #1 at the nurses' station while he was awake so the nurse could see him. Record review of facility policy Care Plan Revision upon Status Change dated 10/24/2022 revealed in part the following: Policy: The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Policy Explanation and Compliance Guidelines: 1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. 2. Procedure for reviewing and revising the care plan when a resident experiences a status change: a. Upon identification of a change in status, the nurse will notify the MDS Coordinator, the physician, and the resident representative, if applicable. b. The MDS Coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on intervention options. c. The team meeting discussion will be documented in the nursing progress notes. d. The care plan will be updated with the new or modified interventions. e. Staff involved in the care of the resident will report resident response to new or modified interventions. f. Care plans will be modified as needed by the N (nurse), DS Coordinator or other designated staff member. g. The Unit Manager or other designated staff member will communicate care plan interventions to all staff involved in the resident's care. h. The Unit Manager or other designated staff member will conduct an audit on all residents experiencing a change in status, at the time the change in status is identified, to ensure care plans have been updated to reflect current resident needs. Record review of facility policy Fall Prevention Program dated 8/15/2022 revealed the following in part: High Risk Protocols: 5. a. Provide interventions that address unique risk factors measured by the risk assessment tool: medications, psychological, cognitive status, or recent change in functional status . 8. When any resident experiences a fall, the facility will: .E. Review the resident's care plan and update as indicated. An Immediate Jeopardy (IJ) situation was determined due to the above failures. The ADMIN and DON were notified and provided with the IJ template on 9/18/2024 at 12:46 p.m. The following Plan of Removal submitted by the facility was accepted on 09/18/2024 at 4:51 p.m. and included: September 18, 2024 [facility] LETTER OF CREDIBLE ALLEGATION FOR REMOVAL OF IMMEDIATE JEOPARDY Attention Sir or Madam: On September 18, 2024, the Facility was notified by the surveyor that immediate jeopardy had been called and the Facility needed to submit a letter of removal. The Facility respectfully submits this Letter for a Plan of Removal pursuant to Federal and State regulatory requirements. The immediate jeopardy is as follows: Issue: F 656 - Develop/Implement Comprehensive Care Plan The facility failed to update or modify fall interventions after falls. Falls: Fall 7/12/24 - Left elbow. Unwitnessed fall. Fall- 9/14/2024 - Hematoma to left side of head. Witnessed fall. Fall- 9/15/24 - Hematoma to right side of head. Witnessed fall. Done for those affected: On 9/17/2024, Resident #1 was reassessed by Director of Nursing head to toe for injury and pain. The MD was notified of the findings with no new orders received. On 9/17/2024, Resident #1 was reassessed by the Director of Nursing and/ or designee related to use of Plavix and potential side effects, as well as falls, fall risk and fall interventions with no concerns noted. The MD was notified with no new orders were received. On 9/17/2024, the IDT reviewed Resident #1's plan of care related falls, injuries, pain and use medication Plavix. The plan of care was updated to reflect interventions regarding falls, injuries, pain and pharmacy consult medication as indicated and the RP was notified. To Identify Other Residents: Beginning 9/17/2024, the Director of Nursing and/ or designee reassessed residents who sustained falls 9/1/2024 through 9/17/2024 head to toe for pain and injury with no new concerns. By 9/17/2024. Beginning 9/17/2024, the Director of Nursing and/ or designee reviewed the status of resident injuries sustained from falls with no concerns in the last 30 days for appropriate treatment, care plan interventions and resolutions. By 9/17/2024. Beginning 9/17/24, the Director of Nursing and/ or designee reviewed the fall risk assessments for current residents for timely completion where indicated fall risk was reassessed and updated. By 9/17/2024. Beginning 9/17/2024, the IDT reviewed the falls care plans for residents identified to be at high risk for falls and/ or residents with physician orders for an anticoagulant for appropriate interventions and implementation. By 9/17/2024. There were updates completed as indicated. Beginning 9/17/2024, the Director of Nursing and/ or designee reviewed the progress notes for the last 30 days to ensure resident falls and/ or changes in condition related to falls were identified and addressed. By 9/17/2024. There were no concerns noted. Beginning 9/17/2024, the Director of Nursing and/or designee educated staff on updated care plans. Care Plans and/or interventions will be updated by the nursing staff at the time of occurrence. Care Plan policy was reviewed and there were no updates. The Kardex and tasks will be updated to ensure DCS are aware of interventions placed in the care plans. Nursing staff were reeducated on reviewing the Kardex and task for updated interventions. Completed 9/17/2024. Beginning 9/17/2024, the Director of Nursing and/ or designee reviewed the care plans for current residents who sustained falls in the last 30 days for implementation of interventions to address the fall. Where applicable the care plans were modified for individualization. By 9/17/2024. Education/ System Change: On 9/17/2024, the Regional Clinical Specialist reeducated the Administrator (Abuse Coordinator) and Director of Nursing on Abuse and Neglect and Abuse Policy to include prompt implementation and documentation of interventions to address resident falls and fall risk. By 9/17/2024. On 9/17/2024, the Regional Clinical Specialist reeducated the Administrator (Abuse Coordinator) and Director of Nursing on fall prevention and the Fall Prevention Policy to include prompt implementation and documentation of interventions, as well as reassessment of falls risks and adequate supervision to prevent resident falls. By 9/17/2024. On 9/17/2024, the Regional Clinical Specialist reeducated the Director of Nursing on the Incident and Accident Policy. By 9/17/2024. On 9/17/2024, the Administrator/ DON and/ or designee began reeducation to 100% of facility staff on the following: By 9/17/2024 Abuse and Neglect and Abuse Policy to include prompt implementation and documentation of interventions to address resident falls and fall risk. Fall Prevention Policy to include prompt implementation and documentation of interventions, as well as reassessment of falls risks and adequate supervision to prevent resident falls. Resident changes in condition to include new and/ or repeat falls, changes in cognition and/ or gait and ADL status. On 9/17/2024, the Director of Nursing and/ or designee began reeducation for the IDT (Administrator, Licensed Nurses, Social Work, Care Management Nurses, Activities Director, Director of Rehab, Dietary Manager) on the policy for comprehensive care plans. Re-education included timely care planning, care plan accuracy, personalized interventions, care plan documentation and implementation of care plan interventions. By 9/17/2024. On 9/17/2024, the Director of Nursing and/ or designee began reeducation with 100% of Licensed Nurses on the Incident and Accident policy to include: By 9/17/2024. Accident and Incident report completion and documentation requirements e.g. immediate actions/ interventions to prevent a fall and supervise residents. Resident fall risk and fall risk reassessment, fall interventions and timeliness, resident supervision related to falls, as well as risk for injury from falls related to use of anticoagulant medication. Resident monitoring and PN documentation post fall (minimum of 72 hours). Changes in condition, to include notifications, interventions, documentation, monitoring and follow-up. Completion of resident skin evaluations, wound assessment forms, pain assessments, treatment orders, monitoring and care plans. Effective 9/18/2024, any facility staff on FMLA, Leave of Absence, non-scheduled workday or PTO will be reeducated by the Administrator, DON and/or designee prior to the start of their next scheduled shift. The Director of Nursing/ designee will review the 24-hour report for any changes in condition related to new falls or risk for falls. Ensure the physician is notified timely and that actions are taken timely to address the change in condition, actual fall and/ or fall risk. By 9/17/2024. An Ad Hoc QAPI was conducted on 9/18/2024, attended by the Administrator, DON, Medical Director and Regional Clinical Specialist to discuss the Immediate Jeopardy concerning F 656- Develop/Implement Comprehensive Care Plan. Monitoring: The Director of Nursing will monitor the following daily for 30 days, then three times weekly for two months, effective 9/18/2024. Changes in condition, to include resident falls. DON will ensure falls are promptly addressed by reviewing the 24-hour report and residents clinical records during the Morning Clinical Meeting Accident and Incidents for completion, immediate interventions and care planning, completion of assessments and notifications. Resident falls and anticoagulant medication are care planned for new falls and new orders for anticoagulants. Skin evals, wounds assessments forms and orders for injuries resulting from Incidents and Accidents. The surveyor confirmed the facility implemented their plan of removal and Monitoring began on 9/19/2024. Interviews on 9/19/2024 10:00 a.m. - 1:08 p.m. with 1 RN, 4 LVN, 1 Med aide and 4 CNAs the staff were not aware of the care plan updates, how interventions new and current are located and the process of which staff was responsible for updating the care plans. ADMIN and DON said they would in-service the staff again. Re-interviews after additional in-services: Interviews on 9/19/2024 at 2:22 p.m. - 9/23/2024 12:54 p.m. with ADMIN, DON, MDS nurses, Therapy Director, Activity Director, SW, OT/PT staff said they were reeducated on resident care plans, timely care planning, care plan accuracy, personalized interventions, care plan documentation and implementation of care plan interventions. They said they would ensure falls are promptly addressed by reviewing the 24-hour report and residents. They said they would ensure anticoagulant medications are care planned for new falls and new orders for anticoagulants. Interviews on 9/19/2024 at 2:22 p.m. - 9/23/2024 12:54 p.m. CNAs A,B,C, D, E, F, G and MA A (7a-7p,7p-7a, 3p-11p) said they were reeducated on the POC and they are aware of interventions placed in the care plans. The staff said they were aware of Resident #'s updated fall interventions. The staff said Resident #1 had a fall mat placed on the right side of his bed and the bed in the lowest position. The staff said Resident #1 should be monitored to ensure he does not try to stand without assistance and he should not be left alone in his room until he is placed in bed. Interviews on 9/19/2024 at 2:22 p.m. - 9/23/2024 12:54 p.m. with LVN A, B, C, D, E, F and G (shifts 8a-8p, 8p-8a) said they were reeducated on the policy for comprehensive care plans. Re-education included timely care planning, care plan accuracy, personalized interventions, care plan documentation and prompt implementation of care plan interventions. Nursing staff said they were reeducated on reviewing the POC and task for updated interventions. Nursing staff said they were reeducated on reviewing the Kardex and task for updated interventions. The nursing staff said the [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for free of accidents, hazards, supervision, and devices., in that: The facility failed to ensure precautionary interventions in place Resident #1, while he was prescribed an anticoagulant, who was a known fall risk that resulted in falls with injuries to the head and hospitalization . An IJ was identified on 9/17/2024. The IJ template was provided to the AIT and DON on 9/17/2024 at 5:06 p.m. While the IJ was removed on 9/20/2021 at 12:31 p.m., with the ADMIN and DON. The facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of pattern due to the facility staff had not been trained on identifying residents at risk for fall, preventions, and interventions, and modification and care plan falls. This failure placed facility residents who were fall risk at risk of serious harm and injury. Findings included: Resident #1 Record review of Resident #1's face sheet dated 9/17/2024 revealed a [AGE] year-old male who admitted to the facility originally on 2/9/2021 and last admitted on [DATE] with the following diagnoses: Fragile X syndrome (genetic disorder and one of the most common causes of inherited intellectual disability), muscle weakness, unspecified falls, lack of coordination and cognitive communication deficit. Record review of Resident #1's Annual MDS revealed he had a BIMS score of 0 which indicated severe cognitive impairment. He used a wheelchair for mobility. Resident #1 requires total assistance (helper does all the support) for sit to stand and bed transfers. Section J1900 - Number of Falls since admission/entry or reentry or prior assessment was left balnk. Record review of facility Incidents by Resident fall report dated 9/17/2024 revealed the following in part: o [Resident #1] - Fall on 7/21/2024 at 9:40 p.m. o [Resident #1] - Fall on 9/14/2024 at 7:34 p.m. o [Resident #1] - Fall on 9/15/2024 at 12:15 p.m. Record review of Resident #1's care plan dated 9/17/2024 revealed the following: Problem: [Resident #1] receives anticoagulant/antiplatelet (medications that help reduce blood clotting) therapy (Plavix medication) Date initiated: 2/2021. Revision: 4/18/2024 Goal: [Resident #1] will be free from discomfort or adverse reactions related to anticoagulant use through the review date. Date initiated: 2/10/2021. Revision on: 6/20/2024. Target date 11/3/2024. Interventions: Administer anticoagulant medications as ordered by physician .Daily skin inspection. Document any abnormalities .Observe/document/report PRN adverse reactions of anticoagulant therapy .bruising. Revision on 8/6/2023, Resident/family /caregiver teaching to include the following: . avoid activities that could result in injury, take precautions to avoid falls . Problem: [Resident #1] is high risk for falls r/t impaired mobility. Date initiated 2/11/2021. Revision on: 4/18/2024. Goal: [Resident #1] risks and injury potential will be minimized through the next review date. Date initiated: 2/11/2021. Revision on: 6/20/2021. Target date: 11/3/2024. Interventions: Anticipate and meet the resident's needs. Dated initiated: 2/11/2021. Follow facility fall protocol. Date initiated 2/19/2021. PT evaluate and treat as ordered or PRN. The resident needs a safe environment with: (even floors free from spills and/or clutter, adequate glare-free light; a working and reachable call light, the bed in low position at night; side rails as ordered, handrails on walls, person items within reach. Date initiated 2/19/2021. Revision on 8/7/2023. Problem: [Resident #1] has had an actual fall with (Specify: no injury, On 12/28/2022) Poor Balance, Unsteady gait [the way a person walks]. 7/12/2023: actual fall, no injury. Date initiated: 1/9/2023. Revision on: 7/12/2023. Goal: [Resident #1] will resume usual activities without further incident through the review date. Date initiated: 1/9/2023. Revision on 6/20/2024. Target date: 11/3/2024. Interventions: Continue interventions on the at-risk plan. Date initiated: 1/9/2023. PT consult for strength and mobility. Date initiated: 1/9/2023 .Staff will round frequently and try to anticipate his needs. Date initiated: 7/21/2024. Staff will start offering [Resident #1] to stand and relieve pressure throughout the day. Date initiated 4/1/2024. Record review of Resident #1's Fall Risk Evaluations dated 7/21/2024 - 9/14/2024 revealed the following: Effective Date: 7/21/2024 - Score 13. Category High Risk. Scoring: If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. A prevention protocol should be initiated immediately and documented on the care plan. Effective Date: 9/14/2024 - Score 15. Category High Risk. Scoring: If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. A prevention protocol should be initiated immediately and documented on the care plan. Effective Date: 9/15/2024 - Score 16. Category High Risk. Scoring: If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. A prevention protocol should be initiated immediately and documented on the care plan. Record review of Resident #1's Order Summary Report dated 9/17/2024 revealed the following in part: . May transfer to [Hospital] and clinical ER for CT of head r/t witness fall with head injury (order date 9/15/2024) .Transfer to .ER for CT of head and X-ray of L [left] shoulder r/t fall (order date 7/22/2024). Clopidogrel Bisulfate oral tablet 75 mg - Give 1 tablet by mouth one time a day for blood thinner (order date 2/10/2021). Record review of facility nursing notes dated 9/14/2024 at 10:06 p.m. revealed the following in part: Change of Condition: Signs/Symptoms Details: witnessed fal [sic], started 09/14/2024 . 9/15/2024 02:00 [2:00 a.m.] NURSING - Nurse Note Note Text: Res arrived back to facility via . Ambulance transport. x2 assist by city ambulance personnel to transfer res from stretcher to bed via slide method. Res arrived back to facility a&o x1 with 0 s/s of distress or discomfort. CT scan of head negative of any new/acute findings. No new orders received with res discharge paperwork from hospital. [name of on call service] oncall contact and notified of situation and res return to facility; spoke with [NAME], NP. [NAME], NP ordered to hold Plavix [keeps blood from coagulating (clotting)] until Monday; order implemented. POC conts [sic] as ordered. Res in bed with bed in lowest position, call light in place and all safety measures in place at this time. 9/15/2024 12:15 .Res in Bistro area in WC eating lunch and witnessed falling on floor r/t leaning forward in WC after numerous attempts of assistance from staff to reposition him in WC so that res can sit back comfortably. Upon assessment SN (LVN A) noted bleeding and swelling from previous head injury to res forehead. res states it hurts but unable to give pain scale rating . Record review of Resident #1's hospital discharge summary dated 9/14/2024 revealed the following: Visit Summary - discharge diagnoses: tear of skin - primary, closed injury of head - primary, contusion (bruise) of right elbow - primary . Record review of Resident #1's hospital discharge summary dated 9/15/2024 revealed the following: Visit Summary - discharge diagnoses: Scalp injury, Fall. CT head without contrast. Findings: Right frontal scalp swelling is demonstrated. Observation and attempted Interview and on 9/17/2024 at 9:12 a.m. revealed Resident #1 was lying in bed on a pressure reducing air mattress. Resident #1 had on a brief, no shirt and no pants, glasses and a baseball style cap. Resident #1's call light was not in reach. The call light was on the floor. The floor on both sides of Resident #1's bed did not have a mat. The Residents bed was in a low position. Interview on 9/17/2024 at 1:35 pm with ADON, said Resident #1 had two witnessed falls on 9/14/2024 and 9/15/2024. She said after the fall on 9/14/2024 they were instructed by the DON to make more frequent rounding and make sure he was visible. She said she did not update Resident #1's care plan after the last two falls. She said care plans should be updated to ensure interventions are documented and put in place. The ADON said the MDS nurses take the load and the ADMIN said a Corp. MDS nurse would update care plans since a MDS nurse quite last week (9/11/24 or 9/12/24). She said it was her understanding MDS A and MDS B would update care plans. She said she was not told it was her responsibility to update the care plan. She said Resident #1's last two falls were discussed in the morning meeting on 9/16/2024 with the IDT. The ADON said MDS A, MDS B and DON were in the morning meeting held on 9/16/2024. She said interventions were discussed related to Resident #1 with the IDT. She said she expected MDS A and MDS B to update Resident #1's care plan interventions. She said care plan interventions for Resident #1 should have been updated to address his recent falls and Resident #1's behavior of pulling up on handrails. She said the interventions are carried over to the cna's plan of care after the care plan is updated. Interview on 9/17/2024 at 2:06 p.m. with the DON said she was aware of Resident #1's last two falls. She said she was notified and instructed the staff to monitor him more frequently. She said Resident #1 should have had fall mat placed on the side of his bed. She said she could not explain why the mat was not there. Surveyor explained earlier observations revealed Resident #1 did not have a mat while he laid in bed. She said she was not sure why he did not have a mat and they would put one out. She said a helmet was not considered because, Resident #1 did not like to take off his caps. She said another type of wheelchair was not considered because the IDT felt it would be restrictive. She said Resident #1's care plan was not updated after the falls or the morning meeting (9/16/2024) where his falls were discussed. She said Resident #1 was at risk of injury because his interventions were not available to facility staff. Interview on 9/17/2024 at 3:08 p.m. with CNA A (via contracted Spanish interpreter) said she was Resident #1's aide. She said she was not told he had two falls during the past weekend. She said she was not informed of any updates to Resident #1's interventions. She said there was not a mat placed at the bedside earlier in the morning when the resident was in the bed. She said a mat was placed at Resident #1 bedside today at approximately 2:00 p.m. She said she would check in the POC for any new updates related to resident interventions and she did not see new fall interventions for Resident #1. Interview on 9/18/2024 at 1:22 p.m. with the Corp. MDS A nurse said she reviewed Resident #1's care plan and said it needed to be cleaned up and we should have showed each fall that occurred. She said resident care plans should be a working document to mitigate what happened. She said Resident #1's care plan should be individualized to address his falls in his room and outside of his room. She said she was not aware that Resident leaned out of his chair on both falls and that he pulls himself up when he is positioned along the handrails in the hallways. Interview on 9/18/2024 at 1:51 p.m. with the Corp. MDS B said she was a traveling MDS nurse and helped out 1 to 2 days a week when needed at a facility. She said care plans are blueprints of what the resident needs. She said an acute issue, like a recent fall, should have been updated by the facility MDS nurses. Interview on 9/18/2024 at 2:40 p.m. with LVN A, said she worked with Resident #1 while he ate lunch on 9/15/2024. She said Resident #1 leaned forward and pushed back from the table, which was his normal behaviors. She said this was his normal behavior. She said Resident #1 pushed back from the table, while in the wheelchair, leaned forward, fell to the floor and hit his head. She said Resident #1 yelled out his head hurts. She said she was not told to update Resident #1's care plan. She said she was told by the DON keep a closer eye on him, which meant to keep him in our eyesight. She said Resident #1's leaning was not new, but it was more exaggerated. She said she was aware Resident #1 had a fall the day prior but was not told about new or updated interventions in his care plan. She said his normal interventions were to anticipate his needs and follow the fall protocol. She said the ADON said we needed to update his care plan because this behavior was not new, but it was more frequent. LVN A said the DON and ADON was responsible for updating the care plans. Interview on 9/18/2024 at 3:12 p.m. with Resident #1's PCP, said she was notified Resident #1 had a fall on 9/14 and he was in his wheelchair, had a hematoma to his head and the nurse [LVN B] said the hematoma was expanding. The PCP said she was at the facility when Resident #1 had the second fall on 9/15/2024 around lunch time. She said he had a raised bump on his head. She said he had tears rolled down his face. She said she observed him today (9/18/2024) in his wheelchair trying to get up using the hand railing. She said she was not sure who updated the care plans but said it was important to include behaviors that caused a risk to the resident's safety and to implement interventions to help to prevent injuries. Observation and Interview on 9/18/2024 at 3:45 p.m. revealed Resident #1 was lying in bed and his bed was not in the low position. CNA B said she is not sure why the bed was not in the low position. She said Resident #1 may have used the remote control for the bed. She removed the bed remote that was wedged between the mattress and bed frame. She said Resident #1 has used the remote before, but she had not notified a nurse of this behavior. She said the bed should be in the low position because Resident #1 is a high fall risk. An interview was attempted on 9/18/2024 at 4:22 p.m. with LVN B by phone. Interview on 9/19/2024 at 8:35 a.m. with Therapy Director said all residents are evaluated after every fall. She said due to Resident #1's cognition, he could not learn new things and the therapy performed would maintain skills he had. She said he had poor safety awareness. She said he required queuing because he will attempt to get up, and it is not safe for him to do so. She said therapy was not effective for preventing fall for Resident #1 and it was for maintenance. Interview on 9/19/2024 at 7:30 p.m. with LVN B, said CNA C notified her Resident #1 was in his room, fell forward out of his wheelchair, fell on the floor and hit his head (on 9/14/2024). LVN B said she went to the Resident #1's room and he had a tear on his right elbow, skin tear to his fifth digit, an abrasion to his right thigh and top of his head. LVN B said the DON told her to fill out the incident report, fall assessment and treat his injuries. LVN B said she was not instructed to update Resident #1's care plan. LVN B said the DON instructed her to complete additional rounding (q 4 hours) and add a fall mat. She said she did not update Resident #1's interventions. LVN B said care management (MDS nurses) was responsible for updating the care plans. Interview on 9/19/2024 at 7:52 p.m. with CNA C said he took Resident #1 to his room. CNA C said he turned to adjust the bed and Resident #1 fell out of his wheelchair onto the floor (on 9/14/2024. CNA C said Resident #1 fell face first and did not make a sound. CNA C said Resident #1 was sent the hospital. CNA C said when the resident returned, he was told to sit with the resident while he laid in bed. He said he was not aware of new interventions for Resident #1 because he was not working with him today. * Record review of facility policy Fall Prevention Program dated 8/15/2022 revealed the following in part: High Risk Protocols: 5. a. Provide interventions that address unique risk factors measured by the risk assessment tool: medications, psychological, cognitive status, or recent change in functional status . 8. When any resident experiences a fall, the facility will: .E. Review the resident's care plan and update as indicated. September 17, 2024 [facility] LETTER OF CREDIBLE ALLEGATION FOR REMOVAL OF IMMEDIATE JEOPARDY Attention Sir or Madam: On September 17, 2024, the Facility was notified by the surveyor that immediate jeopardy had been called and the Facility needed to submit a letter of removal. The Facility respectfully submits this Letter for a Plan of Removal pursuant to Federal and State regulatory requirements. The immediate jeopardy is as follows: Issue: F 689 - Accidents/Supervision The facility failed to provide Resident #1 who is on an anticoagulant medication, adequate supervision and interventions to prevent falls causing head injury. The facility failed to ensure Resident #1's care plan was updated with interventions after 3 falls that resulted in hematomas to the forehead. Done for those affected: o On 9/17/2024, Resident #1 was reassessed by Director of Nursing head to toe for injury and pain. The MD was notified of findings with no new orders received. o On 9/17/2024, Resident #1 was reassessed by the Director of Nursing and/ or designee related to use of Plavix and potential side effects, as well as falls, fall risk and fall interventions with no concerns noted. The MD was notified with no new orders received. o On 9/17/2024, the IDT reviewed Resident #1's plan of care related falls, injuries, pain and use medication Plavix. The plan of care was updated to reflect interventions regarding falls, injuries, pain and pharmacy consult medication as indicated and the RP was notified. To Identify Other Residents: o Beginning 9/17/2024, the Director of Nursing and/ or designee reassessed residents who sustained falls 9/1/2024 through 9/17/2024 head to toe for pain and injury with no new concerns. By 9/17/2024. o Beginning 9/17/2024, the Director of Nursing and/ or designee reviewed the status of resident injuries sustained from falls with no concerns in the last 30 days for appropriate treatment, care plan interventions and resolutions. By 9/17/2024. o Beginning 9/17/24, the Director of Nursing and/ or designee reviewed the fall risk assessments for current residents for timely completion where indicated fall risk was reassessed and updated. By 9/17/2024. o Beginning 9/17/2024, the IDT reviewed the falls care plans for resident identified to be at high risk for falls and/ or residents with physician orders for an anticoagulant for appropriate interventions and implementation. By 9/17/2024. There were updates completed as indicated. o Beginning 9/17/2024, the Director of Nursing and/ or designee reviewed the progress notes for the last 30 days to ensure resident falls and/ or changes in condition related to falls were identified and addressed. By 9/17/2024. There were no concerns noted. o Beginning 9/17/2024, the Director of Nursing and/or designee educated staff on updated care plans. Care Plans and/or interventions will be updated by the nursing staff at the time of occurrence. Care Plan policy was reviewed and there were no updates. The Kardex and tasks will be updated to ensure DCS are aware of interventions placed in the care plans. Nursing staff were reeducated on reviewing the Kardex and task for updated interventions. Completed 9/17/2024. Education/ System Change: o On 9/17/2024, the Regional Clinical Specialist reeducated the Administrator (Abuse Coordinator) and Director of Nursing on Abuse and Neglect and Abuse Policy to include prompt implementation and documentation of interventions to address resident falls and fall risk. By 9/17/2024. o On 9/17/2024, the Regional Clinical Specialist reeducated the Administrator (Abuse Coordinator) and Director of Nursing on fall prevention and the Fall Prevention Policy to include prompt implementation and documentation of interventions, as well as reassessment of falls risks and adequate supervision to prevent resident falls. By 9/17/2024. o On 9/17/2024, the Regional Clinical Specialist reeducated the Director of Nursing on the Incident and Accident Policy. By 9/17/2024. o On 9/17/2024, the Administrator/ DON and/ or designee began reeducation to 100% of facility staff on the following: By 9/17/2024 Abuse and Neglect and Abuse Policy to include prompt implementation and documentation of interventions to address resident falls and fall risk. Fall Prevention Policy to include prompt implementation and documentation of interventions, as well as reassessment of falls risks and adequate supervision to prevent resident falls. Resident changes in condition to include new and/ or repeat falls, changes in cognition and/ or gait and ADL status. o On 9/17/2024, the Director of Nursing and/ or designee began reeducation for the IDT (Administrator, Licensed Nurses, Social Work, Care Management Nurses, Activities Director, Director of Rehab, Dietary Manager) on resident care plans, timely care planning, care plan accuracy, personalized interventions, care plan documentation and implementation of care plan interventions. By 9/17/2024. o On 9/17/2024, the Director of Nursing and/ or designee began reeducation with 100% of Licensed Nurses on the Incident and Accident policy to include: By 9/17/2024. Accident and Incident report completion and documentation requirements e.g. immediate actions/ interventions to prevent a fall and supervise residents. Resident fall risk and fall risk reassessment, fall interventions and timeliness, resident supervision related to falls, as well as risk for injury from falls related to use of anticoagulant medication. Resident monitoring and PN documentation post fall (minimum of 72 hours). Changes in condition, to include notifications, interventions, documentation, monitoring and follow-up. Completion of resident skin evaluations, wound assessment forms, pain assessments, treatment orders, monitoring and care plans. o Effective 9/18/2024, any facility staff on FMLA, Leave of Absence, non-scheduled workday or PTO will be reeducated by the Administrator, DON and/or designee prior to the start of their next scheduled shift. o The Director of Nursing/ designee will review the 24-hour report for any changes in condition related to new falls or risk for falls. Ensure the physician is notified timely and that actions are taken timely to address the change in condition, actual fall and/ or fall risk. By 9/17/2024. An Ad Hoc QAPI was conducted on 9/17/2024, attended by the Administrator, DON, Medical Director and Regional Clinical Specialist to discuss the Immediate Jeopardy concerning F 689-Accidents/ Supervision. Monitoring: The Director of Nursing will monitor the following daily for 30 days, then three times weekly for two months, effective 9/18/2024. o Changes in condition, to include resident falls. DON will ensure falls are promptly addressed by reviewing the 24-hour report and residents clinical records during the Morning Clinical Meeting o Accident and Incidents for completion, immediate interventions and care planning, completion of assessments and notifications. o Resident falls and anticoagulant medication are care planned for new falls and new orders for anticoagulants. o Skin evals, wounds assessments forms and orders for injuries resulting from Incidents and Accidents. Surveyor monitored the plan of removal for effectiveness as follows: Interviews on 9/19/2024 10:00 a.m. - 1:08 p.m. with 1 RN, 4 LVN, 1 Med aide and 4 CNAs the I.J. was not able to be lowered based on staff interviews revealed they were not aware of the care plan updates, how interventions new and current are located and the process of which staff was responsible for updating the care plans. Interviews on 9/19/2024 at 2:22 p.m. - 9/23/2024 12:54 p.m. with ADMIN, DON, MDS nurses, Therapy Director, Activity Director, SW, OT/PT staff said they were reeducated o resident care plans, timely care planning, care plan accuracy, personalized interventions, care plan documentation and implementation of care plan interventions. They said they would ensure falls are promptly addressed by reviewing the 24-hour report and residents. They said they would ensure anticoagulant medications are care planned for new falls and new orders for anticoagulants. Interviews on 9/19/2024 at 2:22 p.m. - 9/23/2024 12:54 p.m. CNAs A,B,C, D, E, F, G and MA A (7a-7p,7p-7a, 3p-11p) said they were reeducated on the POC and they are aware of interventions placed in the care plans. The staff said Resident #1 had a fall mat placed on the right side of his bed and the bed in the lowest position. The staff said Resident #1 should be monitored to ensure he does not try to stand without assistance and he should not be left alone in his room until he is placed in bed. Interviews on 9/19/2024 at 2:22 p.m. - 9/23/2024 12:54 p.m. with LVN A, B, C, D, E, F and G (shifts 8a-8p, 8p-8a) said they were reeducated on the policy for comprehensive care plans. Re-education included timely care planning, care plan accuracy, personalized interventions, care plan documentation and prompt implementation of care plan interventions. Nursing staff said they were reeducated on reviewing the POC and task for updated interventions. Nursing staff said they were reeducated on reviewing the Kardex and task for updated interventions. The nursing staff said they were aware to update acute care plan interventions and they did not have to wait for the MDS nurse to update the care plans. The nursing staff said they understood it was important to update the care plan interventions so the POC for CNAs was updated. The nursing staff said the interventions should be updated and put in place immediately to ensure the residents' safety. The nursing staff said they understood care plan interventions should be individualized to meet specific resident needs. Observation on 9/19/2024 at 11:17 a.m. revealed Resident #1 was in his wheelchair and being pushed by a nurse and she offered him coffee. Observation on 9/20/2024 at 11:03 a.m. revealed Resident #1 was in bed in the lowest position and the fall mat was on the door side (left side as surveyor looked at bed). Observation on 9/20/2024 at 2:56 a.m. revealed Resident #1 was next to the nurse's station with a cup of coffee. There was a nurse standing next to him and talking with him periodically. Observation on 9/23/2024 at 9:40 a.m. revealed Resident #1 was across from station #3 with a coffee cup in his hand. A nurse was at the nurses station within a few steps of the resident. Record review of facility head to toe assessments for high fall risk residents with falls from 9/1/2024 - 9/17/2024 (12 residents). Record review of fall risk assessments for current resident for timely completion where indicated fall risk was reassessed and updated. Resident #2's fall risk assessment indicated he was low risk (7 falls between 7/18/24 and 9/7/24) and he was was not indicated on the high risk for falls reassessment intially, but was corrected after surveyor intervention and review. Record review was conducted of the facility's In-services Training Report dated 9/17/24 conducted by DON to Licensed Nurses (LVNs, RNs) revealed the topic was Incident and Accident Policy - .fall interventions and timeliness, supervision related to falls, and risk for injury from falls related to anticoagulant medications . All in attendance voiced understanding. Record review was conducted of the facility's In-services Training Report dated 9/17/24 conducted by DON to All Staff revealed the topic was Fall and Fall Management Policy - Review Fall Prevention Program and Policy and Reeducated IDT members on Fall Prevention Program and Policy as attached. All in attendance voiced understanding. The Administrator was informed that the Immediate Jeopardy was removed on 9/20/2024 at 12:31 p.m. The facility remained out of compliance at the severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review, the facility failed to ensure residents had a safe, clean, comfortable, and homelike environment for 1 of 10 resident (Resident #2) reviewed for homelike environment. The facility failed to ensure Resident #2's toilet base was free from stains and dirt and toilet was in good repair. These failures could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, uncomfortable, and unsafe. The findings included: Record review of Resident #2's face sheet revealed a [AGE] year-old male admitted on [DATE] with the following diagnoses: Hypertension (high blood pressure), dementia (memory loss), fracture of femur, muscle weakness, unsteadiness of feet and difficulty of walking. Record review of Resident #2's care plan dated 9/19/2024 revealed the following in part: Problem Falls [Resident #] is a risk for fall related to gait/balance problems, hypotension (high blood pressure) (Revision on 5/22/2023). Goal [Resident #1] will not sustain serious injury through the review date. (Revision on 10/13/2023). Interventions .The resident needs a safe environment with, even floors free from spills and/or clutter . Observation and interview on 9/17/2024 at 11:02 a.m. revealed Resident #2's bathroom floor had a liquid substance coming from the base of the toilet. There was approximately a 1-inch black ring around the base of the toilet. The bathroom smelled of urine. Resident #2 said his bathroom was full of water and smelled like urine. He said he told a staff that he could not remember, about fixing his toilet, but it had not been fixed. He said the toilet was leaking and the black ring had been there for months. Interview on 9/17/2024 at 11:46 a.m., with the Activity Dir. said she saw Resident #2's bathroom on 9/16/2024. She said she saw how dirty the toilet was. She said she did not see the water on the floor. She said she put in an order for maintenance. She said the stain around the bottom of the toilet appeared it had accumulated over time and had not just happened. She said she had been Resident #2's ambassador for 1 day and had not seen his room before. She said she completed ambassador rounds, which is where she checks in with residents and made sure there are not problems with their rooms or concerns that a resident would have. She said a resident dignity and rights were at risk. Interview on 9/17/2024 at 12:25 p.m. with the DON said Resident #2's bathroom toilet was missing a ring around the bottom to prevent water from leaking. She said she told the ADMIN to start with 5 or so bathroom at a time and repair them because the building is so old. She said the leaking toilet could be a hazard to Resident #2 because he sometimes stands up when in the bathroom from his wheelchair. She said she saw the toilet had leaked and there was black dirty ring around the bottom. Interview on 9/17/2024 at 12:32 p.m. the Maintenance Dir. said he had not seen Resident #2's room prior to today. He said he checked rooms daily but randomly selected them. He said the bathroom had bad caulking and something was wrong with the wax ring. He said the wax ring was designed to stop sour gas and leaks from under the toilet. He said the bathroom had a had strong odor and it was hard to tell if it was water or urine. He said the black ring around the bottom of the toilet was old caulking that was dirty from dust and dirt that had collected. He said the toilet has deteriorated over time. Record review of facility policy Resident Rights (dated November 2021) revealed the following in part: Dignity and Respect You have the right to: Live in safe, decent and clean conditions .

Based on interviews and record review, the facility failed to ensure residents requiring respiratory care, consistent with professional standards of practice for 1 (CR#1) of 5 residents reviewed for quality of care. The facility failed to provide immediate care to CR#1 when she experienced respiratory distress on [DATE]. After the resident was observed gurgling with emesis by LVN A, the NP was notified; monitoring nor interventions were initiated. When observed by the NP, CR #1 was unresponsive and oxygen saturation dropped to 60%. 911 was called and arrived at 12pm. During the course of hospitalization , CR #1 was declared brain dead and expired on [DATE] after atifical support was removed. This failure placed residents who developed a change in respiratory status at risk of physical harm, emotional distress, mental anguish, and hospitalization or death from possible neglect. On [DATE] at 1:11 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE] at 11:13am the facility remained out of compliance at a scope of isolated with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of their corrective actions. Finding included: Record review of the admission sheet (undated) for CR#1 revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses which included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), vascular dementia (a general term describing problems with reasoning, planning, judgment, memory, and other thought processes caused by brain damage from impaired blood flow to brain), and paraplegia (paralysis that affects all or part of the trunk, legs, and pelvic organs). CR#1 was discharged on [DATE] to acute care hospital. Record review of CR #1's Quarterly MDS, dated [DATE], revealed a BIMS score of 3 out of 15 indicative of severely impaired cognition. CR#1 was dependent on staff for toileting hygiene, shower, and lower body dressing. Partial/moderate assistance with upper body dressing and personal hygiene. Record review of CR#1's care plan, initiated [DATE] and revised on [DATE] revealed the following: Problem: [CR#1] has an ADL self-care performance deficit r/t Dementia Goal: The resident will maintain current level of function through the review date. Interventions: Eating: the resident requires (supervision) with setup. Toilet use: the resident requires (extensive assistance) by (1) staff for toileting. Dressing: the resident requires (extensive assistance) by (1) staff to dress. Record review of CR#1's Nurses note dated [DATE] at 12:29pm written by LVN A revealed read in part: .Note Text: Nurse entered room and observed resident gurgling and with yellow emesis on her gown Nurse called resident name; resident was not responding Nurse initiate V/S BP ,d+[DATE] P 47 BS 194 O2 Sat 90% on RA. Resident V/S Rechecked BP ,d+[DATE] P 58 O2 Sat 83% oxygen applied NP is here to assesses Resident. Resident O2 Sat 74% non-rebreather is applied. NP gave order to send Resident out 911 to [Hospital name]. Resident Guardian is contacted but there was no answer, This Nurse left a voice message to call facility at her earliest convenience . Record review of CR#1's NP's notes dated [DATE] revealed read in part: .Chief Complaint: acute visit. History of Present Illness: Polite 57F long term nursing home resident. Nurse called me to see the resident for sudden change in condition. Per nurse, she had breakfast and medications in am as usual. But around 1150 AM, she did vomit and kept coughing. When I saw her at the bedside, she was unresponsive and very congested breathing was noted. The gown was soaked with gastric emesis. Initial VS, bp,d+[DATE], HR 88, O2sat 88%w/ RA, RR 40 and BG 194. No IM Lasix at this facility per nurse. Stat cxr, CBC, BNP, CMP, NH3 and oral suction and breathing tx and full o2 application. Unfortunately, oral suction was malfunctioning. Breathing tx was given but her o2 sat was down to 60%. it was not successful. Apply NRB with 15L and went up to 82%. bp 112/ 52, hr 68, rr 50, o2 sat 67% with NRB 15 L. Worsening hemodynamic status and still unresponsive. at 1200 PM, called 911 for the sudden neuro change, suspected aspiration related respiratory failure and possible ET for airway protection. Notified Dr. about the change in condition and agreed with the hospital transport for the higher level of care. 911 arrived and took her to the hospital around 12 15 pm without ET, o2sat 81%w/ NRB and no status changed . Record review of CR#1's EMS records dated [DATE] revealed read in part: .Primary Symptom: Neuro - Unconscious/Unresponsive Began: [DATE] 12:00:00 Location: General/Global Activity: General - Seated or Lying Down, Not Sleeping Possible Injury: No Cardiac Arrest: No Narrative: m050 was dispatched to a possible cardiac arrest. M050 aostf a 57 yo female with a cc of unconscious/unresponsive. the pt was found laying semi-Fowler on hospital bed inside of a nursing home. Staff was not present to give a report. It is unknown the pt baseline and when the pt was last seen normal. The pt was being ventilated with a bvm and o2 by e005. The pt had vomit coming from her nose and mouth. The pt was suctioned on scene. The pt was moved to the back of the ambulance. An igel size 4 and end tidal were established. The pt was hyperventilated do to a low o2 sat. The pads were placed on the pt. IV access was obtained. The pt was administered a normal saline bolus. The pt vitals were monitored enroute to the er. The pt bp dropped below 90 systolic. Nor epi was administered while enroute to the er. The pt was suctioned throughout transport. The pt vitals were monitored. The pt bp improved and vitals remained stable. Nor epi was discontinued pmhx as listed. nkda. The pt had a gcs of 3, pupils PERRL, lungs clear and equal, skin warm and dry. 12:29:42 HR 62 O2 Sat 18% , 12:33:19 HR 80 BP 73 / 32 HR 15 O2 Sat 75% . Record review of CR#1's Emergency Department records dated [DATE] revealed read in part: .Procedure-Endotracheal intubation. Time: [DATE] 13:05. Confirmed: Patient, procedure, and site correct, Time-out taken prior to procedure. Indication: Airway protection. - The patient presents with an illness or injury that acutely impaired one or more vital organ systems. There was a high probability of imminent or life-threatening deterioration in the patient's condition during their evaluation in the ED . Record review of CR#1's Neurocritical Care Note dated [DATE] revealed read in part: .Chief Complaint [DATE] 12:50 Pt came from by EMS, unknown hx, unknown baseline. Found unresponsive, hypotensive at seen with BP of ,d+[DATE], started on levophed and 300ml NSS by EMS, ambu-bagged on way here. History of Present Illness 57yoF w/ PMHx prior stroke, stercoral colitis s/p colostomy, chronic paraplegia, wheelchair bound, DVT on Eliquis (unknown medication compliance), and bipolar disorder, is BIBEMS from after she was found unresponsive. Unknown last seen normal. Patient was reportedly GCS 3, and there was no staff available to provide additional history. EMS intubated the patient for airway protection and started a norepi drip when she was found to be hypoxic and hypotensive. Per EMS, patient had a copious amount of dark green mucus in the nose and mouth. CTA shows no intracranial flow. Patient is admitted to for close neuromonitoring and further evaluation with possible progression to brain death . Record review of CR#1's hospital discharge summary revealed read in part: .Date of Admission: Patient was admitted on [DATE]. Date of Discharge: Time of death 20:28 on [DATE]. All Diagnoses This Visit: Altered mental status, Anoxic brain injury, Coma Diffuse cerebral edema, other shock, Respiratory arrest. Hospital Course: 57yoF w/ PMHx prior stroke, stercoral colitis s/p colostomy, chronic paraplegia, wheelchair bound, DVT on Eliquis (unknown medication compliance), and bipolar disorder, is BIBEMS from after she was found unresponsive. Unknown last seen normal. Patient was reportedly GCS 3, and there was no staff available to provide additional history. EMS intubated the patient for airway protection and started a norepi drip when she was found to be hypoxic and hypotensive. Per EMS, patient had a copious amount of dark green mucus in the nose and mouth. CTA shows no intracranial flow. Patient is admitted to for close neuromonitoring and further evaluation with possible progression to brain death. Over the course of her hospitalization patient was declared brain dead (20:28 on [DATE]) by way of cerebral blood flow test. Guardian was contacted and funeral arrangements were made. Patient was taken off of artificial support on [DATE] and transported to the funeral home . In a telephone interview on [DATE] at 9:56a.m., with the Hospital Case Manager, she said CR#1 arrived from the nursing facility intubated and unresponsive. CR#1 was determined to be brain dead. She said per EMS CR#1's 02 was 18%. When the hospital nurse called the nursing home to get a report from the facility, she said there was no answer. She said the hospital had received many pts from that facility in poor condition. She said the facility's Administrator was contacted. The Administrator said it was clinical and asked ADON A to give report. ADON A said the NP was in the room at that time. Hospital Case Manager said she requested NP's number as the doctor had questions. In an interview on [DATE] at 1:13p.m., with LVN B, she said she had not worked with CR#1. She said she worked PRN at this facility, and this was her first day on the floor. When asked in the event of an emergency where would she get the oral suctioning machine from. LVN B said the oral suctioning machine should be at bedside if there was an order. I don't know where the machine is kept. But it's a good question I will definitely ask. In a telephone interview on [DATE] at 1:27p.m., with LVN A, she said when she made her morning round CR#1 was alert, oriented, and talking. CR#1 ate breakfast and took her morning meds. LVN A said she was passing meds when she heard coughing and a gurgling noise. She said she entered CR #1's room and observed CR#1 slumped over. She said when she called CR#1's name, the resident was not responding. She said she checked vitals and her O2 was in the 80s, but the resident was still not responding. She said she called the Unit Manager to assess. The NP was in the facility, and the NP assessed CR#1. Resident O2 Sat were low, non-rebreather was applied. The NP gave the order to send the resident out 911 to the hospital. In an interview on [DATE] at 1:40p.m., with RN Care Coordinator, she said CR#1 was fairly new to their case load. CR#1started their services in [DATE]. She said CR#1was seen by the NP twice a week and once a week by the doctor. She said CR#1 was seen by the NP when CR#1 was transferred to the hospital. She said O2 sat less than 92% required oxygen via nasal cannula and non-rebreather mask was used to deliver high percentage of oxygen. Record review and interview on [DATE] at 1:48p.m., with the DON, ADON A, and ADON B. The DON said CR#1 was still breathing when CR#1 left the facility. ADON A said they were in a meeting when the nurse said CR#1 had a change of condition. On the way to assess the resident, the NP was met on the hallway and was asked to assess CR#1. The NP asked for Lasix IM and was told the facility did not have it. The NP ordered oral suctioning and a breathing treatment. After the treatment the O2 was in low 80s so they changed to nonrebreather mask and watched for a few minutes. ADON A said when she suctioned there were clear liquids, and nothing came out. The NP checked CR#1's eyes for neurological changes with the pen light. They called 911 and the EMS came within ,d+[DATE] minutes. She said the nurse and the NP were in the room with CR#1 while they gathered paperwork. ADON A said the oral suctioning machine was used. She said she connected the tubing to the suction machine and not the nurse so I know the suction machine was working. This State Surveyor asked to see the suction machine used on CR#1. ADON A said the machine was in the central supply to be decontaminated. The DON said the Respiratory Therapist checked the equipment once a month and as needed when visiting the facility as the facility did not have trach/vents. The DON said if the machine malfunctioned, the Respiratory Therapist would label it to be fixed. The State Surveyor reviewed the NP's note in which the NP documented oral suction was malfunctioning. ADON A said the NP was in and out of the room and on her phone most of the time don't know why she documented that. ADON A said CR#1 sats were in low 80s. She suggested to the NP to send CR#1 to the hospital. NP wanted to order stat x-rays and labs. ADON A said 911 wound not have taken CR#1 if she was not breathing. In a telephone interview on [DATE] at 2:16 p.m., the NP said the nurse called her to see CR#1 for sudden change in condition. Around 11:50 AM, CR#1 vomited and kept coughing. She said she saw CR#1 at the bedside. CR#1 was unresponsive and very congested breathing was noted. CR#1 gown was soaked with gastric emesis. There was no IM Lasix at this facility per nurse. She ordered oral suction, breathing treatment, and O2. Breathing tx was given but her O2 sat was down to 60%. It was not successful. Applied NRB with 15L and went up to 82%. CR#1 was still unresponsive. The NP said she documented, Unfortunately; oral suction was malfunctioning in her progress notes because she worked at the hospital and had not seen this suctioning machine before. She said there was clear liquid, no food when suctioning so she assumed the machine was malfunctioning. She said the staff brought 2nd suctioning machine and there was clear liquid. She said she called the Doctor and at 12:00 PM, the EMS was called for the sudden neuro change, suspected aspiration related respiratory failure and possible ET for airway protection. She said brain cells were very sensitive to a lack of oxygen. She said brain cells start dying less than 5 to 10 minutes after their oxygen supply disappears. In an interview on [DATE] at 2:50p.m., Hospital RN said CR#1's admitting diagnosis was anoxic brain injury, coma, and respiratory arrest. In an interview on [DATE] at 3:03p.m., Neurosurgery Doctor said CR#1 was found unresponsive and there was evidence that CR#1 had not gotten oxygen for 30 plus minutes as there was no blood flow to the brain. In an interview on [DATE] at 10:01a.m., with the DON, she said the facility had Lasix in the Ekit. The DON said nurses were reeducated on the contents of Ekit, to include a vial of Lasix and the procedure for updating the pharmacy for Ekit use. In an interview on [DATE] at 10:13a.m., with LVN A, she said one oral suctioning machine was used on CR#1. She said the machine was brought in the room by somebody there were too many people in the room she could not recall who brought the machine. She said she did not see who connected the tubing on the machine. LVN A said, I suctioned her I was the closest one to her. There was only clear liquid. She said the NP was in and out of the room at that time. She said nurses were responsible for sanitizing the used machine and to place it back in the storage room. She said she had not seen a Respiratory therapist in the facility as there were no trach/vent residents. In an interview on [DATE] at 10:33a.m., with CNA BB, she said CR#1 required extensive/total care with all ADLs. She said CR#1 was talking and ate her breakfast that morning. She said she went to take the food cart to the kitchen. It was matter of minutes resident had change of condition. When she returned to the hall the nurses were in the room with CR#1. In a telephone interview on [DATE] at 1:03p.m., with CR#1's Doctor. The Doctor said CR#1 had a change of condition and they started interventions. They checked BP, HR, and O2. Her O2 sat was low so the oxygen was given. Her O2 did not increase so the non-rebreather was applied. Pt was a full code and intended ET. Her BP was fluctuating on lower levels, unresponsive, and she did not respond well to oxygen so 911 was triggered. She said if the pt was full code, unresponsive, checked vitals, and had no pulse. CPR and 911 should be initiated. She said 911 would come in ,d+[DATE] minutes. She said if pt had BP staff should do interventions to keep pt stable until 911 arrives. Record review of facility's Abuse, Neglect, and Exploitation policy (Date Implemented: [DATE]) revealed read in part: . Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Definitions: Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . Policy on Respiratory distress was requested along with Abuse/neglect policy. No policy on respiratory distress was provided on exit. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 1:11pm. The facility's Administrator, the DON, and the Regional Clinical Specialist (on phone) were notified. The Administrator was provided with the IJ template on [DATE] at 10:55am. The following POR submitted by the facility was accepted on [DATE] at 7:41pm. The POR read in part: . LETTER OF CREDIBLE ALLEGATION FOR REMOVAL OF IMMEDIATE JEOPARDY On [DATE], the facility was notified by the state surveyor, that an immediate jeopardy had been called and the facility needed to submit a Plan of Removal pursuant to Federal and State regulatory requirements. The immediate jeopardy allegations are as follows: F- Tag 600: Free from Abuse and Neglect. Facility failed to provide prompt care to CR#l when she experienced respiratory distress in the presence of the NP. Done for those affected: Resident CR#l is no longer in the center. Identify residents who could be affected: o Beginning [DATE], head to toe assessments were completed by Licensed Nurses on all residents to identify any signs of change in condition. Concerns will be reported to the MD/NP. By 5/ ,d+[DATE] o Beginning [DATE], the DON/ designee reviewed the resident progress notes for the last 30 days to ensure concerns related to abuse and neglect and changes of condition were identified and an investigation initiated, and physicians were notified with no concerns noted. By [DATE]. The facility's policy and procedure related to Abuse and Neglect prohibition was reviewed with no concerns and/or updates indicated. By [DATE] Systemic Process: . On [DATE], the Regional Clinical Specialist reeducated the Administrator (Abuse Coordinator) and the Director of Nursing on Abuse and Neglect Policy to include providing prompt care to residents experiencing change in condition. By 5/ ,d+[DATE] o On [DATE], the Administrator/ the DON and/ or designee began reeducation to 100% of the facility staff on the following: By [DATE] o Abuse and Neglect Policy to include reporting and providing prompt care when a resident has a change in condition. o On [DATE], the DON and/ or designee began reeducation to 100% of Licensed Nurses on the following: By [DATE] o Calling report to the ER when transferring resident to the ER o Contents of [NAME].it , to include vial of Lasix and procedure for updating pharmacy of ekit use. o Documentation in the medical record of actions taken when a resident experiences a change in condition o Use of suction machine o Staying with a resident when 911 has been activated o Effective [DATE], any facility staff on FMLA, Leave of Absence, non-scheduled workday or PTO will be reeducated by the Administrator, the DON and/or designee prior to the start of their next scheduled shift. o The Director of Nursing/ designee will review the 24-hour report for any changes in condition. Ensure that physician is notified timely and that actions are taken timely to address the change in condition. By [DATE] Monitoring: An Ad Hoc QAPI was conducted on [DATE], attended by the Administrator, the DON, the Medical Director, and the Regional Clinical Specialist to discuss the Immediate Jeopardy concerning F 600-Free From Abuse and Neglect. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued on [DATE] . The surveyor confirmed the facility implemented their plan of removal and Monitoring began on [DATE]. In an interview on [DATE] at 9:45a.m., with the Administrator and the DON, the Administrator said he was the abuse coordinator he was reeducated by the Regional Clinical Specialist on the Abuse policy. He said he then reeducated all staff on the Abuse and Neglect Policy to include reporting and providing prompt care when a resident has a change in condition. The DON said she reeducated nurses on calling report to the ER when transferring resident to the ER. Contents of Ekit, to include vial of Lasix. Documentation in the medical record of actions taken when a resident experiences a change in condition. Use of suction machine with return demonstration by nurses. Record review was conducted of the facility's In-services Training Report dated [DATE] conducted by the [NAME] Clinical Specialist to the Administrator and the Director of Nursing. Topic: Abuse and Neglect Exploitation/ Prompt Care in the Event of Change in Condition. Contents or summary of training session: the Administrator and the DON were reeducated on the facility's abuse and neglect exploitation policy. Reeducation included examples of abuse and neglect; who was at risk and why. Reeducation also included the need for prompt intervention in the event of a change in condition. Record review was conducted of the facility's In-services Training Report dated [DATE] conducted by the DON to all staff. Topic: Reporting Changes in Condition/ Communication with Charge Nurse/ MD/ NP RP/ Follow up Notification. Contents or summary of training session: Attendees were reeducated on identifying and reporting resident changes in condition and who to report changes to. Examples of changes to observe for reviewed e.g. bruises, skin tears, cough, new complaints of pain, runny nose, increased confusion, diarrhea, abnormal vital signs, odors in urine, bleeding of any kind, and any condition not normal for the resident. Immediate reporting emphasized. Staff also instructed to continue to report observations even if he/she believes it has been reported; as well as notifying the DON/ ADON and if applicable the Administrator of Changes in Condition which are identified and not addressed timely to include after-hours weekendsand holidays. Licensed Nurses reeducated on documentation, MD/NP/RP notification, and change of condition follow-up. Record review was conducted of the facility's In-services Training Report dated [DATE] conducted by the Administrator to all staff. Topic: Abuse and Neglect Exploitation/ Prompt Care in the Event of Change in Condition. Contents or summary of training session: Staff were reeducated on the facility's abuse and neglect exploitation policy. Reeducation included examples of abuse and neglect; who was at risk and why. Reeducation also included the need for prompt intervention in the event of a change in condition. Record review was conducted of the facility's In-services Training Report dated [DATE] conducted by the DON to Licensed Nurses (RN and LVN). Topic: Change in Condition/ Communication with MD/NP/RP and Documentation. Contents or summary of training session: Licensed Nurses were reeducated on identifying and reporting resident changes in condition. Examples of changes reviewed e.g. bruises, skin tears, cough, new complaints of pain, runny nose, increased confusion, diarrhea, abnormal vital signs, bleeding, odors in urine, and conditions reported by residents, staff, and/ or families. The Charge Nurses were reeducated on assessment of residents with reported and identified changes in condition to include head to toe assessment, completion of vital signs, and any other pertinent assessment, as well as completion of the Change in Condition Form and PROMPT communication with the MD/NP with assessment findings. Charge nurses reeducated on following any orders obtained related to change in condition, writing applicable progress notes, with time frames, and monitoring outcomes and communicating them timely with the MD/RP and as necessary with on-coming nurse. Record review was conducted of the facility's In-services Training Report dated [DATE] conducted by the DON to Licensed Nurses (RN and LVN). Topic: Emergency Procedures and Communication. Contents or summary of training session: Licensed Nurses were reeducated on the procedure for monitoring and communication in the event of a medical emergency/ resident change in condition. Licensed Nurses reeducated on ensuring someone remains with the resident and resident was montiored throughout. Monitoring and interventions should be documented in the medical record and staff should remain with resident until EMS/ 911 arrival. Licensed Nurses must call report to the receiving hospital to include details of the resident condition and document communication with hospital staff in the medical record. Record review was conducted of the facility's In-services Training Report dated [DATE] conducted by the DON to Licensed Nurses (RN and LVN). Topic: Oral Suctioning, Checking of Suction Machine for function, Ekit Contents, and updating pharmacy on use. Contents or summary of training session: Licensed Nurses were reeducated on oral suctioning with return demonstration. Reeducation also included how to check suction machines for function, documentation on crash cart check list, and how to validate suction machine function at onset of use with return demonstration on oral suctioning). Licensed Nurses were reeducated on the facility ekits and contents (Cubex, IV, Refrigerator). Reeducation included location of ekits, use of ekits, and pharmacy refill process and notification in the event medication was needed to be refilled. Observed head to toe assessments were completed by Licensed Nurses on all residents to identify any signs of change in condition. No concerns were identified. Observed the DON reviewed the resident progress notes for the last 30 days to ensure concerns related to abuse and neglect and changes of condition were identified and an investigation initiated, and physicians were notified with no concerns noted. During the monitoring phase, interviews were conducted by the state surveyor with various staff on different shifts (Administrator, DON, [NAME] Clinical Specialist, 9 LVNs, 3 CNAs and 4 Medication Aides). Staff interviewed indicated they had received above mentioned training. No concerns noted. The Administrator was informed that the Immediate Jeopardy was removed on [DATE] at 11:13am. The facility remained out of compliance at the severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.