Every finding on record at Merkel Nursing Center

Based on observation, interview, and record review, the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 5 of 20 (Resident #1, Resident #2, Resident #3, Resident #5, and Resident #16) residents reviewed for neglect. 1. The facility failed to ensure 34 of 84 shifts were staffed with at least two nurse aides, per the facility assessment, between the dates of 1/1/26 and 2/11/26. 2. The facility failed to ensure effective training was provided to staff based on resident care requirements and needs. Staff employees designated as Nurse Aide (NA) were aides that had not completed the Nurse Aide Training and Competency Evaluation Program and passed the required written and skills test, required to be a certified nurse aide. 3. The facility failed to ensure there was a sufficient number of qualified and trained staff, needed to meet the needs of Resident #1. Resident #1 was dropped from a mechanical lift transfer on 01/26/2026 while being transferred by one NA (NA-A), which resulted in a distal femur fracture requiring surgical intervention. NA-A who was not certified or properly trained. 4. The facility failed to ensure Resident #5 was free from neglect by not ensuring appropriate interventions and adequate staffing was in place to prevent falls which resulted in multiple rib fractures and hospitalization on 01/15/2026. 5. The facility failed to ensure Resident #3 was free from neglect by not ensuring appropriate interventions and adequate staffing were in place to prevent a fall on 01/31/2026. 6. The facility failed to ensure Resident #2 was free from neglect when Resident #2 was transferred inappropriately by NA-F on 01/29/2026. 7. The facility failed to ensure Resident #16 was free from neglect when her wet clothes were not changed for over 2 hours after asking NA-F and RN-R to help her. An Immediate Jeopardy (IJ) situation was identified on 02/13/2026. While the IJ was removed on 02/16/2026, the facility remained out of compliance at a scope of a pattern with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of their corrective systems. These failures could place residents at risk of injury, serious bodily harm, physical impairment, hospitalization or death.Findings include: During an interview on 2/12/2026 at 11:00 AM, the AIT stated the facility was short staffed and she could not hire certified nursing aides. She stated she expected the nurses to help the NAs provide care. The AIT stated her expectation was for policies and procedures to be followed, that was not always realistic. The AIT stated her expectation was for the residents to be taken care of, by whatever means necessary. The AIT stated there was no evidence of any training records or Nurse Aide checklist for NA-A. The AIT could not confirm NA-A had Abuse and Neglect training. The AIT stated all staff were to receive abuse and neglect training before working on the floor. The AIT stated according to the Nurse Aide checklist, transfers of any type and incontinent care were not allowed to be done alone by NAs. AIT stated LVN-K never notified her with concerns of NAs transferring residents with the mechanical lift alone. The AIT stated it was not safe to only have 1 NA working on the floor. During an interview on 02/12/2026 at 11:30 AM, the ADON stated residents who had multiple falls, were transferred inappropriately, or not having call lights answered were all forms of neglect. ADON stated NAs could not perform any type of transfers or incontinent care alone. ADON stated the facility had difficult time due to being located in a rural area. The ADON stated she works overtime to ensure that resident care is covered but cannot work 24 hours a day. The ADON stated resident care suffers because the facility is short staffed. Resident #1 Record review of Resident #1's face sheet, accessed on 01/28/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: Dementia and Cerebral Ischemic Attack. Record review of Resident #1's Quarterly MDS assessment, dated 12/12/2025, revealed a BIMS of 03, which indicated severe cognitive impairment. Further review revealed Resident #1 used a wheelchair, had no history of falls, and required two or more people to assist for transfers. Record review of Resident #1's care plan, revised on 09/22/2024, revealed: Focus: The resident has an ADL self-care performance deficit.Interventions: The resident requires assistance by 2 staff for transfers using mechanical lift. Record review of facility's incident report, dated 01/26/2026, revealed in part: Resident came up to nurses' desk in a wheelchair pushed by an aide. Stated her left foot and hip [NAME] and stated she had fallen in her room during a transfer for Mechanical lift to wheelchair. Resident stated that she was dropped on the floor during transfer via staff member and staff member told her not to report the fall to anyone. Record review of hospital Discharge summary, dated [DATE], revealed Resident #1 was discharged back to the facility on [DATE] with diagnoses Post Distal Femur Fracture treated with surgery. During an observation and interview on 01/29/2026 at 5:00 PM, Resident #1 was lying in her bed in her room. Resident #1 stated on Monday morning, 1/26/2026, she was transferred using a mechanical lift by NA-A. She stated she was dropped to the floor, NA-A pulled her back into the wheelchair, and she was instructed not to tell anyone. She stated she was routinely transferred by only one staff member. Resident #1 did not report the incident until CNA-D was taking her for a smoke break, a few hours later on 1/26/2026. CNA-D questioned why she was dragging her leg, which prompted her disclosure of the incident. During an interview on 01/29/2026 at 12:00 PM, Resident #4, who had a BIMS of 9 (meaning moderate cognitive impairment), and was Resident #1's roommate. Resident #4 stated she observed NA-A alone in the room transferring Resident #1 using a mechanical lift the morning of 1/26/2026. She stated she heard NA-A say, oh crap and observed Resident #1 and the lift on the floor. Resident #4 stated she had never observed two staff assisting with Resident #1's mechanical lift transfers. During a telephone interview on 03/02/2026 at 4:45 PM, NA-A stated Resident #1 was not able to transfer by herself, dress herself and needed assistance to feed herself. NA -A stated she was shocked because she was accused of dropping Resident #1 while transferring her with the mechanical lift. NA -A stated she never transferred Resident #1 by herself, and NA-C assisted her with the transfer on Monday (01/26/2026) when getting the resident out of bed. NA-A stated the facility never trained her on transferring residents with a mechanical lift, but she knew you always needed two staff to transfer. During a telephone interview on 02/03/2026 at 5:45 PM, NA-C stated she worked on 1/26/2026, with NA-A. NA-C stated she had not received any training in regard to using a mechanical lift to transfer residents. NA-C stated she had never transferred a resident by herself. NA-C stated she heard there were NAs who transferred residents alone but had never witnessed staff doing transfers alone. NA-C stated she did not recall assisting NA-A with transferring Resident #1 from the bed to the wheelchair on Monday morning. NA-C stated she thought LVN-K might have assisted NA-A. NA-C stated she and NA-A were the only aides working that shift with LVN-K. During an interview on 02/04/2026 at 11:20 AM, LVN-K denied assisting NA-A with a transfer for Resident #1 on Monday morning 1/26/26. LVN-K stated she voiced her concerns in the past of NAs transferring residents alone and had reported those concerns to ADON and AIT. During an interview on 02/12/2026 at 11:00 AM, the AIT denied receiving concerns from LVN-K about NAs transferring residents with mechanical lifts alone. During an interview on 02/12/2026 at 11:30 AM, the ADON denied receiving concerns from LVN-K about NAs transferring residents with mechanical lifts alone. Record review of NA-A's personnel files revealed NA-A was hired on 09/25/2025 and worked for facility full time. NA-A and was terminated on 01/28/2026, and there was no evidence of Aide Checklist for Orientation/Evaluation, abuse/neglect training or additional training regarding resident care for NA-A. 2. Record review of Resident #2's face sheet, accessed on 01/28/2026, revealed an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included: fracture of left femur and anxiety disorder. Record review of Resident #2's Quarterly MDS assessment, dated 11/14/2025, revealed a BIMS of 00, which indicated severe cognitive impairment. Resident #2 needed the assistance of 2 or more persons to transfer. Record review of Resident #2's care plan, revised on 01/28/2026, revealed he required two-person maximum assist and two-person mechanical lift transfers. During observation on 01/29/2026 at 4:35 PM, Resident #2 was sitting in his wheelchair when NA-F entered Resident #2's room alone and exited at 4:40 PM. Resident #2 was transferred back to his bed, there was no observation of mechanical lift in the Resident's room. During an interview on 01/29/2026 at 4:45 PM, NA-F stated she was the only aide working and transferred Resident #2 by herself via stand and pivot, without the assistance of a second staff member. She stated the transfer required a mechanical lift and two staff, but she had transferred him without using the mechanical lift, because no help was available and she routinely transferred the resident this way. During an interview on 02/12/2026 at 11:00 AM, the AIT stated Resident #2 was inappropriately transferred and should not have been transferred without the mechanical lift and NA-F should not have transferred Resident #2 without the assistance of an additional aide. Record review of NA-F's personnel files revealed NA-F had a hire date of 2/28/2025, worked full time, had not been certified, and showed no evidence of mechanical lift training. 3. Record review of Resident #3's face sheet, accessed on 01/28/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3 had diagnoses which included: heart failure and kidney disease. Record review of Resident #3's Quarterly MDS assessment, dated 11/19/2025, revealed a BIMS of 07, which indicated moderate cognitive impairment. Resident #3 required Partial/moderate assistance with toileting hygiene, sit to lying, sit to stand, and transfers. Record review of Resident #3's care plan, revised on 10/13/2025, revealed: Focus: The resident is at high risk for falls.Interventions: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. During an observation on 1/29/2026 at 4:10 PM, Resident #4 was observed wheeling down the hall saying, I know you're on the floor; I will get some help. No staff were in the hall or at the nurses' station. Resident #3 was observed sitting on the floor in her room, and her call light was engaged (the light outside her door was flashing and an alarm was sounding at the nurse's station). At 4:15 PM, a hospice aide (that does not work for the facility) found Resident #3 on the floor in her room and went to find help. At 4:20 PM, the hospice aide located the RN-R and NA-F. NA-F went to the front office and got the ADON and the AIT. NA-F, the AIT, and the ADON returned to Resident #3's room at 4:25 PM. Resident #3 was assessed by ADON and was transferred to the Emergency Department by paramedics, for further assessment and returned the same day to the facility. During an interview on 1/29/2026 at 4:15 PM, Resident #3 stated she used the call light to go to the restroom but could not wait, so she stood up and attempted going to the restroom on her own. When she stood, she urinated on herself and then slipped and fell on the floor. She stated she always had to wait a while for staff to answer her call light and she had fallen before. During an interview on 2/12/2026 at 11:00 AM, the AIT stated NA-F was the only aide working on 01/29/2026 during the day shift because the other NA scheduled did not show up. The AIT stated staff no shows happened often. The AIT stated she and the ADON were helping on the floor that day and did not provide a response to why she and the ADON did not assist with answering call light. Record review of the facility timecards, dated 01/29/2026, revealed NA-F was the only direct care staff on shift at the time of Resident #3's fall on 01/29/2026. 4. Record review of Resident #5's face sheet, accessed on 01/28/2026, revealed an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #5 had diagnoses which included: Colon cancer and muscle weakness. Record review of Resident #5's Quarterly MDS assessment, dated 12/12/2025, revealed a BIMS of 09, which indicated moderate cognitive impairment. Resident #5 used a walker and a wheelchair and needed assistance by one staff member for less than half of the effort for transfers. Record review of Resident #5's care plan, revised on 01/20/2026, revealed: Focus: The resident is at high risk for falls related to weakness. Further review of the care revealed no updates to fall interventions since 06/25/2025. Record review of the facility's incident log revealed Resident #5 had falls on the following dates without injury: 12/27/25, 01/06/2026, 01/08/2026, 01/14/2026, 1/15/2026 (4:45 AM) and 01/15/2026 (4:00 PM). Resident #5 had falls on 1/15/2026 at 6:00 PM and 1/24/2026 that resulted in injury. Record review of progress note, dated 1/15/2026 at 4:15 PM, by LVN-E, at 4:00 PM, documented this nurse was summoned to resident's bathroom. Resident was lying on her back near the commode, she stated she was attempting to get on the commode and lost balance and fell on floor. Resident placed on 15-minute checks and encouraged to ask for assistance from staff for transfers -Resident stable no problems. Record review of progress note, dated 1/15/2026 at 6:00 PM, by RN-N, revealed Resident was found on the floor in between the bathroom and the patient's room. She was moving all 4 extremities and wanting to get up. RN assessed Resident #5, and she was placed back in her chair. Paramedics arrived and transferred Resident from her chair to stretcher, resident complained of pain to left rib cage, it was noted that resident was weak and had difficulty standing. She was transported to hospital for evaluation. Record review of progress note, dated 1/16/2026, by LVN-B, documented the Resident was admitted the hospital on 1/15/2026 with a diagnosis of rib fractures from 4th to 8th ribs, pleural effusion, and UTI. Record review of progress note, dated 1/24/2026 at 4:00 PM, by LVN-S, revealed [Resident #5] was reaching down to the floor to pick up her phone and fell bumping left side of her forehead on floor, causing a raised circular area approximately. 2-inch purplish area on resident forehead, and denies much pain. Hospice nurse and [family member] notified, neurological and 15-minute checks initiated. During an interview on 02/08/2026 at 4:50 PM, Resident #5's family representative stated the resident had numerous falls. She stated Resident #5 was anxious and tried to get up on her own. During an interview on 02/11/2026 at 2:20 PM, the ADON stated Resident #5 had metastasized cancer and was always anxious, which was the reason for her decline in condition and multiple falls. She stated they had implemented interventions and did not know why the interventions were not updated in the care plan or medical record. The ADON stated 15-minute checks were started on 1/15/26. Record review of the facility's timecards, dated 01/15/2026, revealed NA-F was the only direct care staff on shift at the time of Resident #5's falls on 01/15/2026 at 4:00 PM and 6:00 PM. 5. Record review of Resident #16's face sheet, accessed on 01/28/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #16 had diagnoses which included: depression and anxiety disorder. Record review of Resident #16's Quarterly MDS assessment, dated 11/21/2025, revealed a BIMS of 01, which indicated severe cognitive impairment. Resident #16 required partial/moderate assistance with transfers and was occasionally incontinent. Resident #16 required partial/moderate assistance with toilet transfers and toilet hygiene. Record review of Resident #16's care plan, revised on 01/23/2026, revealed she required one-person assist with transfers. Resident #16 required staff assistance of 1 for toileting. She has a mental disability and is not able to appropriately call for staff assist. Resident #16 had mixed bladder incontinence with interventions to change/check brief every 2 hours. During an observation on 2/07/2026 between 4:45 PM and 6:45 PM revealed Resident #16 waited for 2 hours for staff to change her after an incontinent episode. At 4:45 PM Resident #16 asked NA-F for assistance and NA-F responded, I can't right now, I am very busy. At 5:15 PM, Resident #16 was sitting in the hall in her wheelchair crying because she still had not been changed. At 5:35 PM, Resident #16 was sitting at the table in the dining room with wet pants and still had not been changed. At 5:45 PM, Resident #16 wheeled down the hall and asked RN-R to change her wet pants and RN-R looked at resident and failed to acknowledge resident's request. At 6:00 PM, Resident #16 was in the dining room, and was upset and attempted to take off her clothes because they were wet. The ADON reprimanded Resident #16 about her inappropriate behavior and told her to go to her room. At 6:45 PM, NA-F entered Resident #16's room and assisted her with changing her clothes. During an interview on 02/13/2026 at 11:45 AM, NA-F stated she was the only aide on shift. She stated the management was helping her. NA-F stated she had worked by herself more since other staff had quit. NA-F stated she did not remember Resident #16 asking to be changed on 2/07/2026, but it probably had occurred she was really busy due to being the only aide working during shift. NA-F stated when she worked alone, she had a hard time getting everything done. She stated being short staffed could have led to residents not getting the care they need and could have been considered neglect. During an interview on 02/12/2026 at 11:00 AM, the AIT stated the facility was short staffed and she could not hire certified nursing aides. She stated she expected the nurses to help the NAs provide care. The AIT stated her expectation was for policies and procedures to be followed, but that was not always realistic. The AIT stated her expectation was for the residents to be taken care of by whatever means necessary. The AIT stated there was no evidence of any training records or Nurse Aide checklist for NA-A. The AIT could not confirm NA-A had Abuse and Neglect training. The AIT stated all staff were to receive abuse and neglect training before working on the floor. The AIT stated according to the Nurse Aide checklist, transfers of any type and incontinent care was not allowed to be done alone by NAs. The AIT stated LVN-K never notified her with concerns of NAs transferring residents with mechanical lift alone. The AIT stated it was not safe to only have 1 NA working on the floor. The AIT stated NA-F was the only aide working on 01/29/2026 during the day shift because the other NA scheduled did not show up. The AIT stated staff no shows happened often. She stated she and the ADON were helping on the floor. When asked why they were all in the office at the time of 5 call lights going off, Resident #3 falling, and Resident #2 being inappropriately transferred, she had no response. She stated she did not know why no one answered the call lights, while she and ADON were at the nurse's station. She stated Resident #2 should not have been transferred without the mechanical lift alone. During an interview on 2/12/2026 at 11:30 AM, the ADON stated residents who had multiple falls, were transferred inappropriately, or not having call lights answered were all forms of neglect. ADON stated NAs could not perform any type of transfers or incontinent care alone. ADON denied receiving concerns from LVN-K about NAs transferring residents with mechanical lifts alone. The ADON stated the facility was short staffed, due to staff not wanting to work, staff quitting and not being able to hire staff. The ADON stated the facility had a difficult time due to being located in a rural area. The ADON stated she worked overtime to ensure resident care was covered but could not work 24 hours a day. The ADON stated resident care suffered because the facility was short staffed. During an interview on 02/13/2026 at 2:30 PM, the MD stated his expectation was for residents to be free from abuse and neglect. The MD stated his expectation was for the facility policies to be followed. The MD stated his expectations were for residents' needs to be assessed and attended to by staff who had the knowledge and skills to provide the necessary care. The MD stated if the policy stated mechanical lift transfers required 2 people, then there needed to be 2 persons when using the mechanical lift. The MD stated being dropped during a mechanical lift transfer could cause a femur fracture, as sustained by Resident #1. The MD stated not following policy/procedure for transferring residents who needed assistance could have led to Resident # 2 receiving an injury. The MD stated he knew there were some issues and staffing, but not to the extent. The MD stated the facility should have been using agency staff. Record review of the facility policy titled Lifting Machine, Using a Mechanical Lift, revised July 2017, documented: At least 2 nursing assistants are needed to safely move a resident with a mechanical lift. Record review of the facility timecards, dated 02/07/2026, revealed NA-F was the only direct care staff on shift on 02/07/2026. Record review of the facility Nurse Aid checklist for Orientation/Evaluation revealed NAs cannot do the following tasks by themselves: helping patients into chair from bed or helping patients into wheelchair. Record review of a document titled, Facility Assessment, dated 01/07/2026, revealed the staffing requirement to be 2 direct care staff and 1 nurse were needed per shift. Record review of NA-A's employee file revealed: NA-A was hired on 9/25/2025 as a part time employee. NA-A went to full time on 11/25/2025 and no evidence of a Nurse Aide Checklist was completed or evidence of mechanical lift training. NA-A went on administrative suspension on 1/26/2026 and was termed on 1/28/2026. Record review of NA-F's employee file revealed: NA-F was hired on 2/8/2025 and was not certified. NA-F had a Nurse Aide Checklist completed on 7/23/2025 with no evidence of mechanical lift training. Record review of facility time sheets dated between 01/01/2026 and 02/11/2026 revealed: 1/02/26 6:00PM -6:00AM there was only 1 direct care staff.1/06/26 6:00PM -6:00 AM there was only 1 direct care staff.1/08/26 6:00PM -6:00 AM there was only 1 direct care staff.1/10/26 6:00AM -6:00AM there was only 1 direct care staff.1/11/26 6:00AM -6:00 AM there was only 1 direct care staff.1/15/26 6:00AM -6:00 AM there was only 1 direct care staff.1/16/26 6:00PM -6:00 AM there was only 1 direct care staff.1/17/26 6:00PM -6:00AM there was only 1 direct care staff.1/18/26 6:00PM -6:00AM there was only 1 direct care staff.1/19/26 6:00AM -6:00 AM there was only 1 direct care staff.1/21/26 6:00PM -6:00 AM there was only 1 direct care staff.1/22/26 6:00PM -6:00 AM there was only 1 direct care staff.1/26/26 6:00AM -6:00 AM there was only 1 direct care staff.1/26/26 6:00PM -6:00 AM there was only 1 direct care staff.1/27/26 6:00AM -6:00 AM there was only 1 direct care staff.1/27/26 6:00PM -6:00 AM there was only 1 direct care staff.1/28/26 6:00PM -6:00 AM there was only 1 direct care staff.1/29/26 6:00AM -6:00 AM there was only 1 direct care staff.1/29/26 6:00PM -6:00 AM there was only 1 direct care staff.1/30/26 6:00PM -6:00 AM there was only 1 direct care staff.1/31/26 6:00PM -6:00 AM there was only 1 direct care staff.2/01/26 6:00AM -6:00 AM there was only 1 direct care staff.2/01/26 6:00PM -6:00 AM there was only 1 direct care staff.2/02/26 6:00PM -6:00 AM there was only 1 direct care staff.2/03/26 6:00AM -6:00 AM there was only 1 direct care staff.2/03/26 6:00PM -6:00 AM there was only 1 direct care staff.2/04/26 6:00AM -6:00 AM there was only 1 direct care staff.2/04/26 6:00PM -6:00 AM there was only 1 direct care staff.2/05/26 6:00AM -6:00 AM there was only 1 direct care staff.2/05/26 6:00PM -6:00 AM there was only 1 direct care staff.2/06/26 6:00AM -6:00 AM there was only 1 direct care staff.2/06/26 6:00PM -6:00 AM there was only 1 direct care staff.2/07/26 6:00AM -6:00 AM there was only 1 direct care staff.2/08/26 6:00AM -6:00 AM there was only 1 direct care staff. Record review of the facility's policy, titled Abuse and Neglect Clinical protocol, dated March 2018, Defines neglect as the failure of the facility, employees, or service providers to provide goods and services to a resident that are necessary avoid physical harm, pain, mental anguish, or emotional distress. This was determined to be an Immediate Jeopardy (IJ) on 02/13/2026 at 12:40 PM. The Administration was notified. The AIT and Owner were provided with the IJ template on 02/13/2026 at 12:40 PM. The following Plan of Removal submitted by the facility was accepted on 02/15/2026 at 2:15 PM: TAG F600 - Freedom from Abuse and Neglect (IJ)Direct Care Staff: A direct care staff can be any trained individual that demonstrates competency according to the facility's aid competency checklist. This may be an NA that is enrolled in a CNA training class and employed less than 120 days, a CNA, and LVN, or an RN that provides direct care to a resident, including but not limited to assistance with ADLs such as eating, bathing, toileting, transfers, hygiene care, etc. There must be two direct care staff on the floor at all times in addition to one LVN/RN charge nurse. There should be a total of one LVN/RN and two direct care staff in the building at all times if there are any mechanical lift residents. Staffing requirements will be assessed weekly based on census and resident needs. There will be two direct care staff if the facility has any residents that use a mechanical lift or are a two-person transfer.DON and ADON will ensure that all agency or temporary direct care staff have documented training prior to working a shift. Current temporary agency is giving us access to their portal so that we can check their credentials. The Sister facility will send us their CNA credentials prior to working a shift. This will be started on 02/14/2026 and will be on going.Corrective Action:Residents #5, 3, 2, and 16 were assessed by ADON for any further injury, pain, or emotional distress on 02/13/2026Resident #1's fall was immediately reported to state agency per reporting requirements on 01/26/2026. Resident #1 assessed and monitored for negative outcomes by LVN E on 01/26/2026NA-A was removed from resident care pending investigation on 01/26/2026 Investigation completed by AIT on 01/28/2026. AIT terminated NA-A as disciplinary action. NA-A does not currently hold a license to refer. AIT created and ADON reviewed an informational handout for incident reporting and mechanical lift use on 01/26/2026. Facility's COTA provided an interactional mechanical lift demonstration for all staff on 01/30/2026Identification of Other Residents at Risk:Reviewed 14/14 incidents within the last 30 days conducted by AIT on 02/13/2026No additional concerns identifiedSystemic Changes:All direct care nursing staff on shift re-educated by ADON and through an informational handout at the nurses station on abuse/neglect policy with a signature sheet after information review, including safe transfer procedures and supervision expectations on 01/26/2026 requiring review for all Direct Care Staff before start of first shift. The AIT provided the education at an in-service on 01/30/2026 with a signature page at the end. New staff are trained upon hire about abuse and neglect in the standard facility trainings. The agency and sister facility will only be sending CNAs. All CNAs have been trained by a Texas-approved training course through NATCEP that reviews abuse and neglect prior to getting their certification. The charge nurse will verbally educate any agency and sister facility staff on call lights, mechanical lift, and abuse and neglect during shift report, prior to the aid starting their shift. The charge nurse will require a verbal return instruction before the aid starts the shift to determine competencyAll residents will be re-educated by the DON on 02/14/2026 about their rights, abuse, and neglect, and reporting.All 26 residents, including residents #2, 3, 5, 8, 16, were at risk for being affected by this deficient practice.The facility will review abuse, neglect, transfers, and reporting upon hire, once a month at the mandatory in-service and provide one-on-one education annually to staff at their hire anniversary. Any violations of policy will result in termination. The charge nurse will verbally educate any agency and sister facility staff on call lights, mechanical lift, and abuse and neglect during shift report, prior to the aid starting their shift. The charge nurse will require a verbal return instruction before the aid starts the shift to determine competency. The charge nurse will initial, date, and log the name of the agency and sister facility staff member that was educated starting 02/15/2026.Mandatory all staff in-service by AIT, COTA, and ADON completed by all staff on 01/30/2026 reviewing falls and fall prevention, reporting incidents, mechanical lift transfers, and abuse and neglect. AIT reinforced expectation that abuse/neglect, mechanical lift, and reporting policy violations by any staff member will result in disciplinary action resulting in termination on 01/26/2026. The abuse and neglect policy, the mechanical lift policy, failure to report policy- all violations of these policies will result in immediate termination. The reinforced expectation of consequence through termination was explained by the AIT in an in-service dated 01/30/2026. The DON trained all staff on falls and call light usage via phone calls with return instruction to ensure retention of information on 02/14/2026. Any staff members that do not answer the phone will not be able to return to work their shift until the staff is retrained on falls and call lights. The DON has a log of active staff members and numbers that she is systematically calling and going through. She initials next to each staff member that has been called and educated.Monitoring:DON/designee will review all incidents daily for 30 days to establish a risk of incident analysis based on patterns of staffing and incidents. Monthly abuse/neglect audit for Direct Care Staff and incidents to QAPI for 3 months.Completion Date: 02/15/2026 Monitoring of the facility's Plan of Removal revealed the following:Reviewed progress notes date 02/13/2026 that read no injuries noted and no complaints of pain for Residents #5, 3, 2, and 16.Review of incident report in TULIP received on 01/26/2026 at 7:07 PM.Review of progress notes dated 01/26/2026, revealed that Resident #1 was assessed and admitted to the hospital immediately after notifying staff of the incident.During an interview on 02/16/2026 at 9:15 am, LVN-E stated that she assessed Resident #1 immediately and notified the physician, ADON, and the family.Review of personnel file revealed NA-A was suspended on 01/26/2026 and terminated on 01/28/2026.Review of in-service regarding two-person mechanical lift protocol and policy, answering call light timely, reporting incidents abuse and neglect, and fall prevention dated 01/30/2026 signed by 16 employees. In-service stated answer call lights within 3 minutes, never ignore a call light, bathroom assistance protocol, and post fall do not move the resident after a fall, assess first, and 2 staff are required to perform a mechanical lift transfer at all times

Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for of 11 residents 20 (Resident #1, Resident #2, and Resident #3) reviewed for falls. 1. The facility failed to ensure Resident #1 was transferred with a mechanical lift by 2 staff, required when using a mechanical lift, which resulted in a distal femur fracture requiring surgical intervention 01/26/2026. 2. The facility failed to ensure Resident #5 had appropriate interventions and adequate staffing to prevent falls which resulted in multiple rib fractures and hospitalization on 01/15/2026. 3. The facility failed to ensure Resident #3 had appropriate interventions and adequate staffing to prevent a fall on 01/31/2026. An Immediate Jeopardy (IJ) situation was identified on 02/13/2026. While the IJ was removed on 02/16/2026, the facility remained out of compliance at a scope of a pattern with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of their corrective systems. This failure could place residents at risk of injury due to not being supervised and risk of serious bodily harm, physical impairment, hospitalization or death.Findings include: 1. Record review of Resident #1's electronic face sheet, accessed on 01/28/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: Dementia (decline in mental ability) and Cerebral Ischemic Attack (stroke). Record review of Resident #1's Quarterly MDS assessment, dated 12/12/2025, revealed a BIMS of 03, which indicated severe cognitive impairment. Further review revealed Resident #1 used a wheelchair, had no history of falls, and required two or more people to assist for transfers. Record review of Resident #1's care plan, revised on 09/22/2024, revealed: Focus: The resident has an ADL self-care performance deficit.Interventions: The resident requires assistance by 2 staff for transfers using mechanical lift. Record review of facility's incident report, dated 01/26/2026, revealed in part: Resident came up to nurses' desk in a wheelchair pushed by an aide. Stated her left foot and hip [NAME] and stated she had fallen in her room during a transfer for Mechanical lift to wheelchair. Resident stated that she was dropped on the floor during transfer via staff member and staff member told her not to report the fall to anyone. Record review of hospital Discharge summary, dated [DATE], revealed Resident #1 was discharged back to the facility on [DATE] with diagnoses Post Distal Femur Fracture treated with surgery. During an observation and interview on 01/29/2026 at 5:00 PM, Resident #1 was lying in her bed in her room. Resident #1 stated on Monday morning 1/26/2026 she was transferred using a mechanical lift by NA-A. She stated she was dropped to the floor, NA-A pulled her back into the wheelchair, and she was instructed not to tell anyone. She stated she was routinely transferred by only one staff member. Resident #1 did not report the incident until CNA-D was taking her for a smoke break, a few hours later on 1/26/2026. CNA-D questioned why she was dragging her leg, which prompted her disclosure of the incident. During an interview on 01/29/2026 at 12:00 PM, Resident #4, who had a BIMS of 9 (meaning moderate cognitive impairment), and was Resident #1's roommate. Resident #4 stated she observed NA-A alone in the room transferring Resident #1 using a mechanical lift the morning of 1/26/2026. She stated she heard NA-A say, oh crap and observed Resident #1 and the lift on the floor. Resident #4 stated she had never observed two staff assisting with Resident #1's mechanical lift transfers. Record review of progress note, dated 01/26/26 at 3:13 PM, signed by LVN-E revealed: CNA-D brought resident up to nurses desk due to Resident wanted to report a fall she had in the mechanical lift a few nights ago to this nurse- Resident stated that night NA-A was transferring her in mechanical lift from wheelchair to bed and resident was dropped on floor in mechanical Lift-Resident unable to state exact date and time of occurrence- Resident complained of left hip pain and left leg pain and left foot pain noted internal rotation at left leg /left foot with large amt of redness and swelling at left foot-Unable to move left lower leg /foot- V/S 154/74-96.5-78-20 O2 sat-97%- MD notified-Received orders Send resident to emergency room for eval and treatment. During a telephone interview on 03/02/2026 at 4:45 PM, NA-A stated Resident #1was not able to transfer by herself, dress herself and needed assistance to feed herself. NA -A stated she was shocked because she was accused of dropping Resident #1 while transferring her with the mechanical lift. NA -A stated she never transferred Resident #1 by herself that NA-C assisted her with the transfer on Monday when getting resident out of bed. NA-A stated the facility never trained her on transferring residents with a mechanical lift, but she knew you always needed two staff to transfer. During a telephone interview on 02/03/2026 at 5:45 PM, NA-C stated she worked on 1/26/2026, with NA-A. NA-C stated she had not received any training in regard to using a mechanical lift to transfer residents. NA-C stated she had never transferred a resident by herself. NA-C stated she had heard there were NAs that had transferred residents alone but had never witnessed staff doing transfers alone. NA-C stated she did not recall assisting NA-A with transferring Resident #1 from bed to wheelchair on Monday morning. NA-C stated she thinks LVN-K might have assisted NA-A. NA-C stated she and NA-A were the only aides working that shift with LVN-K. During an interview on 02/04/2026 at 11:20 am, LVN-K denied assisting NA-A transfer Resident #1 on Monday morning 1/26. LVN-K stated she had voiced her concerns in the past of NAs transferring residents alone and had reported those concerns to ADON and AIT. During an interview on 01/28/2026 at 5:15 PM, the AIT stated the checklist completed by the NAs were what NAs were allowed to do per their facility policy. She stated according to the checklist transfers were not allowed to be done alone by NAs and 2 person Mechanical lift transfers were not on the NA checklist. She stated it was her expectation for all mechanical lifts be performed with 2 staff members. She stated she could not find NA-A's NA checklist or any additional training. The AIT stated all training of NAs was the responsibility of the DON and the ADON. She stated the facility had a hard time keeping a DON and things were misplaced and probably not done correctly. The AIT stated she had never been notified of any concerns of NAs transferring residents with the mechanical lift alone. During an interview on 02/01/2026 at 12:12 PM, the ADON stated NAs could not perform any transfers without a CNA or a nurse. She stated 2 NAs together still could not perform these activities. She stated nurses were supposed to help and supervise the NAs to ensure they were not performing tasks they were not trained in. She stated when 2 NAs were on the floor the nurse was responsible for helping. The ADON denied receiving concerns from LVN-K about NAs transferring residents with mechanical lifts. Record review of NA-A's personnel files revealed NA-A was hired on 09/25/2025 worked for facility full time and was terminated on 01/28/2026, and no evidence of Aide Checklist for Orientation/Evaluation or any training regarding resident care for NA-A was documented. 2. Record review of Resident #3's electronic face sheet, accessed on 01/28/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3 had diagnoses which included: heart failure (chronic condition where the heart muscle is too weak or stiff causing inability of the heart to pump sufficient blood) and kidney disease (damaged kidneys making them not filter the blood properly causing waste buildup). Record review of Resident #3's Quarterly MDS assessment, dated 11/19/2025, revealed a BIMS of 07, which indicated moderate cognitive impairment. Further review revealed Resident #3 needed partial/moderate assistance with toileting hygiene, sit to lying, sit to stand, and transfers. Record review of Resident #3's care plan, revised on 10/13/2025, revealed: Focus: The resident is at HIGH risk for falls.Interventions: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Review of facility timecards, dated 01/29/2026, revealed NA-F was the only direct care staff on shift at the time of Resident #3's fall on 01/29/2026. During an observation on 1/29/2026 at 4:10 PM, Resident #4 was observed wheeling down the hall saying, I know you're on the floor; I will get some help. No staff were in the hall or at the nurses' station. Resident #3 was observed sitting on the floor in her room, and her call light was engaged (the light outside her door was flashing and an alarm was sounding at the nurse's station). At 4:15 PM, a hospice aide (that does not work for the facility) found Resident #3 on the floor in her room and went to find help. At 4:20 PM the hospice aide located the nurse and NA-F. NA-F went to the front office and got the ADON and the AIT. NA-F, the AIT, and ADON returned to Resident #3's room at 4:25 PM. Resident #3 was assessed by staff and was transferred to Emergency Department by paramedics, for further assessment and returned the same day to the facility. During an interview on 1/29/2026 at 4:15 PM, Resident #3 stated she used the call light to go to the restroom but could not wait, so she stood up and attempted going to the restroom on her own. When she stood, she urinated on herself and then slipped and fell on the floor. She stated that she always had to wait a while for staff to answer her call light and that she had fallen before. During an interview on 01/29/2026 at 4:45 PM, NA-F stated she was the only aide on shift. She stated management was helping her. NA-F stated she had worked by herself more since other staff had quit. She stated when she worked alone she had a hard time getting everything done. She stated being short staffed could have led to residents not getting the care they need and could have been considered neglect. 3. Record review of Resident #5's electronic face sheet, accessed on 01/28/2026, revealed an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #5 had diagnoses which included: Colon cancer (disease where cells in the large intestine or rectum grow uncontrollably) and muscle weakness. Record review of Resident #5's Quarterly MDS assessment, dated 12/12/2025, revealed a BIMS of 09, which indicated moderate cognitive impairment. Further review revealed Resident #5 used a walker and a wheelchair and needed assistance by one staff member for less than half of the effort for transfers. Record review of Resident #5's care plan, revised on 01/20/2026, revealed: Focus: The resident is at high risk for falls related to weakness. Further review of the care revealed no updates to fall interventions since 06/25/2025.The facility's incident log revealed Resident #5 had falls on the following dates without injury: 12/27/2025, 01/06/2026, 01/08/2026, 01/14/2026, 1/15/2026 (4:45 am) and 01/15/2026 (4:00 PM). Resident #5 had falls on 1/15/2026 at 6:00 PM and 1/24/2026 that resulted in injury. Record review of progress note dated 1/15/2026 at 4:15 PM, by LVN-E, revealed this nurse was summoned to resident's bathroom. Resident was lying on her back near the commode, she stated she was attempting to get on the commode and lost balance and fell on floor. Resident placed on 15-minute checks and encouraged to ask for assistance from staff for transfers -Resident stable no problems. Record review of progress note dated 1/15/2026 at 6:00 PM, by RN-N, revealed Resident was found on the floor in between the bathroom and the patient's room. She was moving all 4 extremities and wanting to get up. RN assessed [Resident #5], and she was placed back in her chair. Paramedics arrived and transferred Resident from her chair to stretcher, resident complained of pain to left rib cage, it was noted that resident was weak and had difficulty standing. She was transported to hospital for evaluation. Record review of progress note dated 1/16/2026, by LVN-B, reflected Resident was admitted hospital 1/15/26 with diagnosis of rib fractures from 4th to 8th ribs, pleural effusion, and UTI. Record review of progress note dated 1/24/2026 at 4:00 PM, by LVN-S, [Resident #5] was reaching down to the floor to pick up her phone and fell bumping left side of her forehead on floor, causing a raised circular area approx. 2-inch purplish area on resident forehead, and denies much pain. Hospice nurse and daughter notified, neuros and 15-minute checks initiated. During an interview on 02/08/2026 at 4:50 PM, Resident #5's family representative stated Resident #5 had had numerous falls. She stated Resident #5 was anxious and tried to get up on her own. During an observation on 02/10/2026 at 11:00 AM, Resident #5 was sitting in a wheelchair in her room. Resident #5 was unable to answer questions. Room was free from clutter. She had one house shoe on and one house shoe off. During an interview on 02/11/2026 at 2:20 PM, the ADON stated Resident #5 had metastasized cancer and was always anxious, which was the reason for her decline in condition and multiple falls. She stated they had implemented interventions and does not know why the interventions were not updated in the care plan or medical record. The ADON stated 15-minute checks were started on 1/15/2026. Review of facility timecards, dated 01/15/2026, revealed NA-F was the only direct care staff on shift at the time of Resident #5's falls on 01/15/2026 at 4:00 PM and 6:00 PM. During an interview on 01/30/2026 at 11:30 AM, the AIT stated NA-F was the only aide working on 01/29/2026, day shift, because the other NA scheduled did not show up. She stated she and ADON were helping on the floor and it was not safe to only have 1 NA working on the floor. She stated she could not find any staff to hire. The AIT stated her expectation was for the residents to be taken care of by whatever means necessary. She stated she expected the nurses to help and for policies and procedures to be followed but that was not always realistic. During an interview on 02/11/2026 at 3:13 PM, the MD stated his expectation was for the facility to follow their policy regarding transferring residents. The MD stated if the policy stated mechanical lift transfers required 2 people, then there needed to be 2 persons when using the mechanical lift. The MD stated his expectation was staff who transferred residents with a mechanical lift should know how to use it. He stated being dropped during a mechanical lift transfer could cause a femur fracture, as sustained by Resident #1. The MD stated falls should have been assessed. If residents had multiple falls, the facility staff should have assessed and investigated falls to identify the underlying causes and implement interventions to prevent falls. Record review of the facility's policy titled Lifting Machine, Using a Mechanical Lift, revised July 2017, documented: At least 2 nursing assistants are needed to safely move a resident with a mechanical lift. Record review of the facility's document titled Nurse Aid checklist for Orientation/Evaluation revealed NAs cannot do the following tasks by themselves: helping patients into chair from bed or helping patients into wheelchair. This was determined to be an Immediate Jeopardy (IJ) on 02/13/2026 at 12:40 PM. The Administration was notified. The AIT and Owner were provided with the IJ template on 02/13/2026 at 12:40 PM. The following Plan of Removal submitted by the facility was accepted on 02/15/2026 at 2:15 PM: TAG F689 - Free of Accident Hazards / Supervision (IJ) Direct Care Staff: A direct care staff can be any trained individual that demonstrates competency according to the facility's aid competency checklist. This may be an NA that is enrolled in a CNA training class and employed less than 120 days, a CNA, and LVN, or an RN that provides direct care to a resident, including but not limited to assistance with ADLs such as eating, bathing, toileting, transfers, hygiene care, etc. There must be two direct care staff on the floor at all times in addition to one LVN/RN charge nurse. There should be a total of one LVN/RN and two direct care staff in the building at all times if there are any mechanical lift residents. Staffing requirements will be assessed weekly based on census and resident needs. There will be two direct care staff if the facility has any residents that use a mechanical lift or are a two-person transfer. DON and ADON will ensure that all agency or temporary direct care staff have documented training prior to working a shift. Current temporary agency is giving us access to their portal so that we can check their credentials. The Sister facility will send us their CNA credentials prior to working a shift. This will be started on 02/14/2026 and will be on going. Corrective Action for Resident Affected:Resident #1 was dropped in a single-person mechanical lift transfer by NA-A was immediately assessed by LVN-E upon findings, received treatment in hospital, and facility has followed orders upon discharge by 02/13/2026Resident #5 received immediate treatment on 01/15/2026. The resident was assessed by the nurse and sent to the hospital for further evaluation. The resident returned in stable condition. The facility put up reminder posters for the resident to use her call light and educated the resident about the importance of using the call light. The facility has worked with hospice to provide treatment to the resident and continues to follow hospice doctor orders.Resident #3 received immediate treatment on 01/29/2026. The resident was assessed by the ADON. The hospice, doctor, family, and administrator were notified upon discovery. The resident was transferred to the hospital for further evaluation. Hospital results indicate no adverse outcome for the resident. The facility continues to monitor the resident for maladaptive outcomes of the fall such as pain, emotional distress, and injury.Physician, ADON, administrator, and responsible party were notified by LVN-E on 01/26/2026.Neurological checks and monitoring were initiated by LVN-E when a CNA-D brought Resident #1 to the nurse upon resident's complaint of pain on 01/26/2026. LVN-E followed protocol to evaluate the resident after complaints of pain. The charge nurse on duty is responsible for assessing residents with neuro checks after complaints of pain. NA-A was immediately removed from resident care pending investigation on 01/26/2026 and terminated before returning to duty on 01/28/2026 pending investigation. NA-A was not immediately terminated due to pending investigation. Identification of Other Residents at Risk:100% audit of all 9 residents requiring mechanical lift transfers was completed by the ADON and a list displayed at the nurses station on 01/26/2026. The ADON notified all staff in the facility on 01/26/2026 and the list shown in the shift report between charge nurses and in the shower sheet book for the aides. All direct care received a text message about the locations of the mechanical lift on 02/14/2026. The ADON reviews the list of mechanical lift transfers weekly and the shift report.The facility will continue monitoring Residents #3 and #5 as it relates to incidents and staffing comparison. The residents have been educated by ADON on call light usage on the same day as their respective falls on 01/30/2026 and 01/16/2026. Staff in the building were educated by ADON and via informational handout at nurses' station on call light response expectations on 01/16/2026 with a signature page to confirm review before starting first shift. The AIT provided call light education at the in-service on 01/30/2026 with an in-service signature sheet. All nursing staff received education about call light usage and falls from the DON on 02/14/2026 via phone calls. The DON is tracking all staff that she has provided the education to any staff that has not received the education will not be allowed to begin their next shift until they have been educated. All direct care nursing staff will be required to take a quiz starting 02/15/2026 prior to working as a direct care staff. Quizzes will be graded prior to start of shift by the AIT or designee. Any staff that fail the quiz will be re-educated in a one-on-one educational session and retested. If they fail the subsequent quiz, staff will be removed from care. No additional incidents identified based on 9/9 mechanical lift transfer resident interviews done by the ADON.Systemic Changes:All RNs, LVNs, CNAs, and NAs on duty were re-educated by ADON and all staff were required to review an informational protocol handout on the facility's mechanical lift policy, including the requirement for two staff during Mechanical lift transfers, placed on 01/26/2026 before returning to work. The education is documented with staff signature review with the in-services. The handout educated staff on proper protocol for mechanical lift use. A follow-up in-service by AIT was conducted on 01/30/2026 with the COTA providing a return demonstration mechanical lift use. Proper mechanical lift use has been added to new hire packets and competency checklists for direct care staff.Starting 02/14/2026, all agency and sister facility direct care staff will be provided an educational handout for review directed by the charge nurse prior to starting the shift on the floor. The handout will provide an in-service about abuse and neglect, call light usage, mechanical lift transfer, and falls. Verification of competency will be demonstrated with a verbal return of information and staff signature.All RNs, LVNs, CNAs, NAs on staff at the time of Resident #5's fall were re-educated by the ADON and all staff were required to review an informational fall and post-fall in-service at the nurses station with documented signatures on 01/16/2026 requiring review before the start of the first shift. The AIT reviewed falls and fall prevention at the mandatory staff in-service on 01/30/2026 with documented in-service signatures. Staff were educated via informational handout at nurses' station on call light response expectations on 01/16/2026 with a signature page to confirm review. The AIT provided call light education at the in-service on 01/30/2026 with an in-service signature sheet. Direct Care Staff will demonstrate knowledge by returning information about the call light expectations to the ADON on 02/14/2026. All staff received education about call light usage and falls from the DON on 02/14/2026 via phone calls. The DON is tracking all staff that she has provided the education to. Any staff that has not received the education will not be allowed to begin their next shift until they have been educated.New Direct Care Staff will be trained about call light expectations during their on-the-floor training before providing resident care starting 02/14/2025 to be completed the ADON/designee orientator. The orientator will ensure the new staff are competent through return verbal information before initialing the section on the orientation sheet about call lights.On 02/14/2026, the AIT will conduct an audit of in-services about mechanical lift use, incident reporting, abuse/neglect, falls, and call lights to ensure all staff have been trained. Any staff missing the in-service education will not be allowed to work until they have received the training from the AIT/designee with a verbal return instruction. An audit will be completed monthly by the AIT and reported to the IDT in the monthly QAPI meetings for three months Competency validations by COTA and ADON for mechanical lift use were completed by 100% of direct care staff (RNs, LVNs, CNAs, Nas) on 01/30/2026. All staff involved in the competency validations signed an in-service sheet on 01/30/2026. Regular, random observations by charge nurses and DON will be conducted on each shift and documents. The charge nurse will do observations three times a week. DON/designee will conduct random lift transfer observations 3x weekly for 4 weeks, then weekly for 2 months starting 02/13/2026. There will be at least one transfer monitored for each observation day and will include both aid shifts at least once a week. Any noncompliance will result in staff suspension of care until a correct return demonstration is conducted with a charge nurse. The ADON posted signage above mechanical lift resident beds to ensure staff were reminded which residents required mechanical lift use on 01/31/2026. Mechanical lift policy was reinforced with all direct care nursing staff on duty by the ADON and through information handout at the nurses station with clear disciplinary consequences for non-compliance on 01/26/2026 to be reviewed by all Direct Care Staff prior to working their first shift. Staff that have reviewed the document sign that they have reviewed the information on an in-service sheet. A follow-up return demonstration to ensure competency was conducted on 01/30/2026 by the COTA. All nursing staff were deemed competent on 01/30/2026 by the COTA and ADON with signature validation on the in-service sheet. Charge nurse/designee will monitor transfers on each shift for compliance. Checks will be tracked in a log at the nurses station and reviewed monthly by the ADON in QAPI. The charge nurse will monitor a mechanical lift transfer once per shift for four weeks and initial off completion. If there is a non-compliance noted, the staff will be immediately re-educated and removed from duty until a return demonstration is completed properly.The DON trained all Direct nursing Care Staff on falls and call light usage via phone calls with return instruction to ensure retention of information on 02/14/2026. Any Direct Care Staff members that do not answer the phone will not be able to return to work their shift until the staff is retrained on falls and call lights. Monitoring:DON/designee will conduct random lift transfer observations 3x weekly for 4 weeks, then weekly for 2 months starting 02/13/2026. There will be at least one transfer monitored for each observation day and will include both aid shifts at least once a week. The observer will initial a log kept at the nurses station. If non-compliance is noted, staff conducted a mechanical lift improperly will be terminated immediately and the resident will be assessed for pain or injury.Results will be reported at the monthly QAPI for 3 months.Completion Date: 02/14/2026 Monitoring of the facility's Plan of Removal revealed the following:Review of progress notes dated 01/26/2026, revealed that Resident #1 was assessed and admitted to the hospital immediately after notifying staff of the incident.Review of Hospital Discharge Orders and Instructions dated 01/29/2026, revealed that physicians orders and review of physicians' orders revealed they were entered into the system.During an interview on 02/16/2026 at 9:15 AM LVN-E stated that she assessed Resident #1 immediately and notified the physician, ADON, and the family.Review of progress notes dated 01/15/2026, revealed that Resident #5 was assessed and sent to hospital after having multiple falls and complaints of pain on 01/15/2026.During an interview on 02/15/2026 at 6:20 PM, RN-N stated that Resident #5 was assessed and sent to hospital after having multiple falls and complaints of pain on 01/15/2026.Observation on 02/15/2026 at 2:20 PM revealed posters in residents room reminding her to use th3e call light. Resident was unable to answer questions regarding her education.During a phone interview on 02/15/2026 2:35 PM, LVN-B stated that she has educated Resident #5 regarding falls and using her call light. She stated that she had documented the education many times in the progress notes. Review of progress notes revealed multiple entries regarding education on call light.During an interview on 02/16/2026 at 9:15 AM, LVN-E stated that she assessed Resident #1 immediately and notified the physician, ADON, and the family. Review of progress notes dated 01/26/2026, revealed physician and family were notified regarding Resident #1.Review of Neurological checks and monitoring sheet dated 01/26/2026, revealed monitoring was initiated, and that LVN-E followed protocol on 01/26/2026Review of personnel file revealed NA-A was suspended on 01/26/2026 and terminated on 01/28/2026.Observation on 02/15/2026 at 2:20 PM the Mechanical Lift resident list, was displayed at the nurses' station in the shift report book, and in the shower book. The Mechanical Lift resident list identified 9 residents who required transfers by a mechanical lift.During interviews on 02/15/2026 from 2:20 PM- 02/16/2026 9:25 AM, LVN-E and LVN-K stated they work the day shift from 6am-2PM. They stated that they were notified of the Mechanical lift transfer sheet and where it was located on 01/26/2026. They stated that they received a text message on 02/14/2026 with all of the locations of the Mechanical lift list. They verbalized understanding.During interviews on 02/15/2026 from 2:20 PM- 02/16/2026 9:25 AM, CNA-D, NA-H, and NA-F stated they work the day shift from 6am-6PM. They stated that they were notified of the Mechanical lift transfer sheet and where it was located on 01/26/2026. They stated that they received a text message on 02/14/2026 with all of the locations of the Mechanical lift list. They verbalized understanding.During interviews on 02/15/2026 from 2:20 PM- 02/16/2026 9:25 AM, RN-R and RN-T stated they work the evening shift from 2PM-10PM. They stated that they were notified of the Mechanical lift transfer sheet and where it was located on 01/26/2026. They stated that they received a text message on 02/14/2026 with all of the locations of the Mechanical lift list. They verbalized understanding.During interviews on 02/15/2026 from 2:20 PM- 02/16/2026 9:25 AM, LVN-B stated she worked the night shift from 10PM-6am. She stated that she was notified of the Mechanical lift transfer sheet and where it was located on 01/26/2026. She stated that she received a text message on 02/14/2026 with all of the locations of the Mechanical lift list. She verbalized understanding.During an interview on 02/15/2026 at 3:00 PM, the ADON stated that she performed a mechanical lift audit on 01/26/2026 and she displayed the list. She stated that she had reviewed the list weekly for updates.Record review of Weekly Mechanical lift Review List was completed on 02/14/2026 by ADON that stated 9 residents were using Mechanical lifts some or all of the time and that nurse's station Mechanical lift list accurately list all Mechanical lift use. Record review of in-service titled Falls, Post-Fall, Bathroom, dated 01/16/2026 revealed 16 staff signatures. In-service stated answer call lights within 3 minutes, never ignore a call light, bathroom assistance protocol, and post fall protocol. In-service stated, do not move the resident after a fall, assess first.Record review of in-service regarding two-person mechanical lift protocol and policy, answering call light timely, reporting incidents abuse and neglect, and fall prevention dated 01/30/2026 signed by 16 employees. In-service stated answer call lights within 3 minutes, never ignore a call light, bathroom assistance protocol, and post fall do not move the resident after a fall, assess first, and 2 staff are required to perform a mechanical lift transfer at all times.Record review of in-service titled Mechanical lift with return demonstration, dated 01/28/2026 with 9 staff signatures and one dated 01/30/2026 revealed 16 signatures. In-service stated 2 staff are required to perform a mechanical lift transfer at all times.During interviews on 02/15/2026 from 2:20 PM- 02/16/2026 9:25 AM, LVN-E and LVN-K stated they work the day shift from 6am-2PM. They stated that they were in-serviced on 01/16/2026 by ADON regarding falls and call light response and again on 01/30/2026 by the AIT on call light response. They stated on 02/16/2026 prior to working her shift she was educated by the DON regarding falls

Based on observation, interview, and record review the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing sufficient numbers of licensed nurses and nurse aides for 34 of 84 shifts reviewed for nurse staffing and 4 of 28 (Resident #2, Resident #3, Resident # 5 and Resident #16) residents reviewed for sufficient staffing. The facility failed to ensure 34 of 84 shifts were staffed with at least two direct care staff, per the facility assessment, between the dates of 1/1/26 and 2/11/2026 (1/02/26 6:00PM -6:00AM; 1/06/26 6:00PM -6:00 AM; 1/08/26 6:00PM -6:00 AM; 1/10/26 6:00AM -6:00PM; 1/11/26 6:00AM -6:00 PM; 1/15/26 6:00AM -6:00 PM; 1/16/26 6:00PM -6:00 AM; 1/17/26 6:00PM -6:00AM; 1/18/26 6:00PM -6:00AM; 1/19/26 6:00AM -6:00 PM; 1/21/26 6:00PM -6:00 AM; 1/22/26 6:00PM -6:00 AM; 1/26/26 6:00AM -6:00 PM;1/26/26 6:00PM -6:00 AM; 1/27/26 6:00AM -6:00 PM; 1/27/26 6:00PM -6:00 AM; 1/28/26 6:00PM -6:00 AM; 1/29/26 6:00AM -6:00 PM; 1/29/26 6:00PM -6:00 AM; 1/30/26 6:00PM -6:00 AM; 1/31/26 6:00PM -6:00 AM; 2/01/26 6:00AM -6:00 PM; 2/01/26 6:00PM -6:00 AM; 2/02/26 6:00PM -6:00 AM; 2/03/26 6:00AM -6:00 PM; 2/03/26 6:00PM -6:00 AM; 2/04/26 6:00AM -6:00 PM;2/04/26 6:00PM -6:00 AM; 2/05/26 6:00AM -6:00 PM; 2/05/26 6:00PM -6:00 AM; 2/06/26 6:00AM -6:00 PM; 2/06/26 6:00PM -6:00 AM; 2/07/26 6:00AM -6:00 PM; and 2/08/26 6:00AM -6:00 PM). The facility failed to ensure sufficient staffing were in place to prevent Resident #2 from being inappropriately transferred by NA-F on 01/29/2026. The facility failed to ensure sufficient staffing were in place to prevent Resident #3's fall on 01/31/2026. The facility failed to ensure sufficient staffing were in place to prevent Resident #5 from failing which resulted in multiple rib fractures and hospitalization on 01/15/2026. The facility failed to ensure sufficient staffing were in place to prevent Resident #16 not being changed for over 2 hours after asking NA-F and RN-R to help her. An Immediate Jeopardy (IJ) situation was identified on 02/13/2026. While the IJ was removed on 02/16/2026, the facility remained out of compliance at a scope of a pattern with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of their corrective systems. This failure could place residents at risk of not getting needed care and services, a decrease in quality of care and quality of life and/or injury.Findings include:Record review of document titled, Facility Assessment dated 01/07/2026 revealed the staffing requirement to be 2 direct care staff and 1 nurse were needed per shift. Record review of facility time sheets dated between 01/01/2026 and 02/11/2026 revealed: 1/02/26 6:00PM -6:00AM there was only 1 direct care staff.1/06/26 6:00PM -6:00 AM there was only 1 direct care staff.1/08/26 6:00PM -6:00 AM there was only 1 direct care staff.1/10/26 6:00AM -6:00PM there was only 1 direct care staff.1/11/26 6:00AM -6:00 PM there was only 1 direct care staff.1/15/26 6:00AM -6:00 PM there was only 1 direct care staff.1/16/26 6:00PM -6:00 AM there was only 1 direct care staff.1/17/26 6:00PM -6:00AM there was only 1 direct care staff.1/18/26 6:00PM -6:00AM there was only 1 direct care staff.1/19/26 6:00AM -6:00 PM there was only 1 direct care staff.1/21/26 6:00PM -6:00 AM there was only 1 direct care staff.1/22/26 6:00PM -6:00 AM there was only 1 direct care staff.1/26/26 6:00AM -6:00 PM there was only 1 direct care staff.1/26/26 6:00PM -6:00 AM there was only 1 direct care staff.1/27/26 6:00AM -6:00 PM there was only 1 direct care staff.1/27/26 6:00PM -6:00 AM there was only 1 direct care staff.1/28/26 6:00PM -6:00 AM there was only 1 direct care staff.1/29/26 6:00AM -6:00 PM there was only 1 direct care staff.1/29/26 6:00PM -6:00 AM there was only 1 direct care staff.1/30/26 6:00PM -6:00 AM there was only 1 direct care staff.1/31/26 6:00PM -6:00 AM there was only 1 direct care staff.2/01/26 6:00AM -6:00 PM there was only 1 direct care staff.2/01/26 6:00PM -6:00 AM there was only 1 direct care staff.2/02/26 6:00PM -6:00 AM there was only 1 direct care staff.2/03/26 6:00AM -6:00 PM there was only 1 direct care staff.2/03/26 6:00PM -6:00 AM there was only 1 direct care staff.2/04/26 6:00AM -6:00 PM there was only 1 direct care staff.2/04/26 6:00PM -6:00 AM there was only 1 direct care staff.2/05/26 6:00AM -6:00 PM there was only 1 direct care staff.2/05/26 6:00PM -6:00 AM there was only 1 direct care staff.2/06/26 6:00AM -6:00 PM there was only 1 direct care staff.2/06/26 6:00PM -6:00 AM there was only 1 direct care staff.2/07/26 6:00AM -6:00 PM there was only 1 direct care staff.2/08/26 6:00AM -6:00 PM there was only 1 direct care staff. Resident #2Record review of Resident #2's electronic face sheet, dated 01/28/2026, revealed an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included: fracture of left femur (left hip broken bone) and anxiety disorder. Record review of Resident #2's Quarterly MDS assessment, dated 11/14/2025, revealed a BIMS score of 00, which indicated severe cognitive impairment. Further review revealed Resident needed the assistance of 2 or more persons to transfer. Record review of Resident #2's care plan, revised on 01/28/2026, revealed he required two-person maximum assistance and two-person mechanical lift transfers. During observation on 01/29/26 at 4:35 PM, NA-F entered Resident #2's room alone and exited at 4:40 PM. Resident #2 had been transferred back to his bed, there was no observation of mechanical lift in the Resident's room. During an interview on 01/29/2026 at 4:45 PM NA-F stated she was the only aide working and transferred Resident #2 by herself, without the assistance of a second staff member. She acknowledged the transfer required a mechanical lift and two staff, but she had transferred him without using the mechanical lift, because no help was available and that she routinely transferred the resident this way. NA-F stated transferring residents inappropriately could have led to an injury.Resident #3Record review of Resident #3's electronic face sheet, dated 01/28/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3 had diagnoses which included: heart failure (chronic condition where the heart muscle is too weak or stiff causing inability of the heart to pump sufficient blood) and kidney disease (damaged kidneys making them not filter the blood properly causing waste buildup).Record review of Resident #3's Quarterly MDS assessment, dated 11/19/2025, revealed a BIMS score of 07, which indicated severe cognitive impairment. Further review revealed Resident #3 Partial/moderate assistance with toileting hygiene, sit to lying, sit to stand, and transfers.Record review of Resident #3's care plan, revised on 10/13/2025, revealed: Focus: The resident is at HIGH risk for falls.Interventions: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance.During an observation on 1/29/2026 at 4:10 PM, Resident #4 was observed wheeling down the hall saying, I know you're on the floor; I will get some help. No staff were in the hall or at the nurses' station. Resident #3 was observed sitting on the floor in her room, and her call light was engaged (the light outside her door was flashing and an alarm was sounding at the nurse's station). At 4:15 PM, a hospice aide (that does not work for the facility) found Resident #3 on the floor in her room and went to find help. At 4:20 PM the hospice aide located the nurse and NA-F. NA-F went to the front office and got the ADON and the AIT. NA-F, the AIT, and ADON returned to Resident #3's room at 4:25 PM. Resident #3 was assessed by staff and was transferred to the Emergency Department by paramedics, for further assessment and returned the same day to the facility.During an interview on 1/29/2026 at 4:15 PM, Resident #3 stated she used the call light to go to the restroom but could not wait, so she stood up and attempted going to the restroom on her own. When she stood, she urinated on herself and then slipped and fell on the floor. She stated that she always had to wait a while for staff to answer her call light and that she had fallen before. Review of facility timecards, dated 01/29/2026, revealed NA-F was the only direct care staff on shift at the time of Resident #3's fall on 01/29/2026.Resident #5Record review of Resident #5's electronic face sheet, dated 01/28/2026, revealed an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #5 had diagnoses which included: Colon cancer (disease where cells in the large intestine or rectum grow uncontrollably), and muscle weakness.Record review of Resident #5's Quarterly MDS assessment, dated 12/12/2025, revealed a BIMS score of 09, which indicated moderate cognitive impairment. Further review revealed Resident #5 used a walker and a wheelchair and needed assistance by one staff member for less than half of the effort for transfers.Record review of Resident #5's care plan, revised on 01/20/2026, revealed: Focus: The resident is at high risk for falls related to weakness. Further review of the care revealed no updates to fall interventions since 06/25/2025.The facility's incident log revealed Resident #5 had falls on the following dates without injury: 12/27/25, 01/06/2026, 01/08/2026, 01/14/2026, 1/15/2026 (4:45 AM) and 01/15/2026 (4:00 PM). Resident #5 had falls on 1/15/2026 at 6:00 PM and 1/24/2026 that resulted in injury.Record review of progress note dated 1/15/2026 at 4:15 PM, by LVN-E, revealed this nurse was summoned to resident's bathroom. Resident was lying on her back near the commode, she stated she was attempting to get on the commode and lost balance and fell on floor. Resident placed on 15-minute checks and encouraged to ask for assistance from staff for transfers -Resident stable no problems.Record review of progress note dated 1/15/2026 at 6:00 PM, by RN-N, revealed Resident was found on the floor in between the bathroom and the patient's room. She was moving all 4 extremities and wanting to get up. RN assessed [Resident #5], and she was placed back in her chair. Paramedics arrived and transferred Resident from her chair to stretcher, resident complained of pain to left rib cage, it was noted that resident was weak and had difficulty standing. She was transported to hospital for evaluation.Record review of progress note dated 1/16/2026, by LVN-B, Resident was admitted hospital 1/15/26 with diagnosis of rib fractures from 4th to 8th ribs, pleural effusion, and UTI.Record review of progress note dated 1/24/2026 at 4:00 PM, by LVN-S, [Resident #5] was reaching down to the floor to pick up her phone and fell bumping left side of her forehead on floor, causing a raised circular area approx. 2-inch purplish area on resident forehead, and denies much pain. Hospice nurse and daughter notified, neuros and 15-minute checks initiated.During an interview on 02/08/2026 at 4:50 PM, Resident #5's family representative stated Resident #5 had numerous falls. She stated Resident #5 was anxious and tried to get up on her own.During an observation on 02/10/2026 at 11:00 am, Resident #5 was sitting in a wheelchair in her room. Resident#5 was unable to answer questions. Her room was free from clutter. She had one house shoe on and one house shoe was off.During an interview on 02/11/2026 2:20 PM, the ADON stated Resident #5 had metastasized cancer and was always anxious, which was the reason for her decline in condition and multiple falls. She stated they had implemented interventions and does not know why the interventions were not updated in the care plan or medical record. The ADON stated 15-minute checks were started on 1/15/2026.Review of facility timecards, dated 01/15/2026, revealed NA-F was the only direct care staff on shift at the time of Resident #5's falls on 01/15/2026 at 4:00 PM and 6:00 PM.Resident #16Record review of Resident #16's electronic face sheet, dated 01/28/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #16 had diagnoses which included: depression and anxiety disorder.Record review of Resident #16's Quarterly MDS assessment, dated 11/21/2025, revealed a BIMS score of 01, which indicated severe cognitive impairment. Further review revealed Resident required partial/moderate assistance with transfers and was occasionally incontinent.Record review of Resident #16's care plan, revised on 01/23/2026, revealed she required one-person assist with transfers.During an observation on 2/07/2026 at 4:45 PM, Resident #16 waited for 2 hours for staff to change her after an incontinent episode. NA-F told Resident #16 I can't right now, I am very busy. At 5:15 PM, Resident #16 was sitting in the hall in her wheelchair crying because she still had not been changed. At 5:35 PM, Resident #16 was sitting at the table in the dining room and still had not been changed. At 5:45 PM, Resident #16 wheeled down the hall and asked RN-R to change her wet pants and RN-R looked at resident and failed to acknowledge resident's request. At 6:00 PM, Resident #16 was in the dining room, she appeared upset and attempted to take off her clothes because they were wet. The ADON reprimanded Resident #16 about her inappropriate behavior and told her to go to her room. At 6:45 PM, NA-F entered Resident #16's room and assisted her with changing her clothes. During an interview on 2/13/2026 at 11:45 AM NA-F stated that she was the only aide on shift. She stated that the management was helping her. NA-F stated that she had worked by herself more since other staff had quit. She stated when she worked alone, she had a hard time getting everything done. She stated being short staffed could have led to residents not getting the care they need and could have been considered neglect. During an interview on 01/30/2026 at 11:30 am, the AIT stated that NA-F was the only aide working on 01/29/2026 day shift because the other NA scheduled did not show up. She stated that she and the ADON were helping on the floor. When asked why they were all in the office at the time of 5 call lights going off, Resident #3 falling, and Resident #2 being inappropriately transferred, she had no response. She stated Resident #2 should not have been transferred without the mechanical lift, and that it was not safe to only have 1 NA working on the floor. She stated that she could not find any staff to hire. AIT stated that her expectation was for the residents to be taken care of whatever means necessary. She stated that she expected the nurses to help and for policies and procedures to be followed but that was not always realistic. During an interview on 2/12/2026 at 12:30 PM, the ADON stated the facility has been short staffed, due to staff not wanting to work, staff quitting and not being able to hire staff due to being in a rural area. The ADON stated she worked overtime to ensure that resident care was covered but cannot work 24 hours a day. The ADON stated resident care suffers because of being short staffed. During an interview on 2/11/2026 at 3:13 PM, the MD stated he was not aware the facility had been using so many uncertified aides. The MD stated the facility should have been using agency staff to ensure residents were receiving care by staff who were qualified. The MD stated the facility had a hard time hiring certified aides because the facility could not compete with the bigger facilities and/or the hospitals.This was determined to be an Immediate Jeopardy (IJ) on 02/13/2026 at 12:40 PM. The Administration was notified. The AIT and Owner were provided with the IJ template on 02/13/2026 at 12:40 PM and a Plan of Removal was requested.The following Plan of Removal was accepted on 02/15/2026 at 2:15 PM: TAG F725 - Sufficient Nursing Staff (IJ)Direct Care Staff: A direct care staff can be any trained individual that demonstrates competency according to the facility's aid competency checklist. This may be an NA that is enrolled in a CNA training class and employed less than 120 days, a CNA, and LVN, or an RN that provides direct care to a resident, including but not limited to assistance with ADLs such as eating, bathing, toileting, transfers, hygiene care, etc. There must be two direct care staff on the floor at all times in addition to one LVN/RN charge nurse. There should be a total of one LVN/RN and two direct care staff in the building at all times if there are any mechanical lift residents. Staffing requirements will be assessed weekly based on census and resident needs. There will be two direct care staff if the facility has any residents that use a mechanical lift or are a two-person transfer.DON and ADON will ensure that all agency or temporary direct care staff have documented training prior to working a shift. Current temporary agency is giving us access to their portal so that we can check their credentials. The Sister facility will send us their CNA credentials prior to working a shift. This will be started on 02/14/2026 and will be on going.Corrective Action:The facility will require two direct care nursing staff on each rotation starting 02/13/2026. The facility will utilize staffing agency and aides from the sister facility if the facility does not have enough qualified staff. Direct care nursing staff are staff who provide direct care to residents including but not limited to assistance with ADLs. The facility assessment will be completed weekly to assess acuity and needs for direct care nursing staffing requirements. The IDT will review the facility assessment policy for guidance on acuity levels and staffing needs on 02/15/2026. The facility will follow the facility assessment to determine staffing needs. Residents #5, 3, 2, and 16 were assessed by ADON for any further injury, emotional distress, or pain on 02/13/2026. Immediate review of staffing patterns was conducted by the AIT to evaluate gaps in coverage and needs for staffing on 02/09/2026. Multiple gaps in direct care nursing staff were identified. The AIT began contacting temporary staffing agencies on 02/10/2026 to meet staffing requirements. The AIT utilized aides from sister facility to cover gaps until the staffing agency was able to fill assignments. Facility implemented temporary agency staffing to ensure a two direct care staffing coverage on 02/13/2026. The facility will request a copy of the aides certification from the staffing agency. Certification checks will be conducted on all aides arriving from our sister facility. The charge nurse will verbally educate any agency and sister facility staff on call lights, mechanical lift, and abuse and neglect during shift report, prior to the aid starting their shift. The charge nurse will require a verbal return instruction before the aid starts the shift to determine competency. Schedule adjusted by AIT to prevent only one direct care staff at all times on 02/13/2026. Adjustments were made through temp agencies and [sister facility] CNAs. Systemic Changes:The facility assessment was reviewed by the DON and ADON on 02/14/2026 to ensure accurate information Direct Care Staff requirements revised on the facility assessment by AIT and ADON to ensure two direct care staffing requirements are met at all times on 02/13/2026. Direct care nursing staff are staff who provide direct care to residents including but not limited to assistance with ADLsAdministrator and DON will review daily Direct Care Staff sheets immediately on 02/13/2026 and daily for all shifts thereafterFacility has initiated active recruitment efforts by the AIT including agency utilization starting 02/13/2026. If there is noncompliance, the facility will utilize staffing agencies and aides from [sister facility] to cover any gaps in coverage.The DON trained all staff on falls and call light usage via phone calls with return instruction to ensure retention of information on 02/14/2026. Any Direct Care Staff members that do not answer the phone will not be able to return to work their shift until the staff is retrained on falls and call lights.The IDT will create a flow sheet on 02/15/2026 for a response protocol to be enacted when a scheduled direct care nursing staff does not show up for their shift to ensure there are two direct care nursing staff will be on the floor at all times. Monitoring:Daily staffing audits by the AIT will be completed for 30 days starting 02/13/2026. This will be monitored through punch tracking on a spreadsheet. If there is noncompliance, the facility will initiate a PIP to resolve the issue. Weekly review in IDT meeting on 02/13/2026Ongoing review in QAPI for 3 monthsCompletion Date: 02/15/2026Monitoring of the facility's Plan of Removal revealed the following:During an interview on 02/16/2026 at 6:00 PM, the AIT stated the facility assessment was reviewed and updated.Review of Facility assessment, dated 02/16/2026 signed by ADON and Owner revealed: Staffing and Plans- Nurse Aides 2; Staff Direct Care staff 2.Review of schedules and timecards revealed: 02/14/2026 6a-6p CNA-D and Agency CNA worked as direct care staff.Observation on 02/14/2026 at 12:30 PM observed CNA-D and Agency CNA in the facility providing direct patient care.Review of schedules and timecards revealed: 02/14/2026 6p-6a LVN-V worked as direct care staff from 6PM-10PM and ADON worked until 10PM. Review revealed sister facility CNA-U worked from 10PM-6am.Observation on 02/14/2026 at 6:15 PM observed ADON and LVN-V in the facility providing direct patient care.Review of schedules and timecards revealed: 02/15/2026 6a-6p CNA-D and DON worked as direct care staff.Observation on 02/15/2026 at 11:30 am observed CNA-D and DON in the facility providing direct patient care.Review of schedules and timecards revealed: 02/15/2026 6p-6a Agency CNA and NA- Worked as direct care staff.Observation on 02/15/2026 at 6:15 PM observed in the facility Agency CNA and NA-O providing direct patient care.Observation on 02/16/2026 at 3:00 PM observed DON and LVN-K providing direct patient care.Record review of progress notes dated 02/13/2026 revealed no injuries noted and no complaints of pain for Residents #5, 3, 2, and 16.During an interview on 02/16/2026 AIT stated she re-did the schedule and had monitored and updated it daily to ensure the facility was staffed with 2 direct care staff at all times. During an interview on 02/16/2026 the AIT stated she was utilizing a staffing agency for staffing and staff from the sister facility. She stated she had educated charge nurses on location of training materials to be completed by agency and sister staff prior to them working on the floor.Reviewed education hand out for agency and temporary staff covered abuse and neglect, call light usage, mechanical lift transfer, and falls. signed by CNA-U and dated 02/14/2026.During a phone interview on O2/05/2026 at 4:45 PM, CNA-U stated she was given the handout prior to working her shift on 02/14/2026 by RN-R.During an interview on 02/05/2026 at 4:50, RN-R verified CNA-U received the handout and verbalized understanding prior to working her shift on 02/14/2026.02/15/2026 at 6:15 PM observed DON review educational handout for agency CNA coming on-shift. Agency CNA acknowledged the information and signed the form. During an interview on 02/16/2026 at 6:00 PM, the AIT stated she was reviewing staffing daily and on-going.During interviews on 02/15/2026 from 2:20 PM- 02/16/2026 9:25 am, CNA-D, NA-H, and NA-F stated they work the day shift from 6am-6PM. They stated that they were in-serviced on 01/30/2026 by the AIT regarding falls and call light response. They stated on 02/14/2026 they were educated by the DON regarding falls and call lights and took a Quiz. Verified their signature on all in-services and completed Quiz. They stated the expectation was for call lights to me answered within 3 minutes.During interviews on 02/15/2026 from 2:20 PM- 02/16/2026 9:25 am, RN-R and RN-T stated they work the evening shift from 2PM-10PM. They stated that they were in-serviced on 01/30/2026 by the AIT regarding falls and call light response. They stated on 02/14/2026 they were educated by the DON regarding falls and call lights and took a Quiz. Verified their signature on all in-services and completed Quiz. They stated the expectation was for call lights to me answered within 3 minutes.During interviews on 02/15/2026 from 2:20 PM- 02/16/2026 9:25 am, LVN-B stated she worked the night shift from 10PM-6am. She stated that she was in-serviced on 01/30/2026 by the AIT regarding falls and call light response. She stated on 02/14/2026 she was educated by the DON regarding falls and call lights and took a Quiz. Verified her signature on all in-services and completed Quiz. She stated the expectation was for call lights to be answered within 3 minutes.During an interview on 02/15/2026 at 3:25 PM, the DON stated she provided education via phone to all employees regarding falls and call lights on 02/14/2026.Review of Employee roster and in-service signature sheets revealed all staff currently employees for the facility were trained by the DON on 02/14/2026 and 02/16/2026 all prior to working their shift. Reviewed document titled, Flowchart for Direct Care Staff. It included: CNA Staff Member> Temp Agency> Sister Facility Staff> Nurse or RN> DON/ADON.During an interview on 02/16/2026 at 6:00 PM, AIT, ADON, and Owner stated an IDT meeting was held on 02/13/2026. Review of document titled, IDT Meeting, dated 02/13/2026 revealed: Topic: Staffing contingency plan, IJ corrections, staff trainings, mechanical lifts, facility assessment/direct care staff. Attendees: AIT, ADON, Owner, and DONDuring an interview on 02/16/2026 at 6:00 PM the AIT stated an informal QAPI was done on 02/11/2026 with the MD and he stated this would count as QAPI. She stated the MD was notified by the owner when the IJs were called. She stated she was getting all of the information together to have an official QAPI meeting.During an interview on 02/16/2026 at 4:00 PM, the MD stated he did perform a QAPI at the facility on 02/11/2026 and he was a part of the plan of removal. He stated he was notified immediately after the IJs were called. He stated the facility is doing the best they can to fix the immediate concerns.The AIT and Owner were informed that Immediate Jeopardy was removed on 02/16/2026 at 8:20 PM. The facility remained out of compliance at a severity level of no actual harm with the potential for minimum harm that was not immediate jeopardy and a scope of 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 that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 9 (NA-A, NA-C, NA-F, NA-G, NA-H, NA-J, NA-L, NA-M, and NA- P) of 9 NA's reviewed for competency and training and 1 of 8 (Resident #1) residents reviewed for mechanical lift.The facility failed to ensure NA-A did not transfer Resident #1 with a mechanical lift without the assistance of a CNA or nurse, which resulted in Resident #1 receiving a distal femur fracture.The facility failed to ensure nurse aides were trained on how to use a mechanical lift for NA-A, NA-C, NA-F, NA-G, NA-H, NA-J, NA-L, NA-M, and NA- P. An Immediate Jeopardy (IJ) situation was identified on 02/13/2026. While the IJ was removed on 02/16/2026, the facility remained out of compliance at a scope of a pattern with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of their corrective systems.This failure could place residents at risk of injury due to not being supervised and placed them at risk of serious bodily harm, physical impairment, hospitalization or death.Findings include:Record review of the facility provided Nurse Aid checklist for Orientation/Evaluation not dated, revealed NAs cannot do the following tasks by themselves: helping patients into chair from bed or helping patients into wheelchair.Record review of personnel files revealed:NA-A hired on 09/25/2025 worked for facility full time and was terminated on 01/28/2026, and no evidence of Aide Checklist for Orientation/Evaluation or any training regarding resident care for NA-A.NA-C had a hire date of 11/19/2024, worked full time, had not been certified, and showed no evidence of mechanical lift training.NA-F had a hire date of 2/28/2025, worked full time, had not been certified, and showed no evidence of mechanical lift training.NA-G had a hire date of 3/29/2024, worked full time, had not been certified, and showed no evidence of mechanical lift training.NA-H had a hire date of 3/12/2025, worked full time, had not been certified, and showed no evidence of mechanical lift training.NA-J had a hire date of 9/2/2025, worked full time, had not been certified, and showed no evidence of mechanical lift training.NA-L had a hire date of 1/15/2025, worked full time, had not been certified, and showed no evidence of mechanical lift training.NA-P had a hire date of 6/6/2025, worked full time, had not been certified, and showed no evidence of mechanical lift training. During an interview on 01/28/2026 at 3:10 PM, NA-F stated she was not certified. She stated that she had not been trained regarding 2-person mechanical lift transfers. She stated she had performed a skills checklist when she was hired but could not remember if mechanical lifts were on it. She stated she never transferred with a mechanical lift without there being 2 staff. She stated she had no restrictions, and she provided full resident care. During an interview on 01/28/2026 at 3:15 PM, NA-G stated she was not certified. She stated that she had not been trained regarding 2-person mechanical lift transfers. She stated she had performed a skills checklist when she was hired but could not remember if mechanical lifts were on it. She stated she never transferred with a mechanical lift without there being 2 staff. She stated she had no restrictions, and she provided full resident care.During an interview on 01/28/2026 at 5:15 PM, the AIT stated the checklist completed by the NAs was what NAs were allowed to do per the facility policy. She stated that according to the checklist transfers were not allowed to be done alone by NAs and verified that 2-person mechanical lift transfers were not on the NA checklist. She stated that it was her expectation for all mechanical lifts to be performed with 2 staff members. She stated she could not find NA-A's checklist or any training. AIT stated that all training of NAs was the responsibility of the DON and the ADON. She stated that the facility has had a hard time keeping a DON and that things have been misplaced and probably not done correctly. AIT stated she had never been notified of any concerns of NAs transferring residents with the mechanical lift alone.During an interview on 02/01/2026 at 12:12 PM, the ADON stated NAs cannot perform any transfers without a CNA or a nurse. She stated that 2 NAs together still cannot perform these activities. She stated that nurses are supposed to help and supervise the NAs to ensure that they are not performing tasks that they are not trained in. She stated that when 2 NAs are on the floor the nurse is responsible for helping. ADON denied receiving concerns from LVN-K about NAs transferring residents with mechanical lifts.During an interview on 02/11/2026 at 3:13 PM, the MD stated he was not aware the facility had been using so many uncertified aides. The MD stated the facility should have been using agency staff to ensure residents were receiving care by staff were qualified. The MD stated the facility did have a hard time hiring certified aides because the facility could not compete with the bigger facilities and/or the hospitals. The MD stated facility should ensure staff receive the appropriate training and certifications. The MD stated his expectation was that the facility follow their policy regarding training of staff and ensuring staff work within their scope of practice. The MD stated his expectation was if the policy stated mechanical lift transfers required 2 people, then there needed to be 2 persons when using the mechanical lift. The MD stated his expectation was that staff who transfer residents with mechanical lift should know how to use it. The MD stated his expectation was that staff who were not certified follow the facility policy/procedures when providing care to residents. Facility policy titled Lifting Machine, Using a Mechanical Lift, revised July 2017, states: At least 2 nursing assistants are needed to safely move a resident with a mechanical lift.The facility's job description for nurse aide revealed Qualifications: . 2. Must be enrolled in a competency training program approved by the State and performs only services of a type for which he/she has demonstrated competence.4. Demonstrates competency in skills and technical necessary to care for residents' needs as identified through Resident Assessment and described in the Plan of Care.This was determined to be an Immediate Jeopardy (IJ) on 02/13/2026 at 12:40 PM. The AIT and Owner were notified. The AIT and Owner were provided with the IJ template on 02/13/2026 at 12:40 PM. A Plan of Removal was requested.The following Plan of Removal was accepted on 02/15/2026 at 2:15 PM: TAG F726 - Competent Nursing Staff (IJ)Direct Care Staff: A direct care staff can be any trained individual that demonstrates competency according to the facility's aid competency checklist. This may be an NA that is enrolled in a CNA training class and employed less than 120 days, a CNA, and LVN, or an RN that provides direct care to a resident, including but not limited to assistance with ADLs such as eating, bathing, toileting, transfers, hygiene care, etc. There must be two direct care staff on the floor at all times in addition to one LVN/RN charge nurse. There should be a total of one LVN/RN and two direct care staff in the building at all times if there are any mechanical lift residents. Staffing requirements will be assessed weekly based on census and resident needs. There will be two direct care staff if the facility has any residents that use mechanical lift or are a two-person transfer. DON and ADON will ensure that all agency or temporary direct care staff have documented training prior to working a shift. Current temporary agency is giving us access to their portal so that we can check their credentials. The Sister facility will send us their CNA credentials prior to working a shift. This will be started on 02/14/2026 and will be on going.Corrective Action:Resident #1 was dropped in a single-person mechanical lift transfer by NA-A and was immediately assessed by LVN-E upon findings, received treatment in hospital, and facility has followed orders upon discharge by 02/13/2026.All residents residing in the facility have the potential to be affected by not having certified aides. Immediate review of staffing credentials was conducted on 02/02/2026 by AIT. Five of the NA's did not have certification. All uncertified staff will be moved to hospitality aide positions on 02/14/2026 and the facility will utilize temporary staffing agency to meet certified aide requirements.Any Direct Care Staff not meeting CNA requirements were removed from assignment requiring certification on 02/13/2026. If the aides are not certified, they will be moved to a hospitality aid position or relieved from duty and will not count towards the two direct care staff count. The IDT did not have a clear understanding of CNA requirements in relation to NAs that have completed part or the entire NATCEP training and waiting for approval to test until 02/13/2026. The IDT redefined aide requirements on 02/14/2026 with clear definitions and assigned titles accordingly to all aides. Systemic Changes:Facility will ensure only certified nurse aides are assigned to CNA-required roles starting 02/13/2026. The AIT will be responsible for scheduling CNAs for each shift. The facility will utilize temporary staffing agencies and aides from the sister facility, [sister facility], to meet certified aide requirementsVerification by the AIT of active CNA certification will be completed prior to scheduling on 02/13/2026. CNAs have been trained by their NATCEP program instructor through the Texas approved training course on call lights, peri care, mechanical lifts, and resident care as part of their CNA classroom and clinical training per NATCEP requirements. All staff have been educated by AIT on call light usage on 01/30/2026 and have been trained upon hire since. The DON is providing an in-service on call light usage on 02/14/2026 to all nursing staff including RN, LVN, and all aides. The in-service must be completed prior to the beginning of the first shift. Office Manager/designee will perform license verification checks on 02/13/2026 for all direct care staff upon hire, and weekly thereafter for 12 weeks. The AIT will review the list for accuracy and completionThe DON trained all Direct Care Staff on falls and call light usage via phone calls with return instruction to ensure retention of information on 02/14/2026. Any staff members that do not answer the phone will not be able to return to work their shift until the staff is retrained on falls and call lights. Monitoring:Administrator/DON will review staffing roster weekly for 12 weeks to ensure compliance. If non-compliance is discovered, then the facility will utilize staffing agencies and aides from the sister facility in [sister facility town] to ensure there are adequate staffing levels for CNAs. Starting 02/14/2026, all agency and sister facility direct care staff will be provided an educational handout for review directed by the charge nurse prior to starting the shift on the floor on their first shift. Agency and sister facility staff will sign a check-in sheet that they have reviewed the educational material in a binder at the nurses station for every shift worked thereafter starting 02/15/2026. The handout will provide an in-service about abuse and neglect, call light usage, mechanical lift transfer, and falls. Verification of competency will be demonstrated with a verbal return of information and staff signature. Findings will be reviewed in monthly QAPI for 3 months.Completion Date: 02/15/2026Monitoring of the facility's Plan of Removal revealed the following:Review of progress notes dated 01/26/2026, revealed that Resident #1 was assessed and admitted to the hospital immediately after notifying staff of the incident.Review of Hospital Discharge Orders and Instructions dated 01/29/2026, revealed that physicians orders and review of physicians' orders revealed they were entered into the system.During an interview on 02/16/2026 at 9:15 am, LVN-E stated that she assessed Resident #1 immediately and notified the physician, ADON, and the family.During an interview on 02/16/2026 at 3:45 PM, AIT stated that her review of staffing credentials revealed that 5 NA's that did not have certification: NA-F, NA-H, NA-G, and NA-C and NA-J who are no longer employed here. She stated NA-G was the activity director and was no longer working the floor and NA-F and NA-H were changed to HAs.During an interview on 02/15/2026 at 2:55 PM, NA-H stated that she was an HA and that she could not provide direct care. She stated that she could not perform any transfers or any incontinent care.During an interview on 02/16/2026 at 12:00 PM, NA-F stated that she was an HA and that she could not provide any direct resident care. Stated that she can only pass out trays, answer call lights, and push residents wheelchairs. Stated that she could not transfer or perform any direct patient care. During an interview on 02/16/2026 at 12:25 PM, DON stated she received clarification on the difference between an HA and an NA and that the facility was going to ensure that all staff knew their titles and their job qualifications and restrictions.Review of schedules and timecards revealed: 02/14/2026 6a-6p CNA-D and Agency CNA worked as direct care staff.During an observation on 02/14/2026 at 12:30 PM observed CNA-D and Agency CNA in the facility providing direct patient care.Review of schedules and timecards revealed: 02/14/2026 6p-6a LVN-V worked as direct care staff from 6PM-10PM and ADON worked until 10PM. Review revealed sister facility CNA-U worked from 10PM-6am along with NA-W.During an observation on 02/14/2026 at 6:15 PM observed ADON and LVN-V in the facility providing direct patient care.Review of schedules and timecards revealed: 02/15/2026 6a-6p CNA-D and DON worked as direct care staff.During an observation on 02/15/2026 at 11:30 am observed CNA-D and DON in the facility providing direct patient care.Review of schedules and timecards revealed: 02/15/2026 6p-6a Agency CNA and NA-O worked as direct care staff.During an observation on 02/15/2026 at 6:15 PM observed in the facility Agency CNA and NA-O providing direct patient care.During and observation on 02/16/2026 at 3:00 PM observed DON and LVN-K providing direct patient care. Review of in-service regarding two-person mechanical protocol and policy, answering call light timely, reporting incidents abuse and neglect, and fall prevention dated 01/30/2026 signed by 16 employees. In-service stated answer call lights within 3 minutes, never ignore a call light, bathroom assistance protocol, and post fall do not move the resident after a fall, assess first, and 2 staff are required to perform a mechanical lift transfer at all times.During interviews on 02/15/2026 from 2:20 PM- 02/16/2026 9:25 am, LVN-E and LVN-K stated they work the day shift from 6am-2PM. They stated that they were in-serviced on 01/30/2026 by the AIT regarding falls and call light response. They stated on 02/16/2026 prior to working her shift she was educated by the DON regarding falls and call lights and took a Quiz. Verified their signature on all in-services and completed Quiz. They stated the expectation was for call lights to me answered within 3 minutes.During interviews on 02/15/2026 from 2:20 PM- 02/16/2026 9:25 am, CNA-D, NA-H, and NA-F stated they work the day shift from 6am-6PM. They stated that they were in-serviced on 01/30/2026 by the AIT regarding falls and call light response. They stated on 02/14/2026 they were educated by the DON regarding falls and call lights and took a Quiz. Verified their signature on all in-services and completed Quiz. They stated the expectation was for call lights to me answered within 3 minutes.During interviews on 02/15/2026 from 2:20 PM- 02/16/2026 9:25 am, RN-R and RN-T stated they work the evening shift from 2PM-10PM. They stated that they were in-serviced on 01/30/2026 by the AIT regarding falls and call light response. They stated on 02/14/2026 they were educated by the DON regarding falls and call lights and took a Quiz. Verified their signature on all in-services and completed Quiz. They stated the expectation was for call lights to me answered within 3 minutes.During interviews on 02/15/2026 from 2:20 PM- 02/16/2026 9:25 am, LVN-B stated she worked the night shift from 10PM-6am. She stated that she was in-serviced on 01/30/2026 by the AIT regarding falls and call light response. She stated on 02/14/2026 she was educated by the DON regarding falls and call lights and took a Quiz. Verified her signature on all in-services and completed Quiz. She stated the expectation was for call lights to be answered within 3 minutes.During an interview on 02/15/2026 at 3:00 PM, the ADON stated she provided an in-service on 01/16/2026 regarding falls and call-light response.During an interview on 02/15/2026 at 3:05 PM, the AIT stated she provided an in-service regarding call light response on 01/30/2026. During an interview on 02/15/2026 at 3:25 PM, the DON stated she provided education via phone to all employees regarding falls and call lights on 02/14/2026.Reviewed document titled, Weekly License Verification Checks, last completed 02/16/2026 by BOM revealed: NA-W enrolled in college, NA-O enrolled in college, NA-F not licensed, NA-H not licensed, N-G not licensed, and CNA-D licensed. During an interview on 02/16/2026 at 2:50 PM, the AIT who stated that weekly verification checks would be performed by BOM and that she would ensure that this would be completed.During an interview on 02/16/2026 at 2:55 PM, the BOM stated she performed a license verification check on 02/13/2026 and will continue to do that weekly.During an interview on 02/15/2026 at 3:25 PM, the DON stated she provided education via phone to all employees regarding falls and call lights on 02/14/2026.Reviewed in-service training provided by DON on 02/14/2026 revealed 6 signatures. Over the phone training was conducted with 4 employees.Review of Employee roster and in-service signature sheets all staff currently employees for the facility were trained by the DON on 02/14/2026 and 02/16/2026 all prior to working their shift. During an observation on 02/16/2026 9:30 am call light for room [ROOM NUMBER] go off at 9:30 am. LVN-E answered and assisted the resident off of the toilet at 9:33 am.During an observation on 02/16/2026 2:30 PM call light for room [ROOM NUMBER] go off at 2:30 PM and answered at 2:32 PM by DON.Reviewed education hand out for agency and temporary staff that covered abuse and neglect, call light usage, mechanical lift transfer, and falls. signed by CNA- U and dated 02/14/2026.During a phone interview on 02/05/2026 at 4:45 PM, CNA-U stated that she was given the handout prior to working her shift on 02/14/2026 by RN-R.During an interview on 02/05/2026 at 4:50 PM, RN-R verified that CNA-U received the handout and verbalized understanding prior to working on 02/14/2026.Observation on 02/15/2026 at 6:15 PM, DON reviewed educational handout for agency CNA coming on-shift. Agency CNA acknowledged the information and signed the form. During an interview AIT stated that an informal QAPI was done on 02/11/2026 with the MD and he stated that this would count as QAPI. She stated that the MD was notified by the owner when the IJs were called. She stated that she was getting all of the information together to have an official QAPI meeting.During an interview on 02/16/2026 at 4:00 PM, the MD stated that he did perform a QAPI at the facility on 02/11/2026 and that he was a part of the plan of removal. He stated that he was notified immediately after the IJs were called. He stated that the facility was doing the best that they can to fix the immediate concerns.The AIT and Owner were informed that Immediate Jeopardy was removed on 02/16/2026 at 8:20 PM. The facility remained out of compliance at a severity level of no actual harm with the potential for minimum harm that was not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interviews and record reviews, the facility failed to designate a registered nurse to serve as the director of nursing on a full-time basis for 1 of 1 facility reviewed for full-time DON.The facility failed to ensure there was a full-time (worked 40 or more hours a week) DON in 9 of 11 (week 12/14/2025 - 12/20/2025, week 12/21/2025 - 12/27/2025, week 12/28/2025 - 01/03/2026, week 01/04/2026 - 01/10/2026, week 01/11/2026 - 01/17/2026, week 01/18/2026 - 01/24/2026, week 01/25/2026 - 01/31/2026, week 02/01/2026 - 02/07/2026, and week 02/08/2026 - 02/14/2026) weeks reviewed. This failure could affect all residents in the facility by leaving residents and staff without supervisory coverage for nursing care and services.Findings included:Record review of the DON clock-in / clock-out reports for December 2025 to February, 14th 2026, revealed no evidence of 40 hours of DON coverage for: week 12/14/2025 - 12/20/2025, week 12/21/2025 - 12/27/2025, week 12/28/2025 - 01/03/2026, week 01/04/2026 - 01/10/2026, week 01/11/2026 - 01/17/2026, week 01/18/2026 - 01/24/2026, week 01/25/2026 - 01/31/2026, week 02/01/2026 - 02/07/2026, and week 02/08/2026 - 02/14/2026. The DON clock-in/clock-out reports revealed the DON worked 4 hours on 1/13/2026, 7 hours on 1/14/2026, 8 hours on 1/20/2026, 3 hours on 1/30/2026, and 8 hours on 2/5/2026.During an interview on 1/28/2026 at 12:30 p.m., the AIT stated there was no DON present in the building at the time of entrance.During an interview on 1/28/2026 at 12:30 p.m., the owner stated there was no DON present in the building at the time of entrance.During an interview on 1/28/2026 at 12:30 p.m., the ADON stated there was no DON present in the building at the time of entrance.During an interview on 02/05/2026 at 8:55 a.m., the DON stated that 02/05/2026 was her first day working on the floor in the facility and that she was in training. She stated she had done online training prior to 02/05/2026.During an interview on 02/09/2026 at 5:45 p.m., the ADON stated the facility had not had a DON in the building 40 hours per week since mid-December 2025. The ADON stated a DON had been hired but had not been in the building full-time. The ADON stated resident care had been affected because the facility did not have an Infection Preventionist, no one had conducted antibiotic stewardship, and the care plans had not been updated. She stated the previous DON's last day was sometime in December of 2025. She stated the facility had RNs that worked in the facility, but they were not fulfilling the DON duties. She stated both RNs working in the facility did not want to serve in the DON role. The ADON did not specify how resident care was not affected by not having a DON.During an interview on 02/09/2026 at 6:20 p.m., the AIT stated the facility did not have a full-time DON. She stated the facility had hired a DON. She stated the DON had completed online training but had not started full-time in the facility.During a telephone interview on 02/11/2026 at 3:42 p.m., the MD stated it was his expectation for the facility to have a full-time DON. He stated the interim DON was set to start full-time February 23rd, 2026. The MD would not state if there had been any effect on the residents at the facility from there not being a full-time DON. He stated he expected the facility to follow their policies on DON coverage.Record review of the facility policy titled Director of Nursing Services, revised on August 2006, reflected The Director is employed full-time (40-hours per week) and is responsible for, but is not necessarily limited to: a. Developing and periodically updating the nursing service objectives and statements of philosophy; b. Developing standards of nursing practice; c. Developing and maintaining nursing policy and procedure manuals; d. Developing and maintaining written job descriptions for each level of nursing personnel; e. Scheduling of daily rounds to visit residents; f. Developing methods for coordination of nursing services with other resident services; g. Recruiting and retaining the number and levels of nursing personnel necessary to meet the nursing care needs of each resident; h. Developing staff training programs for nursing service personnel; i. Participating in the planning and budgeting for Nursing Services; j. Ensuring that all health services notes are informative and descriptive of the supervision and care rendered including the resident's response to his or her care; k. Assessing the nursing requirements for each resident admitted and assisting the Attending Physician in planning for the resident's care; l. Participating in the development and implementation of the resident assessment (MDS) and comprehensive care plan; m. Establishing resident selection criteria for determining which residents may be fed by paid feeding assistants; and n. Assuring that nursing care personnel are administering care and services in accordance with the resident's assessment care plan.

Based on interview and record review the facility failed to not use any individual working in the facility as a nurse aide for more than 4 months on a full-time basis unless that individual is competent to provide nursing and nursing related services and that individual has completed a training and competency evaluation program, or a competency evaluation program approved by the state or had been deemed or determined competent as provided in S483.150(a) and (b) for 8 of 11 (NA-A, NA-C, NA-F, NA-G, NA-H, NA-J, NA-L, and NA-P) Nurse Aides. The facility failed to ensure NA-A, NA-C, NA-F, NA-G, NA-H, NA-J, and NA-L were certified within the required time frame.This failure could place residents at risk for receiving care from an individual whose skill level was not known. Findings include:Review of the facility's employee files revealed: NA-A had a hire date of 9/25/2025 and worked full time until she was termed on 1/28/2026. NA-C had a hire date of 11/19/2024 and worked full time. NA-F had a hire date of 2/28/2025 and worked full time. NA-G had a hire date of 3/29/2024 and worked full time. NA-H had a hire date of 3/12/2025 and worked full time. NA-J had a hire date of 9/2/2025 and worked full time until she was termed on 2/4/2026. NA-L had a hire date of 1/15/2025 and worked full time until he was termed on 1/28/2026.During a telephone interview on 02/03/2026 at 4:45 p.m., NA-A stated she had worked at the facility since September. NA-A stated she had taken the CNA classes and passed the written test two years ago, but failed the skills test. NA-A stated she had been rescheduled to retake the skills test but never took the retest and now she had to take the classes again.During a telephone interview on 2/3/2026 at 5:45 p.m., NA-C stated she had worked for the facility for over a year. NA-C stated she had completed 40 hours of online CNA training and completed two in person classes provided by the facility. NA-C stated the facility just stopped the CNA classes and she had not completed the certification for that reason.During an interview on 02/03/2026 at 6:35 p.m., NA-F stated she had been working for the facility for over a year. She stated she had taken a written exam in the past and passed the exam but could not pass the clinical exam and was not certified. She stated she was waiting on the next 20 hours of training so that she could complete her certification process.During an interview on 02/09/2026 at 3:50 p.m., NA-H stated she had worked at the facility since March of 2025. NA-H stated she had finished the 60 hours of computer training to become a CNA but still had to do her clinical hours. She stated there was nowhere to take the clinical hours part of certification and that was why she had not tested.During an interview on 02/07/2026 at 5:45 p.m., the AIT stated none of the NAs were certified because they had not tested. She stated the facility was going to have the NAs complete the classes in February at their sister facility, but the NATCEP program had been cancelled. Record review of the Nurse Aide job description, not dated, reflected QUALIFICATIONS: 1. Has completed a training and competency evaluation program or a competency evaluation approved by the State and holds a current certificate from the State. 2. Must be enrolled in a competency training program approved by the State and performs only services of a type for which he/she has demonstrated competence. 3. Personality a tuned to the requirements of meeting needs of the infirm and aged. 4. Demonstrates competency in skills and technical necessary to care for residents' needs as identified through Resident Assessment and described in the Plan of Care.

Based on interview and record reviews, the facility failed to establish an infection prevention and control program that included an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for 3 of 3 months reviewed for antibiotic stewardship.The facility failed to maintain a system to monitor antibiotic use during the months of December 2025, January 2026 and February 2026.These failures placed residents at risk of adverse outcomes associated with the inappropriate use of antibiotics.Findings included:Record review of the facility infection tracking log revealed no evidence of an infection tracking log for antibiotic stewardship program for the months of December 2025, January 2026 and February 2026. During an interview on 02/09/2026 at 5:45 p.m., the ADON said she had performed IP tasks such as tracking infection prior to the previous DON being hired into the facility. The ADON stated she was not currently responsible for the tracking/trending of infections, but she had previously had a binder with all the residents who received antibiotics. She stated the previous DON's last day was sometime in mid-December of 2025 and she could not provide any evidence of antibiotic stewardship since when she had tracked infections and antibiotic use prior to the previous DON taking over. The ADON did not say how residents were affected or could be affected by not maintaining a system to monitor antibiotic use. During an interview on 02/10/2026 at 10:38 a.m. the AIT stated the previous DON, and the new DON had completed the infection preventionist program and were the IPs of the facility. She could not provide any evidence of the infection tracking/trending in the months of December 2025, January 2026 and present. She stated the facility had hired a DON, but she had not started full-time. During an interview on 02/05/2026 at 8:55 a.m., the DON stated 02/05/2026was her first day working on the floor in the facility and that she was still training. She stated she had completed online training prior to 02/05/2026.Record review of facility policy titled Surveillance for Infections, revised on date September 2017, reflected 1. The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and Healthcare-Associated Infections, to guide appropriate interventions, and to prevent future infections. 2. The criteria for such infections are based on the current standard definitions of infections. 3. Infection that will be included in routine surveillance include those with: a. Evidence of transmissibility in a healthcare environment; b. Available processes and procedures that prevent or reduce the spread of infection; c. Clinically significant morbidity or mortality associated with infection (e.g., pneumonia, UTIs, C. difficile); and d. Pathogens associated with serious outbreaks. (e.g., invasive streptococcus Group A, acute viral hepatitis, norovirus, scabies, influenza (Flu).

Based on interviews and record reviews, the facility failed to have a designated Infection Preventionist who worked at least part-time at the facility and had completed specialized training in infection prevention and control for 1 of 1 facility reviewed for infection control.The facility failed to have a designated Infection Preventionist (IP) who worked at least part-time in the months of December 2025, January 2026 and February 2026.This failure could affect residents by placing them at risk of infection spread by the facility not appropriately recognizing and responding to communicable diseases and infections. Findings included:Record review of IP certificate dated 01/14/2026 reflected the DON had completed the course for Nursing Home Infection Preventionist Training. During an interview on 02/09/2026 at 5:45 p.m., the ADON said she had performed IP tasks such as tracking infection prior to the previous DON being hired into the facility. She stated the previous DON's last day was December 12, 2025. She stated she made sure that the new DON had completed training on infection preventionist, but she had not started full-time in the facility and was not keeping track of the infections in the facility at this time. She could not provide any records of where the facility had recently tracked the infections in the facility. The ADON stated there was no IP appointed when the DON position was vacant.During an interview on 02/10/2026 at 10:38 a.m. the AIT stated the previous DON, and the new DON had completed the infection preventionist program. She provided the new DON's Infection Preventionist certificate dated 1/14/2026. She stated the facility had been working with another staff member with infection control and provided a certificate titled Infectious Diseases and Infection Control dated 10/25/2017 for that staff member but it was not a nursing facility-specific Infection Preventionist (IP) training.During an interview on 02/05/2026 at 8:55 a.m., the DON stated 02/05/2026 was her first day working on the floor in the facility and that she was in training. She stated she had completed online training prior to 02/05/2026.Record review of facility policy titled Surveillance for Infections, revised on September 2017, reflected The Infection Preventionist will conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions.At the time of exit, no further policies were provided.

Based on interview and record review, the facility's QAPI committee failed to implement an appropriate action plan to address identified quality deficiencies for 1 of 1 facility.The QAPI committee failed to implement the corrective actions outlined on the Plan of Correction, dated 8/29/2024, for deficient practice F695, F909, F941, F944, F949.This failure could place residents at risk for substandard quality of care due to the failure of the facility to take action on an identified problem affecting resident safety, respiratory treatment, and employee training. Findings included:Record review of a CMS 2567, dated 7/31/2025, reflected that based on observations, interviews, and record review, a deficient practice was cited at F695 (Respiratory/Tracheostomy Care and Suctioning) during the 7/31/2024 SSA recertification survey. Observations, interviews, and records reflected that the facility failed to have oxygen in use signs outside of resident's rooms that utilized oxygen. Record review of the facility's 9/5/2024 Plan of Correction which was submitted in response to the 7/31/2024 SSA recertification survey reflected the facility's plan as Weekly checks by the ADON or DON will be done to ensure the policy is enforced. Then their findings will be reported in the morning meetings which hare Monday through Friday and at Monthly QAPI meetings.During an observation on 12/02/2025 at 09:30 a.m., Resident #3 was wearing a n/c and oxygen was being administered. There was no oxygen in use signs on her doorway leading into her room.During an observation on 12/2/2025 at 9:45 a.m., Resident #11 was sitting in a recliner in their room. Resident #11 was wearing a n/c and oxygen was being administered. There was no oxygen in use signs the doorway leading into the resident's room.During an observation on 12/2/2025 at 10:00 a.m., Resident #7 was lying in bed. Resident #7 was wearing a n/c and oxygen was being administered. There was no oxygen in use signs on her doorway leading into her room.During an observation on 12/02/2025 at 02:31 p.m., Resident #2 was lying in bed on her left side. Resident #2 was wearing a n/c and oxygen was being administered. There was no oxygen in use sign on the doorway leading into her room.Record review of a CMS 2567 dated 7/31/2025 reflected that based on observations, interviews, and record review, a deficient practice was cited at F909 (Resident Bed) during the 7/31/2024 SSA recertification survey. Observations, interviews, and records reflected that the facility failed to assess resident's beds that had bed rails for risk of entrapment. Record review of the facility's 8/20/2024 Plan of Correction submitted in response to the 7/31/2024 SSA recertification survey reflected the facility's plan as, The results of the routine checks will be made monthly at QAPI meetings or immediately if reasonable such as or emergency. The environmental supervisor will report at the monthly QAPI meeting. The Entrapment risks will be reviewed from the checklist generates based on state criteria.Record review of facility documents Bed Rail Appropriateness Checklist for Resident #2, Resident #3, Resident #7, Resident #9 and Resident #21 reflected no evidence that the assessment had been performed since 7/16/2025.Record review of a CMS 2567, dated 7/31/2025, reflected that based on interviews, and record review, a deficient practice was cited at F941 (Communication Training) during the 7/31/2024 SSA recertification survey. Interviews and record reviews reflected the facility failed to train staff on communication.Record review of the facility's 9/5/2024 Plan of Correction submitted in response to the 7/31/2024 SSA recertification survey reflected the facility's plan as, Random audits of all trainings will be completed by the office manager, and the results will be reported to the administrator during morning meetings which happen Monday through friday and at monthly QAPI meetings.Record review of personnel record for the DON reflected a hire date of 7/1/2025. Further review of personnel record provided by the AIT reflected the DON had no evidence she completed the required effective communication training upon hire or while working at the facility.Record review of the personnel records for the DM reflected a hire date of 10/20/2025. Further review of personnel record provided by the AIT reflected the DM had no evidence she completed the required effective communication training upon hire or while working at the facility.Record review of the personnel records for RN C reflected a hire date of 9/1/2025. Further review of the personnel record provided by the AIT reflected RN C had no evidence she completed the required effective communication training upon hire or while working at the facility. Record review of the personnel records for LVN E reflected a hire date of 6/20/2025. Further review of the personnel record provided by the AIT reflected LVN E had no evidence she completed the required effective communication training upon hire or while working at the facility. Record review of the personnel records for NA G reflected a hire date of 11/6/2025. Further review of the personnel record provided by the AIT reflected NA G had no evidence she completed the required effective communication training upon hire or while working at the facility.Record review of the personnel records for NA H reflected a hire date of 2/28/2025. Further review of the personnel record provided by the AIT reflected NA H had no evidence she completed the required effective communication training upon hire or while working at the facility.Review of a CMS 2567, dated 7/31/2025, reflected that based on interviews, and record review, a deficient practice was cited at F944 (QAPI Training) during the 7/31/2024 SSA recertification survey. Interviews and record reviews reflected the facility failed to train staff on QAPI.Review of the facility's 9/5/2024 Plan of Correction submitted in response to the 7/31/2024 SSA recertification survey reflected the facility's plan as, Random audits of all trainings will be completed by the office manager and the results will be reported to the administrator during morning meetings which happen Monday through friday and at monthly QAPI meetings.Record review of personnel record for the DON reflected a hire date of 7/1/2025. Further review of personnel record provided by the AIT reflected the DON had no evidence she completed QAPI training upon hire or while working at the facility.Record review of the personnel records for the DM reflected a hire date of 10/20/2025. Further review of personnel record provided by the AIT reflected the DM had no evidence she completed QAPI training upon hire or while working at the facility.Record review of the personnel records for RN C reflected a hire date of 9/1/2025. Further review of the personnel record provided by the AIT reflected RN C had no evidence she completed QAPI training upon hire or while working at the facility. Record review of the personnel records for LVN E reflected a hire date of 6/20/2025. Further review of the personnel record provided by the AIT reflected LVN E had no evidence she completed QAPI training upon hire or while working at the facility. Record review of the personnel records for NA G reflected a hire date of 11/6/2025. Further review of the personnel record provided by the AIT reflected NA G had no evidence she completed QAPI training upon hire or while working at the facility.Review of a CMS 2567 dated 7/31/2025 reflected that based on interviews, and record review, a deficient practice was cited at F949 (Behavioral Health Training) during the 7/31/2024 SSA recertification survey. Interviews and records reflected the facility failed to train staff on behavioral health.Review of the facility's 9/5/2024 Plan of Correction submitted in response to the 7/31/2024 SSA recertification survey reflected the facility's plan as Random audits of all trainings will be completed by the office manager and the results will be reported to the administrator during morning meetings which happen Monday through friday and at monthly QAPI meetings.Record review of personnel record for the DON reflected a hire date of 7/1/2025. Further review of personnel record provided by the AIT reflected the DON had no evidence she completed behavioral health training upon hire or while working at the facility.Record review of the personnel records for the DM reflected a hire date of 10/20/2025. Further review of personnel record provided by the AIT reflected the DM had no evidence she completed behavioral health training upon hire or while working at the facility.Record review of the personnel records for NA G reflected a hire date of 11/6/2025. Further review of the personnel record provided by the AIT reflected NA G had no evidence she completed behavioral health training upon hire or while working at the facility.During an interview on 12/3/2025 at 3:14 p.m., the ADMN stated he was involved in the QAPI meetings and was aware the facility had deficient practices in no oxygen in use signs, bed rail assessments not performed, and staff training not performed during the last recertification survey. He stated poor oversight by him led to the failure of the plan of correction being carried through. He stated he was not certain but the last time he felt these items were discussed in QAPI was seven months ago. He did not explain why QAPI had not discussed it since that time. He did not state what monitoring system was in place to ensure the plan of correction had been completed. He stated past deficient practices should be discussed during QAPI and the plan of correction should be followed. He stated no follow up could lead to residents at risk of harm and staff not trained effectively.Review of the facility's policy titled Quality Assurance and Performance Improvement Changes to QAPI Plan dated 2017 reflected QAPI performance indicators that are monitored will be reviewed - are they still relevant, do we need to monitor them as frequently, or more frequently? Are our goals, thresholds still relevant, achievable, etc. The QAPI, Committee Chairperson monitors the process according to predetermined time frames, observing if the changes in the process resulted in the desired outcome. If the changes to the process have not resulted in the goal of the PIP, further changes are made and monitoring of the process takes place again. Once the PIP goals have been met, the indicator(s) that failed and initiated the PIP will be monitored routinely for ongoing (but less frequent) measurement, to assure the PIP doesn't get forgotten.

Based on observation, interview, and record review, the facility failed to ensure residents who needed respiratory care were provided with such care consistent with professional standards of practice for 4 of 14 residents (Resident #2, Resident #3, Resident #7 and Resident #11) reviewed for oxygen therapy. The facility failed to provide Oxygen (O2) in use sign on resident doorways for Resident #2, Resident #3, Resident #7 and Resident #11. This failure could place residents who use oxygen at risk of injury from fire.Findings included: Record review of Resident #2's electronic face sheet, dated 12.04.2025, revealed the resident was a [AGE] year-old female admitted 12.21.2022 with diagnoses including heart failure, emphysema (chronic lung disease), tobacco use, type II diabetes mellitus. Record review of Resident #2's Quarterly MDS assessment, dated 09.04.2025, revealed Resident # 2 had a BIMS score of 09, meaning moderate cognitive impairment and received oxygen therapy. Record review of Resident #2's Care Plan, dated 09.04.2025, revealed Resident #2 was a smoker. Record review of Resident #2's physician's orders, dated 12.01.2025, revealed an order for oxygen via n/c at 3 lpm(liters per minute) PRN to keep oxygen saturation levels at 91% or greater. During an observation on 12.02.2025 at 02:31 p.m., Resident #2 was lying in bed wearing oxygen via N/C. Observation revealed there was not an oxygen in use sign on the doorway leading into Resident #2's room. Record review of Resident #3's electronic face sheet, dated 12.04.2025, revealed the resident was an [AGE] year-old female admitted 10.17.2017 with diagnosis including Chronic Obstructive Pulmonary Disease (lung disease), Dementia, Record review of Resident #3's Quarterly MDS assessment, dated 10.17.2025, Resident #3 had a BIMS score of 00 indicating severely impaired cognitive function and received oxygen therapy. Record review of Resident #3's Care Plan, dated 10.18.2025, revealed oxygen therapy as an intervention for COPD . Record review of Resident #3's physician orders, dated 12.01.2025, revealed two 2-4 LPM via n/c continuous to keep SPO2 (percent of oxygenated blood) greater than 90%[ . During an observation on 12.02.2025 at 09:30 AM Resident #3 was lying in bed with O2 via N/C. There was no oxygen in use signs on her doorway. Record review of Resident #7's electronic face sheet on 12.04.2025, revealed a [AGE] year-old female admitted 12.26.2020 with diagnosis including Unspecified Dementia, and Wheezing, Hypoxemia (low levels of oxygen in the blood). Record review of Resident #7's annual MDS, dated 09.12.2025, revealed a BIMS score of 03 indicating severe cognitive impairment oxygen therapy. Record review of Resident #7's Care Plan, dated 09.13.2025, revealed a focus area of oxygen therapy related to shortness of breath. Record review of Resident #7's physician orders, dated 12.01.2025, revealed oxygen via nasal cannula at 2-4 LPM. During an observation on 12.02.2025 at 10:00 a.m., Resident #7 was lying in bed with O2 via N/C on and no oxygen in use signs on doorway. Record review Resident #11's electronic face sheet on 12.04.2025 revealed an [AGE] year-old female admitted 02.22.2021 with diagnoses including Disease of Upper Respiratory Tract and Obstructive Sleep Apnea (breathing disorder). Record review Resident #11's Quarterly MDS, dated 09.12.2025, revealed a BIMS score of 10 indicating moderately impaired cognition and oxygen therapy. Record review of Resident #11's Care Plan, dated 09.12.2025, revealed a focus area of altered respiratory status/difficulty breathing related to obstructive sleep apnea. Record review of Resident #11's physician orders, dated 12.01.2025, revealed O2 at 2L via N/C q (every) shift. During an observation on 12.02.2025 at 09:45 a.m. Resident #11 was sitting in a recliner with O2 via N/C at 3 LPM. There were no Oxygen in Use signs on doorway. During an interview on 02.04.2025 at 10:51 a.m. LVN A stated nursing staff and maintenance were responsible for ensuring the oxygen in use signs were in place for residents that used oxygen. LVN A stated not having the oxygen in use signs could lead to an accident if a cigarette was lit around the oxygen and the staff might not check to see if the resident was wearing oxygen when needed. LVN A stated she did not know who monitored the oxygen in use signs and did not know why this failure occurred. During an interview on 12.04.2025 at 11:45 a.m. the AIT (Administrator in Training) stated she was not aware the oxygen in use signs were not in place. She stated the negative effect of not using oxygen in use signage was not following state guidelines and the potential for fire. She stated the administrator and maintenance director were responsible for ensuring the oxygen signs were in place on the residents' doorways. During an interview on 12.04.2025 at 01:26 p.m. the Maint D stated he was not sure why the oxygen in use signs were not in place. He stated when he checked they needed new signs and felt like it just got forgotten. He stated not knowing oxygen was in the room could be potential for a fire. Record review of the facility's policy titled Oxygen Administration, dated October 2010, revealed: Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. General Guidelines. Equipment and SuppliesThe following equipment and supplies will be necessary when performing this procedure.1. Portable oxygen cylinder (strapped to the stand);2. Nasal cannula, nasal catheter, mask (as ordered);3. Humidifier bottle4. No Smoking/Oxygen in Use signs;5. Regulator6. Personal protective equipment (i.e., gowns, gloves, mask, etc., as needed) . Steps in Procedures.2. Place an Oxygen in Use sign on the outside of the room entrance3. Place an Oxygen in Use sign in a designated place or over the resident's bed.

Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician and others participating in the provision of care for 3 (Resident #3, Resident #10, and Resident #24) of 3 residents reviewed for hospice services. The facility failed to maintain required hospice forms and documentation, that included the hospice plan of care and certificate of terminal illness to ensure Resident #3, Resident #10, and Resident #24 received adequate end-of-life care. The facility failed to have hospice care plans for Resident #3, Resident #10 and Resident #24.The facility failed to have Individual Election, Cancelation or Update forms for Resident #3, Resident #10 and Resident #24. The facility failed to have Physician Certification of Terminal Illness form for Resident #3, Resident #10 and Resident # 24. This failure could place residents at risk of their hospice care needs being met. Findings included: 1. Record review of Resident #3's electronic face sheet, dated 12.04.2025, revealed the resident was an [AGE] year-old female admitted to the facility on 10.17.2017, with the following diagnoses Chronic Obstructive Pulmonary Disease (lung disease), Dementia, Ischemic Heart Disease. Record review of Resident #3's Quarterly MDS assessment, dated 10.17.2025, revealed Resident #3 had a BIMS score of 00 (meaning severely impaired cognitive function) and received oxygen therapy. Record review of Resident #3's Care Plan, dated 10.18.2025, revealed, Focus-Resident is on Hospice care. Record review of Resident #3's physician orders, dated 12.01.2025, revealed, Admit to hospice for end-of-life support and comfort care.During a record review [KA1] on 12.03.2025 at 01:30 p.m., the hospice care binder for Resident # 3 revealed no evidence of the Individual Election, Cancelation or Update form, no Physician Certification of Terminal Illness Form and no updated hospice care plan. 2. Record review of Resident #10's electronic face sheet, dated 12.04.2025, revealed an [AGE] year-old male admitted 11.29.2024 with the following diagnoses CVA (cerebral vascular accident), encephalopathy (brain disease), type 2 diabetes mellitus (blood sugar changes). Record review Resident #10's Quarterly MDS, dated 11.14.2025, revealed Resident #10 had a BIMS score of 00 ( meaning severely impaired), a life expectancy of less than six months, and received hospice care. Record review Resident #10's Care Plan, dated 10.10.2025, revealed: Focus-He may have pain medication therapy per Hospice comfort care. Record Review of Resident #10's physician orders, dated 12.01.2025, revealed admit to hospice care. During a record review [KA2] on 12.03.2025 at 01:30 PM the hospice care binder for Resident #10 revealed no evidence of Individual Election, Cancelation or Update form, no Physician Certification of Terminal Illness Form and no updated hospice care plan. 3. Record review of Resident #24's electronic face sheet dated 12.04.2025 revealed [AGE] year-old female admitted 08.06.2025 with diagnosis of Hypertensive Heart Disease, Essential Hypertension (high blood pressure), chronic kidney disease. Record review of Resident #24's Quarterly MDS, dated 11.19.2025, revealed a BIMS score of 07 meaning severely cognitively impaired, a life expectancy of less than six months, and received hospice care. Record review of Resident #24's Care Plan, dated 08.19.2025, revealed: Focus-has a terminal prognosis related to hypertensive heart disease on hospice care. Record review of Resident #24's physician orders, dated 12.01.2025, revealed, Admit to Nursing Center under care of Dr[KA3] . and hospice care. During a record review[KA4] on 12.03.2025 at 01:30 p.m., the hospice care binder for Resident #24 revealed no evidence of the Individual Election, Cancelation or Update form, no Physician Certification of Terminal Illness Form and no updated hospice care plan. During an interview on 12.04.2025 at 11:01 a.m., the ADON stated she was not sure why all the required documents were not in the hospice binders. She stated not having the hospice care plans did not cause harm to the residents because the facility staff communicated with hospice staff. She stated she did not know who was responsible for ensuring all documents from hospice were in the hospice binder.Review of the facility's policy titled Hospice Program (revised July 2017) revealed: Policy statementHospice services are available to residents at the end of life.Policy Interpretation and Implementation1. Our facility has an agreement in place with at least on Medicare-certified hospice to ensure that residents who wish to participate in a hospice program may do so.5. Hospice providers who contract with this facility: must have a written agreement with the facility outlining (in detail) the responsibilities of the facility and the hospice agency.10. In general, it is the responsibility of the facility to meet the president's personal care and nursing needs in coordination with the hospice representative and ensure that the level of care provided is appropriately based on the individual resident's needs.12. Our facility has designated __________ to coordinate care provide to the resident by our facility staff and hospice staff.He or she is responsible for the following.d. Obtaining the following information from the hospice:1. The most recent hospice plan of care specific to each resident.2. Hospice Election form3. Physician certification and recertification of the terminal illness specific to each resident4. Names and contact information for hospice personnel involved in hospice care of each resident. 13. Coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by our facility. 14. The coordinated care plan will reflect the resident's goals and wishes, as stated in hir or her advance directives and during ongoing communication with the resident or representative

Based on observation, interview, and record review, the facility failed to conduct regular inspections and maintenance of resident bed frames, mattresses, and bed rails, to identify areas of potential entrapment hazards for 4 (Resident #2, Resident #3, Resident #7, and Resident #9) of 14 residents reviewed for physical environment. The facility failed to conduct regular inspections of resident side rails, bed frames and mattresses to identify entrapment risks for Resident #2, Resident #3, Resident #7, and Resident #9. This failure could place residents at risk of injury resulting from equipment malfunction, entrapment, or falls. Findings included: Record review of Resident #2's electronic face sheet, dated 12/3/2025, reflected she was a [AGE] year-old female admitted [DATE] with diagnoses including history of falling and dementia.Record review of Resident #2's quarterly MDS, dated [DATE], reflected a BIMS score of 9 which indicated she had moderate cognitive impairment. Further review of the MDS reflected Resident #2 needed partial to moderate assistance with bed mobility and used bed rail daily. Record review of Resident #2's care plan, dated 9/12/2024, reflected half rails up per physician's order for safety and to assist with bed mobility. Observe for injury or entrapment related to side rail use. Record review of Resident #2's electronic physician orders reflected an order, dated 6/26/2023, reflected Resident #2 may use half or quarter bed rail for bed mobility/positioning or to enable transfers.Record review of facility document Bed Rail Appropriateness Checklist dated 7/16/2025 for Resident #2 reflected no documentation in the Equipment Compatibility & Safety section. There were no other documents provided by facility showing that bed rail entrapment risk assessment had been performed for Resident #2.During an observation on 12/2/2025 at 2:35 p.m., Resident #2 was in her bed and the bed had quarter rails in the up position. She was lying on her left side, her eyes were closed with unlabored respirations, and she was wearing an oxygen nasal cannula.During an observation on 12/3/2025 at 8:12 a.m., Resident #2 was lying in her bed on her right side and the bed had quarter rails in the up position. She was lying on her right side, her eyes were closed with unlabored respirations, and she was wearing an oxygen nasal cannula.Record review of Resident #3's electronic face sheet dated 12/3/2025 reflected she was an [AGE] year-old female admitted on [DATE] and readmitted [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (right sided weakness and right sided mobility issues after having a stroke), Alzheimer's disease (disease affecting the brain and interfering with the ability to think and causes memory deficits), and muscle weakness. Record review of Resident #3's quarterly MDS, dated [DATE], reflected a BIMS score of 0 which indicated she had severe cognitive impairment. Further review of the MDS reflected Resident #2 needed substantial assistance with bed mobility and used bed rail daily.Record review of Resident #3's care plan, dated 8/8/2024, reflected half rails up for safety and better mobility during care provision, to assist with bed mobility. Observe for injury or entrapment related to side rail use.Record review of Resident #3's electronic physician orders reflected an order dated 6/26/2023 which stated Resident #3 may use half or quarter bed rail for bed mobility/positioning or to enable transfers.Record review of facility document Bed Rail Appropriateness Checklist dated 7/16/2025 for Resident #3 reflected documentation in the Equipment Compatibility & Safety section showing bed rails were compatible with mattress/bed frame and did not pose risk of entrapment. There were no other documents provided by facility showing bed rail entrapment risk assessment were performed for Resident #3.During an observation on 12/2/2025 at 9:30 a.m., Resident #3 was laying in her bed with quarter rail in the up position. She had her eyes open but could not respond to questions asked.Record review of Resident #7's electronic face sheet dated 12/03/2025 reflected she was a [AGE] year-old female admitted on [DATE] and readmitted [DATE] with diagnoses including dementia and muscle weakness. Record review of Resident #7's annual MDS, dated [DATE], reflected a BIMS score of 3 which indicated she had severe cognitive impairment. Further review of the MDS reflected Resident #7 needed substantial assistance with bed mobility and used bed rail daily.Record review of Resident #7's care plan, dated 5/27/2020, reflected she had half rails up for safety during care provision, to assist with bed mobility. Observe for injury or entrapment related to side rail use.Record review of Resident #7's electronic physician orders reflected an order dated 8/8/2023 which stated Resident #7 may use half or quarter bed rail for bed mobility/positioning or to enable transfers. Record review of facility document Bed Rail Appropriateness Checklist dated 7/16/2025 for Resident #7 reflected documentation in the Equipment Compatibility & Safety section showing bed rails were compatible with mattress/bed frame and did not pose risk of entrapment. There were no other documents provided by facility showing bed rail entrapment risk assessment were performed for Resident #7.During an observation on 12/3/2025 at 8:13 a.m., Resident #7 was lying in her bed watching television. The bed had quarter rails in the up position. Record review of Resident #9's electronic face sheet dated 12/3/2025 reflected she was an [AGE] year-old female admitted on [DATE] with diagnoses including need for assistance with personal care, unsteadiness on feet, lack of coordination, multiple falls, and muscle weakness.Record review of Resident #9's quarterly MDS, dated [DATE], reflected a BIMS score of 12 which indicated she had moderate cognitive impairment. Further review of the MDS reflected Resident #9 needed substantial assistance with bed mobility and used bed rail daily. Record review of Resident #9's care plan, dated 8/11/2024, reflected she had half rails up for safety during care provision, to assist with bed mobility. Observe for injury or entrapment related to side rail use. Record review of Resident #9's electronic physician orders reflected an order, dated 8/8/2023, which stated Resident #9 may use half or quarter bed rail for bed mobility/positioning or to enable transfers.Record review of facility document Bed Rail Appropriateness Checklist dated 7/16/2025 for Resident #9 reflected documentation in the Equipment Compatibility & Safety section showing bed rails were compatible with mattress/bed frame and did not pose risk of entrapment. There were no other documents provided by facility showing bed rail entrapment risk assessment were performed for Resident #9.During an observation and interview on 12/2/2025 at 9:32 a.m., Resident #9 was in her bed and had half rails in the up position. She stated she used the rails for bed mobility. She stated if the rails got loose, she told the nursing staff. She stated the nursing staff would inform the maintenance director and he would tighten the rails. She stated, at this time, the rails were not loose.During an interview on 12/3/2025 at 2:09 p.m., the Maint D stated he went to the rooms as needed to assess bed rails for entrapment risk. He stated he conducted room inspections and inspected the bed rails at that time. The Maint D stated he also performed assessments of bed rails if staff told him the rails were loose. He stated he worked as the Maintenance Director for approximately three months and never documented the entrapment risk assessments. He stated he would reach out to his supervisor to see where the entrapment risk assessments were kept prior to his taking over as Maintenance Director. He stated he was not told to document those assessments and did not have a schedule that he went by to assess the bed rails. During an interview on 12/3/2025 at 3:46 p.m., Maint D stated he was a CNA prior to taking on the maintenance position. He stated no one told him the bed rails should be assessed prior to today. He stated he reached out to his management and was told bed rails were to be assessed for entrapment risk monthly. He stated the assessment was to make sure bed rails were not loose and fit the bed. He stated it was important to help prevent residents becoming injured or entrapped on the bed rails. During an interview on 12/3/2025 at 3:14 p.m., the ADMN stated his expectation was for bed rails to be assessed for monthly for entrapment risk by the Maintenance Director. He stated poor oversight led to the failure of Maint D not performing scheduled assessments of the bed rails. He stated he was responsible for monitoring Maint D performed those assessments, and he could not remember the last time he looked for them. He stated Maint D worked in his current position for about three months and did not know if he was instructed to perform those monthly bed rail assessments. He did not state who trained him on maintenance duties. He stated not performing the assessments increased the risk of residents being entrapped and could cause them harm.Review of facility policy titled Proper Use of Side Rails, dated December 2016, reflected, The resident will be checked periodically for safety relative to side rail use. If side rail use is associated with symptoms of distress, such as screaming or agitation, the resident's needs and use of side rails will be reassessed. When side rail usage is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk for entrapment (the amount of safe space may vary, depending on the type of bed and mattress being used).

Based on interview and record review, the facility failed to develop, implement, and maintain an effective training program for all new and existing staff for 5 of 16 (ADMN, DON, DM, Maint.D, and NA G) staff reviewed training requirements. The facility failed to implement and maintain a training program that ensured the DON, DM, Maint.D, and NA G received required HIV training upon hire. The facility failed to implement and maintain a training program that ensured the ADMN received required HIV annual training. These failures could place residents at risk of being cared for by staff insufficiently trained on the mode of HIV transmission, HIV prevention, behaviors related to substance abuse, precautions, rights of an infected individual and behaviors associated with HIV transmission. Findings included:Record review of personnel record for the ADMN reflected a hire date of 8/17/2021. Further review of personnel record provided by the AIT reflected no evidence he completed required annual HIV training for the previous 12 months.Record review of personnel record for the DON reflected a hire date of 7/1/2025. Further review of personnel record provided by the AIT reflected no evidence she completed required orientation HIV training.Record review of personnel record for the Maint D reflected a hire date of 1/15/2025. Further review of personnel record provided by the AIT reflected no evidence he completed required orientation HIV training.Record review of personnel record for the DM reflected a hire date of 10/20/2025. Further review of personnel record provided by the AIT reflected no evidence she completed required orientation HIV training.Record review of personnel record for NA G reflected a hire date of 11/6/2025. Further review of personnel record provided by the AIT reflected no evidence she completed required orientation HIV training.gs upon hire. During an interview on 12/3/2025 at 3:50 p.m., the ADMN stated all new hires were given orientation for required training through a hyperlink. He stated required annual training was performed through in-services that were held monthly. He stated he would look for the training required for the employees in question.During an interview on 12/4/2025 at 2:25 p.m., the AIT stated each department head was responsible for ensuring training was completed by employees. If a manager or staff from administration, then the office manager was responsible for ensuring training was completed by employees. She stated the ADMN and office manager monitored the training was completed and updated. She stated HIV training was important to ensure employees were adequately trained in how to provide proper care to residents. She stated the ADMN completed a checklist for annual training, and the office manager completed a checklist for new hire training. She stated the training was not done due to an oversight by the ADMN.During an attempted interview on 12/4/2025 at 2:25 p.m., the office manager was not available for an interview on employee training.During a telephone interview on 12/4/2025 at 3:14 p.m., the ADMN stated he expected staff to have required orientation and annual training. He stated he was responsible for ensuring that training was completed for all employees. He stated he went through the training three months ago and monitored they were completed. He stated not receiving required training could lead to poor quality of care for the residents. The ADMN stated he implemented a detailed orientation training program and implemented that in-service trainings were done on pay day so that employees completed training to receive their paycheck to help ensure that the trainings were completed. During a telephone interview on 12/4/2025 at 3:24 p.m., the DM stated she did not remember getting any orientation training on HIV. She stated she was trained by the ADMN on other subjects but could not remember ever receiving training on HIV. Record review of facility policy titled Orientation Program for Newly Hired Employees, Transfers, Volunteers, dated January 2008, reflected, All newly hired personnel/volunteers/transfers must attend a 10-hour orientation program within their first five (5) days of employment.A checklist is used to record materials reviewed with each employee/transfer/volunteer. A written record will be maintained of each employee's/volunteer's individual orientation program.Record review of facility policy titled [nursing facility name] Nursing Center Personnel Policies, dated July 2025, reflected no information on required personnel training on HIV during orientation or annually.Record review of facility policy titled Staff Development Program, dated December 2009, reflected, Staff development is defined as initial orientation, followed by regularly scheduled in-service training programs. All personnel are required to attend staff development classes.The following in-service training classes are mandatory (i.e., each employee must attend a training class on each of the following topics): a. Hepatitis B; b. AIDS; c. Tuberculosis; d. Infection Control; e. Resident Rights; f. Resident Abuse; g. Fire Safety and Disaster Preparedness; Hazard Communication Plan (i.e., exposure to chemicals); i. Exposure Control (i.e., exposure to blood or body fluids; J. _____; and k. _____.

Based on interview and record review, the facility failed to develop, implement, and maintain an effective training program for all new and existing staff for 6 of 16 (the DON, the DM, RN C, LVN E, NA G, and NA H) staff reviewed for training on effective communication. The facility failed to ensure communication training was provided to DON, DM, RN C, LVN E, NA G, and NA H upon hire. This failure could place residents at risk of not understanding their total health status and not effectively being provided notice of rights and services both orally and in writing in a manner that the resident understands. Findings were:Record review of the personnel record for the DON reflected a hire date of 7/1/2025. Further review of the personnel record provided by the AIT reflected the DON had no evidence that she had completed required effective communication training upon hire or while working at the facility.Record review of the personnel records for the DM reflected a hire date of 10/20/2025. Further review of the personnel record provided by the AIT reflected the DM had no evidence that she had completed required effective communication training upon hire or while working at the facility.Record review of the personnel records for RN C reflected a hire date of 9/1/2025. Further review of the personnel record provided by the AIT reflected RN C had no evidence that she had completed required effective communication training upon hire or while working at the facility. Record review of the personnel records for LVN E reflected a hire date of 6/20/2025. Further review of the personnel record provided by the AIT reflected LVN E had no evidence that she had completed required effective communication training upon hire or while working at the facility. Record review of the personnel records for NA G reflected a hire date of 11/6/2025. Further review of the personnel record provided by the AIT reflected NA G had no evidence that she had completed required effective communication training upon hire or while working at the facility.Record review of the personnel records for NA H reflected a hire date of 2/28/2025. Further review of the personnel record provided by the AIT reflected NA H had no evidence that she had completed required effective communication training upon hire or while working at the facility.During an interview on 12/3/2025 at 3:50 p.m., the ADMN stated all new hires were given orientation for required training through a hyperlink. He stated that required annual training was performed through in-services that were held monthly. He stated he would look for the training required for the employees in question.During an interview on 12/4/2025 at 2:25 p.m., the AIT stated each department head was responsible for ensuring training had been completed by employees. If a manager or staff from administration, then the office manager was responsible for ensuring training had been completed by employees. She stated the ADMN and office manager monitored that the training was completed and updated. She stated effective communication training was important to ensure employees were adequately trained on how to communicate with residents. She stated the ADMN was to complete a checklist for annual trainings, and the office manager completed a checklist for new hire training. She stated the training was not done due to an oversite by the ADMN.During an attempted interview on 12/4/2025 at 2:25 p.m., the office manager was not available for an interview on employee training.During a follow-up telephone interview on 12/4/2025 at 3:14 p.m., the ADMN stated he expected staff to have required orientation and annual training. He stated he was responsible for ensuring that training was completed for all employees. He stated he may have gone through the training 3 months ago and he does monitor that they were completed. He stated not receiving required training could lead to poor quality of care to the residents. The ADMN stated he had started providing a detailed orientation training program and implemented that in-service training to be done on pay day so that employees would complete to receive their paycheck to help ensure that the trainings were completed. During a telephone interview on 12/4/2025 at 3:24 p.m., the DM stated she did not remember getting any orientation training on effective communication. She stated she was trained by the ADMN on other subjects but could not remember ever receiving training on effective communication. Record review of facility policy titled Orientation Program for Newly Hired Employees, Transfers, Volunteers with revision date of January 2008 reflected All newly hired personnel/volunteers/transfers must attend a 10-hour orientation program within their first five (5) days of employment.A checklist is used to record materials reviewed with each employee/transfer/volunteer. A written record will be maintained of each employee's/volunteer's individual orientation program.Record review of facility policy titled [nursing facility name] Personnel Policies revised on July 2025 reflected no information on required personnel training on effective communication during orientation or annually.Record review of facility policy titled Staff Development Program revised on December 2009 reflected Staff development is defined as initial orientation, followed by regularly scheduled in-service training programs. All personnel are required to attend staff development classes.The following in-service training classes are mandatory (i.e., each employee must attend a training class on each of the following topics): a. Hepatitis B; b. AIDS; c. Tuberculosis; d. Infection Control; e. Resident Rights; f. Resident Abuse; g. Fire Safety and Disaster Preparedness; Hazard Communication Plan (i.e., exposure to chemicals); i. Exposure Control (i.e., exposure to blood or body fluids; J. _____; and k. _____.

Based on interview and record review, the facility failed to develop, implement, and maintain an effective training program for all new and existing staff for 4 of 16 (the DM, LVN E, NA G, and NA H) staff reviewed for training on resident's rights. The facility failed to ensure that the DM, LVN E, NA G, and NA H were educated on the rights of the resident, and the responsibilities of the facility to properly care for its residents upon hire.This failure could place residents at risk of their rights not being honored by uninformed staff.The findings were:Record review of the personnel records for the DM reflected a hire date of 10/20/2025. Further review of personnel record provided by the AIT reflected the DM had no evidence that she had completed required resident rights training upon hire or while working at the facility.Record review of the personnel records for LVN E reflected a hire date of 6/20/2025. Further review of the personnel record provided by the AIT reflected LVN E had no evidence that she had completed required resident rights training upon hire or while working at the facility. Record review of the personnel records for NA G reflected a hire date of 11/6/2025. Further review of the personnel record provided by the AIT reflected NA G had no evidence that she had completed required resident rights training upon hire or while working at the facility.Record review of the personnel records for NA H reflected a hire date of 2/28/2025. Further review of the personnel record provided by the AIT reflected NA H had no evidence that she had completed required resident rights training upon hire or while working at the facility.During an interview on 12/3/2025 at 3:50 p.m., the ADMN stated all new hires were given orientation for required training through a hyperlink. He stated that required annual training was performed through in-services that were held monthly. He stated he would look for the training required for the employees in question.During an interview on 12/4/2025 at 2:25 p.m., the AIT stated each department head was responsible for ensuring training had been completed by employees. If a manager or staff from administration, then the office manager was responsible for ensuring training had been completed by employees. She stated the ADMN and office manager monitored that the training was completed and updated. She stated resident rights training was important to ensure employees were adequately trained on how to honor resident rights. She stated the ADMN was to complete a checklist for annual trainings, and the office manager completed a checklist for new hire training. She stated the training was not done due to an oversite by the ADMN.During an attempted interview on 12/4/2025 at 2:25 p.m., the office manager was not available for an interview on employee training.During a follow-up telephone interview on 12/4/2025 at 3:14 p.m., the ADMN stated he expected staff to have required orientation and annual training. He stated he was responsible for ensuring that training was completed for all employees. He stated he may have gone through the training 3 months ago and he does monitor that they were completed. He stated not receiving required training could lead to poor quality of care to the residents. The ADMN stated he had started providing a detailed orientation training program and implemented that in-service training to be done on pay day so that employees would complete to receive their paycheck to help ensure that the trainings were completed. During a telephone interview on 12/4/2025 at 3:24 p.m., the DM stated she did not remember getting any orientation training on resident rights. She stated she was trained by the ADMN on other subjects but could not remember ever receiving training on resident rights. Record review of facility policy titled Orientation Program for Newly Hired Employees, Transfers, Volunteers with revision date of January 2008 reflected All newly hired personnel/volunteers/transfers must attend a 10-hour orientation program within their first five (5) days of employment.A checklist is used to record materials reviewed with each employee/transfer/volunteer. A written record will be maintained of each employee's/volunteer's individual orientation program.Record review of facility policy titled [nursing facility name] Personnel Policies revised on July 2025 reflected no information on required personnel training on resident rights during orientation or annually.Record review of facility policy titled Staff Development Program revised on December 2009 reflected Staff development is defined as initial orientation, followed by regularly scheduled in-service training programs. All personnel are required to attend staff development classes.The following in-service training classes are mandatory (i.e., each employee must attend a training class on each of the following topics): a. Hepatitis B; b. AIDS; c. Tuberculosis; d. Infection Control; e. Resident Rights; f. Resident Abuse; g. Fire Safety and Disaster Preparedness; Hazard Communication Plan (i.e., exposure to chemicals); i. Exposure Control (i.e., exposure to blood or body fluids; J. _____; and k. _____.

Based on interview and record review, the facility failed to develop, implement, and maintain an effective training program for all new and existing staff for 3 of 16 (the DM, RN C, and NA G) staff reviewed for training on abuse, neglect, and exploitation and training for dementia management. The facility failed to ensure that NA G was educated on abuse, neglect and exploitation & dementia management upon hireThe facility failed to ensure that the DM and RN C were educated on dementia management upon hire. These failures could place residents at risk of being abused, neglected, or exploited by uniformed staff and could delay the facility's investigation of abuse, neglect, or exploitation. Findings were:Record review of the personnel records for NA G reflected a hire date of 11/6/2025. Further review of the personnel record provided by the AIT reflected NA G had no evidence that she had completed neither the abuse, neglect, and exploitation training nor the dementia management training upon hire or while working at the facility.Record review of the personnel records for the DM reflected a hire date of 10/20/2025. Further review of the personnel record provided by the AIT reflected the DM had no evidence that she had completed dementia management training upon hire or while working at the facility.Record review of the personnel records for RN C reflected a hire date of 9/1/2025. Further review of the personnel record provided by the AIT reflected RN C had no evidence that she had completed dementia management training upon hire or while working at the facility. During an interview on 12/3/2025 at 3:50 p.m., the ADMN stated all new hires were given orientation for required training through a hyperlink. He stated that required annual training was performed through in-services that were held monthly. He stated he would look for the training required for the employees in question.During an interview on 12/4/2025 at 2:25 p.m., the AIT stated each department head was responsible for ensuring training had been completed by employees. If a manager or staff from administration, then the office manager was responsible for ensuring training had been completed by employees. She stated the ADMN and office manager monitored that the training was completed and updated. She stated abuse, neglect, and exploitation & dementia management training were important to ensure employees were adequately trained on how to recognize and report abuse, neglect, and exploitation to the facility's abuse coordinator. She stated the ADMN was to complete a checklist for annual trainings, and the office manager completed a checklist for new hire training. She stated the training was not done due to an oversite by the ADMN.During an attempted interview on 12/4/2025 at 2:25 p.m., the office manager was not available for an interview on employee training.During a follow-up telephone interview on 12/4/2025 at 3:14 p.m., the ADMN stated he expected staff to have required orientation and annual training. He stated he was responsible for ensuring that training was completed for all employees. He stated he may have gone through the training 3 months ago and he does monitor that they were completed. He stated not receiving required training could lead to poor quality of care to the residents. The ADMN stated he had started providing a detailed orientation training program and implemented that in-service training to be done on pay day so that employees would complete to receive their paycheck to help ensure that the trainings were completed. During a telephone interview on 12/4/2025 at 3:24 p.m., the DM stated she was trained by the ADMN on many subjects but could not remember if she had been educated on abuse, neglect, or exploitation. Record review of facility policy titled Orientation Program for Newly Hired Employees, Transfers, Volunteers with revision date of January 2008 reflected All newly hired personnel/volunteers/transfers must attend a 10-hour orientation program within their first five (5) days of employment.A checklist is used to record materials reviewed with each employee/transfer/volunteer. A written record will be maintained of each employee's/volunteer's individual orientation program.Record review of facility policy titled [name of facility] Personnel Policies revised on July 2025 reflected no information on required personnel training on abuse, neglect, and exploitation or dementia management at orientation or annually.Record review of facility policy titled Staff Development Program revised on December 2009 reflected Staff development is defined as initial orientation, followed by regularly scheduled in-service training programs. All personnel are required to attend staff development classes.The following in-service training classes are mandatory (i.e., each employee must attend a training class on each of the following topics): a. Hepatitis B; b. AIDS; c. Tuberculosis; d. Infection Control; e. Resident Rights; f. Resident Abuse; g. Fire Safety and Disaster Preparedness; Hazard Communication Plan (i.e., exposure to chemicals); i. Exposure Control (i.e., exposure to blood or body fluids; J. _____; and k. _____.

Based on interview and record review, the facility failed to develop, implement, and maintain an effective training program for all new and existing staff for 5 of 16 (the DON, the DM, RN C, LVN E, and NA G) staff reviewed for training on QAPI. The facility failed to ensure that the DON, the DM, RN C, LVN E, and NA G were educated on the facility's QAPI program upon hire. This failure could place residents at risk of their quality of care not being improved upon when a known issue had occurred from staff not being informed on the goals and various elements of the QAPI program. Findings were:Record review of personnel record for the DON reflected a hire date of 7/1/2025. Further review of the personnel record provided by the AIT reflected the DON had no evidence that she had completed QAPI training upon hire or while working at the facility.Record review of the personnel records for the DM reflected a hire date of 10/20/2025. Further review of the personnel record provided by the AIT reflected the DM had no evidence that she had completed QAPI training upon hire or while working at the facility.Record review of the personnel records for RN C reflected a hire date of 9/1/2025. Further review of the personnel record provided by the AIT reflected RN C had no evidence that she had completed QAPI training upon hire or while working at the facility. Record review of the personnel records for LVN E reflected a hire date of 6/20/2025. Further review of the personnel record provided by the AIT reflected LVN E had no evidence that she had completed QAPI training upon hire or while working at the facility. Record review of the personnel records for NA G reflected a hire date of 11/6/2025. Further review of the personnel record provided by the AIT reflected NA G had no evidence that she had completed QAPI training upon hire or while working at the facility.During an interview on 12/3/2025 at 3:50 p.m., the ADMN stated all new hires were given orientation for required training through a hyperlink. He stated that required annual training was performed through in-services that were held monthly. He stated he would look for the training required for the employees in question.During an interview on 12/4/2025 at 2:25 p.m., the AIT stated each department head was responsible for ensuring training had been completed by employees. If a manager or staff from administration, then the office manager was responsible for ensuring training had been completed by employees. She stated the ADMN and office manager monitored that the training was completed and updated. She stated QAPI training was important to ensure employees were adequately trained on how the facility's QAPI program works on its known areas that could be improved upon. She stated the ADMN was to complete a checklist for annual trainings, and the office manager completed a checklist for new hire training. She stated the training was not done due to an oversite by the ADMN.During an attempted interview on 12/4/2025 at 2:25 p.m., the office manager was not available for an interview on employee training.During a follow-up telephone interview on 12/4/2025 at 3:14 p.m., the ADMN stated he expected staff to have required orientation and annual training. He stated he was responsible for ensuring that training was completed for all employees. He stated he may have gone through the training 3 months ago and he does monitor that they were completed. He stated not receiving required training could lead to poor quality of care to the residents. The ADMN stated he had started providing a detailed orientation training program and implemented that in-service training to be done on pay day so that employees would complete to receive their paycheck to help ensure that the trainings were completed. During a telephone interview on 12/4/2025 at 3:24 p.m., the DM stated she did not remember getting any orientation training on QAPI. She stated she was trained by the ADMN on other subjects but could not remember ever receiving training on QAPI. Record review of facility policy titled Orientation Program for Newly Hired Employees, Transfers, Volunteers with revision date of January 2008 reflected All newly hired personnel/volunteers/transfers must attend a 10-hour orientation program within their first five (5) days of employment.A checklist is used to record materials reviewed with each employee/transfer/volunteer. A written record will be maintained of each employee's/volunteer's individual orientation program.Record review of facility policy titled [name of facility] Personnel Policies revised on July 2025 reflected no information on required personnel training on QAPI at orientation or annually.Record review of facility policy titled Staff Development Program revised on December 2009 reflected Staff development is defined as initial orientation, followed by regularly scheduled in-service training programs. All personnel are required to attend staff development classes.The following in-service training classes are mandatory (i.e., each employee must attend a training class on each of the following topics): a. Hepatitis B; b. AIDS; c. Tuberculosis; d. Infection Control; e. Resident Rights; f. Resident Abuse; g. Fire Safety and Disaster Preparedness; Hazard Communication Plan (i.e., exposure to chemicals); i. Exposure Control (i.e., exposure to blood or body fluids; J. _____; and k. _____.

Based on interview and record review, the facility failed to develop, implement, and maintain an effective training program for all new and existing staff for 4 of 16 (the DON, the DM, LVN E, and NA G) staff reviewed for training on infection control. The facility failed to ensure that the DON, the DM, LVN E, and NA G were educated on infection control upon hire. This failure could place residents at risk of contracting facility acquired infections from staff not being informed on proper infection prevention and control practices when performing resident care activities that pertain to that staff member's role.Findings were:Record review of personnel record for the DON reflected a hire date of 7/1/2025. Further review of the personnel record provided by the AIT reflected the DON had no evidence that she had completed infection control training upon hire or while working at the facility.Record review of the personnel records for the DM reflected a hire date of 10/20/2025. Further review of the personnel record provided by the AIT reflected the DM had no evidence that she had completed infection control training upon hire or while working at the facility.Record review of the personnel records for LVN E reflected a hire date of 6/20/2025. Further review of the personnel record provided by the AIT reflected LVN E had no evidence that she had completed infection control training upon hire or while working at the facility. Record review of the personnel records for NA G reflected a hire date of 11/6/2025. Further review of the personnel record provided by the AIT reflected NA G had no evidence that she had completed infection control training upon hire or while working at the facility.During an interview on 12/3/2025 at 3:50 p.m., the ADMN stated all new hires were given orientation for required training through a hyperlink. He stated that required annual training was performed through in-services that were held monthly. He stated he would look for the training required for the employees in question.During an interview on 12/4/2025 at 2:25 p.m., the AIT stated each department head was responsible for ensuring training had been completed by employees. If a manager or staff from administration, then the office manager was responsible for ensuring training had been completed by employees. She stated the ADMN and office manager monitored that the training was completed and updated. She stated infection control training was important to ensure employees were adequately trained on how to prevent infections. She stated the ADMN was to complete a checklist for annual trainings, and the office manager completed a checklist for new hire training. She stated the training was not done due to an oversite by the ADMN.During an attempted interview on 12/4/2025 at 2:25 p.m., the office manager was not available for an interview on employee training.During a follow-up telephone interview on 12/4/2025 at 3:14 p.m., the ADMN stated he expected staff to have required orientation and annual training. He stated he was responsible for ensuring that training was completed for all employees. He stated he may have gone through the training 3 months ago and he does monitor that they were completed. He stated not receiving required training could lead to poor quality of care to the residents. The ADMN stated he had started providing a detailed orientation training program and implemented that in-service training to be done on pay day so that employees would complete to receive their paycheck to help ensure that the trainings were completed. During a telephone interview on 12/4/2025 at 3:24 p.m., the DM stated she did not remember getting any orientation training on infection control. She stated she was trained by the ADMN on other subjects but could not remember ever receiving training on infection control. Record review of facility policy titled Orientation Program for Newly Hired Employees, Transfers, Volunteers with revision date of January 2008 reflected All newly hired personnel/volunteers/transfers must attend a 10-hour orientation program within their first five (5) days of employment.A checklist is used to record materials reviewed with each employee/transfer/volunteer. A written record will be maintained of each employee's/volunteer's individual orientation program.Record review of facility policy titled [name of facility] Personnel Policies revised on July 2025 reflected no information on required personnel training on infection control at orientation or annually.Record review of facility policy titled Staff Development Program revised on December 2009 reflected Staff development is defined as initial orientation, followed by regularly scheduled in-service training programs. All personnel are required to attend staff development classes.The following in-service training classes are mandatory (i.e., each employee must attend a training class on each of the following topics): a. Hepatitis B; b. AIDS; c. Tuberculosis; d. Infection Control; e. Resident Rights; f. Resident Abuse; g. Fire Safety and Disaster Preparedness; Hazard Communication Plan (i.e., exposure to chemicals); i. Exposure Control (i.e., exposure to blood or body fluids; J. _____; and k. _____.

Based on interview and record review, the facility failed to develop, implement, and maintain an effective training program for all new and existing staff for 3 of 16 (the DON, the DM, and NA G) staff reviewed for training on behavioral health. The facility failed to ensure that the DON, the DM, and NA G were educated on behavioral health upon hire. This failure could place residents diagnosed with a mental, psychosocial, or substance use disorder at risk of not receiving the care specific to their individual needs.Findings were:Record review of personnel record for the DON reflected a hire date of 7/1/2025. Further review of the personnel record provided by the AIT reflected the DON had no evidence that she had completed behavioral health training upon hire or while working at the facility.Record review of the personnel records for the DM reflected a hire date of 10/20/2025. Further review of the personnel record provided by the AIT reflected the DM had no evidence that she had completed behavioral health training upon hire or while working at the facility.Record review of the personnel records for NA G reflected a hire date of 11/6/2025. Further review of the personnel record provided by the AIT reflected NA G had no evidence that she had completed behavioral health training upon hire or while working at the facility.During an interview on 12/3/2025 at 3:50 p.m., the ADMN stated all new hires were given orientation for required training through a hyperlink. He stated that required annual training was performed through in-services that were held monthly. He stated he would look for the training required for the employees in question.During an interview on 12/4/2025 at 2:25 p.m., the AIT stated each department head was responsible for ensuring training had been completed by employees. If a manager or staff from administration, then the office manager was responsible for ensuring training had been completed by employees. She stated the ADMN and office manager monitored that the training was completed and updated. She stated behavioral health training was important to ensure employees were adequately trained on how to prevent behaviors. She stated the ADMN was to complete a checklist for annual trainings, and the office manager completed a checklist for new hire training. She stated the training was not done due to an oversite by the ADMN.During an attempted interview on 12/4/2025 at 2:25 p.m., the office manager was not available for an interview on employee training.During a follow-up telephone interview on 12/4/2025 at 3:14 p.m., the ADMN stated he expected staff to have required orientation and annual training. He stated he was responsible for ensuring that training was completed for all employees. He stated he may have gone through the training 3 months ago and he does monitor that they were completed. He stated not receiving required training could lead to poor quality of care to the residents. The ADMN stated he had started providing a detailed orientation training program and implemented that in-service training to be done on pay day so that employees would complete to receive their paycheck to help ensure that the trainings were completed. Record review of facility policy titled Orientation Program for Newly Hired Employees, Transfers, Volunteers with revision date of January 2008 reflected All newly hired personnel/volunteers/transfers must attend a 10-hour orientation program within their first five (5) days of employment.A checklist is used to record materials reviewed with each employee/transfer/volunteer. A written record will be maintained of each employee's/volunteer's individual orientation program.Record review of facility policy titled [name of facility]Personnel Policies revised on July 2025 reflected no information on required personnel training on behavioral health at orientation or annually.Record review of facility policy titled Staff Development Program revised on December 2009 reflected Staff development is defined as initial orientation, followed by regularly scheduled in-service training programs. All personnel are required to attend staff development classes.The following in-service training classes are mandatory (i.e., each employee must attend a training class on each of the following topics): a. Hepatitis B; b. AIDS; c. Tuberculosis; d. Infection Control; e. Resident Rights; f. Resident Abuse; g. Fire Safety and Disaster Preparedness; Hazard Communication Plan (i.e., exposure to chemicals); i. Exposure Control (i.e., exposure to blood or body fluids; J. _____; and k. _____.

Based on interview and record review, the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, that were complete and accurate for 1 (Resident #7) of 12 residents reviewed for resident records.The facility failed to ensure Resident #7's physician order and face sheet matched Resident #7's care plan for DNR.This failure could place residents at risk of having CPR when they or their representatives have requested no CPR treatment.Findings included: Record review of Resident #7's electronic face sheet, dated [DATE], reflected she was a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses including dementia (losing your memory and other thinking skills so much that it gets in the way of your daily life). Further review of face sheet reflected Resident #7was a Full Code status, meaning she would receive CPR if her heart stopped beating, or she stopped breathing. Record review of Resident #7's annual MDS, dated [DATE], reflected a BIMS score of 03 indicating severe cognitive impairment. Further review of the MDS reflected Resident #7 did not have a disease that might result in a life expectancy of less than six months.Record review of Resident #7's care plan, dated [DATE], reflected she was a DNR code status and, if respirations and heart ceased to beat, she would not have CPR started, with last revision dated [DATE].Record review of Resident #7's clinical record reflected an OOHDNR dated [DATE]. During an observation on [DATE] at 8:13 a.m., Resident #7 was lying in her bed watching television. The bed had quarter rails in the up position. During an attempted interview on [DATE] at 1:57 p.m., Resident #7's representative did not answer the telephone.During an interview on [DATE] at 9:53 a.m., the ADON stated she was responsible for updating care plans and verifying physician orders matched the resident's current code status. She stated she was not employed at the facility when the order for code status was placed in Resident #7's electronic record. The ADON stated she worked for the facility almost six months, and the DON started after her. She stated the DON was not in the facility. She did not state what system was in place for monitoring medical records to ensure orders were entered accurately and timely.During an interview on [DATE] at 10:48 a.m., LVN D stated she knew a resident's code status by the sticker on the outside of their door. She stated a red sticker was a DNR. She stated the code status was also found in the electronic medical record under the physician orders. She stated the care plan should match the code status. LVN D stated if the care plan and code status did not match it could cause confusion on whether CPR needed to be performed or not. She stated if there was conflicting information in a resident's chart, it could delay treatment or cause CPR to be performed on a resident that did not want CPR.During an interview on [DATE] at 10:50 a.m., LVN A stated she knew a resident's code status by looking in the Code Status binder at the nurses' station. She stated she also could look up code status in the electronic physician orders and a resident's care plan. She stated code status information should have been the same on the physician orders, care plan and face sheet to minimize confusion on what that resident's wishes were in an emergency situation where CPR may need to be performed.During an interview on [DATE] at 1:30 p.m., the ADON stated she found the OOHDNR for Resident #7. She stated Resident #7's care plan was correct that Resident #7 was not to have CPR treatment. She stated she was not sure why the electronic physician orders or the code binder at the nurses' station did not match the care plan, but she would get them corrected. She stated not having matching physician orders, care plan, face sheet, and code status binder could cause a resident to receive the wrong life saving treatment or delay in life saving treatment. She stated both her and the DON were responsible for monitoring that code status was correct.During an interview on [DATE] at 2:25 p.m., the AIT stated she expected physician orders to be updated immediately and updated in electronic medical record within 24 hours of an order being received. She stated the nurses were responsible for collecting the OOHDNR orders and should have placed those orders in a bin. She stated the office manager would gather the OOHDNR orders from the bin and scan them into the electronic chart for the appropriate resident. She stated if the electronic order in the resident chart did not match the OOHDNR order document and care plan, resident's rights may be violated in an emergency event requiring CPR. She stated performing CPR to a resident that had an OOHDNR could lead to a licensure issue for the nurse providing treatment in a situation where CPR would need to be performed. The AIT stated performing CPR on a resident that had chosen to not have that treatment could also have severe physical consequences for the resident. Record review of facility policy titled, Accurate Record Keeping with no date reflected, The nursing facility is committed to maintaining accurate, truthful, and complete records in all areas, including but not limited to clinical documentation, billing, resident assessments, staffing records, and financial reports.Any discrepancies or missing information must be reported immediately to a supervisor or the DON.The facility will conduct periodic internal audits of records to verify accuracy and compliance. Any identified errors or discrepancies will be reviewed, corrected and used for staff education.Record review of facility policy titled, Advanced Directives revised on [DATE], reflected, Information about whether or not the resident has executed an advanced directive shall be displayed prominently in the medical record.The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. The resident has the right to refuse treatment, whether or not he or she has an advanced directive. A resident will not be treated against his or her own wishes.

Based on observation, interview, and record review, the facility failed to ensure the resident's environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 2 of 24 residents (Resident #1 and Resident #2) whose records were reviewed for quality of care. 1. The facility failed to ensure Resident #1 was supervised to prevent the ingesting of chemical. 2. The facility failed to ensure Resident #2 received adequate supervision to prevent the resident from leaving the facility. An Intermediate Jeopardy (IJ) was identified on 08/14/2025. The IJ template was provided to the facility on [DATE] at 5:00 p.m. While the IJ was removed on 08/20/2025, the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of pain, mental anguish, emotional distress, diminished quality of life, and serious physical harm. The findings included: 1. Record review of Resident #1's Face Sheet, dated 08/08/2025, revealed an [AGE] year-old female who was admitted into the facility on [DATE]. Resident #1's diagnoses included Pneumonitis due to inhalation of other solids and liquids (lung inflammation caused by inhaling a foreign substance other than those with specific codes, such as food (aspiration) or oils and essences), GERD (a chronic digestive disorder where stomach contents flow back into the esophagus, causing symptoms like heartburn, regurgitation, and chest pain), Respiratory failure, unspecified with hypoxia (a condition where the lungs are unable to adequately oxygenate the blood [hypoxia]), Other contact with exposures hazardous to health (situation where someone has been exposed to substances or conditions in the environment that pose a risk to their health, but are not infectious diseases or specific chemical toxicities), Dementia in other diseases classified elsewhere (dementia that arises as a secondary condition from a different underlying disease, rather than as a primary condition), unspecified severity, with agitation, Anxiety disorder (a mental health condition characterized by excessive and uncontrollable worry, fear, or panic that interferes with daily life) due to know physiological condition, Mild cognitive impairment of unknown etiology (a person experiences cognitive decline that is not severe enough to be diagnosed as dementia, but the underlying cause of this decline is not clear, and Essential (Primary) Hypertension (high blood pressure with no known, identifiable cause). Record review of Resident #1's Quarterly MDS, dated [DATE], revealed Resident #1's BIMS score was 00, which indicated severe cognitively impaired response. Section C - Cognitive Patterns, C0100 revealed Resident #1 was rarely/never understood in interview to conduct assessment. Record review of Resident #1 Care Plan did not have an intervention addressing ingesting non edible's until after the incident on 08/05/2025. Record review of Residents #1's Event Note, dated 07/30/2025, completed by LVN O, revealed Resident #1 had ingested (drank) Hibiclens [hazardous antimicrobial cleanser] as reported by CNA A. Further documentation revealed CNA A entered Resident #1's room at approximately 5:30 p.m. and observed Resident #1 in her recliner. Upon observation, Resident #1 was throwing up and coughing. CNA A noticed Resident #1 had Hibiclens. The nurse was notified immediately. Review of progress notes dated 7/30/2025 revealed medical personnel were contacted, and Resident #1 was transported to the hospital. Record review of Resident #1's hospital records, dated 7/30/2025, revealed she developed facial flushing with wheezing, distressful bouts of coughing, and was found hypoxic with O2 saturation of 87% on room air. Resident #1 was admitted to the hospital on [DATE]. Record review of hospital records dated 08/05/2025 revealed Resident #1 remained hospitalized until discharged on 08/05/2025 with the diagnoses of Aspiration pneumonitis, Hypoxia, and Accidental ingestion of substance. Record review of Resident #1's hospital admission Sheet, dated 07/30/2025 at 7:01 p.m., revealed Resident #1 arrived at the emergency room and was admitted with diagnoses of Accidental ingestion of substance, Aspiration pneumonitis, and Hypoxia. Record review of Resident #1's hospital History and Physical, dated 07/30/2025 at 9:50 a.m., revealed Resident #1 was admitted to the hospital and had a background medical history of prior heavy alcohol consumption as obtained from Resident #1's family member. Record review revealed, Patient had accidentally ingested unspecified amount of Hibiclens brand chlorhexidine antiseptic cleanser at the nursing home this evening. Volume of ingested Hibiclens could not be ascertained. Resident #1 developed interval facial flushing with wheezing. EMS was called. With patient given a dose of Benadryl 50mg IM and a run of DuoNeb with 125 mg of IV Solu-Medrol. Poison control was reportedly contacted from the nursing home with recommendation to have patients sent to the ER for observation and symptomatic management. Arrival to the ED, patient was having stressful bouts of coughing and was found hypoxic with O2 saturation at 87% on room air. She was placed on 2 L of supplemental oxygen to bring her O2 stat. Into the mid-90s. Test at 3 done in the ED did not show any acute cardiopulmonary process. Lab draw was only remarkable for borderline leukocytosis white count at 11. Beside auscultation reveals very coarse breath sounds with continued distressful coughing. Patient was admitted for telemetric observation and symptomatic management with the need for supplemental oxygen therapy. Record review of Resident #1's hospital discharge instructions, dated [DATE], revealed Resident #1 was admitted into the hospital on [DATE] for complaint of cough with shortness of breath. Resident #1 was admitted to the hospital with diagnosis of accidental ingestions of antiseptic cleansing agent as well as aspiration pneumonitis. Discharge diagnoses included Dysphagia (difficulty swallowing) and Aspiration pneumonitis. Record review of the Material Safety Data Sheet for product identifier Hibiclens, dated 06/13/2012, revealed - irritating to eyes; should be kept out of the reach of children; Other hazards: may cause irritation of respiratory tract. Record review of the Incident Investigation Report, not dated, provided by DON C on 08/08/2025, revealed the following [in part]: Incident Description: Only July 30, 2025, during meal service, staff member [CNA A] discovered resident [Resident #1] vomiting red-colored substant while delivering food trays. Initial concern was potential hematemesis (blood in vomit). Upon closer examination, staff determined the red substance appeared consistent with the Hibiclens antiseptic skin cleaner that had been inadvertently left in the resident's room. The resident was observed coughing and appeared to have ingested an unknown quantity of red-colored Hibiclens cleansing solution.Plan of Correction: Incident Summary: On 07/30/2025, [Resident #1] ingested skin cleaning solution, resulting in immediate hospitalization due to high levels of toxicity. The Resident survived but required emergency medical intervention and hospitalization. During an interview on 08/08/2025 at 2:54 p.m., CNA A said she was the first one to find Resident #1 and contact as she was passing out dinner trays. CNA A said she walked into Resident #1's room and witnessed her as she threw up red vomit and coughed profusely. CNA A said she saw a red bottle on her rolling table, the label had Hibiclens on the bottle, and the bottle was empty. CNA A said she reported the incident to the charge nurse on duty on 07/30/2025, but the nurse was no longer employed with the facility. CNA A said the nurse called 911 and poison control. CNA A said the resident was taken to the hospital by ambulance. CNA A said prior to the incident, she had last seen the resident an hour prior at approximately 4:30pm, and said the bottle of Hibiclens was on her table next to her recliner approximately 1/4 full of liquid. During an on interview on 08/10/2025 at 3:11 p.m., NA B said she was on duty with Resident #1 ingested the chemical Hibiclens. NA B said she went into her room after CNA A reported the incident to the nurse and witnessed Resident #1 coughing up red stuff. NA A said she saw a plastic bottle, labeled Hibiclens on Resident #1's bed side table and the bottle was empty. NA A said Resident #1's vomit was bright red, and Resident #1 was coughing profusely and loudly. During an interview on 08/10/2025 at 3:34 p.m., ADON E said she was not aware how the Hibiclens was brought into the facility as it was not used by the facility on a regular basis. She said Resident #1 would ambulate by wheelchair, pushing the chair with her feet and wander up and down the hall and into other residents' rooms. During an interview on 08/11/2025 at 9:58 a.m., the Administrator-in-Training F said she was notified Resident #1 ingested chemicals the day the incident occurred by text from ADON E and LVN O. The Administrator-in-Training F said she had not read the hospital records, but was aware the incident had caused some respiratory issues and Resident #1 required the assistance of oxygen when she was transported to the emergency room on 7/30/2025. The Administrator-in-Training F said the incident was investigated, and the facility could not determine how the chemical was brought into the building. The Administrator-in-Training F said Resident #1 ingested the skin cleanser and she interviewed the staff on duty the day of the incident. The Administrator-in-Training F said she would in-service staff on the need to keep chemicals locked and out of reach of residents on 08/29/2025 even though the incident occurred 07/30/2025. The Administrator-in-Training F said the facility scheduled all-staff in-services on a monthly basis. The Administrator-in-Training F said the facility had difficulty getting all staff together at one time so monthly in-services worked best for the staff. During an interview on 08/12/2025 at 10:45 a.m., the Primary Care Doctor G said he was aware Resident #1 ingested antibacterial skin cleanser and the dangers of ingesting the chemical depended on the amount ingested. The Primary Care Doctor G said Resident #1 ingested enough to cause excessive coughing and vomiting that required hospitalization. The Primary Care Doctor G said the fact that Resident #1 ingested skin cleanser, that can cause nausea, vomiting, and diarrhea, was serious because a person does not typically ingest skin cleanser. The Primary Care Doctor G said the skin cleanser Resident #1 ingested was typically used on the skin prior to surgery. The Primary Care G Doctor said the skin cleanser would act as a deterrent as it can cause the throat and skin to become irritated and reflux can cause the chemical to come back up and irritate the esophagus and throat. During a follow-up interview on 08/13/2025 at 1:19 p.m., CNA A said when she entered Resident #1's room, she observed Resident #1 sitting in her recliner. CNA A said Resident #1 was throwing up dark red vomit and coughing profusely. CNA A said she observed an empty bottle of antibacterial skin cleanser on Resident #1's bed side table approximately 12 inches from where Resident #1 was sitting. CNA A said the vomit was on the inside of the recliner between her arm of chair and Resident #1's lap on the right side and bright enough that she thought the vomitus was blood. CNA A said she immediately notified LVN O of the incident. 2. Resident #2 was an [AGE] year-old male, admitted to the facility on [DATE]. Primary diagnoses of Hemiplegia and Hemiparesis following Cerebral Infarction affecting right non-dominate side (stroke characterized by paralysis and weakness on one side of the body) and unspecified dementia (a decline in cognitive function without a clear underlying cause). Record review of Resident #2's Quarterly MDS, dated [DATE], revealed a BIMS score of 10 which indicated moderate cognitive impairment, Section GG revealed Resident #2 had lower extremity impairment to one side and ambulated using a walker. He required supervision or touching assistance when walking. Record review of Resident #2's Care Plan, dated as reviewed on 07/04/2025 revealed: Focus 7/4/25: Today he eloped from the facility, he was found about a mile away. The care plan revealed no evidence addressing at risk elopement status prior to the incident. Record review of the Wander Risk assessment dated [DATE] revealed Resident #2 was scored at risk of wandering. Record review of progress note, dated 07/04/2025 at 1:20 p.m., revealed Resident #2 was found unsupervised by a family friend on 07/04/2025 walking down the street, in front of the flower shop, and was returned to the facility by the family friend. In an interview on 08/12/2025 at 12:41 p.m., Resident #2 said he lives about 8 blocks away and wanted to go home. He learned the code from watching other staff exit the facility and was going to walk home. He said he was about halfway there before he was brought back. In an interview on 08/12/25 at 2:40 pm, CNA I said on 07/04/25 she brought Resident #2's lunch tray to his room and left it in his room on his bedside table. She could not recall the specific time but said lunch generally starts around 11:30 pm. She said the light was on and door was closed to the bathroom, and she thought the resident was in the bathroom. In an interview on 08/13/25 at 11:06 am, LVN L said 07/04/25 at approximately 12:20 pm, it was reported to her during lunch they could not find Resident #2. A head count was completed, and it was determined that Resident #2 was missing. She did not contact the police. At 12:40 pm, she got into her car to go search for the resident and as she was driving down the street, she saw the resident in a family friends car bringing him back to the facility. She said the resident was returned to the facility at 12:50 am. She said lunch was usually served starting at 11:30 am. In an observation on 08/13/2025 at 12:30 pm of the area outside of the facility revealed the street in front of the facility had a speed limit of 45 miles per hour, no sidewalks, and an active railroad track adjacent to the road. In an interview on 08/13/2025 at 1:04 pm, DON C said she was not employed at the time of incident. She said Resident #2 was currently not on any precautions for elopement nor was he at the time of the incident. When asked if there were any interventions in place in Resident #2's care plan addressing his high elopement risk, she did not know and was not able to access the resident's care plan due to not being able to get into Point Click Care, the electronic charting system due to password settings. In an interview on 08/13/2025 at 1:12 pm, ADON E said when Resident #2's family comes to visit, he gets agitated wanting to go home. In an interview on 08/13/2025 at 1:15 pm, Activity Director M said she had observed Resident #2 expressing to his family when they visit that he wants to go home. In an interview on 08/13/2025 at 3:00 pm, the Administrator-in-Training F said before the incident, Resident #2 would sit in the lobby area watching the birds. The resident's family told her Resident #2 memorized the code from watching people and staff leave the facility. She said Resident #2 eloped during lunch time, at the time there were no staff in the lobby area as they were assisting the other residents with eating. In an interview on 08/13/2025 at 3:10 pm, LVN N said Resident #2 did express to her about 2 weeks ago that he wanted to go home. She said Resident #2 was not on any type of elopement precautions, but she keeps an eye on him. A record review of the facility policy Safety and Supervision of Residents, dated as revised July 2017, revealed the following [in part]: Policy Statement: Our facility strives to make the environment as free from accidents hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.Policy Interpretation and Implementation:Facility-Orientated Approach to Safety:2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI reviews of safety and incident/accident data; and a facility-wide commitment to safety at all levels of the organization.Individualized, Resident-Centered Approach to Safety:1. Our individualized, resident-centered approach to safety addresses safe and accident hazards for individual residents.2. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. 3. The care team shall target interventions to reduce individual risk related to hazards in the environment, including adequate supervision and assistive devices. Systems Approach to Safety:1. The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly. 2. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. Resident Risks and Environmental Hazards:1 Due to the complexity and scope, certain residents risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environments hazards include:e. Unsafe Wandering;f. Poison control. A record review of the facility policy Wandering and Elopements, dated as revised March 2019, revealed the following [in part]: Policy Statement: The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents.Policy Interpretation and Implementation:1. If identified as a risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. This was determined to be an Immediate Jeopardy that was called on 08/14/2025 at 4:50 p.m. The Administrator was notified on 08/14/2025 at 5:00 p.m. that an Immediate Jeopardy (IJ) situation was identified due to the above failures. The Administrator was provided the Immediate Jeopardy (IJ) template on 08/14/2025 5:00 p.m. and the plan of removal was requested. The facility's plan of removal was accepted on 08/18/2025 at 11:15 a.m. and included the following: Plan of Removal of Immediacy of the lack of adequate supervision F689 - Quality of Care - Accidents Hazards and Adequate Supervision Date of Survey: August 8-13, 2025 Administrator: [Administrator Q] Date of POR: August 14, 2025 CITATION SUMMARY The facility failed to ensure residents' environment remained free of accident hazards and that each resident received adequate supervision to prevent accidents for 2 of 2 residents reviewed, specifically: 1. Resident #1 ingested hazardous antimicrobial cleanser (Hibiclens) resulting in hospitalization. 2. Resident #2 eloped from facility undetected for approximately 1 hour. ROOT CAUSE ANALYSIS - UNDERLYING CAUSES IDENTIFIED PRIMARY UNDERLYING CAUSES: 1. Inadequate Chemical Storage Protocols * Root Cause: Need for strengthened chemical management procedures to optimize secure storage practices facility-wide * Contributing Factor: Need for expanded training protocols to ensure consistent identification of products requiring specialized handling procedures * System Optimization: Establishment of documentation protocols needed to ensure comprehensive tracking of environmental safety assessments 2. Insufficient Cognitive Assessment and Care Planning * Root Cause: Development of systematic protocols required to align BIMS assessments with individualized supervision requirements * Contributing Factor: Care plans were updated to include ingestion risk for residents with cognitive impairment (BIMS 0-10) * System Development: Need for automated supervision protocol implementation utilizing cognitive assessment score parameters 3. Inadequate Elopement Prevention System * Root Cause: Need for structured documentation system to formalize headcount verification and tracking processes * Contributing Factor: Resident demonstrated capability to obtain and implement facility security protocols, resulting in unsupervised egress * System Enhancement: Documentation protocols to be established for systematic visual monitoring of high wandering risk residents RESIDENTS AT RISK - IMMEDIATE SAFETY ASSESSMENT COMPLETED Administrator and DON completed comprehensive risk assessment on August 15, 2025 HIGH-RISK RESIDENTS IDENTIFIED (Immediate Enhanced Supervision Required): Chemical Ingestion Risk: * All residents with BIMS scores 0-7 AND history of pica or inappropriate ingestion behaviors- 1 resident * All residents with moderate to severe dementia (regardless of BIMS if documented swallowing of non-food items)-13 residents * Residents on psychotropic medications affecting judgment- 11 residents. Elopement Risk * All residents with BIMS scores 0-10 AND documented wandering behaviors- 1 resident * Residents with documented exit-seeking behaviors in past 90 days- 1 resident * Residents with new admission or recent medication changes affecting cognition- 2 residents Environmental Safety Risk * All residents requiring substantial assistance or total dependence for decision-making- 14 residents * Residents with combination of mobility and cognitive impairment- 14 residents IMMEDIATE PROTECTED MEASURES FOR AT-RISK RESIDENTS(Implemented August 15, 2025): For Chemical Hazard Risk Residents: * ADON implemented daily room sweeps to remove any hazardous items * Charge Nurse updated care plans to include CHEMICAL HAZARD RISK alert For Elopement Risk Residents: * Administrator implemented 15-minute visual checks with documented log * DON assigned specific staff member responsibility for location verification each shift For Environmental Safety Risk Residents: * IDT completed emergency care plan updates with specific safety interventions * DON assigned enhanced supervision levels based on individual risk factors * Charge Nurse implemented buddy system pairing high-risk residents with specific CNAs PLAN OF CORRECTION IMMEDIATE CORRECTIVE ACTIONS TAKEN Chemical Safety (Resident #1): - chemical products immediately removed from resident room in common areas by DON on 07/321/2025. - charge nurse, LVN O contacted poison control to ensures next steps immediately after assessing Resident #1 on 07/30/2025. - charge nurse, LVN O stayed with Resident #1 and continued to monitor her for safety while awaiting for the ambulance on 07/30/2025. Elopement Prevention (Resident #2): - door access code changed facility-wide on 07/09/2025 by [contracted fire vendor]. - Charge Nurse, LVN R, updated elopement risk assessment on 07/10/2025 to reveal a high risk for elopement (Resident #2). - provided one-on-on supervision by aide to resident for five (5) hours on 07/04/2025 upon return to the facility and ended when DON determined there was no immediate risk for elopement and staff on duty had been in-serviced on what to do in case of elopement. - contact MD and facility obtained a UA order on 07/10/2025, UA results came back positive for UTI on 07/14/2025, give [antibiotics] oral tablet 500mg from 07/14/2025 - 07/21/2025. [ADON] verified function of exit alarms on 07/04/2025 by pushing crash bar without the code entered and secured egress points by checking if the locks were working when the door was pulled on both sides. SYSTEMIC CORRECTIVE ACTIONS 1. CHEMICAL SAFETY PROGRAM OVERHAUL Target Completion: August 14, 2025, at midnight STEP-BY-STEP IMPLEMENTATION: August 14 by Midnight 1. Administrator assigns DON to lead chemical safety team 2. Team consisting of DON, ADON, maintenance supervisor, and administrator conducts room-by-room audit using standardized checklist: * document all chemical locations (name, quantity, storage method) * remove ANY chemical found in resident areas immediately 3. Maintenance Supervisor create master inventory list of all facility chemicals 4. Maintenance supervisor designate secure storage areas: housekeeping closet (main), medication room (antiseptics), maintenance room (industrial chemicals) 5. Maintenance supervisor find secure area to store shower supplies. 6. Administrator create chemical access log sheets for each storage location 7. Administrator post AUTHORIZED PERSONNEL ONLY signs on all chemical August 14 by midnight 1. DON conduct mandatory staff training for staff BEFORE they are able to return to work 2. DON Training content: chemical hazards, proper storage, never leave unattended rule, emergency procedures 3. Each staff member signs competency form stating they have completed the in-service before they can return to work. Staff will complete a quiz about the training. Staff failing the quiz will be required to receive one-on-one training from a member of the chemical safety team Clarification - We do not take things away from residents. Our Approach: We provide oversight and monitoring of products that could hurt people. For resident person care items (soap, lotion, perfume, cologne): * We keep items safe through proper storage * Staff help residents use items safely * Items are secured immediately after use * We ensure residents with cognitive impairment cannot access items unsupervised Accountability: Our facility takes responsibility for keeping everyone safe while respecting resident preferences and autonomy. 2. ELOPEMENT PREVENTION PROGRAM Target Completion: August 14, 2025, by midnight STEP-BY-STEP IMPLEMENTATION: 1. Administrator meets with maintenance to assess current door security by testing alarms, faulty mechanisms, and codes. 2. Maintenance supervisor inventory all exterior doors and windows accessible to residents 3. Maintenance supervisor retest door alarms on all exterior exits: * Front entrance (main priority) * Emergency exits * Patio/courtyard door 4. DON implement immediate visual check system: * Post visual check sheets at the nurses' station * Assign specific staff for 15-minute checks of high wandering risk residents * Create accountability system with signatures and timestamps 5. DON/designee update resident care plans for ALL residents with cognitive impairment to add that they are higher risk for chemical hazards 6. ADON/designee conduct headcount procedure training for all nursing staff BEFORE they can return to work. 7. Administrator create and laminate emergency elopement response cards for all staff. 8. Administrator provide local police non-emergency number by all unit phones. 9. DON/designee conduct mock elopement drill with each shift the first shift they work. 10. Administrator post updated elopement response procedure at nurses' stations 11. Staff will complete an elopement in-service with a final quiz to determine competency. Any staff found incompetent in elopement procedures will be required to complete one-on-one training with the administrator. Ongoing Daily Process: * Every 15 minutes: Hall aid visual checks of high wandering risk residents (documented) * Every 2 hours: Charge nurse facility-wide headcount (all shifts). * Once a day: Charge nurse test door alarms and review high wandering risk resident list. Responsible Person: Administrator Monitoring: Administrator monthly elopement drill logs and quarterly policy compliance checks 3. ENHANCE SUPERVISION PROTOCOLS Target Completion: August 14, 2025, by midnight STEP-BY-STEP IMPLEMENTATION: August 14 by midnight 1. IDT begins reviews all current care plans for residents with BIMS scores 0-10. 2. DON create priority list of residents requiring enhanced supervision. 3. ADON assign designated CNA responsibility per shift for each resident with BIMS score between 0-10. 4. IDT update care plans for Resident #1 and #2 immediately. Add specific interventions: * Resident #1: Visual supervision during all activities, especially meals. No chemicals/cleaning products in room or within reach * Resident #2: 15-minute visual checks, escort for all outdoor activities The ADON/DON will be responsible for ensuring that the interventions on the care plan will be completed. A log of checks will be established, requiring initials. The chemical log will keep up with documentation for resident #1's interventions with logs for supervision checks and sweeps of the room. 5. ADON/designee communicate changes to all shifts via shift huddles. By August 15, IDT review ALL resident care plans 1. DON document new supervision requirements in nursing notes 2. Administrator create daily assignment sheets that specify which staff monitors which high-risk (BIMS 0-10) residents. 3. ADON conduct supervision training for all nursing staff BEFORE they return to work: 4. Staff will complete a quiz to determine competence. Any staff that does pass the quiz will receive one-on-one training with the ADON 5. ADON/designee implement daily huddles at start of each shift to review high-risk residents Ongoing Daily Process * Shift report: Charge nurse specific handoff for all enhanced supervision residents * Weekly: IDT meeting to assess effectiveness of supervision plans * Monthly: IDT full care plan reviews for all enhanced supervision residents Responsible Person: Director of Nursing Monitoring: Administrator daily supervision logs and weekly care plan effectiveness reviews. 4. ENVIRONMENTAL SAFETY PROGRAM Target Completion: August 14, 2025, by midnight STEP-BY-STEP IMPLEMENTATION: Administrator assigns Safety Committee (DON, Maintenance Director, one floor nurse from each shift) 1. Maintenance supervisor create standardized safety checklist covering: * Chemical storage verification * Door alarm functionality * Resident room hazard assessment * Common area safety check * Exit security verification 2. DON implement three (3) daily safety rounds: * 6-2: Day charge nurse - focus on overnight incidents and morning setup * 2-10: Evening charge nurse - focus on mealtime safety and visitor activities * 10-6: Night charge nurse - focus on sleep safety and security Daily Process: 1. Each safety round documented by charge nurse on 24-hour report. 2. Any hazards noted must be corrected by DON within 2 hours (non-urgent) or immediate (urgent) 3. Charge nurse reports finding to DON within one (1) hour of discovery 4. DON/designee reviews all safety forms and trends issues weekly Monthly System Setup: 1. Administrator schedule monthly safety committee meeting with QAA/QAPI 2. IDT create safety suggestion system for staff and families 3. Maintenance supervisor set up quarterly comprehensive facility safety audit schedule 4. Each department supervisor conduct a safety walkthrough Ongoing Daily Process: * Daily: Charge nurse conduct a chart safety round findings * Weekly: DON analyzes trends and reports to Administrator, document corrective actions * Monthly: Safety Committee reviews all incidents and updates protocols; all incidents will be reported by the QAA/QAPI committee. Responsible party: Administrator Monitoring: Daily safety logs, weekly trend reports, monthly committee reviews Ensuring Safety of Other Residents ADON will complete a BIMS and Wandering Risk assessment on all residents to determine which residents need higher levels of supervisions, including 15-minute safety checks for residents with a high risk to wander and 1 hour safety checks for residents with cognitive impairment. Administrator will create a log for initials that checks were completed. QUALITY ASSURANCE MEASURES 1. MONITORING SYSTEM * Daily safety round with written documentation * Weekly QA meetings with IDT to review safety incidents * Administrator monthly trend analysis of safety-related occurrences * Administrator quarterly external safety audit 2. STAFF ACCOUNTABILITY * DON/designee mandatory safety competency testing every six (6) months * Administrator progressive discipline policy for safety violations * Administrator [TRUNCATED]

Based on interview and record review, the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 8 residents reviewed (Resident #15) resulting in prolonged pain for the resident. The facility failed to administer PRN pain medication to Resident #15 on 10/08/2021. This failure could result in worsening of pain and injury to residents. The findings were as follows: Review of Resident #15's face sheet revealed Resident #15 was [AGE] year-old female who admitted to the facility on [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #15's MDS dated [DATE] revealed a BIMS of 5 which indicated severe cognitive impairment . Review of Residents #15's comprehensive care plan dated 02/01/2022 revealed: Focus: She has a pelvic, left wrist fractures related to a fall at home 8/2021. She has had no surgical intervention, but her left arm is casted on admission. Date initiated: 09/08/2021; Revision on 09/13/2021Interventions: 10/08/2021: she had a visit with ortho: left wrist x-ray stable, cast removed, she has left wrist removable cockup splint. No orders on pelvic fracture. 12/23/2021 Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance. Date initiated: Focus: She was on pain medication therapy (Tylenol #3 1 tablet by mouth every 4 hours as needed; Tylenol 325mg 2 tablets by mouth every 4 hours as needed) related to injury (pelvic and wrist fractures) Date initiated: 09/08/2021; Revision: 09/10/2021 Goal: She will be free of any discomfort or adverse side effects from pain medication and feel comfortable. Interventions: Administer [MEDICATION(S)] medication as ordered by physician. Monitor/document side effects and effectiveness every shift. Focus: She has acute/chronic pain related to arthritis, fractures of her pelvis and left wrist status post [MEDICAL RECORD OR PHYSICIAN ORDER] Goal: She will verbalize adequate relief of pain or ability to cope with incompletely relieved pain and feel comfortable. Interventions: Administer [MEDICATION(S)] (Tylenol, Tylenol #3) as per orders. Give ½ hour before treatments or care. Anticipate her need for pain relief and respond immediately to any complaint of pain. She is able to call for assistance when in pain, unable to reposition herself, she can ask for medication, unable to tell you how much pain is experienced, tell you what increases or alleviates pain. Cognitive impairment. Review of Resident #15's MARs through September 2021 and January 2022 revealed the following: September 2021 she received Tylenol #3 a total of 51 times, October 2021 she received Tylenol #3 a total of 26 times, November 2021 she received Tylenol #3 a total of 15 times, December 2021 she received Tylenol #3 a total of 4 times and January 2022 she received Tylenol #3 a total of 2 times. Of the 98 times Resident #15 received Tylenol #3 between September 2021 and January 2022, the medication was only administered by LVN A once . In an interview with CNA C on 01/12/22 at 12:15 PM, CNA C stated LVN A frequently refuses to give residents pain medication. She stated the residents will ask LVN A for medication and explain heir pain level was high but LVN A will tell them it isn't and offer over the counter pain medication or nothing at all. She reported an incident on 10/08/2021 in which Resident #15 was supposed to go to an appointment and was crying due to pain related to multiple fractures sustained in a fall prior to admission. LVN A was asked by Resident #15 and staff to give her pain medication and she refused. Resident #15's daughter was present at the time and she also asked LVN A to give the pain medication and was told in front of CNA C, CNA D, CNA E, and LVN B that the crying was a behavior the resident was displaying and she needed to go to the doctor without medication so he could see how much pain the resident was experiencing. She stated the direct care staff do not officially report when LVN A refused to give medication for fear of retaliation, but she and others have brought their concerns to the ADON. CNA C also explained direct care staff do not have a place to document when a resident requests pain medication and it was denied. She stated they do not have access to put notes in the charts. In an interview with CNA D on 01/12/2022 at 12:25 PM, she stated LVN A often refused to give residents pain medication when it was requested. She described the incident regarding Resident #15 on 10/08/2021 not getting pain medication. She stated she had reported the problem to the DON and ADON, and she believed they spoke to LVN A, but nothing had changed. She stated the staff does not report LVN A for fear of retaliation. In an interview with LVN B on 01/12/2022 at 12:45 PM, she reported she was aware LVN A refused to give pain medication to residents. She stated she witnessed LVN A refuse Resident #15 and the resident's daughter on 10/08/2021 and was present when the daughter was told the resident's crying was a behavior and not pain. She stated the direct care staff are afraid to say anything to administration because they fear retaliation from LVN A. In an interview with CNA E on 01/12/2022 at 1:00 PM, she stated LVN A refused to give pain medication to residents because they will get addicted. She stated she was present during the incident with Resident #15 on 10/08/2021 as well. She explained the staff do not report the issue anymore due to retaliation and that administration backs LVN A up. In an interview with CNA F on 01/12/2022 at 1:24 PM, she stated she told LVN A when a resident asked for pain medication, but she never gets a response from her, so she does not know if they are given medication or not. She stated there was no way for the direct care staff to follow up other than asking the nurse or the resident. She explained direct care staff do not have access to put notes in the chart when a resident requests medication and/or does not receive it. She stated she and the other staff no longer report LVN A due to fear of retaliation. In an interview with LVN A on 01/12/2022 at 1:33, she stated the issue regarding the pain medication had been addressed and refused to elaborate. In an interview with ADON in training on 01/12/2022 at 2:25 PM, she stated she was not employed by the facility when the incident with Resident #15 occurred but was made aware of it. She stated the acting ADON and the DON had addressed the issue with LVN A. In an interview with ADON on 01/12/2022 at 2:47 PM, she explained LVN A had been talked to about not giving pain medication to residents when they request it. She stated LVN A had been talked to by the administrator regarding withholding pain medication as well. She explained she believed the issue was due to LVN A and the medical director being concerned the residents will become addicted but she has told LVN A that if a resident asks for medication and it was ordered she was to give it . In an interview with DON on 01/12/2022 at 3:08 PM, she stated she was not aware LVN A had refused to give pain medication to Resident #15. She stated she was aware LVN A routinely withholds narcotic pain medication and stated she had addressed it with her on several occasions . In an interview with the facility administrator on 01/12/2022 at 4:30 PM, he stated he was aware of the concerns about pain medication not being given by LVN A, but he thought it had been handled by DON and ADON. In an interview with facility administrator on 01/31/2022 at 2:10 PM he stated LVN A was counseled on administering pain medication by himself as well as the DON and ADON. He stated it was verbal and there was no record of these counseling sessions. He stated after the incident occurred, LVN A called Resident #15's daughter to apologize for her behavior. In an interview with the daughter of Resident #15 on 01/31/2022 at 1:45 PM she stated she arrived at the facility to accompany her mother to a doctor appointment on 10/08/2021 and while they were loading her into the van, she was crying and grimacing. She stated she went to ask LVN A if her mother could have some pain medication before she left for the appointment and LVN A told her no and to let the doctor see how much pain she is in. She stated she did not know if the staff had asked LVN A to give Resident #15 pain medication before she arrived. She stated she was told the owner of the facility had talked to LVN A regarding the incident, and she did not believe there had been any other instances when her mother did not receive medication when requested. In an interview with the medical director on 01/31/2022 at 2:58 PM, she stated she had not been made aware of any issues regarding the residents not getting pain medication. She stated she expected the nurses to use proper nursing judgment when administering medication and does not condone withholding medication from residents when it was appropriate to for them to have it . In an interview with facility's physical therapist on 02/01/2022 at 8:50 AM he stated that he has never had any issue with residents receiving pain medication when he requests it for them. He stated that he has no way to ensure that residents receive medication other than asking the nurses. He reported that Resident #15 can verbalize if she is in pain and can ask for medication if she needs it. He stated that Resident #15 progressed very well and quickly after her admission to the facility. He had no knowledge of the incident on 10/08/2021. In an interview with COTA on 02/01/2022 at 8:50 AM she stated that when Resident #15 was first admitted to the facility she did have a significant amount of pain due to her fractures and that she was able to verbalize her pain adequately. She stated Resident #15 was not able to rate her pain on a scale, but she had non-verbal cues like crying and grimacing that made her pain/discomfort apparent. She stated that she had never had any issues or concerns with the residents receiving pain medication. She reported no knowledge of the incident on 10/08/2021. In an with LVN A on 02/01/2022 at 10:00 AM she stated she did not remember telling Resident #15 or her daughter she could not have pain medication. She stated that does not feel like that was something she would ever do. She stated she does not feel that she withholds pain medication if the residents need it. She stated there have been nurses that have worked at the facility in the past that would give residents prn pain medication without properly assessing their pain and many residents expected the medications whether they needed it or not. She stated if a resident asks her for pain medication or a staff member requests medication for the resident t she assess the resident to find out the site and severity of the pain. She stated if the resident was unable to rate their pain on a 0-10 scale, she uses visual/non-verbal cues like crying, grimacing, groaning to determine their pain level. She stated often she will request another nurse help her assess the resident if they cannot communicate their pain. Observation of Resident #15 on 01/12/2022 through 02/01/2022 revealed no signs or symptoms of pain or discomfort. Resident #15 frequently walked through the halls with her walker. Review of facility schedule/assignments for nursing dated October 2021 on 02/01/2022 revealed that LVN A was scheduled to work and was assigned to Resident #15s hall on 10/08/2021. Review of LVN A's employee file on 01/31/2022 revealed no documentation of counseling or any disciplinary action regarding any complaints. Record review of the facility's policy Administering Pain Medication dated October 2010 stated in part The pain management program is based on a facility-wide commitment to resident comfort. 'Pain management' is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. Record review of the facility's policy Pain Assessment and Management dated March 2015 stated in part Observe the resident (during rest and movement) for physiologic and behavioral (non-verbal) signs of pain, Possible Behavioral Signs of Pain: verbal expressions such as groaning, crying, screaming, Review the resident's clinical record to identify conditions or situations that may predispose the resident to pain, including [CONDITION(S)] arthritis, [CONDITION(S)], fractures.

Based on observations, record review and interviews the facility failed to ensure 3 of 4 residents reviewed for falls received adequate supervision and assistance devices to prevent accidents. (Resident # 1, 6 and # 7). The facility failed to: 1). ensure Resident # 1 was protected from falls after the resident was assessed to be at high risk of falls and to ensure appropriate safety measures were taken after the resident experienced a fall on 01/02/15. Resident # 1 fell again on 01/09/15 and was hospitalized with a fractured hip. 2). ensure Resident # 7's chair alarm (tabs monitor) was properly placed on the chair so that it would function correctly. 3) ensure that Resident # 6 was wearing the alarm she had been assesed and care planned to need for safety. 4). failed to have a system in place to check all alarms for functionality and train staff accordingly. These failures could place 7 residents in the facility who had bed and/or chair alarms at risk for falls and injuries. Findings include: Resident # 1 ( Closed Record ) Review of the Resident's admission MDS dated [DATE] indicated the Resident was admitted to the facility on [DATE]. Resident # 1 was 85 at the time of admission. The admission [DIAGNOSES REDACTED]. According to the MDS the resident had short and long term memory problems and was moderately impaired for daily decision making. Review of the resident's functional status indicated the resident was independent with bed mobility and transfers, requiring setup help only. The Resident was independent to walk in her room, walking in corridor, and ambulating on the unit, however Resident # 1 required supervision while ambulating off the unit. Resident # 1 was independent with setup help only with dressing, eating, toilet use and personal hygiene. The Resident required one person physical assist with bathing. Resident # 1 was assessed as not steady while moving from a seated to a standing position, walking ( with assistive device if used), turning around and facing opposite direction while walking, moving on and off toilet, and surface to surface transfers (transfers between bed and chair or wheelchair). According to the MDS Resident # 1 used a walker. The Resident was assessed to be occasionally incontinent of urine and continent of bowel. At the time of the MDS assessment the Resident had not experienced any falls in the facility. Review of Resident # 1's "Morse Fall Scale" dated 11/01/14 (date of admission) indicated the resident was a High Risk for falling with a score of 80. The fall risk assessment indicated the resident had a history of [REDACTED]. According to the instructions on the fall risk assessment, a fall risk assessment should be done at admission, quarterly, at change of condition and after a fall. According to Resident # 1's care plan dated 11/07/14 and updated on 11/11/14 indicated the resident was at risk for falls related to Dementia, Urinary Tract Infections, Orthostatic hypotension, Rheumatoid arthritis, Chronic Obstructive Pulmonary Disease, shortness of breath, weakness, Congestive Heart Failure and unsteady gait/balance. Goal was the resident will be free of falls through the review date, which was planned for 02/09/15. Interventions were: -anticipate and meet the resident's needs -Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all request for assistance. -Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. -Ensure resident is wearing appropriate footwear when ambulating with walker. -Follow facility fall protocol. Review of the facility's Policy and Procedure for falls dated September 2014 indicated the following: In part--- --The RN on duty will perform a fall assessment within 24 hrs of admission. If noted to be a risk, the appropriate steps will be initiated to ensure resident safety. --The assessment will indicate the resident to be at risk for falls. It is then planned and appropriate measures are taken: encourage call light, personal alarm, bed alarm, landing strip, gripper socks, and therapy. --The care is again reviewed every 90 days, after inpatient hospital stays and PRN (as needed) falls. --The charge nurse on duty at the time of the actual fall will log it in the computer, report it to the physician and appropriate family member or responsible party. The charge nurse will document possible causes and facts surrounding the falls, (i.e.) ambulating without walker, not using call bell for assistance, had taken own personal alarm off, was medicated for anxiety etc. the charge nurse will document steps taken at that time to try to ensure the safety of the resident. Review of an update to Resident # 1's care plan dated 01/02/15 (date of fall) indicated the Resident had a fall. According to documentation on the update the Resident stood up in the dining room to begin ambulating back to her room, lost her balance and fell to the floor. The Resident received a skin tear to her right elbow that was cleaned, TAO was applied, covered with a Telfa dressing and tape. Review of the goals indicated the resident will resume usual activities without further incident through the review date of 01/23/15 with a target date of 04/02/15. Interventions were : -Check range of motion every shift for 3 days. -monitor/document/report as need for 72 hours to Medical Doctor for signs and symptoms of pain, bruised, change in mental status, new onset of confusion, sleepiness, inability to maintain posture and agitation. -Neuro-checks as per protocol if applicable -Provide activities that promote exercise and strength building where possible -Vital signs as needed, take blood pressure lying/sitting/standing once in the first 24 hours if ortho hypotension. Despite the Resident's fall on 01/02/15 while rising from a chair in the dining room no new fall risk assessment was completed or new interventions implemented to prevent future falls or injuries per the facility's fall protocol During an interview with the DON on 01/28/15 at 1:20 p.m. she said they do not automatically put alarms on residents. She said she had been advised that an alarm can be viewed as a restraint if a resident does not want it. The DON said she looks for trends with falls and that Resident # 1 had only had one fall (01/02/15) which occurred in the dining room while she was using her walker. She said they could not have placed an alarm on the Resident's walker. Review of a nursing note dated 01/05/15 at 12:08 p.m. indicated the Resident is complaining of weakness and not being able to stand very well. Note left for doctor. Review of a nursing note dated 01/05/15 at 5:08 p.m. indicated the Resident's doctor saw her. The doctor ordered a urinalysis with a culture and sensitivity (C & S ) due to the Resident's increased confusion. The urinalysis was to be collected on 01/07/15 for pick-up by the lab on 01/08/15, Will continue to monitor. Review of physician progress notes [REDACTED]. Review of a Provider Investigation report dated 01/09/15 at 5:30 p.m. indicated the following: - LVN "C" heard Resident #1 hollering and observed her on the floor. Nurse "C" took the resident's vital signs, then notified the doctor, DON and the Resident's daughter. Nurse "C" observed the resident's right foot pointing outward. The Resident was sent to the hospital per physician order, the daughter will meet the resident at the hospital. -Under Provider action taken post-investigation...was documented Resident #1 will be placed on heightened supervision level upon return to the facility. Possible rearrangement of furniture for safer walkway. -Nurse's progress note dated 01/09/15 at 5:30 p.m. and attached to the Provider Investigation indicated Resident # 1 was observed in the floor, vital signs were 177/100, respirations were 18, pulse was 69, 02 SATs was 96 %, temperature was 97.6 degrees, resident unable to move her right leg. Daughter notified will meet at hospital, EMS transported resident. -Also attached to the Provider Investigation was an Incident Report filled out by LVN "C". The report was dated 01/09/15 at 4:43 p.m. Under Predisposing Environmental Factors was checked "fall alarm". Under Predisposing Environmental Factors was checked "Furniture". Predisposing Physiological Factors was checked "gait imbalance" and "weakness/fainted". Under Predisposing Situation Factors was checked "improper footwear" and "ambulating with out assist". Under Witnesses ..it was documented "no witnesses found". -Under Incident Description was the following information documented; -Nursing description...at 15:30 (3:30 p.m.) I heard someone call for help. Resident was observed in the floor of her room. Complained of right hip pain and right elbow pain. I noticed her right foot laying flat on the floor and the resident was holding her right hip area. I asked if she could move her foot, and she stated No. I called for help and another staff called the doctor. He stated to take resident to the hospital. The other staff called the family and the DON. The EMS came and transported. I stayed with the resident until EMS came. We put a pillow under her head and a blanket over her to stay warm. I tried to comfort her and keep her calm. The resident said I slipped and my leg hurts. " I tripped over the table beside my chair." It was noted that her walker was in front of the door. During an interview with the DON on 01/28/15 at 1:20 p.m. She said there were no trends identified related to the Resident # 1's previous fall prior to the fall on 01/09/15. She said Resident # 1 had a history of [REDACTED].# 1 had an infection. She said she was informed after the resident fell on [DATE] that the family had requested a bed alarm. She said a nurse had put the alarm on the resident's bed, however she herself knew nothing about the alarm until after 01/09/15. The DON said she would not have put an alarm on the resident yet. The DON said she had not identified any trends concerning falls with Resident # 1 and she did not want to cause Resident # 1 to become agitated from an alarm. During an interview with LVN "C" on 01/28/15 at 4:10 p.m. she said she had worked on Resident # 1's hall on the afternoon of 01/09/15. She said she passed by the Resident's room about 3:15 p.m. and Resident # 1 was asleep in her big chair with the T V on. LVN "C" said a little before 5:00 p.m. she heard Resident # 1 call for help. She said when she went into the Resident's room she saw the resident on the floor and she knew she was injured. She said staff called the doctor, the family and EMS and the resident was sent to the hospital. According to LVN "C" the Resident said she caught her foot on the bedside table when she was getting up. LVN "C" said just the day before the family had asked her to put a bed alarm on the Resident's bed. LVN "C" said the resident was independent in her room and would walk around her room , toilet herself at times and get her own clothes. Review of Resident's # 1's care plan dated 01/09/15 indicated the Resident got up out of a chair in her room, tripped over the bedside table and fell to floor, landing on her right hip. Resident complained of pain to right hip, sent via ambulance to hospital with a [DIAGNOSES REDACTED]. Resident # 7 Review of Resident #7's admission MDS dated [DATE] indicated the Resident was [AGE] years old at the time of admission. The Resident was admitted to the facility on [DATE] with a BIMS of 10 out of a possible 15 indicating the Resident had moderate cognitive impairment. Resident # 7 was not displaying any behaviors at the time of admission, however was assessed to experience hallucinations. According to the assessment Resident # 7 required set up help for bed mobility and locomotion on the unit. The Resident required supervision with set up help for transfers, walking in the room, walking in the corridor, locomotion off the unit, dressing, eating and toilet use. Resident # 7 required extensive assistance with one person for personal hygiene and bathing. The Resident was assessed to be not steady, but able to stabilize without staff assistance for moving from a seated to standing position, walking, turning around and facing the opposite direction while walking, moving from surface to surface (like between chair to bed) and moving on and off the toilet. According to the assessment the Resident used a wheelchair for mobility. Resident # 7 was frequently incontinent of urine and was continent of bowel. The Resident was admitted with [DIAGNOSES REDACTED]. According to the fall history on the assessment Resident # 7 had a fall within the last month and the last two to six months and had at least two or more falls without injury since admission into the facility. Review of Resident # 7's fall risk assessment (Morse Fall Scale) dated 12/17/14 indicated under instructions the fall risk assesment should be done at admission, quarterly, at change of condition and after a fall. Scoring indicated a score of 45 or higher indicated High Risk. Resident # 7 scored 80. According to the assessment the resident had a history of [REDACTED]. The Resident had impaired judgement/decision making, with diagnostic indicators of Psychosis and Schizophrenia and the Resident was taking antipsychotic medication. Under the section on External Factors was documented "walker" using incorrectly picks up while ambulating. Under the summary section of the assessment was documented "unsteady gait and balance" as a potential risk factor for falls that should be care planed with interventions and control of removal risk factors that had been identified. Review of Resident # 7's care plan for falls dated 12/23/14 as initiated indicated the resident is at risk for falls related to Psychoactive drug use, limited mobility, gait and balance problems. The goal was the resident will be free of falls through the review period which would end on 03/23/14. Interventions were....anticipate and meet the resident needs -be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. -encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. -ensure that the resident is wearing appropriate non-slip footwear when mobilizing in the wheelchair. -follow facility fall protocol. -the resident uses chair/bed electronic alarms. Ensure the devices are in place as needed. Date initiated was 01/12/2015. Added to the care plan was the following updates. -the resident had an actual fall (12/20/14 at 2:50 p.m.). Resident slid out of wheelchair to floor landing on buttocks while attempting to reposition. Small abrasion to left knee, cleansed, TAO, open to air. -12/21/14 at 1:05 a.m. Resident slid out of wheelchair, landing on buttocks, while mobilizing in hall, no injury. -12/26/14 at 1:43 a.m. Resident slid out of bed to floor, landing on buttocks, while attempting to go to the bathroom unassisted, no injury. reminded the resident to pull call light for assistance. -12/27/14 at 5:26 a.m. Resident fell out of bed to floor, landing on buttocks, while attempting to transfer self from bed to wheelchair, no injury. -01/11/15 at 5:50 a.m. Resident slid of bed to floor while attempting to transfer self to wheelchair without assistance, no injury. Pressure alarm applied to bed and tab alarm while in wheelchair. -01/13/15 at 7:09 a.m. Resident confused, ambulating in room, began losing balance, CNA alerted by alarm, guided resident to floor. This revision was dated 01/23/15. There was no documentation found that the facility had completed a new fall risk assessment after any of the previous (6) falls as noted on instructions on the facility form "Morse Fall Risk Scale." Continued review of Resident #7's care plan under goals. -the resident will resume usual activities without further incident through the review date, the target date was 03/23/15. Under interventions was documented: -check range of motion every shift times 3 days -make sure pressure alarm to bed and tab alarm while in wheelchair are in place and working. -monitor/document/report PRN X's 72 hours to MD for signs and symptoms, pain, bruises, change in mental status, new onset of confusion, sleepiness, inability to maintain posture, agitation. -neuro-checks per protocol, if applicable. -Pharmacy consult to evaluate medications. -provide activities that promote exercise and strength building where possible. -vital signs as needed. Review of a health status note dated 01/27/15 at 5:30 a.m. indicated resident pulled call light, resident observed on floor, resident states she did not fall, she slid off the bed to the floor, resident state she did not hurt anything she just slid to the floor. Review of a health status note dated 01/28/15 at 9:33 p.m. indicated the resident took off her bed alarm, knows how to turn off the bed alarm after it sounds. Review of a health status note dated 01/29/15 at 10:11 a.m. indicated the resident is alert and awake, forgetful at times, requires frequent reminding to use call light for transfers and allow staff to assist her. Continues to disconnect chair and bed alarm. Gait unsteady, uses wheelchair for mobility, propels self, with difficulty. Difficulty using feet and arms at the same time. During an observation and interview of Resident # 7 on 01/29/15 at 11:05 a.m. LVN "R" revealed the resident had a tabs monitor (alarm) pinned to her shirt while she was sitting in the wheelchair. LVN "R" was asked how the tabs monitor worked. LVN "R" said she would demonstrate, and she asked Resident # 7 to stand up from the wheelchair assisted by LVN "R". When Resident # 7 stood up the tabs monitor pulled off the resident's shirt and did not alarm. LVN "R" looked at the tabs monitor that was on the wheelchair and said it had been put on the wheelchair incorrectly, that is why it failed to alarm as it should have. LVN "R" said who ever put the tabs monitor on the resident and her wheelchair had incorrectly looped the string around the back of the wheelchair which kept it from triggering the alarm when the resident stood up. (note a tabs monitor is an alarm that runs on a battery. The alarm is attached to a string with a clip that attaches to the residents clothes. When the resident attempts to get up the tension on the string sets the alarm off and signals the staff the resident is getting up.) Resident # 6 Review of Resident # 6's Significant Change MDS dated [DATE] indicated the resident was [AGE] years old. The resident was unable to complete a brief interview for mental status. Her cognitive skills for daily decision making were assessed to be moderately impaired. The resident also had short and long term memory problems and could not recall the current seasons, staff, names and faces or whether or not she was in the nursing facility.She required limited assistance of one person for bed mobility and walking in her room. The resident was able to walk in the corroidor with extensive assistance of person. Locomothion on and off the unit required extensive assistance of one person. Toilet use required limited assistance of one person and was frequently incontinent of urine. Her mobility device was a walker, The Resident's current [DIAGNOSES REDACTED]. According to the assessment the resident had experienced two or more falls without injury since admission to the facility. Review of Resident # 6's care plan dated 01/29/15 indicated the resident had a history of [REDACTED]. The plan documented that falls had occurred on 03/25/14, 09/18/14, 10/29/14, 11/17/14, 11/19/14 11/22/14, 11/25/14 , 11/26/14, 11/28/14, 11/29/14, 12/13/14 and 12/18/14. Interventions included "Pressure alarm in recliner and bed. Tabs alarm while in wheelchair." Observation on 01/29/15 at 9:15 a.m. indicated Resident # 6 was in her room seated in her recliner. Two alarms were attached to the bedside table next to her recliner. A tabs alarm was clipped to Resident # 6' s clothing and the other (pressure) alarm was in her bed. Interview on 01/29/15 at 2:10 p.m. with CNA "A" in Resident # 6's room while the resident was seated in her recliner confirmed that the alarm attached to the resident's bed was a pressure alarm and the alarm attached to the resident while she set in her recliner was a tabs pull alarm. During an interview with the DON on 1/29/15 at 2:35 p.m. she confired that Resident # 6 had numerous falls and that alarms had been placed on the resident. The DON said Resident # 6 had end stage cancer and was more confused than before and she would take the alarms off and try to go to the bathroom, however she is not capable of doing that anymore. Observation was made of the resident in her recliner at this time. The Resident was seated in the recliner with a tabs alarm attached to her clothing. The DON said she had noticed the alarm when she had assisted the resident with her lunch earlier in the day. The DON confirmed at this time that a pressure alarm was supposed to be in the recliner and the tabs alarm used when the resident was in her wheelchair. During an interview with CNA's "D", CNA "M" and CNA "J" on 01/29/15 at 2:15 p.m. the CNA's said the batteries were changed in the alarms only when the alarm starts to beep which meant the battery was low and going dead. They said there was no set schedule or system for checking the alarms for functionality. During an interview with the DON on 01/29/15 at 2:55 p.m. she said the facility does not obtain doctor's orders to place alarms on residents. She said the alarms were care plan but there was not a system for checking the alarms for functionality. The DON said the staff had been trained on alarms, but not formally and there was no written documentation of their training. During an interview on 01/29/15 at 4:45 p.m. the administrator and the ADON said they believed there had been a policy regarding the use of alarms written a couple of years ago, however, they were unable to locate the policy at this time. The administrator said alarms do not stop falls, but they do alert staff that the individual is up. On 01/29/15 the DON provided a list of 7 current residents ( including Resident # 6 and 7) who had alarms.

Based on observation, interview and record review the facility failed to ensure adequate supervision and safety devices to prevent accidents for 1 of 4 resients (Resident #6) who were reviewed for accients. A. ensure 1 resident (#6) of 4 residents reviewed for smoking safety received adequate supervision and safety devices to prevent accidents. Resident #6 caught her hair on fire while smoking unsupervised. B. have an ambu bag on the crash cart to aid in the performance of Cardio Pulmonary Resuscitation (CPR). This failure could affect 12 residents in the facility who are designated as being Full Code, by decreasing the effectiveness of CPR. This failure has the potential to affect four residents in the facility who smoke who are risk for cigarette related burns, fires and/or death. The findings included: 1. Observation on [DATE] at 2:30 p.m. Resident #6 was out on the front porch patio with a staff member smoking. Resident #6 had to be reminded by staff numerous times to flick her ashes off her cigarette to keep them from falling on her clothes. Resident #6 was observed to have tremors to both hands. She was observed to be starring out into space when the staff was not interacting with her. Review of Resident #6's Face Sheet dated [DATE] indicated the resident was a [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]., and depressive disorder. In an interview on [DATE] at 2:45 p.m. with Resident #6 she said that a couple of weeks ago she was outside smoking by herself. She said that it was windy that day and while trying to light her cigarette she caught the top of her hair on fire. She said that she was unaware that her hair was on fire until the staff member LVN A came out to smoke and saw her. She said that the top of her hair was singed. Resident #6 was noted to be very slow to respond to surveyors questions. She required a lot of time to process the questions and respond. In an interview on [DATE] at 2:45 p.m. with the Administrator he said that he was aware of the incident with Resident #6. He said that an incident report had been completed. He said that he was unaware that he needed to report the incident to State Office. In an interview on [DATE] at 3:00 p.m. with the DON she said that there were three other smokers that smoked independently. In an interview on [DATE] at 3:10 p.m. with the ADON she said that she was unaware that the incident with Resident #6 catching her hair on fire should have been reported to state office. In an interview on [DATE] at 3:45 p.m. with Resident #7 he said that he has been smoking with Resident #6 for some time. He said that he heard about her catching her hair on fire. He said that he was not at all surprised. He said that he is surprised that she has not burned herself up a long time ago. He said that she sits out there with a lighted cigarette and sometimes just stares out into space. He said that many times he has seen her cigarettes burn up with the ashes intact and they just fall into her lap, He said that there are times she can ' t even light her cigarettes because her hands shake and someone out there smoking has to light her cigarettes or her. In an interview on [DATE] at 3:50 p.m. with Resident #8 he said that he smokes independently whenever he wants in the designated smoking area. He said that he carries his cigarettes on his person but does not have a lighter. He said the lighters are kept at the nurse ' s station. He said that he has smoked many times with Resident #6 and she has always smoked unsupervised but he felt like she should have had a staff member with her. He said that some days her hands tremor pretty bad and she has a hard time lighting her cigarette. He said that there are lots of times he has observed her sitting with a lighted cigarette and forgetting to flick the ashes and the cigarette burns down and falls off in her lap. He said that in his opinion she should have always had a staff member with her while she was smoking. In an interview on [DATE] at 4:15 p.m. with Resident #9 who also smokes independently she said that she had heard about Resident #6 catching her hair on fire. She said that she was not at all surprised. She said that she has often times seen Resident #6 when she could barely hold a cigarette because of her hand tremors. She said that she was glad that she now requires a staff member to supervise her smoking. In an interview on [DATE] at 4:20 p.m. with LVN A she said that she was going outside for a smoke break at 3:00 p.m. and she saw Resident #6 outside in the smoking area alone smoking. She said as she approached the resident she noticed she had something in her hair. She said as she took a closer look she saw that there was smoke coming from the top of the residents head. She said that her hair was singed and that her eyebrow was also singed. When she asked the Resident what happened. She said that Resident #6 told her she was lighting her cigarette and she must have caught her hair on fire. LVN A said that the resident was not aware at the time that her hair was on fire. She said that Resident #6 was confused that day, but not any more than normal. She said that Resident #6 should have been supervised while she was smoking. In an interview on [DATE] at 4:30 p.m. with LVN B she said that she was the charge nurse on the day [DATE] when Resident #6 caught her hair on fire. She said it was a particularly windy day and Resident #6 was outside smoking unsupervised and while she was lighting her cigarette she caught the top of hair on fire. She said that LVN A who was going out for a smoke break and saw that the resident ' s hair had been on fire. She said that LVN A brought Resident #6 back inside the facility. LVN A said that she assessed the residents face and scalp for any burns. She said on the top of her head, the hair was singed. She said that her scalp and forehead was a little red. She said that she cleansed the area to remove the singed hair. She said she put some cream on her scalp and her forehead. She said she completed an incident report and documented the event in the nurse ' s notes (via computer). She said that she notified Resident #6 ' s Primary Care Physician. She said that Resident #6 is often confused and has tremors in both hands. She said that Resident #6 should have been supervised while she was smoking long before the incident occurred. In an interview on 7|22| 14 at 10:00 a.m. with the DON she said that she had done a smoking assessment on Resident #6 in [DATE] and found her to be able to smoke unsupervised. She said that she now has to have supervision because while she was outside smoking unsupervised she caught the top of her hair on fire. She said that she singed her hair and her eyebrow. She said that she added to the care plan that the resident could not smoke unsupervised. She said that she communicated that with the resident and the staff. She said that the resident has not smoked without supervision since that incident. She said that she did not do a new smoking assessment as she was already confident that the resident could no longer smoke independently. The facility smoking policy dated [DATE] revealed...Residents who smoke will be assessed every six months and as needed to determine their need for supervision while smoking. The DON was not aware that this incident should have been called in to state office. She said that she is still pretty new to this position and she just didn't know. In an interview on [DATE] at 4:00 p.m. with the DON she said she was unable to find any nurse ' s notes in Resident #6 ' s clinical record describing the incident, notification of the physician or an order for [REDACTED].#6 ' s scalp and forehead by LVN B. Review of Resident #6 ' s quarterly Minimum Data Set (MDS) dated [DATE] revealed that resident was understood and understands. Her Brief Interview of Mental Status (BIMS) score was 08 out of a potential score of 15. ( BIMS is a brief screener that aids in detecting cognitive impairment. A total score of ,[DATE] indicates Resident # 6 is moderately impaired). Her care plan dated [DATE] revealed that Resident #6 is confused at times and has difficulty making decisions. Review of Resident #6 ' s Annual assessment MDS dated [DATE] revealed a BIMS score of 9 out of a potential score of 15. ( BIMS is a brief screener that aids in detecting cognitive impairment. A total score of ,[DATE] indicates Resident # 6 is moderately impaired). Delirium Inattention (Did resident have difficulty focusing attention, easily distracted, out of touch or difficulty following what was said). Behavior present, fluctuates (comes and goes, changes in severity). Record review of Resident # 6 ' s Smoking-Safety Screen dated [DATE] revealed the following: Resident with cognitive loss, no visual deficits, and resident has problems with dexterity; smokes ,[DATE] cigarettes per day, resident can light her own cigarette, likes to smoke morning, afternoon, and evenings. Resident needs facility to store lighter and cigarettes, Plan of Care (POC) is used to assure resident is safe while smoking. Interdisciplinary Team Committee (IDTC) decision; Resident is able to smoke unsupervised, aware of rules of where to smoke, and safety measures... Review of the facility Smoking Policy dated 8\5\2013 and signed by the facility Administrator revealed the following: It is the policy of Merkel Nursing Center to ensure the safety of all resident ' s. Residents, visitors, and employees may only smoke in the designated smoking area(s) provided. The designated smoking area is the front porch patio. Residents who smoke will be assessed every six months and as needed to determine their need for supervision while smoking. All residents that are able to smoke without supervision are allowed to keep their cigarettes. Residents who need supervision will be allowed to smoke according to staff availability. All resident lighters are to be kept at the nurse ' s station... Record review of Resident #6 ' s Clinical Progress Note dated [DATE] from Cross Timbers Senior Services revealed the following: Symptoms Demonstrating Medical Necessity/depression, anxiety, delusions. Thought content and Process ...insight poor, judgment poor Clinical note revealed Client outside smoking. Client appears to exhibit major mental status decline. Client exhibited extremely slow thought process. Exhibiting major blank staring. Two to three minute verbal delay. Utilized past relationship to offer support and affirmation. Provided cognitive and social stimulation to increase cognitive awareness... Record Review of Resident # 6 ' s Clinical Progress Note dated [DATE] from Cross Timbers Senior Services revealed ...insight poor, judgment poor...Client appears to be declining mentally. Client no longer willingly interacts with staff or other residents. Continues to go outside and smoke but does not interact with other...Client appeared to be extremely slow reaction time when interacting with therapist. When client attempted to answer questions it would take up to two to three minutes for her to respond. Provided cognitive and social stimulation to help increase cognitive awareness. Record review of the Facility Incident Report dated [DATE] written by LVN B revealed the following: Resident outside smoking when staff went out to smoking area and noticed something in resident ' s hair and eyebrow and found it to be singed hair. Resident stated she was lighting a smoke and the wind blew and caught her bangs on fire. Immediate action taken, Resident was brought into facility and assessed area was cleansed and cream to area, slight redness but no blister or pain voiced. Predisposing Psychological Factors... confused, impaired memory Record review of Resident #6 ' s Care Plan dated [DATE] revealed the following: The resident has impaired cognitive function/impaired thought processes r/t insomnia, psychosis, depression, and alcohol-induced dementia...Interventions Communication, The resident understands consistent, simple, directive sentences. Provide the resident with necessary cues-stop and return if agitated. Keep the residents routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. Record review of Resident #6 ' s Care Plan dated [DATE] revealed the following: The resident is a smoker, resident outside smoking on patio, wind blowing, caught top of hair on fire, singeing top of forehead-no injury, slight pink, cleansed and Eurcerin lotion applied Goals The resident will not suffer injury from unsafe smoking practices through the review date, target date [DATE] interventions ...the resident requires supervision while smoking... Record review of Resident #6 ' s Care Plan dated [DATE] revealed the following: Focus Resident has depression r/t dementia, decline in condition and increased tremors... Review of Provider Letter #,[DATE] dated [DATE] Guidelines for Reporting Incidents Health & Safety Code $$ 242.122 and 40 Texas Administrative Code (TAC) $$ 19.602(a) require a facility staff member who has cause to believe that the physical or mental health or welfare of a resident has been adversely affected by abuse, neglect, exploitation...Facilities are required by 42 Code $$19.601(c)(2) to ensure that all alleged violations involving mistreatment, neglect, or abuse including injuries of unknown source and misappropriation of resident property, are reported immediately to DADS. Facilities are also required to report certain other incidents, which may or may not constitute abuse, neglect, or exploitation. Certified facilities are required by 42 Code of Federal Regulations (CFR) $$ 483.13(c)(2) and (4) to report alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source and misappropriation of resident property, and the results of the investigation conducted by the facility to the state survey and certification agency. The facility or facility staff must report the following incidents (,[DATE]) to the Consumer Rights and Services section, DADS State Office, Austin, TX, immediately *within 24 hours( upon learning of the incident and send a written investigation report to the Consumer Rights Services Section no later than the fifth working day after the oral report... The facility must have evidence that all alleged violations are thoroughly investigated and must prevent further potential abuse while the investigation is in progress... Neglect as defined in 40 TAC $$19.101(81) The facility must determine if an injury, harm, or death of a resident was due to a facility failure to provide services, treatment, or care of a resident...For Certified facilities, neglect is also defined at 42 CFR $$488.301 and prohibited at $$483.13(b)and(c). Review of list provided by DON on [DATE] showed 4 of 40 residents were identified as smokers. 2. During review of the facility crash cart with the DON on [DATE] at 1:00 p.m. there was no ambu bag located on the crash cart. In an interview with the DON on [DATE] at 1:00 p.m., she said that the Maintenance Supervisor was responsible for restocking the crash cart and confirmed that there was no ambu-bag on the crash cart and that there was not one available in the facility. The DON said that she would order an ambu-bag immediately. Review of the facility policy titled POLICY ON CRASH CART approved [DATE] revealed: It is the policy of this facility to maintain a crash cart in central supply. The cart shall be used in emergency situations and contain the following items: Back board for effective compressions while performing CPR while resident in bed. Portable O2 with mask, tubing and cannula. Suction machine with appropriate tubing and yankauers. Med and large airway. Non sterile gloves and PPE equipment ie: goggles, paper gown, face shield, hand sanitizer Ambu bag or bags Biohazard bags/universal precautions compliance kit The crash cart is to be checked on a routine basis (monthly and prn) to ensure suction is working and portable O2 is in good working order. Review of list provided by DON on [DATE] showed 12 of 40 resident were identified as Full Code.

Based on observations, interviews, and record reviews the facility failed to implement policy and procedure that prohibits neglect for one of three residents (Resident #9) reviewed for aspiration risk. The facility failed to: a) Position Resident #9 while eating to remain in an upright position to avoid choking; b) React or respond when Resident #9 was choking while eating. Resident #9 coughed, spit up her food, tried to clear her throat and gagged while gasping for air when she was being fed by staff in the dining room. An Immediate Jeopardy was identified 05/01/12 at 4:29 p.m. While the immediate jeopardy was removed 05/02/12 at 3:07 p.m. the facility remained out of compliance at a scope of no actual harm with potential for more than minimal harm and a severity level of pattern because the facility had not had time to evaluate it's own action plan for effectiveness. Three residents were placed at high risk for aspiration, pneumonia and death if the deficient practice continued. Findings include: Review of Resident #9's signed physician orders [REDACTED]. Gale Encyclopedia of Medicine), Allergic rhinitis, Menopausal disorder, Constipation and Abnormal loss of weight. "[MEDICAL CONDITION]'s disease... causes involuntary, jerking or writhing movements, slow, uncoordinated fine movements, difficulty with speech, difficulty swallowing...common causes of death include complications related to the inability to swallow, and pneumonia..." Mayoclinic.com "...The position of a patient during and after mealtime can have a great affect on the individual's ability to swallow and can also serve as a method to prevent aspiration. Individuals should be in an upright position with head tilted slightly downward during mealtime, and should remain upright for 30-45 minutes following meals to prevent regurgitation and aspiration of food. Modified seating may have to be utilized to ensure appropriate positioning during mealtimes..." (www.hdsa.org) Review of Resident #9's "Interdisciplinary Care Plan" dated 01/10/12 revealed, "...I need assist with all ADL's (activities of daily living)...One aide to assist with eating..." No care plan for risk of aspiration or positioning while eating was found. Review of Resident #9's MDS (Minimum Data Set) dated 04/05/12 revealed she needed extensive assistance with eating and required one person physical assistance. Review of Resident #9's MDS dated [DATE] revealed her diet was Mechanically altered. Observation on 05/01/12 at 12:55 p.m. revealed Resident #9 was in a geri chair in the dining room at the assisted feeding table. Resident #9 had slid down in the geri chair to nearly a lying down position. Her legs were hanging off the right side of the geri chair. Resident #9's knees hit the underside of the table three times. Observation on 05/01/12 at 1:09 p.m. revealed CNA A assisting Resident #9 to eat. CNA A placed Resident #9's pureed food in a cup that contained milk. Resident #9 drank from the cup's straw with assistance. Resident #9 was not repositioned prior to drinking from the cup. Observation on 05/01/12 at 1:10 p.m. revealed the DON to be observing Resident #9 being fed by CNA A. The DON did not intervene or redirect CNA A. Resident #9 was observed to be coughing, spitting up and clearing her throat. Observation on 05/01/12 at 1:17 p.m. revealed Resident #9 to gag and gasp for air and pivot her head after being fed a spoonful of food. Staff did not assist or intervene. Resident #9 had involuntary spastic movements of her entire body. In an interview on 05/01/12 at 1:34 p.m., the DON said Resident #9 prefers to eat in a lying position and that it did no good to reposition her. In an interview on 05/01/12 at 4:30 p.m., the DON said there was nothing more she could think of to keep Resident #9 positioned upright while eating. An Immediate Jeopardy was identified 05/01/12 at 4:29 p.m. While the immediate jeopardy was removed 05/02/12 at 3:07 p.m. the facility remained out of compliance at a scope of no actual harm with potential for more than minimal harm and a severity level of pattern because the facility had not had time to evaluate it's own action plan for effectiveness. The facility submitted an Action Plan 05/02/12 that read, "(Name of facility), May 2, 2012. Action plan for Immediate Jeopardy. List of residents that are at risk for aspiration (three names listed). The facility recognizes that resident safety is of utmost importance. The facility will correct this by the following: DON/ADON inserviced nursing staff on 05/01/12 and 05/02/12 for proper positioning of (resident #9's name) at risk for aspiration and for use of new table while feeding (resident #9's name). ADON placed slide resistant material in (resident #9's name) chair on 05/01/12 for better positioning during meal times. Table was placed on geri chair for better positioning and safety for (resident #9's name). DON/ADON inserviced nursing staff on 05/02/12 for proper positioning during meal times for (#'s 9, 10 and 11's names). This action plan will be observed daily by nurses for continued effectiveness. The DON will observe and meet with Administrator on a weekly basis to assure this deficient practice does not recur." In an interview on 05/02/12 at 11:25 a.m., CNA B said she had been inserviced on proper positioning of residents when they eat. She said all staff were to assist with keeping residents upright when eating. In an interview on 05/02/12 at 11:27 a.m., CNA C said inservices were given to staff on keeping residents upright when they eat, and to reposition residents if they slid down in their chairs. Observation on 05/02/12 at 12:22 p.m. revealed Resident #9 in her geri chair in the dining room. Resident #9 was seated in an upright position. A slide-resistant material was on the chair. Resident #9 was fed by a staff member. Resident #9 did not choke or gag while eating. Review of Resident #9's "Interdisciplinary Care Plan" dated 05/01/12 revealed, "Problems/Needs-I have a risk for aspiration while eating. Objectives-I'll have no aspiration for 90 days. Approaches- 1. Up in geri chair for meals with table applied. 2. Dyson (a rubbery-like pad that prevents sliding down) applied to back and seat. 3. Spoon fed per staff. 4. Observe me for sliding and reposition as needed..." Review of the facility's policy received 05/03/12 dated 2006 entitled "Choking" revealed "...Purpose To clear airway of blockage of foreign object or food...Assessment Guidelines...Inability to speak...level of consciousness, respiratory distress, universal sign of inability to breathe by holding the neck....Procedure...1. Look for signs and symptoms of distress- A) unable to speak or breathe; B) turning blue and/or unconsciousness. 2. If resident is coughing, allow him/her to cough to dislodge the object himself. 3. Coughing is a defense mechanism of the body which serves the purpose of ejecting foreign objects from air passages. 4. The universal sign for respiratory distress is holding the throat with both hands..." Review of the facility's policy received 05/03/12 (undated) entitled "Positioning/Turning" revealed "...Residents who are not able to reposition themselves are turned by the staff every 2 hours: To prevent contracture. To stimulate circulation. To promote lung expansion and drainage of respiratory secretions...." The action plan was reviewed for completion and accepted 05/02/12. The immediate jeopardy was removed 05/02/12 at 3:07 p.m. but the facility remained out of compliance at a severity level of potential for harm that is not immediate jeopardy and a scope of pattern. Review of the facility's Action Plan dated 05/02/12 revealed three residents at risk for aspiration.

Based on observations, interviews and record reviews the facility failed to implement written policies and procedures that prohibit neglect of residents. The facility failed to: a) Position Resident #9 while eating to remain in an upright position to avoid choking; b) React or respond when Resident #9 was choking while eating. Resident #9 coughed, spit up her food, tried to clear her throat and gagged while gasping for air when she was being fed by staff in the dining room. An Immediate Jeopardy was identified 05/01/12 at 4:29 p.m. While the immediate jeopardy was removed 05/02/12 at 3:07 p.m. the facility remained out of compliance at a scope of no actual harm with potential for more than minimal harm and a severity level of pattern because the facility had not had time to evaluate it's own action plan for effectiveness. Three residents were placed at high risk for aspiration, pneumonia and death if the deficient practice continued. Findings include: Review of the facility's policy entitled, "Rights of Nursing Facility Residents" , undated, received 05/01/12 revealed "...nursing facility resident has the right ...to be free from abuse, neglect..." Review of the facility's policy received 05/03/12 dated 2006 entitled "Choking" revealed "...Purpose To clear airway of blockage of foreign object or food...Assessment Guidelines...Inability to speak...level of consciousness, respiratory distress, universal sign of inability to breathe by holding the neck....Procedure...1. Look for signs and symptoms of distress- A) unable to speak or breathe; B) turning blue and/or unconsciousness. 2. If resident is coughing, allow him/her to cough to dislodge the object himself. 3. Coughing is a defense mechanism of the body which serves the purpose of ejecting foreign objects from air passages. 4. The universal sign for respiratory distress is holding the throat with both hands..." Review of Resident #9's signed physician orders [REDACTED]. Gale Encyclopedia of Medicine), Allergic rhinitis, Menopausal disorder, Constipation and Abnormal loss of weight. "[MEDICAL CONDITION]'s disease... causes involuntary, jerking or writhing movements, slow, uncoordinated fine movements, difficulty with speech, difficulty swallowing...common causes of death include pneumonia..." Mayoclinic.com "...The position of a patient during and after mealtime can have a great affect on the individual's ability to swallow and can also serve as a method to prevent aspiration. Individuals should be in an upright position with head tilted slightly downward during mealtime, and should remain upright for 30-45 minutes following meals to prevent regurgitation and aspiration of food. Modified seating may have to be utilized to ensure appropriate positioning during mealtimes..." (www.hdsa.org) Review of Resident #9's "Interdisciplinary Care Plan" dated 01/10/12 revealed, "...I need assist with all ADL's (activities of daily living)...One aide to assist with eating..." No care plan for risk of aspiration or positioning while eating was found. Review of Resident #9's MDS (Minimum Data Set) dated 04/05/12 revealed she needed extensive assistance with eating and required one person physical assistance. Review of Resident #9's MDS dated [DATE] revealed her diet was Mechanically altered. Observation on 05/01/12 at 12:55 p.m. revealed Resident #9 was in a geri chair in the dining room at the assisted feeding table. Resident #9 had slid down in the geri chair to nearly a lying down position. Her legs were hanging off the right side of the geri chair. Resident #9's knees hit the underside of the table three times. Observation on 05/01/12 at 1:09 p.m. revealed CNA A assisting Resident #9 to eat. CNA A placed Resident #9's pureed food in a cup that contained milk. Resident #9 drank from the cup's straw with assistance. Resident #9 was not repositioned prior to drinking from the cup. Observation on 05/01/12 at 1:10 p.m. revealed the DON to be observing Resident #9 being fed by CNA A. The DON did not intervene or redirect CNA A. Resident #9 was observed to be coughing, spitting up and clearing her throat. Observation on 05/01/12 at 1:17 p.m. revealed Resident #9 to gag and gasp for air and pivot her head after being fed a spoonful of food. Staff did not assist or intervene. Resident #9 had involuntary spastic movements of her entire body. In an interview on 05/01/12 at 1:34 p.m., the DON said Resident #9 prefers to eat in a lying position and that it did no good to reposition her. In an interview on 05/01/12 at 4:30 p.m., the DON said there was nothing more she could think of to keep Resident #9 positioned upright while eating. An Immediate Jeopardy was identified 05/01/12 at 4:29 p.m. and the Administrator, DON and ADON were informed. The facility submitted an Action Plan 05/02/12 that read, "(Name of facility), May 2, 2012. Action plan for Immediate Jeopardy. List of residents that are at risk for aspiration (three names listed). The facility recognizes that resident safety is of utmost importance. The facility will correct this by the following: DON/ADON inserviced nursing staff on 05/01/12 and 05/02/12 for proper positioning of (resident #9's name) at risk for aspiration and for use of new table while feeding (resident #9's name). ADON placed slide resistant material in (resident #9's name) chair on 05/01/12 for better positioning during meal times. Table was placed on geri chair for better positioning and safety for (resident #9's name). DON/ADON inserviced nursing staff on 05/02/12 for proper positioning during meal times for (#'s 9, 10 and 11's names). This action plan will be observed daily by nurses for continued effectiveness. The DON will observe and meet with Administrator on a weekly basis to assure this deficient practice does not recur." In an interview on 05/02/12 at 11:25 a.m., CNA B said she had been inserviced on proper positioning of residents when they eat. She said all staff were to assist with keeping residents upright when eating. In an interview on 05/02/12 at 11:27 a.m., CNA C said inservices were given to staff on keeping residents upright when they eat, and to reposition residents if they slid down in their chairs. Observation on 05/02/12 at 12:22 p.m. revealed Resident #9 in her geri chair in the dining room. Resident #9 was seated in an upright position. A slide-resistant material was on the chair. Resident #9 was fed by a staff member. Resident #9 did not choke or gag while eating. Review of Resident #9's "Interdisciplinary Care Plan" dated 05/01/12 revealed, "Problems/Needs-I have a risk for aspiration while eating. Objectives-I'll have no aspiration for 90 days. Approaches- 1. Up in geri chair for meals with table applied. 2. Dyson (a rubbery-like pad that prevents sliding down) applied to back and seat. 3. Spoon fed per staff. 4. Observe me for sliding and reposition as needed..." Review of the facility's policy received 05/03/12 (undated) entitled "Positioning/Turning" revealed "...Residents who are not able to reposition themselves are turned by the staff every 2 hours: To prevent contracture. To stimulate circulation. To promote lung expansion and drainage of respiratory secretions...." The action plan was reviewed for completion and accepted 05/02/12. The immediate jeopardy was removed 05/02/12 at 3:07 p.m. but the facility remained out of compliance at a severity level of potential for harm that is not immediate jeopardy and a scope of pattern. Review of the facility's Action Plan dated 05/02/12 revealed three residents at risk for aspiration.

Based on observations, interviews and record reviews the facility failed to provide necessary care and services to maintain the highest practicable physical well-being for one of three residents (Resident #9) reviewed for aspiration risks. The facility failed to: a) Position Resident #9 while eating to remain in an upright position to avoid choking; b) React or respond when Resident #9 was choking while eating. Resident #9 coughed, spit up her food, tried to clear her throat and gagged while gasping for air when she was being fed by staff in the dining room. An Immediate Jeopardy was identified 05/01/12 at 4:29 p.m. While the immediate jeopardy was removed 05/02/12 at 3:07 p.m. the facility remained out of compliance at a scope of no actual harm with potential for more than minimal harm and a severity level of pattern because the facility had not had time to evaluate it's own action plan for effectiveness. Three residents were placed at high risk for aspiration, pneumonia and death if the deficient practice continued. Findings include: Review of the facility's policy received 05/03/12 dated 2006 entitled "Choking" revealed "...Purpose To clear airway of blockage of foreign object or food...Assessment Guidelines...Inability to speak...level of consciousness, respiratory distress, universal sign of inability to breathe by holding the neck....Procedure...1. Look for signs and symptoms of distress- A) unable to speak or breathe; B) turning blue and/or unconsciousness. 2. If resident is coughing, allow him/her to cough to dislodge the object himself. 3. Coughing is a defense mechanism of the body which serves the purpose of ejecting foreign objects from air passages. 4. The universal sign for respiratory distress is holding the throat with both hands..." Review of Resident #9's signed physician orders [REDACTED]. Gale Encyclopedia of Medicine), Allergic rhinitis, Menopausal disorder, Constipation and Abnormal loss of weight. "[MEDICAL CONDITION]'s disease... causes involuntary, jerking or writhing movements, slow, uncoordinated fine movements, difficulty with speech, difficulty swallowing...common causes of death include pneumonia..." Mayoclinic.com "...The position of a patient during and after mealtime can have a great affect on the individual's ability to swallow and can also serve as a method to prevent aspiration. Individuals should be in an upright position with head tilted slightly downward during mealtime, and should remain upright for 30-45 minutes following meals to prevent regurgitation and aspiration of food. Modified seating may have to be utilized to ensure appropriate positioning during mealtimes..." (www.hdsa.org) Review of Resident #9's "Interdisciplinary Care Plan" dated 01/10/12 revealed, "...I need assist with all ADL's (activities of daily living)...One aide to assist with eating..." No care plan for risk of aspiration or positioning while eating was found. Review of Resident #9's MDS (Minimum Data Set) dated 04/05/12 revealed she needed extensive assistance with eating and required one person physical assistance. Review of Resident #9's MDS dated [DATE] revealed her diet was Mechanically altered. Observation on 05/01/12 at 12:55 p.m. revealed Resident #9 was in a geri chair in the dining room at the assisted feeding table. Resident #9 had slid down in the geri chair to nearly a lying down position. Her legs were hanging off the right side of the geri chair. Resident #9's knees hit the underside of the table three times. Observation on 05/01/12 at 1:09 p.m. revealed CNA A assisting Resident #9 to eat. CNA A placed Resident #9's pureed food in a cup that contained milk. Resident #9 drank from the cup's straw with assistance. Resident #9 was not repositioned prior to drinking from the cup. Observation on 05/01/12 at 1:10 p.m. revealed the DON to be observing Resident #9 being fed by CNA A. The DON did not intervene or redirect CNA A. Resident #9 was observed to be coughing, spitting up and clearing her throat. Observation on 05/01/12 at 1:17 p.m. revealed Resident #9 to gag and gasp for air and pivot her head after being fed a spoonful of food. Staff did not assist or intervene. Resident #9 had involuntary spastic movements of her entire body. In an interview on 05/01/12 at 1:34 p.m., the DON said Resident #9 prefers to eat in a lying position and that it did no good to reposition her. In an interview on 05/01/12 at 4:30 p.m., the DON said there was nothing more she could think of to keep Resident #9 positioned upright while eating. An Immediate Jeopardy was identified 05/01/12 at 4:29 p.m. and the Administrator, DON and ADON were informed. The facility submitted an Action Plan 05/02/12 that read, "(Name of facility), May 2, 2012. Action plan for Immediate Jeopardy. List of residents that are at risk for aspiration (three names listed). The facility recognizes that resident safety is of utmost importance. The facility will correct this by the following: DON/ADON inserviced nursing staff on 05/01/12 and 05/02/12 for proper positioning of (resident #9's name) at risk for aspiration and for use of new table while feeding (resident #9's name). ADON placed slide resistant material in (resident #9's name) chair on 05/01/12 for better positioning during meal times. Table was placed on geri chair for better positioning and safety for (resident #9's name). DON/ADON inserviced nursing staff on 05/02/12 for proper positioning during meal times for (#'s 9, 10 and 11's names). This action plan will be observed daily by nurses for continued effectiveness. The DON will observe and meet with Administrator on a weekly basis to assure this deficient practice does not recur." In an interview on 05/02/12 at 11:25 a.m., CNA B said she had been inserviced on proper positioning of residents when they eat. She said all staff were to assist with keeping residents upright when eating. In an interview on 05/02/12 at 11:27 a.m., CNA C said inservices were given to staff on keeping residents upright when they eat, and to reposition residents if they slid down in their chairs. Observation on 05/02/12 at 12:22 p.m. revealed Resident #9 in her geri chair in the dining room. Resident #9 was seated in an upright position. A slide-resistant material was on the chair. Resident #9 was fed by a staff member. Resident #9 did not choke or gag while eating. Review of Resident #9's "Interdisciplinary Care Plan" dated 05/01/12 revealed, "Problems/Needs-I have a risk for aspiration while eating. Objectives-I'll have no aspiration for 90 days. Approaches- 1. Up in geri chair for meals with table applied. 2. Dyson (a rubbery-like pad that prevents sliding down) applied to back and seat. 3. Spoon fed per staff. 4. Observe me for sliding and reposition as needed..." Review of the facility's policy received 05/03/12 dated 2006 entitled "Choking" revealed "...Purpose To clear airway of blockage of foreign object or food...Assessment Guidelines...Inability to speak...level of consciousness, respiratory distress, universal sign of inability to breathe by holding the neck....Procedure...1. Look for signs and symptoms of distress- A) unable to speak or breathe; B) turning blue and/or unconsciousness. 2. If resident is coughing, allow him/her to cough to dislodge the object himself. 3. Coughing is a defense mechanism of the body which serves the purpose of ejecting foreign objects from air passages. 4. The universal sign for respiratory distress is holding the throat with both hands..." Review of the facility's policy received 05/03/12 (undated) entitled "Positioning/Turning" revealed "...Residents who are not able to reposition themselves are turned by the staff every 2 hours: To prevent contracture. To stimulate circulation. To promote lung expansion and drainage of respiratory secretions...." The action plan was reviewed for completion and accepted 05/02/12. The immediate jeopardy was removed 05/02/12 at 3:07 p.m. but the facility remained out of compliance at a severity level of potential for harm that is not immediate jeopardy and a scope of pattern. Review of the facility's Action Plan dated 05/02/12 revealed three residents at risk for aspiration.