Every finding on record at Mesa Vista Inn Health Center

Based on observation, interview and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 6 (Resident #2) residents reviewed for resident rights: The facility failed to have Resident #2's call light within reach while he was in bed. This deficient practice could affect residents who used their call light or desire to use the call light and place them at risk of not being able to notify staff of their needs. The findings were: Record review of Resident #2's admission Record, dated 06/30/2026, reflected an [AGE] year-old male admitted [DATE]. Record review of Resident #2's quarterly MDS, dated [DATE], reflected a BIMS score of 03 out of 15 indicating severely impaired cognition. It reflected Resident #2 had a diagnosis of Non-Alzheimer's dementia (cognitive disorder severe enough to interfere with daily life). Record review of Resident #2's care plan, undated, reflected:Focus The resident has a communication problem r/t dementia, initiated 11/27/2024, with intervention Ensure/provide a safe environment: Call light in reach. Initiated 11/27/2024. Focus The resident is risk for falls r/t cognitive impairment, initiated 11/27/2024, with intervention Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. During an observation on 06/30/2026 at 04:32PM, CNA C walked out of Resident #2's room with his roommate, taking him to the dining room in his wheelchair. During an observation and interview on 06/30/2026 at 04:46 PM, revealed Resident #2 was sitting up in his bed and his call light was on the floor and not within reach. Resident #2 was able to note that he could not reach the call light, and he was unable to answer further questions pertaining to his call light. CNA C came back to Resident #2's room and stated Resident #2's call light was not within reach of Resident #2. She revealed she normally made sure Resident #2's call light was within reach when she came into his room because he was a fall risk, but she did not check Resident #2's call light before she left his room earlier. During an interview on 07/01/2026 at 04:31 PM, the DON revealed every resident's call light should be within reach so the residents can use it as soon as they needed assistance. During an interview on 07/02/2026 at 10:55 AM, the ADM revealed call lights should be within reach of residents. It was important to have the call light within reach so resident can ask for assistance. Record review of an email with the ADM on 07/01/2026 at 04:59 PM revealed the facility did not have a policy on call lights. Record review of the facility's policy Resident Rights, revised 11/28/2016, reflected The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that include measurable objectives and time frames to meet residents' medical, nursing, and mental and psychosocial needs for 1of 6 residents (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1's care plan was updated with the facility's new interventions for his wandering behaviors. This failure could place residents at risk of not having their needs met and not receiving appropriate care. The findings included:Record review of Resident #1's admission Record, dated 06/30/2026, reflected a [AGE] year-old male initially admitted [DATE] and re-admitted [DATE]. Record review of Resident #1's quarterly MDS, dated [DATE], reflected a BIMS score of 06 out of 15 indicating severely impaired cognition. Resident #1 had wandering behaviors daily. It reflected Resident #1 had a diagnosis of Non-Alzheimer's dementia (cognitive disorder severe enough to interfere with daily life). Record review of Resident #1's care plan, undated, reflected The resident is at risk for wandering, dated 04/11/2025, with interventions dated 04/11/2025 and no new interventions since 04/11/2025. Record review of Resident #1's progress note, dated 6/10/2026 at 12:29PM and authored by LVN A, reflected constant reminders to stay out of women rooms, multiple timesreminders not to follow women aroundstates understanding however constant remindersInterventions: Directed to the resident's room to decrease stimulation, Encourage activities, no new orders During an interview on 07/01/2026 at 03:41 PM, LVN B, (Resident #1's current nurse) revealed Resident #1 walked into female's rooms and an intervention the nursing staff implemented was to keep Resident #1 out of the women's hallways. LVN B was not sure if this was notated on Resident #1's care plan but the nursing staff knew through communication with each other. During an interview on 07/02/2026 at 10:14 AM, the DON revealed they investigated incidents where Resident #1 wandered into the women's hallways and no harm occurred. She revealed interventions should be updated on residents' care plans after every incident. She revealed the nursing staff learned about new interventions for residents in the daily huddles with the nursing staff. During an interview on 07/02/2026 at 10:55 AM, the ADM revealed any new intervention after any incident should be updated in the care plan because it was the resident's plan of care. During an interview on 07/02/2026 at 11:44 AM, CNA D revealed for residents who wandered they stopped women going to men's halls, men going into women's halls. Record of the facility's policy Comprehensive Care Planning, undated reflected The comprehensive care plan will describe the following - The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs.

Based on interviews, and record reviews, the facility failed to develop and implement a comprehensiveperson-centered care plan for each resident, consistent with the resident rights, which includes measurable objective andtimes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in thecomprehensive assessment for 1 Resident (Resident #1) of 5 residents reviewed for comprehensive person-centered. care plans. The facility failed to ensure Resident #1's comprehensive care plan addressed the active diagnosis of osteoporosis. This deficient practice could place residents at risk of missed or miscommunicated care. Findings included: Record review of Resident #1's electronic face sheet dated 06/16/2026 reflected a [AGE] year-old female admitted on [DATE] with a diagnosis of osteoporosis (bone disease characterized by weak fragile bones). Record review of Resident #1's annual MDS assessment dated [DATE] reflected that she could rarely understand and rarely be understood. She was not a candidate for a BIMS which signified her cognitive status was severely impaired. She was dependent on staff for ADLs. She was coded to have an active diagnosis of osteoporosis. She was not inter-viewable. Record review of Resident #1's comprehensive care plan dated 06/03/2026 did not reflect her diagnosis of osteoporosis. Record review of Resident #1's Active Orders as of: 06/16/2026 reflected she was prescribed alendronate sodium (works by slowing down bone breakdown, increase bone density and lower risk of fractures) oral tablet 70 mg for osteoporosis, give one time a day every Thursday with a start date of 05/28/2025. Record review of Resident #1's MAR dated 05/1/2026 to 5/31/2026 reflected she received alendronate sodium once a week for the month of May 2026. During an interview on 06/16/2026 at 12:10 pm, the MDS nurse stated Resident #1's osteoporosis was an active diagnosis, and she was treated for it, so it needed to be on her comprehensive care plan. She stated she did not know how it was missed and an inaccurate care plan could lead to inaccurate information and care provided. She stated she was accountable for the care plans with an interdisciplinary team. During an interview on 06/16/2026 at 3:15 pm, the DON stated she was not aware that Resident #1's osteoporosis was not reflected in her care plan. She stated accurate care plans are needed for the resident's specific care required. During an interview on 06/16/2026 at 3:18 pm, the ADM stated Resident #1's comprehensive care plan needed to reflect her active diagnoses because she received that care and care could be missed or wrong if the care plan was inaccurate. Record review of the facility's policy and procedure titled Comprehensive Care Planning (undated) reflected The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.

Based on interview and record review, the facility failed to review and revise the comprehensive care plan for 1 (Residents #1) oof 5 residents reviewed for comprehensive care plans, in that: Resident #1's comprehensive care plan was not revised to reflect that she no longer took antipsychotic and antianxiety medications. This deficient practice could result in substandard level of care. Findings included: Record review of Resident #1's electronic face sheet dated 06/16/2026 reflected a [AGE] year-old female readmitted on [DATE]. Her diagnoses included: anxiety (feeling nervousness, or unease), major depressive disorder (serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities and various emotional and physical problems) and insomnia (sleep disorder). Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected she was not taking an antipsychotic or antianxiety medication. She was not a candidate for a BIMS which signified her cognitive status was severely impaired. Record review of Resident #1's annual MDS assessment dated [DATE] reflected that she could rarely understand and rarely be understood. She was not a candidate for a BIMS which signified her cognitive status was severely impaired. She was dependent on staff for ADLs. She was not coded to be taking an antianxiety or antipsychotic medication. Record review of Resident #1's Active Orders as of: 06/16/2026 reflected she was not prescribed an antipsychotic or antianxiety medication. Record review of Resident #1's comprehensive care plan dated 06/10/2025 reflected Focus, the resident requires anti-psychotic medications r/t mood/behaviors, Interventions, administer medications as ordered. Monitor/document for side effects and effectiveness. Further review reflected, Focus, the resident uses anti-anxiety medications, Interventions, give anti-anxiety medications ordered by physician. Monitor/document side effects and effectiveness. During an interview on 06/16/2026 at 12:10 pm, the MDS nurse stated Resident #1's comprehensive care plan was reviewed but not revised when she was no longer prescribed and taking antipsychotic and antianxiety medications. She stated that information was important, especially for monitoring the residents for side effects and behaviors. She stated Resident #1 had not been on an antianxiety or antipsychotic medication through 2 MDS assessment cycles. During an interview on 06/16/2026 at 3:15 pm, the DON stated she was not aware that Resident #1's care plan needed to be reviewed and revised after MDS assessments for changes in the required care. During an interview on 06/16/2026 at 3:18 pm, the ADM stated Resident #1's comprehensive care plan needed to reflect her active diagnoses because she received that care and care could be missed or wrong if the care plan was inaccurate. Record review of the facility's policy and procedure titled Comprehensive Care Planning (undated) reflected. The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 4 of 32 residents reviewed (Resident #2, Resident #39, Resident #79, and Resident #94) and 3 of 4 (LNV E, RN G and MA H) facility staff observed for infection control. 1. The facility failed to ensure LVN E maintained proper hand hygiene during wound care for Resident #2. 2. The facility failed to ensure Resident #39's indwelling urinary catheter bag was not in a trash can with a dirty brief. 3. The facility failed to ensure Resident #79's indwelling urinary catheter bag was not touching the floor. 4. The facility failed to ensure RN G wore a PPE gown while administering medication to Resident #94, who was on enhanced barrier precautions, through a PEG/G tube (a flexible feeding tube inserted through the abdominal wall into the stomach that allows for the delivery of nutrition, fluids, and medications directly into the stomach). 5. The facility failed to ensure MA H sanitized scissors before using them to open a bottle of medication during medication pass. These failures could place residents at risk for cross contamination and infection. The findings included:1. Record review of Resident #2's face sheet, dated 4/24/26, revealed the resident was a [AGE] year-old female, initially admitted to the facility on [DATE], readmitted on [DATE], with diagnoses including sacral spina bifida with hydrocephalus (a congenital condition in which the spinal column does not close completely and is accompanied by excess cerebrospinal fluid accumulation in the brain), pressure ulcer of contiguous site of back, buttock, and hip, stage 4 (full-thickness tissue loss with exposed bone, tendon, or muscle), cellulitis (bacterial skin infection), neuromuscular dysfunction of bladder (impaired bladder function caused by nerve damage), and acquired absence of left leg above knee (surgical amputation). Record review of Resident #2's admission MDS assessment, dated 4/7/26/ revealed the resident's cognition was fully intact for daily decision making. Record review of Resident #2's care plan, initiated 4/3/2026 and revised 4/21/2026, revealed the resident had pressure ulcers or potential for pressure ulcer development including stage 4 right sacrum (full-thickness tissue loss with exposed structures), unstageable deep tissue injury to the right first toe (persistent non-intact skin with obscured tissue damage), and stage 4 right knee pressure ulcer (full-thickness skin and tissue loss), with interventions including staff were to administer treatments as ordered and monitor for effectiveness, assess, record, and monitor wound healing at least weekly including wound measurements and wound bed status, report loose or missing dressings to the nurse, provide assistance with repositioning at least every two hours, avoid positioning the resident on pressure ulcer locations, use lifting devices and draw sheets to reduce friction, provide incontinent care and moisture barrier application, monitor for new skin breakdown, and follow physician-ordered wound care treatments for the resident's sacrum, right toe, and right knee. During an observation on 4/24/26 at 9:51 a.m. revealed LVN E and CNA F prepared and provided wound care to Resident #2's bottom. During wound care LVN E stated he forgot the tape for the wound bandage and needed to retrieve it from the nurse wound supply cart. LVN E left the room. LVN E returned without the tape and went into the resident's restroom and began washing his hands. LVN E turned off the water faucet with his barehand. LVN E then went back to the resident's room door and opened it with his barehand. LVN E then asked another staff member (with unknown hand hygiene) to hand him the tape he forgot. LVN E then grabbed the tape with his bare hands and placed it on the bedside table with other clean supplies. LVN E then washed his hands and returned to the bedside, put on new clean gloves, and used the contaminated tape to secure Resident #2's dressings to her skin. During wound care, an unknown person entered the resident's shared bathroom, to which the door was open to, LVN E stopped wound care reached over, closed the bathroom door with his gloved hand, and then went back to place tape to secure the resident's bandages. During an interview on 4/24/26 at 10:35 a.m. LVN E stated he did not realize he touched the sink with his bare hand or the door handle and then touched the tape. LVN E stated although he had touched the tape at that point the resident's wounds were already covered by a bandage and the tape was only used to secure the bandage. LVN E stated he thought he used his foot to close the bathroom door. LVN E stated if he had used his gloved hand to close the door it would be an issue of infection control for the resident's wounds. During an interview on 4/24/26 at 3:23 p.m. the DON stated the nurse should not touch the clean supplies if he contaminated his hands because the supplies were no longer as clean as possible to prevent infections. Record review of facility policy, undated, titled Hand Hygiene revealed .hand hygiene continues to be the primary means of preventing the transmission of infection.hand hygiene was required .after contact with a resident's mucous membranes and body fluids or excretions.recommended techniques for washing hands with soap and water include. rubbing hands together vigorously for at least 20 seconds covering all surfaces of the hands and fingers.recommended techniques for performing hand hygiene with an ABHR include applying product. covering all surfaces of hands and fingers.gloves. are not a substitute for hand hygiene. Record review of facility policy, undated, titled Fundamentals of Infection Control Precautions revealed .hand hygiene continues to be the primary means of preventing the transmission of infection. and staff were required to perform hand hygiene .before and after entering indwelling catheters.after contact with a resident's mucous membranes and body fluids or excretions.after handling soiled or used linens, dressings, bedpans, catheters and urinals.after removing gloves or aprons.gloves do not replace the need for hand washing.failure to change gloves between resident contacts is an infection control hazard.non-invasive resident care equipment is cleaned daily or as need between use.equipment that is visibly soiled with blood or body fluids will be cleaned immediately with an approved disinfectant.environmental surfaces (e.g., bed rails, bedside tables, carts, commodes, doorknobs, faucet handles). required adequate disinfection. 2. Record review of Resident #39's admission record revealed the resident was a [AGE] year-old male, admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including unspecified dementia with behavioral disturbance (progressive cognitive decline affecting memory, reasoning, and behavior), urinary tract infection (infection involving the urinary system), acute kidney failure (sudden decline in kidney function), benign prostatic hyperplasia without lower urinary tract symptoms (noncancerous enlargement of the prostate gland), chronic obstructive pulmonary disease (chronic inflammatory lung disease causing airflow limitation), and protein-calorie malnutrition (nutritional deficiency resulting from inadequate protein and caloric intake). Record review of Resident #39's significant change MDS, dated [DATE], revealed the resident's cognition was severely impaired for daily decision making. The MDS also revealed he had an indwelling catheter. Record review of Resident #39's care plan, initiated 1/30/2026 and revised 4/21/2026, revealed the resident had an indwelling Foley catheter related to benign prostatic hyperplasia without lower urinary tract symptoms (noncancerous enlargement of the prostate), with cognitive impairment resulting in attempts to pull out the Foley catheter. The care plan included goals for the resident to remain free from signs and symptoms of urinary tract infection, remain free from catheter-related trauma or complications, maintain urinary drainage, and reduce agitation or behaviors toward the catheter. Interventions included staff were to position the catheter bag and tubing below bladder level and in a privacy bag, maintain the drainage bag off the floor, assess tubing for kinks, secure tubing to prevent pulling, monitor intake and output, monitor for catheter-related pain or discomfort, monitor for signs and symptoms of urinary tract infection, educate staff and the resident on catheter care and removal risks, and report abnormalities to the physician. During an observation and interview on 4/21/26 at 5:59 a.m. revealed Resident #39 was lying in bed. Resident #39's catheter bag was inside the trashcan next to his bed. The trashcan contained a dirty brief. LVN K stated the resident had placed the catheter in the trashcan on his own. She stated there was a used brief in the trash can and that could cause cross contamination. LVN K stated she tried to educate the resident to keep the catheter in place because he tried to pull it out or empty it himself. LVN K stated she was unsure what could be done as an intervention for his catheter being in the trashcan. 3. Record review of Resident #79's admission record revealed the resident was a [AGE] year-old male, admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including vascular dementia with mood disturbance (decline in cognitive function caused by impaired blood flow to the brain accompanied by mood-related symptoms), unspecified dementia with psychotic disturbance (cognitive decline with hallucinations, delusions, or other psychotic features), presence of urogenital implants (urinary device placement), obstructive and reflux uropathy (urinary tract obstruction and backward flow of urine), benign prostatic hyperplasia with lower urinary tract symptoms (enlarged prostate causing urinary symptoms), metabolic encephalopathy (global brain dysfunction caused by systemic illness), and recurrent major depressive disorder. Record review of Resident #79's quarterly change MDS, dated [DATE], revealed the resident's cognition was severely impaired for daily decision making. The MDS also revealed he had an indwelling catheter. Record review of Resident #79's care plan, initiated 7/23/2021 and revised 1/18/2026, revealed the resident had a suprapubic catheter related to obstructive uropathy secondary to benign prostatic hyperplasia with lower urinary tract symptoms (urinary obstruction caused by enlarged prostate), with goals for the resident to remain free from signs and symptoms of urinary tract infection and catheter-related trauma. The care plan included interventions for staff to position the catheter bag and tubing below the level of the bladder and in a privacy bag, maintain the drainage bag off the floor each shift, check tubing for kinks, ensure tubing was anchored to the resident's leg or linens to prevent pulling, monitor intake and output, monitor for pain or discomfort, monitor for urinary tract infection signs and symptoms, provide catheter site care, and report complications or abnormalities to the physician. During an observation and interview on 4/21/26 at 5:59 a.m. revealed Resident #79 was lying in bed. Resident #79's catheter bag was touching the floor. LVN K stated the bag should not be touching the floor because it could cause cross contamination. During an interview on 4/23/26 at 10:37 a.m. the DON stated residents' catheter bags should not be touching the floor. The DON stated a basin could be used to put the catheter bag in to keep it from resting on the floor. The DON stated Resident #79 liked to place his catheter bag in the trashcan. The DON stated he had returned from the hospital recently from pulling out his catheter. The DON stated they tried to use a basin but Resident #39 would just throw it. The DON stated a catheter touching the floor or a dirty brief could be an infection control issue and the basin would have helped the catheter from getting contaminated. Record review of facility policy, undated, titled Catheter Care, Nursing Policy and Procedure, revealed .to keep the catheter and tubing free of kinks. Keep tubing off floor.be sure the catheter tubing and drainage bag are kept off the floor. during catheter care. 4. Record review of Resident #94's admission sheet dated 4/17/2020 documented a [AGE] year-old female resident with diagnoses including psychosis, insomnia, depression, dementia, anxiety, hypercholesterolemia (elevated levels of cholesterol in the blood), and hypertension (high blood pressure). Record review of Resident #94's MDS assessment dated [DATE] revealed a BIMS could not be conducted due to the resident rarely or never being understood and recorded the use of a feeding tube in Section K – Swallowing/Nutritional Status K0520 Nutritional Approaches. Record review of Resident #94's order summary revealed an active order for CLEAN PEG SITE AND CHANGE PEG TUBE DRESSING/REPLACE PEG SYRINGE Q NIGHT SHIFT every night shift with an order date of 3/14/2025 and no end date. Record review of Resident #94's care plan with an initiation date of 4/03/2024 revealed Resident is on enhanced barrier precautions ., with interventions including Gloves and gown should be donned if any of the following activities are to occur: linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bed mobility, wound care, enteral feeding care, catheter care, trach care, bathing, or other high-contact activity. During an observation of g-tube medication administration on 4/22/2026 at 9:20 AM, RN G was observed wearing gloves while administering medications through Resident #94's g-tube. RN G did not wear a protective gown while administering the medications. A sign regarding information for EBP was observed posted outside Resident #94's door. During an interview with RN G on 4/22/26 at 9:26 AM, RN G stated he should have also worn a gown when administering Resident #94's medications through the g tube since the resident was on EBP. RN G stated if a gown was not worn, it could cause the resident to get an infection. During an interview with the DON on 4/22/26 at 3:14 PM, the DON stated for the peg tube, RN G should have worn a gown, and that proper use of PPE was important because Resident #94 was at risk of infection because the peg tube was an internal device placing the resident at risk of exposure to outside organisms like bacteria. Review of the facility policy titled Enhanced Barrier Precautions, dated 4/01/2024, noted EBP are indicated for residents with any of the following: Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO, and Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. 5. During an observation of MA H on 4/22/26 at 9:30 AM, revealed MA H took a pair of scissors out of an opened bag sitting on top of a medication cart and used them to open the foil on a new bottle of Lactulose solution. MA H did not sanitize the scissors before using them to open the foil. During an interview with MA H on 4/22/26 at 9:45 AM, MA H stated she should have sanitized the scissors before using them to open the foil, because the scissors could cause an infection if they were not sanitized before use. During an interview with the DON on 4/22/26 at 3:14 PM, the DON stated MA H should have sanitized the scissors before using them to open the medication bottle. The DON stated it was important to sanitize the scissors before using them to keep the medication as clean as possible and not to expose it to contamination and infection. Review of the facility policy titled Fundamentals of Infection Control Precautions, undated, noted Resident care equipment and articles 3. Non-invasive resident care equipment is cleaned daily or as need between use .

Based on observations, interviews, and record reviews, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 3 of 8 residents (Resident #2, Resident #72, and Resident #89) whose rooms were observed for personal refrigerators. The facility failed to assist in maintaining personal refrigerator logs, in fridge thermometers, and/or discarding spoiled food for Residents #2, #72, and #89. These deficient practices could place residents at risk of food-bone illnesses.The findings were: 1.Record review of Resident #2's face sheet, dated 4/24/26, revealed the resident was a [AGE] year-old female, initially admitted to the facility on [DATE], readmitted on [DATE], with diagnoses including sacral spina bifida with hydrocephalus (a congenital condition in which the spinal column does not close completely and is accompanied by excess cerebrospinal fluid accumulation in the brain), major depressive disorder, and acquired absence of left leg above knee (surgical amputation). Record review of Resident #2's admission MDS assessment, dated 4/7/26 revealed the resident's cognition was fully intact for daily decision making. Record review of Resident #2's care plan revealed the resident had a focus area of impaired cognitive function/dementia or impaired thought processes, initiated on 04/03/2026, with interventions including staff providing consistent communication, reducing environmental distractions, offering structured activities, maintaining routine, monitoring for changes in cognitive status, and providing cues for redirection and safety, and a focus area of ADL self-care performance deficit, initiated on 04/03/2026, with interventions including staff assistance with bathing, dressing, toileting, and bed mobility, use of assistive devices, staff participation with transfers, repositioning in bed, encouragement of participation in self-care to the fullest extent possible, and monitoring and reporting changes in function. During an observation on 4/24/26 at 9:17 a.m., Resident #2 had a personal refrigerator in her room, the refrigerator did not have a thermometer or a temperature log. Resident #2 stated no one from the facility ever checked her refrigerator. 2.Record review of Resident #72's admission record/face sheet revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including unspecified intracranial injury without loss of consciousness, subsequent encounter (brain injury affecting neurological function); major depressive disorder, recurrent, unspecified (mood disorder characterized by persistent sadness and impaired functioning); other chronic pain (ongoing pain affecting daily activities); lumbago with sciatica, right side (lower back pain radiating down the leg affecting mobility); age-related osteoporosis without current pathological fracture (bone loss increasing risk for fractures and impacting physical strength); osteonecrosis, unspecified (bone tissue death due to decreased blood supply affecting mobility and function); and personal history of traumatic brain injury (prior brain injury associated with potential long-term cognitive and neurological impairment). Record review of Resident #72's admission MDS assessment, dated 3/2/26 revealed the resident's cognition was fully intact for daily decision making. Record review of Resident #72's care plan revealed the resident had a focus area of impaired cognitive function/dementia or impaired thought processes, initiated on 02/26/2026, with interventions including staff providing consistent communication, reducing environmental distractions, engaging the resident in simple structured activities, maintaining routine, monitoring and reporting changes in cognitive status, providing cues for redirection, and use of task segmentation to support memory deficits, and a focus area of ADL self-care performance deficit, initiated on 02/26/2026, related to generalized weakness and abnormal gait, with interventions including staff assistance with bathing, dressing, toileting, and bed mobility, assistance with personal hygiene, encouragement of participation in self-care, use of assistive devices, staff support with transfers, and monitoring and reporting changes in function. During an observation on 4/21/26 at 8:19 a.m., Resident #72 had a personal refrigerator in his room. The refrigerator did not contain a thermometer or a temperature log. During a follow-up observation and interview on 4/24/26 at 3:15 p.m., no thermometer was inside the personal refrigerator and no temperature log. Resident #72 stated no staff had told him he would be responsible for cleaning out his refrigerator. He stated that housekeeping had come and wiped off the top of the refrigerator. Resident #72 stated no one had mentioned anything about a thermometer to him. 3. Record review of Resident #89's admission record/face sheet, the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including unspecified dementia with agitation (a progressive cognitive disorder characterized by impaired memory, judgment, and increased behavioral disturbances such as agitation), major depressive disorder (a mental health disorder characterized by persistent feelings of sadness, loss of interest, and impaired daily functioning), anxiety disorder (a condition involving excessive worry, nervousness, and impaired concentration), insomnia (a sleep disorder characterized by difficulty initiating or maintaining sleep), metabolic encephalopathy (a condition involving altered mental status due to systemic metabolic dysfunction), paraplegia (paralysis of the lower extremities resulting in significant mobility limitations), mononeuropathy and polyneuropathy (nerve disorders causing weakness, numbness, and decreased functional ability), chronic pain (persistent pain affecting physical function and activity tolerance), and history of spinal cord injury (resulting in long-term neurological and mobility impairments). Record review of Resident #89's quarterly MDS assessment, dated 3/19/26 revealed the resident's cognition was fully intact for daily decision making. Record review of Resident #89's care plan revealed the resident had a focus area of impaired cognitive function/impaired thought processes, initiated on 02/26/2020, with interventions including staff providing consistent communication, reducing environmental distractions, maintaining routine, using simple instructions, providing cues for redirection, and monitoring and reporting changes in cognitive status, and a focus area of ADL self-care performance deficit, initiated on 05/18/2018, related to paraplegia, with interventions including staff assistance with bathing, dressing, toileting, and bed mobility, provision of sponge baths as needed, nail care and hygiene monitoring, assistance with transfers, encouragement of participation in self-care, and use of call light for assistance, and a focus area of impaired mobility related to paraplegia, with interventions including staff assistance with bed mobility, transfers, and supervision with locomotion. During an observation, interview, and record review on 4/21/26 at 8:06 a.m., Resident #89 was observed to have a personal refrigerator in his room. The refrigerator had a temperature log attached to the outside; however, the log did not indicate the month and included entries labeled 1st-15th and 16th-23rd. The freezer compartment contained ice buildup with brown discoloration noted in areas. The bottom of the refrigerator contained a towel with an unknown brown substance. A nutritional shake labeled with another resident's name, dated 1/3/26 with instructions to keep frozen, was observed in the refrigerator. Multiple food items were observed without dates. The resident stated staff and family had not assisted with cleaning out the refrigerator. During a joint interview on 4/23/26 at 11:28 a.m., the Administrator and DON stated they had champions who were assigned to each hallway. They stated the champions should be checking the residents' personal refrigerators. They stated they were unsure who the specific champion for Resident #89 was. They stated each fridge should have a thermometer and temperature log. They stated residents and their families were expected to keep the refrigerators clean themselves and supply a thermometer for the fridge. They stated if they had not been provided with a thermometer by family the facility could provide one for them. They stated Resident #89 was never roommates with the resident who was listed on the health shake he had in his fridge and Resident #89 had behaviors of not allowing staff to help him clean his fridge. They stated staff should have noticed the condition of Resident #89's fridge and assisted him with it. The facility stated they were responsible for the residents and they could get sick if they consumed spoiled items. Record review of facility policy titled Personal Refrigerators Policy, (Dietary Services Policy & Procedure Manual, FP 00-10.1), no date, revealed residents of the facility may place a personal or dormitory size refrigerator in their room if space permits and under Life Safety Code regulations. the care and maintenance of any refrigerator is the responsibility of the resident and/or responsible party. housekeeping can assist the resident and/or family member by inspecting the refrigerators at least weekly and assist with removal of outdated food items and cleanliness. the resident and/or resident representative should clean and maintain the refrigerator according to the manufacturer's user manual. the refrigerator compartment should be maintained at temperatures of 35-41 degrees. the freezer compartment should be maintained at zero degrees or less. temperatures can be monitored by the use of a thermometer designed for a refrigerator/freezer. food should be stored in the refrigerator/freezer as determined by the food item. expired food items should not be consumed and should be discarded. any food that shows signs of spoilage. should not be consumed and should be discarded. food stored in the refrigerator that is to be consumed by the resident should be according to the resident's diet ordered by the physician.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accidents and hazards as was possible for 3 of 18 residents (Resident #29, Resident #41, and Resident #52) reviewed for quality of care. 1. The facility failed to ensure Resident #41 did not have scissors stored openly on top of the nightstand. 2. The facility failed to ensure Resident #52 did not have a bottle of mouth wash in a shared room with Resident #11. 3. The facility failed to ensure Resident #29 did not have mouth wash or tiger balm in her room. These failures could place residents at risk of harm or injury and contribute to avoidable accidents and a decline in health. The findings included:1.Record review of Resident #41's admission sheet dated 02/27/2026 documented a [AGE] year-old female with diagnoses including malignant neoplasm of the nasal cavity (cancer) and epilepsy (seizure disorder). Record review of Resident #41's MDS assessment dated [DATE] documented a BIMS score of 13 indicating intact cognition and recorded the diagnoses of cancer and epilepsy. Further review of the MDS, documented Resident #41 had impairment in functional abilities including the need for partial/moderate assistance with ADLs. Record review of Resident #41's order summary documented an order for the seizure medication Levetiracetam. Levetiracetam was ordered as Levetiracetam 500 mg, Give 1 tablet by mouth two times a day for Seizures. Record review of Resident #41's care plan documented The resident has Seizure Disorder, with a goal The resident will remain free from injury related to seizure activity ., and The resident has impaired visual function ., with a goal The resident will maintain optimal quality of life within limitation imposed by visual function ., and The resident has an ADL Self Care Performance Deficit ., with a goal The resident will maintain or improve current level of function . During an interview with RN I on 4/21/26 at 7:45 AM, RN I stated Resident #41 should not have scissors sitting out in her room, because she could harm herself. RN I stated the scissors should be stored with the nurses while not in use by the resident. During an observation on 4/21/26 at 7:29 AM, a pair of full-size scissors was observed sitting in an opened container on Resident #41's nightstand. On 4/21/2026 between 7:30 AM and 7:35 AM, RN I was observed walking in and out of Resident #41's room. No scissors were seen in RN I's hands after exiting the resident's room. During an interview with the DON on 4/21/2026 at 1:28 PM, the DON stated residents should not have scissors in their rooms because they were sharp objects, and they could accidentally harm themselves. Review of the facility admission agreement dated 9/01/2025 noted in section Items Not Allowed in Resident Room Medications: (includes all Prescription and Over-the-Counter drugs ., and Note: Items labeled 'Keep out of the reach of children' should be evaluated on a case-by-case basis and stored in a manner that is not readily available to other residents. and Scissors or Knives-should be evaluated on a case-by-case basis and stored in a manner that is not readily available to other residents. 2. Record review of Resident #52's admission record/face sheet revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] from an acute care hospital with diagnoses including unspecified dementia, mild, with anxiety (cognitive impairment affecting memory, reasoning, and judgment); depression (persistent mood disorder causing sadness or loss of interest); anxiety disorder (excessive worry or fear); gait and mobility abnormalities (impaired walking or movement); and history of transient ischemic attack (TIA) (temporary interruption of blood flow to the brain causing stroke-like symptoms). Record review of Resident #52's discharge return anticipated MDS assessment, dated 4/13/26, revealed her cognition was intact for daily decision making. Record review of Resident #52's care plan, initiated 03/06/2026 and revised 03/19/2026, revealed the resident had impaired cognitive function/dementia or impaired thought processes. The care plan further revealed goals for the resident to maintain safety and cognitive function, with interventions including consistent supervision, reducing confusion through structured routines, communicating with the resident using simple and direct instructions, monitoring for changes in cognitive status or decision-making ability, providing structured activities appropriate to the resident's abilities, and maintaining a safe environment due to cognitive impairment. Record review of Resident #11's admission record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] from an acute care hospital with diagnoses including vascular dementia, moderate, with mood disturbance (progressive cognitive decline affecting memory, reasoning, behavior, and judgment); depression (persistent mood disorder causing sadness or loss of interest); anxiety disorder (excessive worry or fear); insomnia (sleep disorder causing difficulty falling or staying asleep); and cerebral infarction (stroke resulting from interrupted blood flow to the brain). Record review of Resident #11's quarterly MDS assessment, dated 4/13/26, revealed her cognition was moderately impaired for daily decision making. Record review of Resident #11's care plan revealed the resident had the potential to demonstrate physical behaviors including anger, depression, and self-abusive behavior, evidenced by slashing her abdomen with a butter knife to relieve headache pain, with interventions including use of plastic silverware for safety. Further review revealed interventions to evaluate medication side effects, provide choices regarding care and activities, modify the environment to reduce triggers, notify the charge nurse of physically abusive behaviors, obtain psychiatric/psychogeriatric consultation as indicated, and send the resident to the emergency room for evaluation as needed. These findings indicated the facility identified the resident as being at risk for unsafe behaviors requiring environmental safety precautions and supervision. During an observation on 4/21/26 at 8:00 a.m. Resident #52 and Resident #11 were both in their beds in their shared room. There was a bottle of mouth wash on Resident #52's nightstand. Resident #52 stated it was her mouth wash. During an interview on 4/24/26 at 3:13 p.m. the DON stated no residents were allowed to keep mouth wash in their room because of their mental state and they may not be aware of how to use the item properly. 3. Record review of Resident #29's face sheet dated 04/24/2026 revealed a [AGE] year-old female admitted to the facility on [DATE], with diagnoses of Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (experiencing a decline in cognitive abilities). Record review of Resident #29's MDS dated [DATE] revealed a BIMS score of 5 out of 15 indicating severe cognitive impairment and had not had any information inputted regarding personal hygiene. Record review of Resident #29's care plan provided on 04/24/2026 revealed a focus area for the following: The resident has an ADL Self Care performance deficit, initiated on 04/02/2026, with interventions including Assist with personal hygiene as required: hair, shaving, oral care as needed, initiated on 04/02/2026. During an observation on 04/21/2026 at 6:48 a.m., revealed Resident #29 had mouthwash and Tiger balm in their cabinet drawer both with a label stating, Keep out of reach of children. During an observation on 04/22/2026 at 8:58 a.m., revealed Resident #29 had mouthwash and Tiger balm in their cabinet drawer both with a label stating, Keep out of reach of children. During an interview on 04/22/2026 at 8:59 a.m., Resident #29 stated she used the tiger balm on her legs when she was sore. Resident #29 stated they had used the mouthwash previously and had always kept the tiger balm and mouthwash in their room. Resident #29 stated staff do know, and she had never been told anything about it. Resident #29 stated they had not hurt themselves with either mouth wash or tiger balm and that other than her roommate other resident had rarely gone in her room. During an interview on 04/22/2026 at 3:14 p.m., CNA A stated Resident #29 was in the memory care unit and that they didn't think anyone could have mouth wash or medication such as tiger balm in their possession. CNA A stated Resident #29 should not have mouthwash or tiger balm because other residents wander in and out of other rooms. CNA A stated the risk to residents that had mouthwash or tiger balm in their room could be residents eating either poisoning themselves. During an interview on 04/22/2026 at 3:36 p.m., LVN B stated residents in the memory care unit needed assistance with mouth hygiene, and they kept mouth hygiene products in a closet that was locked. LVN B stated Resident #29 resided in the memory care unit. LVN B stated residents could not have tiger balm because it could be considered medication in which a doctor's order would have been needed and the item would have been kept away from the resident. LVN B stated they had seen residents wonder in and out of other rooms. When asked what the danger would be for a resident to have mouthwash or tiger balm in their room, LVN B stated residents could put either in their mouth or residents could have an allergic reaction. During an interview on 04/22/2026 at 4:06 p.m., the DON stated residents could not have any medications, mouthwash or any products that had a label stating out of reach for children in their rooms. When asked what the danger would be for a resident to have mouthwash or tiger balm in their room the DON stated the resident could ingest it, have an allergy or reaction to it, or other residents could wander into each other's rooms and take things.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to include procedures that assured the accurate dispensing and administering of all drugs for 3 of 7 carts (700/800 hall nurse cart, 700/800 hall medication cart, and 100/400 nurse cart) reviewed for pharmacy services. 1.The facility failed to ensure the controlled substance reconciliation logs were signed for accuracy of medication quantities during shift change. 2. The facility failed to remove expired medications (Naproxen 220mg, and 5 insulins) from the medication cart. This failure could place residents at risk of not receiving their prescribed medications, experiencing untreated pain and anxiety, and a decreased quality of life.The findings included: 1.During an observation of the 700/800 hall nurse cart on 4/23/2026 at 9:12 AM, four signatures were observed to be missing from the controlled medication reconciliation log used to audit the count of controlled substances between cart exchange. During an interview with LVN L on 4/23/2026 at 9:12 AM, LVN L stated there should not be missing signatures on the controlled medication reconciliation log. LVN L stated it was important for the log to be accurate to make sure no discrepancies exist. LVN L stated if signatures were missing from the log, medications could be missing, and residents might not get the medications they need. During an observation of the 700/800 hall medication cart on 4/23/26 at 9:22 AM, four signatures were observed missing from the controlled medication reconciliation log, and one signature was signed in advance of the next cart exchange. During an interview with LVN M on 4/23/2026 at 9:22 AM, LVN M stated there should not be missing signatures or signatures signed in advance of cart exchange on the controlled medication reconciliation log. LVN M stated the log should be signed at the time of the medication count to ensure accuracy, and staff members should be conducting the count at the same time. LVN M stated if the count of controlled medication was off, residents could be missing their medications, and their care could be delayed. During an interview with the DON on 4/23/2026 at 10:41 AM, the DON stated her expectation for the controlled medication reconciliation logs was that they should not have missing signatures or be signed in advance of the medication count. The DON stated staff should be signing the log at the time of the count to ensure the accuracy of the inventory. The DON stated if the log was inaccurate, they would need to address it, because medications could be missing or a drug diversion could occur. Review of the facility's policy titled Controlled Medications-Administration, dated 2025, noted Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility, in accordance with federal and state laws and regulations. 8. At each shift change, a physical inventory of all controlled medications is conducted by two licensed nurses and/or one nurse and a .Med Tech or equivalent as allowed by your State regulatory agency and is documented on an audit record. 2.During an observation of the 100/400 hall nurse cart on 4/23/2026 at 9:39 AM, a bottle of Naproxen 220 mg (an analgesic medication for pain relief) with a manufacturer's expiration date of 5/2025 was observed inside the cart. Further observation of the cart revealed it contained five insulins which were outside of the 28 day opened by expiration date. During an interview with LVN J on 4/23/2026 at 9:39 AM, LVN J stated that expired insulins and other medications should not be in the cart because they might not be effective or safe. During an interview with the DON on 4/23/2026 at 10:41 AM, the DON stated there should not be expired medications in the medication carts. The DON stated expired medications should not be administered to residents, because the resident might not get the full dose or full potency of the medication, and it could be less effective. The DON further stated her expectation for staff was that they check the carts every shift for expired items. Review of the facility policy titled Medication Labels dated 2025 noted Medications are labeled in accordance with facility requirements, state, and federal laws. and 1. Each prescription medication label includes: Expiration date .

Based on observation, interviews, and record reviews the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 warming kitchen reviewed for sanitation in that: The DA (Dietary Aide) failed to wash her hands prior to plating food.CNA A entered the warming kitchen during meal service without a hair net and did not wash her hands prior to getting ice out of the ice machine to fill a glass.There were no paper towels in the paper towel dispenser by the handwashing sink in the warming kitchen.These failures could place residents at risk for food-borne illness, and food contamination. The findings included: During an observation of meal service from the warming kitchen in the secure unit on 04/21/26 at 12:40 pm, the DA was observed plating food from the steam table without washing her hands. During meal service, she returned to the main kitchen to obtain more plates and left a second time to retrieve more bowels. The DA did not wash her hands upon returning to the warming kitchen to continue plating food from the steam table. During the same observation period while food was being served, CNA A was observed entering the warming kitchen without a hair net and did not wash her hands. She went to the ice machine to fill a glass with ice and then left the kitchen. During the observation, it was also noted there were no paper towels in the paper towel dispenser above the hand washing sink. During an observation and interview with the DM and DA on 04/21/26 at 1:14 pm, the DM brought more plates to the DA. The DM was asked if staff were allowed to come into the kitchen during meal service without a hair net and without washing their hands. The DM stated that no one should enter the area during meal service without a hair net. The DM also stated the DA as well as the CNA should have washed their hands prior to serving food or getting ice out of the machine. The surveyor pointed out the lack of paper towels in the dispenser to the DM. The DM stated that housekeeping was supposed to keep all dispensers filled and stated she would ensure the housekeeper was made aware of this need and would fill the dispenser. Record review of The Dietary Food Service Personnel Policy and Procedures dated 2012 under the section Sanitation and Food Handling listed:All employees receive instruction in sanitation during orientation and through in-service training programs.Hair nets or hats covering the hairline are worn at all times. [NAME] guards are required for facial hair.Wash your hands (with soap and hot water) before starting work, after coughing or sneezing, handling garbage, picking up an article from the floor, after handling soaps or detergents, after using the toilet, after smoking, and after all breaks. Touching something that is not clean and then handling food can cause food poisoning.

Based on observations, interviews, and record review, the facility failed to ensure residents who need respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice for 1 of 1 resident (Resident #5) reviewed for quality of care. The facility failed to ensure Resident #5's sterile water was dated on the oxygen concentrator. This failure could place residents at risk for infection. The findings include: Record review of Resident #5's face sheet, dated 04/21/2026, revealed a [AGE] year-old female readmitted to the facility on [DATE], with an original admission date of 01/02/2023, with a primary diagnosis of aftercare following joint replacement surgery and chronic obstructive pulmonary disease, unspecified (progressive lung disease that makes it difficult to breathe) Record review of Resident #5's MDS assessment, dated 03/14/2026, revealed that a BIMS could not be obtained, but the resident's cognition was severely impaired. Record review of Resident #5's care plan provided on 04/21/2026 revealed a focus area for the following: The resident has COPD initiated on 01/02/2023, with interventions including Give oxygen therapy when ordered and as ordered by the physician initiated on 01/02/2023. Record review of Resident #5's order summary dated 04/21/2026 revealed the following order: May administer oxygen 2-4L via NC for hypoxia O2 less than 88% as needed with an order date of 05/26/2025. During an observation on 04/21/2026 at 10:55 a.m., Resident #5's oxygen concentrator had a sterile water container attached to it with no date. During an observation on 04/22/2026 at 9:47 a.m., Resident #5's oxygen concentrator had a sterile water container attached to it with no date. During an interview on 04/22/2026 at 3:14 p.m., CNA A stated they weren't aware that Resident #5 had an oxygen concentrator. CNA A stated they weren't sure if the sterile water needed to be dated or not. During an interview on 04/22/2026 at 3:36 p.m., LVN B stated residents who used oxygen concentrators, with sterile water containers, should have the sterile water dated to signify when it was put on the oxygen concentrator. LVN B stated she wasn't aware if Resident #5 was on oxygen. LVN B stated the purpose of it was to know when the sterile water was changed and if there was no date, the risk could be the resident not getting enough moisture or the resident could get a dry nose. LVN B stated the nurse was responsible for dating the sterile water. During an interview on 04/22/2026 at 4:06 p.m., the DON stated they would need to check the policy to confirm if sterile water should have been dated. The DON stated they knew in the past they dated the sterile water, but weren't sure of the exact policy. The DON stated sterile water was dated to know how long it could be in the room and if not, the risk could be it expiring or it being exposed to mildew or bacteria. The DON stated the nurse that replaced the sterile water would be the one to date it. Record review of the facility's policy titled 2.0 Nasal Cannula, with a revision date of 06/01/2006 revealed: 16.If using a non-disposable humidifier, change bottle every seven days and change water every 24 hours to prevent bacterial contamination.

Based on interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice for 1 of 1 resident (Resident #9) reviewed for quality of care: The facility did not maintain communication, coordination, or collaboration with the dialysis facility for Resident #9. This failure could affect residents who received dialysis treatments and place them at risk of complications and not receiving proper care and treatment to meet their needs. The findings included: Record review of Resident #9's care plan, dated 4/22/26, revealed a [AGE] year-old female, admitted on [DATE], with diagnosis with diagnoses including end stage renal disease (a permanent kidney condition in which the kidneys have lost nearly all ability to function, requiring renal replacement therapy such as dialysis), anemia, unspecified (a condition characterized by a decreased number of red blood cells or hemoglobin, commonly associated with chronic kidney disease due to decreased erythropoietin production), and unspecified protein-calorie malnutrition (a state of inadequate nutritional intake which may occur in residents with chronic illness, including those receiving dialysis due to dietary restrictions and increased metabolic demands). The care plan further revealed the resident had a focus area of need for hemodialysis related to end stage renal disease, initiated on 5/25/24, with interventions including staff not drawing blood or taking blood pressure in the arm with graft, encouraging the resident to attend scheduled dialysis appointments, monitoring for dry skin and applying lotion as needed, monitoring labs and reporting to the physician as needed, monitoring for peripheral edema, monitoring and reporting signs and symptoms of depression and obtaining a mental health consult if needed, monitoring and reporting signs and symptoms of infection at the access site including redness, swelling, warmth, or drainage, monitoring and reporting signs and symptoms of renal insufficiency, monitoring and reporting signs and symptoms including bleeding, hemorrhage, bacteremia, and septic shock, obtaining vital signs and weight per protocol and reporting significant changes, and working with the resident to relieve discomfort related to side effects of the disease and treatment, and indicated the resident receives dialysis every Tuesday, Thursday, and Saturday, with a goal that the resident will have no signs or symptoms of complications from dialysis through the review date. Record review of Resident #9's physician orders/April 2026 Medication Administration Report, revealed an active order for Dialysis - Date: every Tuesday, Thursday, and Saturday. Time: chair time 11 a.m., pick up 10 a.m. Address: [dialysis center]. Transport: facility transport (Tuesday and Thursday), [dialysis center] (Saturday). Bring with: dialysis binder and lunch. one time a day every Tue, Thu, Sat related to end stage renal disease, and an additional order for Weight from Dialysis center one time a day every Tue, Thu, Sat for weight. Record review of Resident #9's dialysis communication forms, from dates 3/4/26-4/23/26 revealed:3/4/26 - pre-dialysis section not signed by nurse, dialysis documentation completed, post-dialysis section blank3/7/26 - pre-dialysis section completed, dialysis documentation completed, post-dialysis section signed but not completed3/10/26 - no form and no nursing note3/12/26 - no form and no nursing note3/14/26 - pre-dialysis section completed, dialysis documentation completed, post-dialysis section completed3/17/26 - resident refused dialysis per nursing note3/19/26 - nursing note present regarding a fall, no dialysis forms present3/21/26 - pre-dialysis section completed, dialysis documentation completed, post-dialysis section not completed3/24/26 - no form and no nursing note3/26/26 - pre-dialysis section completed but not signed by nurse, dialysis documentation completed, post-dialysis section blank3/28/26 - pre-dialysis section completed, dialysis documentation completed, post-dialysis section not signed by nurse3/31/26 - no form and no nursing note4/4/26 - resident initially refused dialysis then attended, post-dialysis section not completed4/7/26 - pre-dialysis section completed but not signed by nurse, no dialysis documentation, no post-dialysis documentation4/9/26 - pre-dialysis section completed, dialysis documentation completed, post-dialysis section blank4/11/26 - post-dialysis documentation missing4/14/26 - post-dialysis documentation missing4/16/26 - pre-dialysis section completed, dialysis documentation completed, post-dialysis section blank4/18/26 - post-dialysis documentation missing4/21/26 - no dialysis documentation form found4/23/26 - no dialysis documentation form found Record review of Resident #9's weight records, documentation revealed the following: 3/5/26 at 5:03 PM - 94.2 lbs, post-treatment weight from dialysis center3/7/26 at 7:54 PM - 98.2 lbs, chair or sitting scale3/10/26 at 5:01 PM - 93.2 lbs, post-treatment weight from dialysis center3/12/26 at 4:07 PM - 93.2 lbs, post-treatment weight from dialysis center3/14/26 at 8:41 PM - 87.2 lbs, post-treatment weight from dialysis center3/17/26 at 7:14 PM - 93.2 lbs, post-treatment weight from dialysis center3/19/26 at 4:46 PM - 93.2 lbs, post-treatment weight from dialysis center3/21/26 at 6:45 PM - 97.4 lbs, chair or sitting scale3/24/26 at 4:36 PM - 97.6 lbs, post-treatment weight from dialysis center3/26/26 at 6:30 PM - 97.68 lbs, post-treatment weight from dialysis center3/28/26 at 7:51 PM - 97.4 lbs, chair or sitting scale3/31/26 at 8:18 PM - 98.3 lbs, post-treatment weight from dialysis center4/4/26 at 9:59 PM - 95.24 lbs, post-treatment weight from dialysis center4/7/26 at 9:24 PM - 95.4 lbs, post-treatment weight from dialysis center4/8/26 at 8:40 AM - 98.3 lbs, chair or sitting scale4/9/26 at 4:42 PM - 97.0 lbs, post-treatment weight from dialysis center4/11/26 at 9:14 PM - 97.7 lbs, chair or sitting scale4/14/26 at 5:36 PM - 97.2 lbs, post-treatment weight from dialysis center4/16/26 at 5:19 PM - 97.3 lbs, post-treatment weight from dialysis center4/18/26 at 6:07 PM - 97.9 lbs, chair or sitting scale4/21/26 at 6:36 PM - 95.0 lbs, post-treatment weight from dialysis center4/23/26 at 9:26 PM - 94.4 lbs, post-treatment weight from dialysis center No facility weights were found for 3/3/26, 3/12/26, and 3/24/26. During an interview on 4/22/26 at 11:05 a.m., Resident #9 stated the nurses at the nursing facility did not check her fistula and reported she checked it herself to ensure it was vibrating. During an interview on 4/24/26 at 2:37 p.m. RN I stated she was the nurse responsible for Resident #9 on 4/21/26 and 4/23/26 and she had not checked the resident's dialysis binder to ensure she filled out the pre assessment form prior to the resident leaving for dialysis. She stated she forgot to look at it. RN I stated the form needed to be filled out by the nursing facility staff in the pre assessment area and post assessment area so they and the dialysis center could compare information and note any changes in the resident's condition. RN I stated there was a breakdown in communication between the nursing facility and dialysis facility when the form was not completed and they could miss a change in the resident's condition. During an interview on 4/24/26 at 3:31 p.m. the DON stated she expected staff to fill out pre and post assessments on the dialysis communication forms. The DON stated she had not checked the forms were being completed before or delegated it to anyone yet because they were still figuring out their processes. The DON stated not completing the forms completely or accurately could cause inaccurate information and miscommunication. The DON stated for post dialysis they could miss a change in the resident's condition. Record review of the facility's policy, undated, titled Dialysis, Nursing Policy & Procedure Manual 2013, revised November 2013, revealed .Dialysis is a process used to remove fluid and waste products from the body when the kidneys are unable to do so.the purposes of dialysis are to maintain the life and well-being of the patient. and to remove unwanted substances from the blood.the facility will establish baseline information from the dialysis center. monitor changes from the baseline.the resident will receive education to access device care and restrictions.the site will be assessed for bleeding, bruising, lack of pulsations. every shift. the nurse will palpate the access. a thrill. should be felt. auscultate the access. a bruit. should be heard. conduct this procedure every shift. record the results of the examination.the facility will monitor departures and returns from the dialysis center. document the resident's vital signs, general appearance, orientation.the date and time that the resident leaves the facility. and returns. will be recorded.strict intake and output will be maintained. daily weights will be maintained. fluid restrictions will be monitored.if the resident refuses dialysis treatment, document exactly what the resident verbalizes. notify the attending physician and the dialysis center.

Based on observation, interview, and record review, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 2 of 33 residents (Residents #88 and #113) reviewed for assessments: Resident #88's Quarterly MDS dated [DATE] did not indicate she was receiving hospice services. Resident #113's Quarterly MDS dated [DATE] did not indicate she was receiving hospice services. These failures could place residents at risk for inadequate care due to inaccurate assessments.Findings included: Record review of Resident #88's admission Record dated 04/24/26 documented a [AGE] year-old female originally admitted to the facility on [DATE] and the last admission on [DATE]. The diagnoses included Alzheimer's disease (a progressive irreversible neurodegenerative disorder and the most common cause of dementia, characterized by memory loss, cognitive decline, and behavioral changes), unspecified severe protein calorie malnutrition (a critical medical condition indicating extreme muscle wasting, fat loss, or starvation), bipolar disorder, current episode mixed, moderate (a complex state where symptoms of both mania/hypomania and depression occur simultaneously, and unspecified anxiety disorder (diagnosis for symptoms of anxiety that cause significant distress or impairment, but do not meet the full criteria for specific disorders like Generalized Anxiety Disorder).Record review of Resident #88's last Quarterly MDS assessment dated [DATE] in Section O item K1 did not have hospice checked to indicate that these services were being delivered while she was a resident. Record review of Resident #88's care plan with the last revision date of 11/13/25 had a focus stating The resident has a terminal prognosis and/or is receiving hospice services. DX: Alzheimer's Disease. One of the goals included was The resident's comfort will be maintained through the review date. One of the interventions listed was If receiving hospice services, work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met. Interview with the MDS D on 04/24/26 at 11:25 am, revealed a failure to check hospice on the Resident #88's Quarterly Assessment. MDS D stated this section should have been checked to indicate she was receiving hospice services to ensure accuracy. 2.Record review of Resident #113's face sheet dated 04/21/2026 revealed a [AGE] year-old female readmitted to the facility on [DATE], with an original admission date of 10/15/2025, with diagnoses that include unspecified dementia, unspecified severity, with other behavioral disturbances (cognitive decline), acute respiratory failure with hypoxia (the lungs fail to deliver sufficient oxygen to the blood) and alcoholic cirrhosis of liver with ascites (scarring of the liver due to long-term excessive alcohol consumption). Record review of Resident #113's MDS dated [DATE] revealed that a BIMS score could not be obtained but that the resident was severely impaired. Further review of the MDS under Section O – Special Treatments, Procedures, and Programs revealed the assessment did not include hospice care in the section O0110. Special Treatments, Procedures, and Programs in the box next to K1 Hospice care. Record review of Resident #113's care plan provided on 04/21/2026 revealed a focus area for the following: Resident requires hospice as evidenced by terminal illness, DX: End stage liver disease initiated on 01/27/2026. Record review of Resident #113's order summary dated 4/21/2026 revealed and order stating Admit to . hospice. with an order date of 01/27/2026. Record review of Resident #113's medical record revealed a document titled Facility Notification which stated the resident admitted to hospice on 01/27/2026. During an interview on 04/24/2026 at 9:22 a.m., MDS D revealed they failed to check hospice on the quarterly MDS assessment. MDS D confirmed Resident #113 was currently on hospice and that it should have been checked off to indicate the care the resident is receiving regarding nursing services. MDS D stated they followed the RAI manual. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.20.1, dated October 2025, noted in Section O – Special Treatments, Procedures, and Programs Steps for Assessment 1. Review the resident's medical record to determine whether or not the resident received or performed any of the treatments, procedures, or programs within the assessment period defined for each column and Coding Instructions for Column b. While a Resident Check all treatments, procedures, and programs that the resident received or performed after admission/entry or reentry to the facility and within the last 14 days.

Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level 1 residents with mental illness were provided with a PASRR Level II assessment accurately 1 of 6 residents (Resident #6) whose records were reviewed for PASRR services. The facility failed to conduct a Level 1 PASRR screening for Resident #6 after a diagnosis of PTSD and coordinate with the Local Authority to conduct a Level 2 PASRR evaluation to determine the need for specialized services. This deficient practice could place residents at risk of a diminished quality of life related to not receiving or benefiting from specialized PASRR services to meet their needs.The findings included: Record review of Resident #6's admission sheet dated 9/12/2025 with an original admission date of 3/01/2024 documented an [AGE] year-old male resident with a diagnosis of PTSD on admission [DATE]). Record review of Resident #6's MDS assessment dated [DATE] documented a BIMS score of 7 indicating moderate cognitive impairment and included a diagnosis of PTSD in Section I - Active Diagnoses Active Diagnoses in the last 7 days I6100. Post Traumatic Stress Disorder (PTSD). Record review of Resident #6's order summary included an active order for the anticonvulsant medication Depakote with an order date of 02/07/2025. Depakote was ordered as Depakote 125 mg, Give 2 capsule by mouth two times a day for mood. Record review of Resident #6's care plan with an initiation date of 4/21/2026 documented The resident has a history of trauma that may have a negative impact. The trauma is PTSD, with a interventions including: Identify situation/event/images that trigger recollections of the traumatic event and limit the resident's exposure to these as much as possible. These triggers could include: loud noises, overstimulation, sudden approaches from behind. Monitor for escalating anxiety, depression for suicidal thought and report immediately to the nurse. Monitor for escalating anxiety, depression, sleep disturbance, substance abuse, or suicidal thoughts and report immediately to the physician and to the mental health provider is applicable. Record review of Resident #6's PASRR screening dated 02/20/2024 revealed no answer was recorded in Section C PASRR Screening C0100. Mental Illness Is there evidence or an indicator this is an individual that has a Mental Illness? During an interview with MDS LVN D on 4/23/2026 at 4:40 PM, MDS LVN D stated it was important for the PASRR assessments to be accurate, because a resident could lose out on a potential service if they qualify for it. During a second interview with MDS LVN D on 4/24/2026 at 10:23 AM, MDS LVN D stated a PASRR Level 1 screening should have been done after Resident #6's diagnosis of PTSD and that it was important for the local authority to come evaluate the resident in case any interventions needed to be put into place like extra support should the resident qualify for services. During a third interview with MDS LVN D on 4/24/2026 at 12:29 PM, MDS LVN D stated they do not have a facility policy for PASRR services, and they follow the HHSC website. During an interview with the DON on 4/24/2026 at 12:52 PM, the DON stated her expectation for PASRR was for everyone to be educated appropriately on the PASRR process and the guidelines for conducting the assessments. The DON further stated it was important to know the PASRR status of a resident to provide the appropriate services they might need.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles for 1 of 7 medication carts (100/400 hall nurse cart) reviewed for medication storage and labeling. The facility failed to ensure all insulins located inside the 100/400 hall nurse cart were properly labeled with opened dates. This failure could place residents who receive medications at risk for not receiving the intended therapeutic effects of their prescribed medications.The findings included: During an observation of the 100/400 hall nurse cart on 4/23/2026 at 9:39 AM, revealed it contained two insulins which had no opened date. During an interview with LVN J on 4/23/2026 at 9:39 AM, LVN J stated it was important to have the opened date on the insulins so it is known when they will expire, because if expired medications were given to residents, it would be unknown what the effect could be. During an interview with the DON on 4/23/2026 at 10:41 AM, the DON stated her expectation for staff was that they check the carts every shift for expired items. Review of the facility policy titled Medication Labels dated 2025 noted Medications are labeled in accordance with facility requirements, state, and federal laws. and 1. Each prescription medication label includes: Expiration date .

Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 4 residents (Resident #82) reviewed for accuracy of records: The facility failed to ensure Resident #82's hospice binder was accurate with their DNR status. These failures could affect residents whose records were maintained by the facility and could place the residents at risk of errors in care and treatment.The findings include: Record review of Resident #82's face sheet, dated [DATE], revealed a [AGE] year-old male readmitted to the facility on [DATE], with an original admission date of [DATE], with a primary diagnosis of Alzheimer's disease, unspecified (progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior). Record review of Resident #82's MDS assessment, dated [DATE], revealed the resident's BIMS score was a 3 out of 15 which indicated the resident's cognition was severely impaired. Record review of Resident #82's care plan provided on [DATE] revealed a focus area for the following: Resident has an order for Do Not Resuscitate (DNR), initiated on [DATE], with interventions including in absences of b/p, pulse, respiration, CPR will not be initiated initiated on [DATE]. Record review of Resident #82's order summary dated [DATE] revealed the following order: DNR with a start date [DATE]. Record review of Resident #82's medical record revealed a DNR document for Resident #82, signed by Resident #82's responsible party on [DATE] and signed by a physician on [DATE]. Record Review of Resident #82's hospice binder revealed the binder included a page which labeled Resident #82 as a full code. During an interview on [DATE] at 3:33 p.m., the Hospice TM stated Resident #82 was DNR and that they had previously sent a representative to the facility with the DNR documents to be placed in Resident #5's hospice binder. The Hospice TM stated the hospice binder should be accurate and have the resident's appropriate directive status. During an interview on [DATE] at 3:51 p.m., LVN B stated Resident #82 was a DNR and was on hospice services. LVN B stated the hospice binder should have the DNR in it and it should be accurate because that would make the decision to resuscitate or not. LVN B confirmed Resident #82's hospice binder reflected Resident #82 was a full code. LVN B stated they checked the binder daily for the resident's care and for any changes. During an interview on [DATE] at 3:58 p.m., the DON stated that residents' hospice binders should be up to date and accurate, so everyone was on the same page regarding the residents' care. The DON stated staff would clarify the code status with the resident's electronic record if unsure. The DON stated they believed there was no risk to the residents because the nurse would take extra measures. The DON stated there was no policy regarding hospice binders. During an interview on [DATE] at 12:38 p.m., the Administrator stated there was no policy regarding clinical records.

Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality of care for 1 of 6 residents (Resident #128) whose medical records were reviewed for accuracy, in that: The facility failed to develop a baseline care plan within 48 hours of Resident #128's admission to the facility. This failure could place residents at risk of not receiving needed care and treatment.The findings included: Record review of Resident #128's admission sheet dated 4/17/2026 documented a [AGE] year-old male resident with diagnoses including encephalopathy (a group of conditions that cause brain dysfunction), type 2 diabetes mellitus, cognitive communication deficit, disorientation (a state of mental confusion where a person is unsure about time, place, identity, or situation), hyperlipidemia (high cholesterol), alcoholic cirrhosis of the liver (scarring of the liver tissue due to long term alcohol use), and dementia. Record review of Resident #128's MDS assessment dated [DATE] documented a BIMS score of 14 indicating intact cognition and recorded the diagnoses of dementia, diabetes mellitus, hyperlipidemia, encephalopathy, alcoholic cirrhosis of the liver, cognitive communication deficit, and disorientation. Record review of Resident #128's Baseline Care Plan Acknowledgement form noted a copy of the baseline care plan was provided to the resident and the resident representative on 4/17/2026, however a baseline care plan was not included in the resident's medical record until 4/21/2026. During an interview with Resident #128 on 4/21/26 at 10:28 AM, Resident #128 stated the facility gave me a plan of care, but they took it back, because I could not read it without reading glasses. During an interview with Resident #128's Family Contact on 4/21/26 at 11:00 AM, the Family Contact stated she did not receive a baseline care plan and lived out of state. Resident #128's Family Contact further stated she had not spoken with the resident or seen a picture of him in years. During an interview with the DON on 4/23/2026 at 10:55 AM, the DON stated she would find out if the baseline care plan was the first care plan on file in a resident's medical record, or if it was located in a different place in the medical record. During a second interview with the DON on 4/23/2026 at 3:08 PM, the DON stated the CNAs look to the Kardex to determine the type of care a resident requires, and the Kardex was developed from the care plan. The DON stated if the care plan was not available, the CNAs could ask a nurse about a resident's level of care. The DON further stated a lot of the time they gave the baseline care plan verbally if the resident's responsible party was not present. During an interview with the Administrator on 4/23/2026 at 5:20 PM, the Administrator stated, Resident #128 did not get a baseline care plan until 4/21/2026 and it was a clinical records error. The Administrator stated they based the resident's care on the report from the hospital and the orders. The Administrator further stated the care plan should have been in the system before 4/21/2026, but they identified the omission and added it to the medical record. Record review of the facility's policy titled Base Line Care Plans, undated, noted Completion and implementation of the baseline care plan within 48 hours of a resident's admission is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admissions; and to ensure the resident and representative, if applicable, are informed of the initial plan for delivery of care and services by receiving a written summary of the baseline care plan. Thus facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan will-Be developed within 48 hours of a resident's admission.

Based on observation, interview, and record review, the facility failed to treat each resident with dignity and respect in a manner and environment that enhances their quality of life for 1 of 6 residents (Resident #64) reviewed for dignity. Resident #64's catheter bag was not placed in a privacy bag and was visible from the hallway. This failure could place residents at risk for diminished quality of life, loss of dignity and self-worth.The findings included: Record review of Resident #64's admission sheet dated 4/17/2026 documented a [AGE] year-old male resident with diagnoses including type 2 diabetes mellitus, obstructive and reflux uropathy (blockage or reflux of urine leading to kidney damage), hyperlipidemia (high cholesterol), dementia, and liver cirrhosis (scarring of the liver tissue). Record review of Resident #64's MDS assessment dated [DATE], revealed a BIMS score was not recorded and documented in section C0700 the resident's memory was OK, and the resident was Independent on making decisions regarding tasks of daily life. Further review of the MDS recorded the resident's use of an indwelling catheter. Record review of Resident #64's order summary included an active order to provide Foley catheter care every shift with an order date of 3/31/2026. Record review of Resident #64's care plan with an initiation date of 4/02/2026 documented the resident has indwelling Catheter with interventions including Position catheter bag and tubing below the level of the bladder and in a privacy bag. During an observation on 4/21/2026 at 7:36 AM, Resident #64 was seen in his room with his catheter bag located on the side of the bed facing the hallway. The catheter bag was not inside a privacy bag. During a second observation on 4/21/2026 at 10:35 AM, the door to Resident #64's room was open and his catheter bag was not in a privacy bag and was visible from the hallway. During an interview with the ADON on 4/21/2026 at 10:38 AM, the ADON stated Resident #64's catheter bag should not be visible from the hallway, and it should be in a privacy bag for the resident's dignity. During an interview with the DON on 4/42/26 at 1:28 PM, the DON stated Resident #64's catheter bag should not be visible from the hallway and should be covered with a privacy bag to preserve the resident's dignity. Record review of the facility policy titled Residents Rights, undated, noted The resident has a right to personal privacy and confidentiality of his or her personal and medical records. 1. Personal privacy includes accommodations, medical treatment .

Based on observations, interviews, and record review, the facility failed to respect the residents' right to confidentiality in his or her personal and medical records for 1 (Resident #2) of 13 residents reviewed for dignity. The facility failed to ensure Resident #2's shared bathroom door remained closed during wound care. This failure could cause a decrease in feelings of self-worth by being exposed during care. Findings included: Record review of Resident #2's face sheet, dated 4/24/26, revealed the resident was a [AGE] year-old female, initially admitted to the facility on [DATE], readmitted on [DATE], with diagnoses including sacral spina bifida with hydrocephalus (a congenital condition in which the spinal column does not close completely and is accompanied by excess cerebrospinal fluid accumulation in the brain), pressure ulcer of contiguous site of back, buttock, and hip, stage 4 (full-thickness tissue loss with exposed bone, tendon, or muscle), cellulitis (bacterial skin infection), neuromuscular dysfunction of bladder (impaired bladder function caused by nerve damage), and acquired absence of left leg above knee (surgical amputation). Record review of Resident #2's admission MDS assessment, dated 4/7/26/ revealed the resident's cognition was fully intact for daily decision making. Record review of Resident #2's care plan, initiated 4/3/2026 and revised 4/21/2026, revealed the resident had pressure ulcers or potential for pressure ulcer development including stage 4 right sacrum (full-thickness tissue loss with exposed structures), unstageable deep tissue injury to the right first toe (persistent non-intact skin with obscured tissue damage), and stage 4 right knee pressure ulcer (full-thickness skin and tissue loss), with interventions including staff were to administer treatments as ordered and monitor for effectiveness, assess, record, and monitor wound healing at least weekly including wound measurements and wound bed status, report loose or missing dressings to the nurse, provide assistance with repositioning at least every two hours, avoid positioning the resident on pressure ulcer locations, use lifting devices and draw sheets to reduce friction, provide incontinent care and moisture barrier application, monitor for new skin breakdown, and follow physician-ordered wound care treatments for the resident's sacrum, right toe, and right knee. During an observation on 4/24/26 at 9:51 a.m. LVN E and CNA F prepared and provided wound care to Resident #2's bottom. Resident #2 was lying in the bed with her back facing the bathroom door area in her room. The bathroom door was open from 9:51 a.m. till 10:17 a.m. when an unknown person entered the shared bathroom. LVN E reached over and closed the bathroom door. During an interview on 4/24/26 at 10:35 a.m. LVN E stated Resident #2's bathroom door should have been closed during the wound care. LVN E stated he did not know it was a shared bathroom. He stated the door should be closed to provide privacy and dignity for the resident. During an interview on 4/24/26 at 3:23 p.m. the DON stated the bathroom door should have been closed during wound care to provide privacy for the resident. Record review of facility policy titled Resident Rights, policy, no date, revealed .the resident has a right to a dignified existence.a facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life.personal privacy includes accommodations, medical treatment. personal care.the facility must respect the resident's right to personal privacy, including the right to privacy in his or her oral, written, and electronic communications.the resident has a right to be treated with respect and dignity.

Based on observations, interview and record review the facility failed to post the nurse staffing data on a daily basis at the beginning of each shift for 1 (4/21/26) of 4 days reviewed in that: The daily posted nurse staffing data was not posted in the facility on 4/21/26. This deficient practice could affect all residents and could result in residents and visitors being unaware of staffing levels in the facility.Findings include: Observation on 4/21/26 at 6:42 AM of the Facility Staffing Disclosure posting on a bulletin board near the front entry revealed the clear case was empty. No staffing information was posted. In an interview on 4/21/26 at 6:42 AM the BOM stated the clear case was where they normally posted the nurse staffing hours. The BOM stated she could let this surveyor know once one was posted. Interview on 4/24/26 at 3:36 PM the DON stated it was her responsibility to post the nurse staffing hours daily. She stated there should always be something in the case even if it was from the previous day. The DON stated it was important for anyone entering he building to see what the staff ratio was daily. Record review of a facility document titled Mandatory Posting, no date, revealed Daily Staffing by shift of Licensed and Unlicensed Nursing Staff was on the list.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents (Resident #3) reviewed for infection control in that: LVN A did not wash his hands between removing soiled gloves and putting on clean gloves when providing direct care to Resident #3 who had a skin tear and was on enhanced barrier precautions (EBP). The DON did not wash her hands after touching a window blind, bed controls, and bed linens prior to providing direct care to Resident #3 who had a skin tear and was on EBP. This deficient practice could affect residents who are receiving wound care or were on enhanced barrier precautions placing them at risk for infection.The findings were: Record review of Resident #3's admission record printed on 12/23/2025 revealed she was a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Parkinsonism (slow movements, stiffness, tremor and problems with walking and balance) and a stage IV pressure ulcer (full-thickness skin and tissue loss exposing bone, tendon, or muscle) of the sacral region (triangular bone at the base of the spine). The admission record indicated that Resident #3 was seen by the MD Wound Care who provided orders for daily treatment. Record review of Resident #3's comprehensive care plan printed on 12/23/2025 revealed a care plan that revealed, Resident #3 had a skin tear on the right arm and left thigh requiring treatment for the injury, date initiated 12/4/2025 and required enhanced barrier precautions, date initiated 11/10/2025. Resident #3 had a stage IV pressure ulcer (PU) to her sacrum (present on admission) requiring treatment, date initiated 11/10/2025. Record review of Resident #3's orders printed on 12/23/2025 revealed that she was to receive wound care treatment once a day for non-pressure wounds of the right arm, left thigh, and a stage IV PU, sacrum. During a wound care treatment observation on 12/23/2025 at 2:25 PM, Resident # 3 was observed lying in bed with her eyes closed. She did not give a response when LVN A or the DON communicated with her prior to or during the procedure. She had received morphine sulfate prior to the treatment for pain as ordered. LVN A and the DON prepared to perform wound care on Resident #3's right arm skin tear. Resident #3 had a sign on her door that reflected Enhanced Barrier Precautions. Prior to starting the procedure, LVN A and the DON washed their hands and donned (put on) gowns and gloves.In preparation for the procedure, the DON lowered and closed the blinds, adjusted the bed using the attached remote, and moved the sheets exposing Resident #3's right arm. She then held Resident #3's arm up for treatment, touching both sides of the arm an inch from the wound cover without washing her hands or changing gloves.LVN A was observed cleaning the wound with wound cleanser. He needed more gloves, so he removed his soiled gloves, walked to the treatment cart, obtained more gloves, and donned a clean set of gloves without washing his hands. He completed dressing the wound. During an interview with LVN A on 12/23/2025 at 4:15 PM, he stated that the Wound Care MD saw the resident weekly and LVN A made rounds with the MD. He agreed that he had missed the hand washing step during an interview at the conclusion of the wound care treatment procedure. LVN A stated that hands should be washed before starting a wound care procedure, anytime you change a task during wound care, and after finishing wound care. He stated that the impact of not washing his hands during wound care at the appropriate times can open (the resident) for infection and [NAME] down. During an interview with the DON on 12/23/2025 at 3:43 PM, the DON agreed that she had not changed her gloves during the procedure after touching non-sterile surfaces and prior to direct contact with Resident #3. She stated that hands should be washed during wound care at the beginning of wound care, anytime your hands are soiled, when going from touching something dirty, you wash them in between. The DON stated that the impact to the resident of not washing their hands at the appropriate times was it is open for infection, the possibility of spreading infection and bacteria. Record review of LVN A's and the DON's orientation and training competencies revealed that both were trained in infection control and handwashing in 2024 and held a current nursing license. Record review of the facility's undated policy Hand Hygiene revealed, You may use alcohol-based hand cleaner or soap/water for the following:Before and after performing any invasive procedure (e.g., fingerstick blood sampling);Before and after changing a dressingUpon and after coming in contact with a resident's intact skin, (e.g., when taking a pulse or blood pressure, and lifting a resident)After contact with a resident's mucous membranes and body fluids or excretionsAfter handling soiled or used linens, dressings, bedpans, catheters and urinalsAfter handling soiled equipment or utensilsAfter removing gloves or aprons

Based on interview and record review, the facility failed to ensure residents had the right to be free from accidents and hazards for 1 of 4 residents (Resident #1) reviewed for accidents and hazards. On 04/09/24, Resident #1, who resided in the Memory Care wing of the facility, managed to undo the lock on the window of his room, kick out the screen and climb out the window. Resident #1 then left the property and was not located until the morning of 04/10/24. The non-compliance was identified as past noncompliance. The IJ began on 04/09/24 and ended on 04/10/24. The facility had corrected the noncompliance before the investigation began on 12/15/24. This failure could place residents at risk of harm, serious injury, or death. Findings include: Record review of Resident #1's Admission Record documented a [AGE] year-old male admitted to the facility 04/01/24 with diagnoses that included unspecified dementia, severe, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; major depressive disorder (mental disorder characterized by at least 2 weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities); paranoid schizophrenia (a type of psychosis where your mind doesn't agree with reality), and epilepsy (a group of non-communicable neurological disorders characterized by recurrent epileptic seizures). Record review of Resident #1's Care Plan with the admitted [DATE] documented a Focus of The resident is at risk for wandering related to disoriented to place, history of attempts to leave facility unattended (from previous), impaired safety awareness. Resident wanders aimlessly. Interventions included Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book; If the resident is exit seeking, stay with the resident and notify the charge nurse by calling out, sending another staff members, call system, etc. Record review of Resident #1's Admission MDS dated [DATE] documented a BIMS score of 3. Record review of Resident #1's Discharge MDS dated [DATE] documented a BIMS score of 11. Record review of a timeline created by the Regional Compliance Nurse revealed that resident was last seen in the facility around 1:00 pm on 04/09/24 when he was given a Tylenol by the nurse and then he went to his room to lay down. Around 4:00 pm staff noted resident was not in his room, his bedroom window was open and the screens were torn. The staff determined that Resident #1 used the hanging rod in his closet to unscrew the window fastener on his window so that he could open and window and get out. Elopement protocols were immediately put in place and the facility and surrounding areas were searched. The family and physician were notified. The police were notified. Employees at a nearby service station confirmed they had seen Resident #1 in their parking lot but he was no longer there. The city's bus system was provided with a flyer for their drivers to watch for the resident. The search continued throughout the night. Around 8:55 am on 04/10/24, the Regional Compliance Nurse was driving toward the city's main homeless shelter when she spotted Resident #1 standing on the corner. Resident #1 agreed to get in her car and allowed her to return him to the facility. Resident #1 did not know how he got to where he was found but stated to the nurse that he was looking for work. He was taken to the facility and assessed for injuries. A skin assessment noted only two small abrasions which appeared to be scabbed over. The physician sent him to the ER for evaluation. Upon Resident #1's return to the facility later that day, he was placed in another room that overlooked the secured courtyard. Observation revealed that all of the window fasteners in the Memory Care Unit had been replaced with a device that required special tools to remove them. Record review of monitoring forms revealed Resident #1 was placed on 15-minute monitoring which remained in place until his discharge on 05/28/24. Record review of inservice training dated 4/9/24 revealed that 100% of the staff consisting of 112 employees, were inserviced on the elopement protocols. Prior to and after this incident, Elopement Drills were conducted which included staff having to find an identified individual. Inservice training was conducted on all shifts. Record review of Resident #1's Care Plan reflected it was updated on 4/10/24 with an elopement. The interventions included Q 15 minute checks x 3 days, assess/record/report to MD risk factors for potential elopement, supervise closely and make regular compliance rounds whenever resident is in room, determine the reason the resident is attempting to elope, distract resident from elopement attempts by offering pleasant diversions, structured activities, food, conversation, television, books, and if the resident is exit seeking, stay with the resident and notify the charge nurse by calling out, sending another staff member, call system, etc. Record review indicated that all residents in the Memory Care Unit were reassessed for Elopement Risk. No other residents had been noted to make attempts to elope other than going to the exit doors which alarmed when attempts were made to push them open without entering a code in the keypad. Observation of door alarms were noted to sound when pushed without first entering a code on the keypad to enter or exit the secure unit. Interviews with 12 staff members who worked either first or second shift, revealed they received training monthly on elopement protocols and participated in Elopement Drills. Staff also noted that Resident #1 was seen going to the nurses station numerous times during the day to call one of his family members to try and get her to come and get him. Staff interviewed revealed that Resident #1 frequently stayed in his room and rarely participated in activities. Interview with the 12 staff members were conducted on 12/18/24 from 1:42 p.m. to 12/19/24 at 11:40 a.m. Staff indicated the protocol was to do a thorough sweep of the facility when they noticed a resident missing. The nurse manager would be informed and a Code Orange would be announced. Management takes over after Code Orange is announced. Staff further indicated they are constantly keeping an eye on their residents on the memory care unit by checking on them every 1 to 2 hours. Record review of Resident #1's Nurse Progress Notes in his electronic medical record, revealed that on 05/25/24, Resident #1 was involved in an altercation with another resident. Resident #1 hit Resident #2 in his eye as they were passing in the hall and fractured Resident #2's eye. The attack was unprovoked. Record review of discharge notice in the electronic medical record revealed Resident #1 was given a discharge notice on 05/28/24 with the reasons for discharge being: 1) The discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility. and 2) The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident. Resident #1 was sent to the hospital for altered mental status and did not return to this facility. The facility Administrator was presented with a PNC IJ template on 12/20/24 at 9:21 a.m. The facility had already completed a thorough investigation and put protocols in place to prevent a similar occurrence and had discharged the identified resident.

Based on observation, interview and record review the administrator failed to use its resources effectively and efficiently to maintain the highest physical wellbeing for 1 of 32 residents in that: The DON failed to: 1. Implement a written CPR policy, train the nursing staff, and monitor the administering of emergency CPR for one resident, resident #1, who was coded full code and experienced harm (death). 2. Monitor nursing staff CPR qualification, verification of current CPR certification, and CPR competency. 3. Failed to have in place flash sheets on the medical record or Nurse MAR that identified the resident's code status. 4. To have a written procedure for coding a resident at admissions that could not produce a DNR certificate. 5. Bring to the QA Committee the issue of CPR Process and Full/DNR Code Identification as a key clinical indicator requiring a Plan of Action. The Medical Director failed to: 1. Provide oversight and monitoring of the facility's CPR process. 2. Address and resolve concerns between the facility's CPR process and a failure by a LVN to administered CPR to an unresponsive resident that was full code at time of death. 3. Inquire as to who declared the resident dead; the physician assumed the DON had determined the resident was deceased rather than the Hospice Nurse. 4. Bring to the QA Committee the issue of CPR Process and Full/DNR Code Identification as a key clinical indicator requiring a Plan of Action. The Administrator failed to: 1. Supervise the DON train and monitored direct care staff on CPR procedures for resident #1 who was coded full code and experienced harm (death). 2. Address and resolve concerns between the facility's CPR process and a failure by a LVN to administered CPR to an unresponsive resident that was full code at time of death. 3. Have in place a written CPR process. 4. Bring to the QA Committee the issue of CPR Process and Full/DNR Code Identification as a key clinical indicator requiring a Plan of Action. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm at a scope of pattern due to the plan of removal was still being monitored for compliance. This deficient practice could affect 62 residents coded full code at risk of not receiving immediate CPR pending nursing staff ascertaining the full code status in the medical record and/or the Nurse MAR. Findings included: During interview on [DATE] at 10:21 a.m. with the DON she stated that: she did not know whether LVN A knew how to check the code status on residents. The DON stated: we assumed the nurse would check the chart. During interview on [DATE] at 3:24 p.m. with the DON she stated: In place before (prior to the IJ) was make sure code validated in chart, kard-X. Now (after the IJ), make sure upon hire we obtain CPR card, all staff trained on CPR process, where the code status are at (chart, flash cards, kard-X, MAR and closet. The DON added that the IJ resulted because the alleged perpetrator, LVN A, assumed resident # 1 was DNR. LVN B accepted, according to the DON, LVN A's comment that resident # 1 was dead and therefore LVN B did not initiate CPR to an unresponsive resident. The DON confirmed that it was not in LVN A's scope of practice to declare a resident deceased . The DON could not provide an explanation as to why LVN A and LVN B assumed that the resident # 1's code status was DNR. Likewise, the DON could not give an explanation as to why LVN A acted beyond her scope of practice to say that resident # 1 was dead. The DON confirmed that resources and training were available to LVN A and LVN B on ascertaining the code status of resident #1. The DON further confirmed that the facility did not have in place at the time of the incident a written policy on the CPR process; especially as to when to administer CPR to an unresponsive resident when the code status was not known. The DON stated: (after the IJ) On admission, we will ask for code status, ask family, if unknown the resident will be coded full code. The family will be told to produce documentation that the resident should be DNR. The DON confirmed that she did not bring to the QA Committee the issue of CPR Process and Full/DNR Code Identification as a key clinical indicator requiring a Plan of Action. During interview on [DATE] at 3:00 p.m. with the Administrator he stated that: after the IJ all staff would be trained before starting each shift on the written CPR process. Training would also include code status procedures, the dots system, and explained how the code identification system worked. He felt the IJ resulted because LVN A wrongly assumed the resident's code status and did not perform CPR. The Facility's investigation finding was that the incident was confirmed because the employee failed to provide CPR. The employee was terminated. Before the IJ, according to the Administrator, Provider responses included: in-service on CPR; re-training on abuse and neglect; and Mock Code Blue evaluations. The Administrator confirmed that there was not written policy prior to the IJ on the CPR process. He confirmed that he did not bring to the QA Committee the issue of CPR Process and Full/DNR Code Identification as a key clinical indicator requiring a Plan of Action. During telephone interview on [DATE] at 11:05 a.m. with the Medical Director, witnessed by the DON, he stated that: I have overall medical oversight of the facility which included the CPR process. I was told the resident was dead by the DON. We do not do CPR on a dead resident. (The DON responded that the resident was declared dead by the Hospice nurse and not her). It was a concern that an issue developed over CPR; we did a quick ad-hoc QA meeting to discuss the situation and develop ways to deal with the situation The Medical Director confirmed that he did not bring to the QA Committee the issue of CPR Process and Full/DNR Code Identification as a key clinical indicator requiring a Plan of Action. Review of resident # 1's face sheet, undated, revealed that: resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of resident #1's physician order [REDACTED]. Review of resident # 1's care plan dated [DATE] revealed that Resident Request Code status was checked as Full Code Review of resident # 1's physician order [REDACTED]. Review of Facility Investigation revealed that: incident was confirmed; and that Employee failed to provide CPR and was terminated. The facility submitted a plan of removal dated [DATE] at 4:53 p.m. to remove the immediacy consisting of the following actions: The following plan of action outlines immediate interventions employed by the Facility to abate any further concerns surrounding the above issue: a. Residents in the facility have the right to determine their wishes with regard to cardiopulmonary resuscitation (full Code) or a Do Not Resuscitate. Mesa Vista will follow these wishes which allows full implementation of the residents Advance Directives and promotes person-centered care. b. An audit was initiated to check resident code status and ensure correct orders are in place based on resident wishes. The audit was initiated on 10.27.17 and will be completed by 10.28.17. c. There will be at least one CPR certified licensed nurse on each shift. 1. An audit of the licensed nurse files was conducted by HR on 10.27.17 to determine their CPR certification. Those without certification will be required to produce one within 30 days. The Director of Nursing will ensure that there is at least once CPR certified licensed nurse on staff when making the schedule. The DON and Administrator will review the licensed nurse schedule on Mondays and Fridays to ensure there is a licensed nurse in the facility. i. Those responsible for nurse scheduling will have a list of CPR certified licensed nurses on hand. 2. Upon hire, licensed nurses will be given 30 days to complete their CPR certification if not already certified. HR Director will audit licensed nurse's monthly to ensure they are CPR certified. d. Mock codes will be completed on a quarterly basis to ensure staff is prepared to manage a code blue situation. 1. Mock codes started on [DATE] and were completed for all shifts post incident on [DATE] and is ongoing. 2. Next quarterly mock codes will be due in the month of [DATE] for all shifts. The quarterly mock codes will be scheduled for March, June, September and December. e. The facility will review all code status orders and initiate either a red (for DNR) or green (for full code) sheet and place it in front of the resident chart. The intent of the process is to allow staff a quick reference to know what the resident advanced directive wishes are. 1. New admits that do not have a DNR will be considered full code. f. The facility initiated a dot process on 10.27.17 to identify resident code status in their rooms, as an alternate identification place to the resident medical record/chart. A red dot will indicate the resident is a DNR and a green dot will indicate that the resident is a full code. This process will be completed by 10.28.17 and either red or green dots will be placed in all closets depending on the resident code status. 1. All facility staff (nursing, administration, dietary, housekeeping) will be in-services on the new dot process by 10.31.17. 2. Licensed nurses will be in-services on 10.28.17 to initiate the dot on new admissions or change the dots if code status is changed as they receive orders. Red and green dots will be placed at nurses stations for licensed staff to use by 10.28.17. a. Facility social worker will conduct audits on the resident dots to ensure correct code status color is in place. This audit will be done on a weekly basis for four weeks and then on a monthly basis and on an as needed basis. This audit will begin the week of 10.30.17. b. This in-service will be completed by 10.31.17. c. Administrative staff will check resident dots in the closet when they are conducting their daily quality of life rounds during the morning 7 days a week. This process will begin 10.30.17. d. CNAs will check resident closets to make sure that the dots are in place during their initial (first rounds) each day. The CNAs conduct walking rounds at the beginning of each shift. This process will begin 10.28.17 once all dots are placed. e. Licensed nurses, CNAs, dietary, housekeeping, administrative staff were in-services by administrator/DON to check code status for the resident, either using the clinical record or the dot in their closet, as soon as an unresponsive resident is found. This in-service was initiated on 10.28.17 and will be completed by 10.31.17. f. Staff will not be allowed to start their designated shift till they have been in-serviced. B. The facility electronic record system was triggered to print the code status orders on the resident MARs and Nurse MARs. a. Licensed nurses were in-serviced to review the MARs and NMARs if needed to identify resident code status if the clinical chart is not easily available on 10.28.17 by the DON. This in-service will be completed no later than 10.31.17. b. The November MARs and NMARs will have the code status printed on them. C. In the first crucial moments, when a resident is found unresponsive, without vital signs, licensed nurses will initiate CPR per AHA guidelines. a. All staff (nursing, dietary, housekeeping, administrative) will be in-services to check for the code status in the resident record/chart when an unresponsive resident is found. b. In-service was initiated by the DON on this process for licensed nurses on 10.27.17 and will be completed by 10.31.17. c. An in-service was initiated by the DON for all other staff (direct care, administration, housekeeping/laundry, dietary) D. As the administrative staff is conducting education on the POR for all staff the Administrator is checking the names of the staff against a facility list which will be completed by 10.31.17. E. The facility administrator will monitor the items listed in the plan on a monthly basis and report findings to medical director and the facility QAPI team in the QA meetings for four months and then as needed. Verification of Plan of Removal: Observation on [DATE] at 1:15 p.m. revealed the presence of at least one CPR certified staff member, LVN H on Wing A (Day Shift). Observation of nursing staff at 4:30 p.m. revealed the presence of the following qualified CPR staff: LVN I and LVN J. Review of employee files for the said staff revealed the presence of a CPR card. On-going Observation on [DATE] at 4:20 p.m. of four closets (room [ROOM NUMBER], 706, 501 and 502 (C Wing) revealed the existence of code status dots. Observation on [DATE] at 2 p.m. of CNA K and CNA L revealed that CNAs were checking the dots in the closets; room [ROOM NUMBER], 706, 501 and 502 (C Wing), A wing: 302, 305, 212, and 402 During interview on [DATE] at 1:20 p.m. with DON she stated that, no nursing staff had been hired since the date of the approved POR; but a new hire was scheduled for [DATE]. Interview on [DATE] at 1:45 p.m. with the DON revealed that a Mock Code training on the new CPR process was scheduled for December, 2017. During interview on [DATE] at 1:30 p.m. with the Social Worker she stated that, the weekly process of auditing the CPR system (SW Code sheets against dots and flash sheets on the Nurse MAR and clinical record would start the week of [DATE]. During interview with DON on [DATE] at 1:45 pm. and ADON D at 4:30 p.m. revealed that training was in process regarding the new CPR and Code system was on-going. Interview on [DATE] at 4:35 p.m. with staff revealed that they were in-serviced on the dot system before going on shift. During interview with CNA M (evening shift) and CNA K (evening shift) revealed they received an in-service prior to going on shift. During interview on [DATE] at 4:37 p.m. with the ADON D she stated that the night shift would receive the new training on CPR and code identification. During interview on [DATE] at 2:38 p.m. with the Administrator he stated that: he will check that the POR tasks were completed; at the next QA meeting in [DATE] the POR would be formatted into an action plan; which would be part of the Plan of Correction. Record review of the facility A/C Wing Code Audit sheet revealed that the audit was completed on [DATE]. Record review of attendance sign-in sheets revealed that the facility conducted Mock Code training on [DATE] and [DATE]. Record review of two new admissions records, resident # 24 and # 25, revealed that that the full code sheet was present in the front of the chart and on the Nurse MAR [DATE]. Record reviewed revealed that the clinical record and the electronic Nurse MAR [DATE] contained the code status for the following residents: resident # 26, #4, #27, #22, #28, #29, #30, #31, and #32. While the IJ was removed on [DATE] at 5:21 p.m., the facility remained out of compliance at a level of actual harm with a scope identified as pattern until all residents were assessed and staff was in-serviced on code identification and provision of CPR. Information provided by the DON on [DATE] revealed that 62 resident were coded full code.

Based on interview and record review, the facility failed to provide the necessary care and services to attain and maintain the highest practicable physical well-being in accordance with the care plan for 1 of 25 residents (resident #1) whose care was reviewed for Code Status in that: LVN A and B did not immediately provide CPR to Resident #1 who was unresponsive and full code status. LVN A assumed resident #1 was do not resuscitate status because resident #1 was hospice. These failures resulted in identification of an IJ (Immediate Jeopardy) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a level of actual harm with a scope identified as pattern until all residents were assessed and staff was in-serviced on code identification and provision of CPR. This deficient practice could affect 62 residents in the facility who were Full Code and could result in their request for full code not being honored and not receiving CPR immediately if their heart stopped and result in death. The findings were: Record review of resident #1's facesheet ([DATE]) revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed she was readmitted from the hospital for GI bleed on [DATE]. Record review of resident #1's 60 day MDS ([DATE]) revealed resident #1 had no speech, rarely/never understood others. Resident #1 was assessed with [REDACTED]. Record review of resident #1's physician's orders [REDACTED].#1 was admitted to hospice at this time for atherosclertic [MEDICAL CONDITION]. Further record review of the physician's orders [REDACTED]. Review of Facility Investigation dated [DATE] revealed that: incident was confirmed; and that Employee failed to provide CPR (cardiopulmonary resuscitation-a medical procedure involving repeated compression of a patient's chest, performed in an attempt to restore the blood circulation and breathing of a person who has suffered [MEDICAL CONDITION]) and was terminated. Review of resident # 1's physician order [REDACTED]. Record review of resident #1's careplan ([DATE]) revealed resident #1's code status was full code, a goal was for the code status to be maintained for the next 90 days. Further review of resident #1's careplan revealed an approach was to inform staff of the code status and to monitor for a decrease in change of condition and to report to the physician and family. There was no intervention to initiate CPR in the approach column. Record review of resident #1' nurses notes documented by LVN A on [DATE] at 3:00 a.m. revealed resident #1 had high respirations and hospice was contacted. Vital signs were ,[DATE] (blood pressure), 90-pulse, respiration-30, 98.3-temperature. According to the nurses notes, resident #1 was administered PRN medication-upon follow up at 2:30 a.m. the medication was effective, eyes were closed, respirations were even and unlabored. Further record review revealed the nurse will continue to monitor. Record review of resident #1's nurses notes by LVN A on [DATE] at 0320 a.m. revealed resident passed away at 3:20 a.m. Hospice, director of nursing, and family were notified. Further record review of this note revealed resident #1 was awake on 3:10 a.m. rounds and resident #1 was in no distress. Resident #1's respirations had calmed down with the 2 a.m. dose of [MEDICATION NAME]; respirations were 18, pulse-62, blood pressure-,[DATE], at 2:45 a.m. At 3:10 a.m. resident #1 was lying in her bed, eyes open, respirations even and unlabored. At 3:20 a.m. resident #1 had passed away. Eyes closed, no respirations, no pulse, skin mottling to hands, and unresponsive. Resident #1's son was notified at 3:23 a.m. Further review revealed hospice arrived at 4:00 a.m. with the resident's son. Resident #1's official time of death was 4:12 a.m. on [DATE]. Further review revealed there was no documentation CPR was initiated by any staff. Record review of resident #1's hospice admission-initial and comprehensive assessment note (visit date [DATE]) revealed resident #1 was a full code and the son says he wished all measures be made to keep resident #1 alive. Record review of resident #1's careplan conference summary ([DATE]) revealed she was full code (son was in attendance). Record review of LVN A's CPR certification revealed it was current (received on [DATE], LVN A) and LVN B's CPR certification was current as of [DATE]. Record review of the facility's inservice following the incident revealed staff were inserviced on DNR and code status on [DATE]. Interview on [DATE] at 6:46 p.m. with LVN I revealed she would check the resident's chart to check for the code status and call for help and have someone call a code. Interview on [DATE] at 4:35 p.m. with LVN P revealed if she found a resident unconscious she would either stay with the resident or check the resident's chart for the code status. She did not indicate if she would initiate CPR. Interview with resident #1's son on [DATE] at 3:15 p.m. revealed when resident #1 entered the facility ([DATE]) we (family) agreed to the hospice when asked by the hospice nurse and the son said yes. Further interview with resident #1's son revealed they never pursued DNR for resident #1 and they were in complete agreement that whatever it takes to keep resident #1 alive to do it. Interview on [DATE] at 6:05 p.m. with LVN C, ADON revealed if a resident was found unresponsive she would get the chart and look towards the front of the chart for the code status and grab the crash cart for the resident (if full code) and send a nurse to call 911. Interview on [DATE] at 6:17 p.m. with CNA K revealed if he found a resident unresponsive he would call the nurse, keep the resident comfortable, and check the kardex for the code status. Interview on [DATE] at 6:24 p.m. with CNA O revealed if he found a resident unresponsive, he would immediately run and get the nurses and wait for directions. Further interview with CNA O revealed he did not know where to check for the code status. Interview on [DATE] at 8:05 a.m. with the DON revealed after the incident the facility conducted mock codes monthly and weekends. The facility also reviewed their education and training of nurses. Further interview with the DON confirmed LVN A realized resident #1 was a full code after checking resident #1's chart. She did not check resident #1's chart during the incident. The DON reported the mock codes training was for the facility's protocols and expectations of the nurses. The facility did not have mock codes prior to the incident. Further interview with the DON at 8:16 a.m. revealed during the mock survey's conducted, the staff were taught to go to the chart, the protocol was not written anywhere. Interview on [DATE] at 10:32 a.m. with the DON revealed the facility went by the protocols of the American Heart Association and their training the nurses received in CPR as facility practices as to what to do when they saw a resident unresponsive. Further interview revealed there was no written protocol or policy on how the nurses should respond should they find a resident unconscious. The DON reported on orientation, she informed the new nurses that the chart is what they needed to check for the code status of a resident. Interview on [DATE] at 4:41 p.m. with LVN B revealed LVN A informed her that resident #1 was full code at the beginning of the shift. Further interview with LVN B revealed LVN B informed LVN A to notify the physician, hospice nurse, and the DON. LVN B reported she did not ask LVN A why CPR was not initiated because resident #1 was LVN A's resident. During interview on [DATE] at 10:21 a.m. with the DON she stated that: she did not know whether LVN A knew how to check the code status on residents. The DON stated: we assumed the nurse would check the chart. Interview on [DATE] at 2:35 p.m. with RN S revealed she would check the chart or flashers (green colored (full code) or red colored sheets (DNR)) in front of the MAR, stay with the resident and get someone to check the chart for her. Further interview with RN S revealed she would be waiting for the staff to return with the code status. Interview on [DATE] at 2:37 p.m. with LVN T revealed if she found someone unconscious she would check the chart and if the code status wasn't in the chart, she would check the crash cart or nurses MAR, then start CPR. LVN T reported she would also stay with the resident and have a staff (CNA or someone) to check the code status and stay with the resident and check for airway, breathing, and circulation. LVN T did not indicate when she would initiate CPR. Interview on [DATE] at 2:45 p.m. with LVN U revealed if she found a resident unconscious she would check the charts, crash carts for the residents code status, check the vital signs, get the crash cart and turn on the emergency lights or yell for help. Further interview revealed LVN U did not indicate when she would start CPR. Interview on [DATE] at 1:30 p.m. with LVN A confirmed on [DATE] at 3:15 a.m. CNA V came to her and informed her resident #1 was not responsive. LVN A stated she called hospice and the hospice nurse stated to call the family. LVN A reported she called the DON. LVN A reported the hospice nurse inform her resident #1 was palliative care but didn't informed her that resident #1 was DNR, after the hospice pronounced resident #1's death, LVN A checked resident #1's chart and saw she was full code. LVN A reported looking back, she should have checked the chart whether resident #1 was full code or not and that she was under the impression to call hospice and follow orders provided. LVN A thought resident #1 was DNR. LVN A reported she was under the impression because resident #1 went on hospice and she was DNR. Interview on [DATE] at 4:15 p.m. with CNA V revealed she found resident #1 between 3 a.m. to 3:15 a.m. (could not recall date) resident stopped breathing, CNA V reported she called the nurse, who came to check the vital signs, the nurse started panicking and asked a second nurse on duty. Further interview with CNA V revealed LVN A asked the second nurse what was she supposed to do and the second nurse told LVN A to call hospice. Observation on [DATE] at 6:40 p.m. of A Wing revealed the following: A kardex list of residents and their code status dated [DATE] and a crash cart list of residents and their code status dated [DATE]. The crash cart resident code list was reviewed and cross-referenced with the current list of residents code status given by the facility on [DATE]. Review of the crash cart list and current list revealed discrepancies such as new admissions were not reflected on the crash cart list. Observation of random charts revealed red (DNR) and green (Full Code) sheets in front of charts that identified residents code status. Record review of a statement from LVN A on [DATE] at 2:00 p.m. (from the facility's investigation) revealed on [DATE] at 3:20 a.m. CNA T called LVN A to resident #1's room, stating CNA T thought she changed resident #1 and without a pulse/respirations, LVN A called LVN B, who assessed resident #1 to be without a pulse. LVN A immediately called hospice and was told by hospice to notify the family. Afterwards, the DON was notified. At 4:00 a.m. hospice and the family were at the facility and the hospice nurse pronounced the time of death. It was not until LVN A was completing her documentation that LVN A found the order for full code and resident #1 was hospice. Record review of a statement from LVN B on [DATE] at 2:30 p.m. (regarding the event of [DATE] and resident #1) revealed LVN B did not know resident #1 and had no interaction with resident #1 at any time. At about 3:10 a.m. LVN A asked her (LVN B) to come to resident #1's room to help her. LVN B checked resident #1's pulse and there was no pulse. LVN A informed LVN B that she (LVN A) had been in the room about 10 minutes ago. Then LVN A called hospice and the DON. Further review of LVN B's statement confirmed she did not check resident #1's chart for the code status. Record review of the American Heart Association (AHA) site: HTTPS://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/part-5-adult-basic-life-support-and-cardiopulmonary-resuscitation-quality/ revealed BLS is the foundation for saving lives after [MEDICAL CONDITION]. Fundamental aspects of adult BLS include immediate recognition of sudden [MEDICAL CONDITION] and activation of the emergency response system, early CPR, and rapid defibrillation with an automated external defibrillator (AED). Further review revealed Begin chest compressions as quickly as possible after recognition of [MEDICAL CONDITION]. Record review of the facility's record of inservice for [DATE], [DATE], and [DATE] (initiated after the incident) revealed a Mock code blue evaluation check off list. The check off list noted the following: 1) team leader identified? 2) did the team leader designate a staff to specific duties?, 3) did the nurse check the chart for code status? 4) did a staff member call 911/EMS? 5) did a staff member bring the emergency cart to location? 6) did a staff member bring the AED to the location? 7) was CPR started prior to AED placement? etc Further review revealed there were no steps to identify if CPR was immediately initiated. During interview on [DATE] at 11:11 a.m. with LVN B she stated that: I would accept another nurse's statement about the code status of the deceased resident; because the other nurse worked with the resident. The Administrator, Corporate Nurse, VP Operations Nurse, and DON were notified on [DATE] at 5:00 p.m. that an Immediate Jeopardy situation was identified. During interview on [DATE] at 3:00 p.m. with the Administrator he stated that: after the IJ all staff would be trained before starting each shift on the written CPR process. Training would also include code status procedures, the dots system, and explained how the code identification system worked. He felt the IJ resulted because LVN A wrongly assumed the resident's code status and did not perform CPR. The Facility's investigation finding was that the incident was confirmed because the employee failed to provide CPR. The employee was terminated. Before the IJ, according to the Administrator, Provider responses included: in-service on CPR; re-training on abuse and neglect; and Mock Code Blue evaluations. The Administrator confirmed that there was no written policy prior to the IJ on the CPR process. He confirmed that he did not bring to the QA Committee the issue of CPR Process and Full/DNR Code Identification as a key clinical indicator requiring a Plan of Action. Interview on [DATE] 10:21 a.m. with the DON revealed she did not know whether the LVN A knew how to check the code status on the residents; we assumed the nurse would check the resident's status. Further interview with the DON revealed (after the immediate jeopardy) On admission, we will ask for code status, ask family, if unknown the resident will be coded full code. The family will be told to produce documentation that the resident should be DNR. The DON confirmed that she did not bring to the QA Committee the issue of CPR Process and Full/DNR Code Identification as a key clinical indicator requiring a Plan of Action. During interview on [DATE] at 3:41 p.m. with DON she stated that: Policy does not contain the statement to initiate CPR for a non-responsive resident until the code status is established; it is an assumption in the Process for Performing CPR. This is a process that has existed but it was not previously published at the time of the incident. The written form of the Process was done on [DATE]; but it has always been in effect. In CPR certification you are taught that the resident is full code until information shows otherwise. We will elaborate on # 2 to clearly establish to begin CPR until information shows otherwise. We will start educating staff on the written process. The written CPR Process had not been reviewed and signed by the Medical Director, Administrator, DON and Pharmacist as of [DATE] During interview on [DATE] at 3:24 p.m. with the DON she stated: In place before (prior to the IJ) was make sure code validated in chart, kard-X. Now (after the IJ), make sure upon hire we obtain CPR card, all staff trained on CPR process, where the code status are at (chart, flash cards, kard-X, MAR and closet. The DON added that the IJ resulted because LVN A assumed resident # 1 was DNR. LVN B accepted, according to the DON, LVN A's comment that resident # 1 was dead and therefore LVN B did not initiate CPR to an unresponsive resident. The DON confirmed that it was not in LVN A's scope of practice to declare a resident deceased . The DON could not provide an explanation as to why LVN A and LVN B assumed that the resident # 1's code status was DNR. Likewise, the DON could not give an explanation as to why LVN A acted beyond her scope of practice to say that resident # 1 was dead. The DON confirmed that resources and training were available to LVN A and LVN B on ascertaining the code status of resident #1. The DON further confirmed that the facility did not have in place at the time of the incident a written policy on the CPR process; especially as to when to administer CPR to an unresponsive resident when the code status was not known. During telephone interview on [DATE] at 11:05 a.m. with the Medical Director, witnessed by the DON, he stated that: I have overall medical oversight of the facility which included the CPR process. I was told the resident was dead by the DON. We do not do CPR on a dead resident. (The DON responded that the resident was declared dead by the Hospice nurse and not her). It was a concern that an issue developed over CPR; we did a quick ad-hoc QA meeting to discuss the situation and developed ways to deal with the situation The Medical Director confirmed that he did not bring to the QA Committee the issue of CPR Process and Full/DNR Code Identification as a key clinical indicator requiring a Plan of Action. During interview on [DATE] at 9:25 a.m. with the HR Manager he stated that: tracking of CPR was based on verifying the CPR card and keeping a copy on file listing expiration date. He confirmed that a copy of LVN A's card was not received until [DATE]; and given to surveyor on [DATE]. The facility submitted a plan of removal dated [DATE] at 4:53 p.m. to remove the immediacy consisting of the following actions: The following plan of action outlines immediate interventions employed by the Facility to abate any further concerns surrounding the above issue: a. Residents in the facility have the right to determine their wishes with regard to cardiopulmonary resuscitation (full Code) or a Do Not Resuscitate. Mesa Vista will follow these wishes which allows full implementation of the residents Advance Directives and promotes person-centered care. b. An audit was initiated to check resident code status and ensure correct orders are in place based on resident wishes. The audit was initiated on 10.27.17 and will be completed by 10.28.17. c. There will be at least one CPR certified licensed nurse on each shift. 1. An audit of the licensed nurse files was conducted by HR on 10.27.17 to determine their CPR certification. Those without certification will be required to produce one within 30 days. The Director of Nursing will ensure that there is at least once CPR certified licensed nurse on staff when making the schedule. The DON and Administrator will review the licensed nurse schedule on Mondays and Fridays to ensure there is a licensed nurse in the facility. i. Those responsible for nurse scheduling will have a list of CPR certified licensed nurses on hand. 2. Upon hire, licensed nurses will be given 30 days to complete their CPR certification if not already certified. HR Director will audit licensed nurse's monthly to ensure they are CPR certified. d. Mock codes will be completed on a quarterly basis to ensure staff is prepared to manage a code blue situation. 1. Mock codes started on [DATE] and were completed for all shifts post incident on [DATE] and is ongoing. 2. Next quarterly mock codes will be due in the month of [DATE] for all shifts. The quarterly mock codes will be scheduled for March, June, September and December. e. The facility will review all code status orders and initiate either a red (for DNR) or green (for full code) sheet and place it in front of the resident chart. The intent of the process is to allow staff a quick reference to know what the resident advanced directive wishes are. 1. New admits that do not have a DNR will be considered full code. f. The facility initiated a dot process on 10.27.17 to identify resident code status in their rooms, as an alternate identification place to the resident medical record/chart. A red dot will indicate the resident is a DNR and a green dot will indicate that the resident is a full code. This process will be completed by 10.28.17 and either red or green dots will be placed in all closets depending on the resident code status. 1. All facility staff (nursing, administration, dietary, housekeeping) will be in-services on the new dot process by 10.31.17. 2. Licensed nurses will be in-services on 10.28.17 to initiate the dot on new admissions or change the dots if code status is changed as they receive orders. Red and green dots will be placed at nurses stations for licensed staff to use by 10.28.17. a. Facility social worker will conduct audits on the resident dots to ensure correct code status color is in place. This audit will be done on a weekly basis for four weeks and then on a monthly basis and on an as needed basis. This audit will begin the week of 10.30.17. b. This in-service will be completed by 10.31.17. c. Administrative staff will check resident dots in the closet when they are conducting their daily quality of life rounds during the morning 7 days a week. This process will begin 10.30.17. d. CNAs will check resident closets to make sure that the dots are in place during their initial (first rounds) each day. The CNAs conduct walking rounds at the beginning of each shift. This process will begin 10.28.17 once all dots are placed. e. Licensed nurses, CNAs, dietary, housekeeping, administrative staff were in-services by administrator/DON to check code status for the resident, either using the clinical record or the dot in their closet, as soon as an unresponsive resident is found. This in-service was initiated on 10.28.17 and will be completed by 10.31.17. f. Staff will not be allowed to start their designated shift till they have been in-serviced. B. The facility electronic record system was triggered to print the code status orders on the resident MARs and Nurse MARs. a. Licensed nurses were in-serviced to review the MARs and NMARs if needed to identify resident code status if the clinical chart is not easily available on 10.28.17 by the DON. This in-service will be completed no later than 10.31.17. b. The November MARs and NMARs will have the code status printed on them. C. In the first crucial moments, when a resident is found unresponsive, without vital signs, licensed nurses will initiate CPR per AHA guidelines. a. All staff (nursing, dietary, housekeeping, administrative) will be in-services to check for the code status in the resident record/chart when an unresponsive resident is found. b. In-service was initiated by the DON on this process for licensed nurses on 10.27.17 and will be completed by 10.31.17. c. An in-service was initiated by the DON for all other staff (direct care, administration, housekeeping/laundry, dietary) D. As the administrative staff is conducting education on the POR for all staff the Administrator is checking the names of the staff against a facility list which will be completed by 10.31.17. E. The facility administrator will monitor the items listed in the plan on a monthly basis and report findings to medical director and the facility QAPI team in the QA meetings for four months and then as needed. Verification of Plan of Removal: Observation on [DATE] at 1:15 p.m. revealed the presence of at least one CPR certified staff member, LVN H on Wing A (Day Shift). Observation of nursing staff at 4:30 p.m. revealed the presence of the following qualified CPR staff: LVN I and LVN J. Review of employee files for the said staff revealed the presence of a CPR card. On-going Observation on [DATE] at 4:20 p.m. of four closets (room [ROOM NUMBER], 706, 501 and 502 (C Wing) revealed the existence of code status dots. Observation on [DATE] at 2 p.m. of CNA K and CNA L revealed that CNAs were checking the dots in the closets; room [ROOM NUMBER], 706, 501 and 502 (C Wing), A wing: 302, 305, 212, and 402 During interview on [DATE] at 1:20 p.m. with DON she stated that, no nursing staff had been hired since the date of the approved POR; but a new hire was scheduled for [DATE]. Interview on [DATE] at 1:45 p.m. with the DON revealed that a Mock Code training on the new CPR process was scheduled for December, 2017. During interview on [DATE] at 1:30 p.m. with the Social Worker she stated that, the weekly process of auditing the CPR system (SW Code sheets against dots and flash sheets on the Nurse MAR and clinical record would start the week of [DATE]. Interview on [DATE] at 2:50 p.m. with LVN W revealed if he found someone unresponsive he would assess the resident, have someone check the code status and initiate CPR, he would not wait for verification of code status. Further interview with LVN W revealed he was inserviced on the new process at 5:00 a.m. [DATE]. Interview on [DATE] at 4:27 p.m. with LVN I revealed she would initial CPR immediately if she found a resident unresponsive. Further interview revealed call would call for help and call a code. LVN I reported she was inserviced yesterday. During interview with DON on [DATE] at 1:45 p.m and ADON D at 4:30 p.m. revealed that training was in process regarding the new CPR and Code system was on-going. Interview on [DATE] at 4:35 p.m. with staff revealed that they were in-serviced on the dot system before going on shift. During interview with CNA M (evening shift) and CNA K (evening shift) revealed they received an in-service prior to going on shift. During interview on [DATE] at 4:37 p.m. with the ADON D she stated that the night shift would receive the new training on CPR and code identification. During interview on [DATE] at 2:38 p.m. with the Administrator he stated that: he will check that the POR tasks were completed; at the next QA meeting in [DATE] the POR would be formatted into an action plan; which would be part of the Plan of Correction. Record review of the facility A and C Wing Code Audit sheet revealed that the audit was completed on [DATE]. Record review of attendance sign-in sheets revealed that the facility conducted Mock Code training on [DATE] and [DATE]. Record review of two new admissions records, resident # 24 and # 25, revealed that that the full code sheet was present in the front of the chart and on the Nurse MAR [DATE]. Record reviewed revealed that the clinical record and the electronic Nurse MAR [DATE] contained the code status for the following residents: resident # 26, #4, #27, #22, #28, #29, #30, #31, and #32 While the IJ was removed on [DATE] at 5:21 p.m., the facility remained out of compliance at a level of actual harm with a scope identified as pattern until all residents were assessed and staff was in-serviced on code identification and provision of CPR. Information provided by the DON on [DATE] revealed that 62 resident were coded full code.

Based on observation, record review and interview, the facility failed to develop and implement written policies and procedures that prohibit the neglect of 1 of 25 (residents #1) whose care was reviewed for Code Status in that: LVN A and B did not immediately provide CPR to Resident #1 who was unresponsive and full code status. LVN A assumed resident #1 was do not resuscitate status because resident #1 was hospice. These failures resulted in identification of an IJ (Immediate Jeopardy) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a level of actual harm with a scope identified as pattern until all residents were assessed and staff was in-serviced on code identification and provision of CPR. This deficient practice could affect 62 residents in the facility who were Full Code and could result in their request for full code not being honored and not receiving CPR immediately if their heart stopped and result in death. The findings were: The facility's Abuse and Neglect Prohibition Policy and Procedure (undated) documented Each resident has the right to be free from mistreatment, neglect, and misappropriation. Neglect means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Injuries of an unknown origin may occur as a result of neglect. Record review of resident #1's facesheet ([DATE]) revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed she was readmitted from the hospital for GI bleed on [DATE]. Record review of resident #1's 60 day MDS ([DATE]) revealed resident #1 had no speech, rarely/never understood others. Resident #1 was assessed with [REDACTED]. Record review of resident #1's physician's orders [REDACTED].#1 was admitted to hospice at this time for atherosclertic [MEDICAL CONDITION]. Further record review of the physician's orders [REDACTED]. Review of Facility Investigation dated [DATE] revealed that: incident was confirmed; and that Employee failed to provide CPR (cardiopulmonary resuscitation-a medical procedure involving repeated compression of a patient's chest, performed in an attempt to restore the blood circulation and breathing of a person who has suffered [MEDICAL CONDITION]) and was terminated. Review of resident # 1's physician order [REDACTED]. Record review of resident #1's careplan ([DATE]) revealed resident #1's code status was full code, a goal was for the code status to be maintained for the next 90 days. Further review of resident #1's careplan revealed an approach was to inform staff of the code status and to monitor for a decrease in change of condition and to report to the physician and family. There was no intervention to initiate CPR in the approach column. Record review of resident #1' nurses notes documented by LVN A on [DATE] at 3:00 a.m. revealed resident #1 had high respirations and hospice was contacted. Vital signs were ,[DATE] (blood pressure), 90-pulse, respiration-30, 98.3-temperature. According to the nurses notes, resident #1 was administered PRN medication-upon follow up at 2:30 a.m. the medication was effective, eyes were closed, respirations were even and unlabored. Further record review revealed the nurse will continue to monitor. Record review of resident #1's nurses notes by LVN A on [DATE] at 0320 a.m. revealed resident passed away at 3:20 a.m. Hospice, director of nursing, and family were notified. Further record review of this note revealed resident #1 was awake on 3:10 a.m. rounds and resident #1 was in no distress. Resident #1's respirations had calmed down with the 2 a.m. dose of [MEDICATION NAME]; respirations were 18, pulse-62, blood pressure-,[DATE], at 2:45 a.m. At 3:10 a.m. resident #1 was lying in her bed, eyes open, respirations even and unlabored. At 3:20 a.m. resident #1 had passed away. Eyes closed, no respirations, no pulse, skin mottling to hands, and unresponsive. Resident #1's son was notified at 3:23 a.m. Further review revealed hospice arrived at 4:00 a.m. with the resident's son. Resident #1's official time of death was 4:12 a.m. on [DATE]. Further review revealed there was no documentation CPR was initiated by any staff. Record review of resident #1's hospice admission-initial and comprehensive assessment note (visit date [DATE]) revealed resident #1 was a full code and the son says he wished all measures be made to keep resident #1 alive. Record review of resident #1's careplan conference summary ([DATE]) revealed she was full code (son was in attendance). Record review of LVN A's CPR certification revealed it was current (received on [DATE], LVN A) and LVN B's CPR certification was current as of [DATE]. Record review of the facility's inservice following the incident revealed staff were inserviced on DNR and code status on [DATE]. Interview on [DATE] at 6:46 p.m. with LVN I revealed she would check the resident's chart to check for the code status and call for help and have someone call a code. Interview on [DATE] at 4:35 p.m. with LVN P revealed if she found a resident unconscious she would either stay with the resident or check the resident's chart for the code status. She did not indicate if she would initiate CPR. Interview with resident #1's son on [DATE] at 3:15 p.m. revealed when resident #1 entered the facility ([DATE]) we (family) agreed to the hospice when asked by the hospice nurse and the son said yes. Further interview with resident #1's son revealed they never pursued DNR for resident #1 and they were in complete agreement that whatever it takes to keep resident #1 alive to do it. Interview on [DATE] at 6:05 p.m. with LVN C, ADON revealed if a resident was found unresponsive she would get the chart and look towards the front of the chart for the code status and grab the crash cart for the resident (if full code) and send a nurse to call 911. Interview on [DATE] at 6:17 p.m. with CNA K revealed if he found a resident unresponsive he would call the nurse, keep the resident comfortable, and check the kardex for the code status. Interview on [DATE] at 6:24 p.m. with CNA O revealed if he found a resident unresponsive, he would immediately run and get the nurses and wait for directions. Further interview with CNA O revealed he did not know where to check for the code status. Interview on [DATE] at 8:05 a.m. with the DON revealed after the incident the facility conducted mock codes monthly and weekends. The facility also reviewed their education and training of nurses. Further interview with the DON confirmed LVN A realized resident #1 was a full code after checking resident #1's chart. She did not check resident #1's chart during the incident. The DON reported the mock codes training was for the facility's protocols and expectations of the nurses. The facility did not have mock codes prior to the incident. Further interview with the DON at 8:16 a.m. revealed during the mock survey's conducted, the staff were taught to go to the chart, the protocol was not written anywhere. Interview on [DATE] at 10:32 a.m. with the DON revealed the facility went by the protocols of the American Heart Association and their training the nurses received in CPR as facility practices as to what to do when they saw a resident unresponsive. Further interview revealed there was no written protocol or policy on how the nurses should respond should they find a resident unconscious. The DON reported on orientation, she informed the new nurses that the chart is what they needed to check for the code status of a resident. Interview on [DATE] at 4:41 p.m. with LVN B revealed LVN A informed her that resident #1 was full code at the beginning of the shift. Further interview with LVN B revealed LVN B informed LVN A to notify the physician, hospice nurse, and the DON. LVN B reported she did not ask LVN A why CPR was not initiated because resident #1 was LVN A's resident. During interview on [DATE] at 10:21 a.m. with the DON she stated that: she did not know whether LVN A knew how to check the code status on residents. The DON stated: we assumed the nurse would check the chart. Interview on [DATE] at 2:35 p.m. with RN S revealed she would check the chart or flashers (green colored (full code) or red colored sheets (DNR)) in front of the MAR, stay with the resident and get someone to check the chart for her. Further interview with RN S revealed she would be waiting for the staff to return with the code status. Interview on [DATE] at 2:37 p.m. with LVN T revealed if she found someone unconscious she would check the chart and if the code status wasn't in the chart, she would check the crash cart or nurses MAR, then start CPR. LVN T reported she would also stay with the resident and have a staff (CNA or someone) to check the code status and stay with the resident and check for airway, breathing, and circulation. LVN T did not indicate when she would initiate CPR. Interview on [DATE] at 2:45 p.m. with LVN U revealed if she found a resident unconscious she would check the charts, crash carts for the residents code status, check the vital signs, get the crash cart and turn on the emergency lights or yell for help. Further interview revealed LVN U did not indicate when she would start CPR. Interview on [DATE] at 1:30 p.m. with LVN A confirmed on [DATE] at 3:15 a.m. CNA V came to her and informed her resident #1 was not responsive. LVN A stated she called hospice and the hospice nurse stated to call the family. LVN A reported she called the DON. LVN A reported the hospice nurse inform her resident #1 was palliative care but didn't informed her that resident #1 was DNR, after the hospice pronounced resident #1's death, LVN A checked resident #1's chart and saw she was full code. LVN A reported looking back, she should have checked the chart whether resident #1 was full code or not and that she was under the impression to call hospice and follow orders provided. LVN A thought resident #1 was DNR. LVN A reported she was under the impression because resident #1 went on hospice and she was DNR. Interview on [DATE] at 4:15 p.m. with CNA V revealed she found resident #1 between 3 a.m. to 3:15 a.m. (could not recall date) resident stopped breathing, CNA V reported she called the nurse, who came to check the vital signs, the nurse started panicking and asked a second nurse on duty. Further interview with CNA V revealed LVN A asked the second nurse what was she supposed to do and the second nurse told LVN A to call hospice. Observation on [DATE] at 6:40 p.m. of A Wing revealed the following: A kardex list of residents and their code status dated [DATE] and a crash cart list of residents and their code status dated [DATE]. The crash cart resident code list was reviewed and cross-referenced with the current list of residents code status given by the facility on [DATE]. Review of the crash cart list and current list revealed discrepancies such as new admissions were not reflected on the crash cart list. Observation of random charts revealed red (DNR) and green (Full Code) sheets in front of charts that identified residents code status. Record review of a statement from LVN A on [DATE] at 2:00 p.m. (from the facility's investigation) revealed on [DATE] at 3:20 a.m. CNA T called LVN A to resident #1's room, stating CNA T thought she changed resident #1 and without a pulse/respirations, LVN A called LVN B, who assessed resident #1 to be without a pulse. LVN A immediately called hospice and was told by hospice to notify the family. Afterwards, the DON was notified. At 4:00 a.m. hospice and the family were at the facility and the hospice nurse pronounced the time of death. It was not until LVN A was completing her documentation that LVN A found the order for full code and resident #1 was hospice. Record review of a statement from LVN B on [DATE] at 2:30 p.m. (regarding the event of [DATE] and resident #1) revealed LVN B did not know resident #1 and had no interaction with resident #1 at any time. At about 3:10 a.m. LVN A asked her (LVN B) to come to resident #1's room to help her. LVN B checked resident #1's pulse and there was no pulse. LVN A informed LVN B that she (LVN A) had been in the room about 10 minutes ago. Then LVN A called hospice and the DON. Further review of LVN B's statement confirmed she did not check resident #1's chart for the code status. Record review of the American Heart Association (AHA) site: HTTPS://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/part-5-adult-basic-life-support-and-cardiopulmonary-resuscitation-quality/ revealed BLS is the foundation for saving lives after [MEDICAL CONDITION]. Fundamental aspects of adult BLS include immediate recognition of sudden [MEDICAL CONDITION] and activation of the emergency response system, early CPR, and rapid defibrillation with an automated external defibrillator (AED). Further review revealed Begin chest compressions as quickly as possible after recognition of [MEDICAL CONDITION]. Record review of the facility's record of inservice for [DATE], [DATE], and [DATE] (initiated after the incident) revealed a Mock code blue evaluation check off list. The check off list noted the following: 1) team leader identified? 2) did the team leader designate a staff to specific duties?, 3) did the nurse check the chart for code status? 4) did a staff member call 911/EMS? 5) did a staff member bring the emergency cart to location? 6) did a staff member bring the AED to the location? 7) was CPR started prior to AED placement? etc Further review revealed there were no steps to identify if CPR was immediately initiated. During interview on [DATE] at 11:11 a.m. with LVN B she stated that: I would accept another nurse's statement about the code status of the deceased resident; because the other nurse worked with the resident. The Administrator, Corporate Nurse, VP Operations Nurse, and DON were notified on [DATE] at 5:00 p.m. that an Immediate Jeopardy situation was identified. During interview on [DATE] at 3:00 p.m. with the Administrator he stated that: after the IJ all staff would be trained before starting each shift on the written CPR process. Training would also include code status procedures, the dots system, and explained how the code identification system worked. He felt the IJ resulted because LVN A wrongly assumed the resident's code status and did not perform CPR. The Facility's investigation finding was that the incident was confirmed because the employee failed to provide CPR. The employee was terminated. Before the IJ, according to the Administrator, Provider responses included: in-service on CPR; re-training on abuse and neglect; and Mock Code Blue evaluations. The Administrator confirmed that there was no written policy prior to the IJ on the CPR process. He confirmed that he did not bring to the QA Committee the issue of CPR Process and Full/DNR Code Identification as a key clinical indicator requiring a Plan of Action. Interview on [DATE] 10:21 a.m. with the DON revealed she did not know whether the LVN A knew how to check the code status on the residents; we assumed the nurse would check the resident's status. Further interview with the DON revealed (after the immediate jeopardy) On admission, we will ask for code status, ask family, if unknown the resident will be coded full code. The family will be told to produce documentation that the resident should be DNR. The DON confirmed that she did not bring to the QA Committee the issue of CPR Process and Full/DNR Code Identification as a key clinical indicator requiring a Plan of Action. During interview on [DATE] at 3:41 p.m. with DON she stated that: Policy does not contain the statement to initiate CPR for a non-responsive resident until the code status is established; it is an assumption in the Process for Performing CPR. This is a process that has existed but it was not previously published at the time of the incident. The written form of the Process was done on [DATE]; but it has always been in effect. In CPR certification you are taught that the resident is full code until information shows otherwise. We will elaborate on # 2 to clearly establish to begin CPR until information shows otherwise. We will start educating staff on the written process. The written CPR Process had not been reviewed and signed by the Medical Director, Administrator, DON and Pharmacist as of [DATE] During interview on [DATE] at 3:24 p.m. with the DON she stated: In place before (prior to the IJ) was make sure code validated in chart, kard-X. Now (after the IJ), make sure upon hire we obtain CPR card, all staff trained on CPR process, where the code status are at (chart, flash cards, kard-X, MAR and closet. The DON added that the IJ resulted because LVN A assumed resident # 1 was DNR. LVN B accepted, according to the DON, LVN A's comment that resident # 1 was dead and therefore LVN B did not initiate CPR to an unresponsive resident. The DON confirmed that it was not in LVN A's scope of practice to declare a resident deceased . The DON could not provide an explanation as to why LVN A and LVN B assumed that the resident # 1's code status was DNR. Likewise, the DON could not give an explanation as to why LVN A acted beyond her scope of practice to say that resident # 1 was dead. The DON confirmed that resources and training were available to LVN A and LVN B on ascertaining the code status of resident #1. The DON further confirmed that the facility did not have in place at the time of the incident a written policy on the CPR process; especially as to when to administer CPR to an unresponsive resident when the code status was not known. During telephone interview on [DATE] at 11:05 a.m. with the Medical Director, witnessed by the DON, he stated that: I have overall medical oversight of the facility which included the CPR process. I was told the resident was dead by the DON. We do not do CPR on a dead resident. (The DON responded that the resident was declared dead by the Hospice nurse and not her). It was a concern that an issue developed over CPR; we did a quick ad-hoc QA meeting to discuss the situation and developed ways to deal with the situation The Medical Director confirmed that he did not bring to the QA Committee the issue of CPR Process and Full/DNR Code Identification as a key clinical indicator requiring a Plan of Action. During interview on [DATE] at 9:25 a.m. with the HR Manager he stated that: tracking of CPR was based on verifying the CPR card and keeping a copy on file listing expiration date. He confirmed that a copy of LVN A's card was not received until [DATE]; and given to surveyor on [DATE]. The facility submitted a plan of removal dated [DATE] at 4:53 p.m. to remove the immediacy consisting of the following actions: The following plan of action outlines immediate interventions employed by the Facility to abate any further concerns surrounding the above issue: a. Residents in the facility have the right to determine their wishes with regard to cardiopulmonary resuscitation (full Code) or a Do Not Resuscitate. Mesa Vista will follow these wishes which allows full implementation of the residents Advance Directives and promotes person-centered care. b. An audit was initiated to check resident code status and ensure correct orders are in place based on resident wishes. The audit was initiated on 10.27.17 and will be completed by 10.28.17. c. There will be at least one CPR certified licensed nurse on each shift. 1. An audit of the licensed nurse files was conducted by HR on 10.27.17 to determine their CPR certification. Those without certification will be required to produce one within 30 days. The Director of Nursing will ensure that there is at least once CPR certified licensed nurse on staff when making the schedule. The DON and Administrator will review the licensed nurse schedule on Mondays and Fridays to ensure there is a licensed nurse in the facility. i. Those responsible for nurse scheduling will have a list of CPR certified licensed nurses on hand. 2. Upon hire, licensed nurses will be given 30 days to complete their CPR certification if not already certified. HR Director will audit licensed nurse's monthly to ensure they are CPR certified. d. Mock codes will be completed on a quarterly basis to ensure staff is prepared to manage a code blue situation. 1. Mock codes started on [DATE] and were completed for all shifts post incident on [DATE] and is ongoing. 2. Next quarterly mock codes will be due in the month of [DATE] for all shifts. The quarterly mock codes will be scheduled for March, June, September and December. e. The facility will review all code status orders and initiate either a red (for DNR) or green (for full code) sheet and place it in front of the resident chart. The intent of the process is to allow staff a quick reference to know what the resident advanced directive wishes are. 1. New admits that do not have a DNR will be considered full code. f. The facility initiated a dot process on 10.27.17 to identify resident code status in their rooms, as an alternate identification place to the resident medical record/chart. A red dot will indicate the resident is a DNR and a green dot will indicate that the resident is a full code. This process will be completed by 10.28.17 and either red or green dots will be placed in all closets depending on the resident code status. 1. All facility staff (nursing, administration, dietary, housekeeping) will be in-services on the new dot process by 10.31.17. 2. Licensed nurses will be in-services on 10.28.17 to initiate the dot on new admissions or change the dots if code status is changed as they receive orders. Red and green dots will be placed at nurses stations for licensed staff to use by 10.28.17. a. Facility social worker will conduct audits on the resident dots to ensure correct code status color is in place. This audit will be done on a weekly basis for four weeks and then on a monthly basis and on an as needed basis. This audit will begin the week of 10.30.17. b. This in-service will be completed by 10.31.17. c. Administrative staff will check resident dots in the closet when they are conducting their daily quality of life rounds during the morning 7 days a week. This process will begin 10.30.17. d. CNAs will check resident closets to make sure that the dots are in place during their initial (first rounds) each day. The CNAs conduct walking rounds at the beginning of each shift. This process will begin 10.28.17 once all dots are placed. e. Licensed nurses, CNAs, dietary, housekeeping, administrative staff were in-services by administrator/DON to check code status for the resident, either using the clinical record or the dot in their closet, as soon as an unresponsive resident is found. This in-service was initiated on 10.28.17 and will be completed by 10.31.17. f. Staff will not be allowed to start their designated shift till they have been in-serviced. B. The facility electronic record system was triggered to print the code status orders on the resident MARs and Nurse MARs. a. Licensed nurses were in-serviced to review the MARs and NMARs if needed to identify resident code status if the clinical chart is not easily available on 10.28.17 by the DON. This in-service will be completed no later than 10.31.17. b. The November MARs and NMARs will have the code status printed on them. C. In the first crucial moments, when a resident is found unresponsive, without vital signs, licensed nurses will initiate CPR per AHA guidelines. a. All staff (nursing, dietary, housekeeping, administrative) will be in-services to check for the code status in the resident record/chart when an unresponsive resident is found. b. In-service was initiated by the DON on this process for licensed nurses on 10.27.17 and will be completed by 10.31.17. c. An in-service was initiated by the DON for all other staff (direct care, administration, housekeeping/laundry, dietary) D. As the administrative staff is conducting education on the POR for all staff the Administrator is checking the names of the staff against a facility list which will be completed by 10.31.17. E. The facility administrator will monitor the items listed in the plan on a monthly basis and report findings to medical director and the facility QAPI team in the QA meetings for four months and then as needed. Verification of Plan of Removal: Observation on [DATE] at 1:15 p.m. revealed the presence of at least one CPR certified staff member, LVN H on Wing A (Day Shift). Observation of nursing staff at 4:30 p.m. revealed the presence of the following qualified CPR staff: LVN I and LVN J. Review of employee files for the said staff revealed the presence of a CPR card. On-going Observation on [DATE] at 4:20 p.m. of four closets (room [ROOM NUMBER], 706, 501 and 502 (C Wing) revealed the existence of code status dots. Observation on [DATE] at 2 p.m. of CNA K and CNA L revealed that CNAs were checking the dots in the closets; room [ROOM NUMBER], 706, 501 and 502 (C Wing), A wing: 302, 305, 212, and 402 During interview on [DATE] at 1:20 p.m. with DON she stated that, no nursing staff had been hired since the date of the approved POR; but a new hire was scheduled for [DATE]. Interview on [DATE] at 1:45 p.m. with the DON revealed that a Mock Code training on the new CPR process was scheduled for December, 2017. During interview on [DATE] at 1:30 p.m. with the Social Worker she stated that, the weekly process of auditing the CPR system (SW Code sheets against dots and flash sheets on the Nurse MAR and clinical record would start the week of [DATE]. Interview on [DATE] at 2:50 p.m. with LVN W revealed if he found someone unresponsive he would assess the resident, have someone check the code status and initiate CPR, he would not wait for verification of code status. Further interview with LVN W revealed he was inserviced on the new process at 5:00 a.m. [DATE]. Interview on [DATE] at 4:27 p.m. with LVN I revealed she would initial CPR immediately if she found a resident unresponsive. Further interview revealed call would call for help and call a code. LVN I reported she was inserviced yesterday. During interview with DON on [DATE] at 1:45 p.m and ADON D at 4:30 p.m. revealed that training was in process regarding the new CPR and Code system was on-going. Interview on [DATE] at 4:35 p.m. with staff revealed that they were in-serviced on the dot system before going on shift. During interview with CNA M (evening shift) and CNA K (evening shift) revealed they received an in-service prior to going on shift. During interview on [DATE] at 4:37 p.m. with the ADON D she stated that the night shift would receive the new training on CPR and code identification. During interview on [DATE] at 2:38 p.m. with the Administrator he stated that: he will check that the POR tasks were completed; at the next QA meeting in [DATE] the POR would be formatted into an action plan; which would be part of the Plan of Correction. Record review of the facility A and C Wing Code Audit sheet revealed that the audit was completed on [DATE]. Record review of attendance sign-in sheets revealed that the facility conducted Mock Code training on [DATE] and [DATE]. Record review of two new admissions records, resident # 24 and # 25, revealed that that the full code sheet was present in the front of the chart and on the Nurse MAR [DATE]. Record reviewed revealed that the clinical record and the electronic Nurse MAR [DATE] contained the code status for the following residents: resident # 26, #4, #27, #22, #28, #29, #30, #31, and #32 While the IJ was removed on [DATE] at 5:21 p.m., the facility remained out of compliance at a level of actual harm with a scope identified as pattern until all residents were assessed and staff was in-serviced on code identification and provision of CPR. Information provided by the DON on [DATE] revealed that 62 resident were coded full code.

Based on observation, record review and interview, the facility failed to develop and implement written policies and procedures that prohibit the neglect of 1 of 25 (residents #1) whose care was reviewed for Code Status in that: LVN A and B did not immediately provide CPR to Resident #1 who was unresponsive and full code status. LVN A assumed resident #1 was do not resuscitate status because resident #1 was hospice. These failures resulted in identification of an IJ (Immediate Jeopardy) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a level of actual harm with a scope identified as pattern until all residents were assessed and staff was in-serviced on code identification and provision of CPR. This deficient practice could affect 62 residents in the facility who were Full Code and could result in their request for full code not being honored and not receiving CPR immediately if their heart stopped and result in death. The findings were: Record review of resident #1's facesheet ([DATE]) revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed she was readmitted from the hospital for GI bleed on [DATE]. Record review of resident #1's 60 day MDS ([DATE]) revealed resident #1 had no speech, rarely/never understood others. Resident #1 was assessed with [REDACTED]. Record review of resident #1's physician's orders [REDACTED].#1 was admitted to hospice at this time for atherosclertic [MEDICAL CONDITION]. Further record review of the physician's orders [REDACTED]. Review of Facility Investigation dated [DATE] revealed that: incident was confirmed; and that Employee failed to provide CPR (cardiopulmonary resuscitation-a medical procedure involving repeated compression of a patient's chest, performed in an attempt to restore the blood circulation and breathing of a person who has suffered [MEDICAL CONDITION]) and was terminated. Review of resident # 1's physician order [REDACTED]. Record review of resident #1's careplan ([DATE]) revealed resident #1's code status was full code, a goal was for the code status to be maintained for the next 90 days. Further review of resident #1's careplan revealed an approach was to inform staff of the code status and to monitor for a decrease in change of condition and to report to the physician and family. There was no intervention to initiate CPR in the approach column. Record review of resident #1' nurses notes documented by LVN A on [DATE] at 3:00 a.m. revealed resident #1 had high respirations and hospice was contacted. Vital signs were ,[DATE] (blood pressure), 90-pulse, respiration-30, 98.3-temperature. According to the nurses notes, resident #1 was administered PRN medication-upon follow up at 2:30 a.m. the medication was effective, eyes were closed, respirations were even and unlabored. Further record review revealed the nurse will continue to monitor. Record review of resident #1's nurses notes by LVN A on [DATE] at 0320 a.m. revealed resident passed away at 3:20 a.m. Hospice, director of nursing, and family were notified. Further record review of this note revealed resident #1 was awake on 3:10 a.m. rounds and resident #1 was in no distress. Resident #1's respirations had calmed down with the 2 a.m. dose of [MEDICATION NAME]; respirations were 18, pulse-62, blood pressure-,[DATE], at 2:45 a.m. At 3:10 a.m. resident #1 was lying in her bed, eyes open, respirations even and unlabored. At 3:20 a.m. resident #1 had passed away. Eyes closed, no respirations, no pulse, skin mottling to hands, and unresponsive. Resident #1's son was notified at 3:23 a.m. Further review revealed hospice arrived at 4:00 a.m. with the resident's son. Resident #1's official time of death was 4:12 a.m. on [DATE]. Further review revealed there was no documentation CPR was initiated by any staff. Record review of resident #1's hospice admission-initial and comprehensive assessment note (visit date [DATE]) revealed resident #1 was a full code and the son says he wished all measures be made to keep resident #1 alive. Record review of resident #1's careplan conference summary ([DATE]) revealed she was full code (son was in attendance). Record review of LVN A's CPR certification revealed it was current (received on [DATE], LVN A) and LVN B's CPR certification was current as of [DATE]. Record review of the facility's inservice following the incident revealed staff were inserviced on DNR and code status on [DATE]. Interview on [DATE] at 6:46 p.m. with LVN I revealed she would check the resident's chart to check for the code status and call for help and have someone call a code. Interview on [DATE] at 4:35 p.m. with LVN P revealed if she found a resident unconscious she would either stay with the resident or check the resident's chart for the code status. She did not indicate if she would initiate CPR. Interview with resident #1's son on [DATE] at 3:15 p.m. revealed when resident #1 entered the facility ([DATE]) we (family) agreed to the hospice when asked by the hospice nurse and the son said yes. Further interview with resident #1's son revealed they never pursued DNR for resident #1 and they were in complete agreement that whatever it takes to keep resident #1 alive to do it. Interview on [DATE] at 6:05 p.m. with LVN C, ADON revealed if a resident was found unresponsive she would get the chart and look towards the front of the chart for the code status and grab the crash cart for the resident (if full code) and send a nurse to call 911. Interview on [DATE] at 6:17 p.m. with CNA K revealed if he found a resident unresponsive he would call the nurse, keep the resident comfortable, and check the kardex for the code status. Interview on [DATE] at 6:24 p.m. with CNA O revealed if he found a resident unresponsive, he would immediately run and get the nurses and wait for directions. Further interview with CNA O revealed he did not know where to check for the code status. Interview on [DATE] at 8:05 a.m. with the DON revealed after the incident the facility conducted mock codes monthly and weekends. The facility also reviewed their education and training of nurses. Further interview with the DON confirmed LVN A realized resident #1 was a full code after checking resident #1's chart. She did not check resident #1's chart during the incident. The DON reported the mock codes training was for the facility's protocols and expectations of the nurses. The facility did not have mock codes prior to the incident. Further interview with the DON at 8:16 a.m. revealed during the mock survey's conducted, the staff were taught to go to the chart, the protocol was not written anywhere. Interview on [DATE] at 10:32 a.m. with the DON revealed the facility went by the protocols of the American Heart Association and their training the nurses received in CPR as facility practices as to what to do when they saw a resident unresponsive. Further interview revealed there was no written protocol or policy on how the nurses should respond should they find a resident unconscious. The DON reported on orientation, she informed the new nurses that the chart is what they needed to check for the code status of a resident. Interview on [DATE] at 4:41 p.m. with LVN B revealed LVN A informed her that resident #1 was full code at the beginning of the shift. Further interview with LVN B revealed LVN B informed LVN A to notify the physician, hospice nurse, and the DON. LVN B reported she did not ask LVN A why CPR was not initiated because resident #1 was LVN A's resident. During interview on [DATE] at 10:21 a.m. with the DON she stated that: she did not know whether LVN A knew how to check the code status on residents. The DON stated: we assumed the nurse would check the chart. Interview on [DATE] at 2:35 p.m. with RN S revealed she would check the chart or flashers (green colored (full code) or red colored sheets (DNR)) in front of the MAR, stay with the resident and get someone to check the chart for her. Further interview with RN S revealed she would be waiting for the staff to return with the code status. Interview on [DATE] at 2:37 p.m. with LVN T revealed if she found someone unconscious she would check the chart and if the code status wasn't in the chart, she would check the crash cart or nurses MAR, then start CPR. LVN T reported she would also stay with the resident and have a staff (CNA or someone) to check the code status and stay with the resident and check for airway, breathing, and circulation. LVN T did not indicate when she would initiate CPR. Interview on [DATE] at 2:45 p.m. with LVN U revealed if she found a resident unconscious she would check the charts, crash carts for the residents code status, check the vital signs, get the crash cart and turn on the emergency lights or yell for help. Further interview revealed LVN U did not indicate when she would start CPR. Interview on [DATE] at 1:30 p.m. with LVN A confirmed on [DATE] at 3:15 a.m. CNA V came to her and informed her resident #1 was not responsive. LVN A stated she called hospice and the hospice nurse stated to call the family. LVN A reported she called the DON. LVN A reported the hospice nurse inform her resident #1 was palliative care but didn't informed her that resident #1 was DNR, after the hospice pronounced resident #1's death, LVN A checked resident #1's chart and saw she was full code. LVN A reported looking back, she should have checked the chart whether resident #1 was full code or not and that she was under the impression to call hospice and follow orders provided. LVN A thought resident #1 was DNR. LVN A reported she was under the impression because resident #1 went on hospice and she was DNR. Interview on [DATE] at 4:15 p.m. with CNA V revealed she found resident #1 between 3 a.m. to 3:15 a.m. (could not recall date) resident stopped breathing, CNA V reported she called the nurse, who came to check the vital signs, the nurse started panicking and asked a second nurse on duty. Further interview with CNA V revealed LVN A asked the second nurse what was she supposed to do and the second nurse told LVN A to call hospice. Observation on [DATE] at 6:40 p.m. of A Wing revealed the following: A kardex list of residents and their code status dated [DATE] and a crash cart list of residents and their code status dated [DATE]. The crash cart resident code list was reviewed and cross-referenced with the current list of residents code status given by the facility on [DATE]. Review of the crash cart list and current list revealed discrepancies such as new admissions were not reflected on the crash cart list. Observation of random charts revealed red (DNR) and green (Full Code) sheets in front of charts that identified residents code status. Record review of a statement from LVN A on [DATE] at 2:00 p.m. (from the facility's investigation) revealed on [DATE] at 3:20 a.m. CNA T called LVN A to resident #1's room, stating CNA T thought she changed resident #1 and without a pulse/respirations, LVN A called LVN B, who assessed resident #1 to be without a pulse. LVN A immediately called hospice and was told by hospice to notify the family. Afterwards, the DON was notified. At 4:00 a.m. hospice and the family were at the facility and the hospice nurse pronounced the time of death. It was not until LVN A was completing her documentation that LVN A found the order for full code and resident #1 was hospice. Record review of a statement from LVN B on [DATE] at 2:30 p.m. (regarding the event of [DATE] and resident #1) revealed LVN B did not know resident #1 and had no interaction with resident #1 at any time. At about 3:10 a.m. LVN A asked her (LVN B) to come to resident #1's room to help her. LVN B checked resident #1's pulse and there was no pulse. LVN A informed LVN B that she (LVN A) had been in the room about 10 minutes ago. Then LVN A called hospice and the DON. Further review of LVN B's statement confirmed she did not check resident #1's chart for the code status. Record review of the American Heart Association (AHA) site: HTTPS://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/part-5-adult-basic-life-support-and-cardiopulmonary-resuscitation-quality/ revealed BLS is the foundation for saving lives after [MEDICAL CONDITION]. Fundamental aspects of adult BLS include immediate recognition of sudden [MEDICAL CONDITION] and activation of the emergency response system, early CPR, and rapid defibrillation with an automated external defibrillator (AED). Further review revealed Begin chest compressions as quickly as possible after recognition of [MEDICAL CONDITION]. Record review of the facility's record of inservice for [DATE], [DATE], and [DATE] (initiated after the incident) revealed a Mock code blue evaluation check off list. The check off list noted the following: 1) team leader identified? 2) did the team leader designate a staff to specific duties?, 3) did the nurse check the chart for code status? 4) did a staff member call 911/EMS? 5) did a staff member bring the emergency cart to location? 6) did a staff member bring the AED to the location? 7) was CPR started prior to AED placement? etc Further review revealed there were no steps to identify if CPR was immediately initiated. During interview on [DATE] at 11:11 a.m. with LVN B she stated that: I would accept another nurse's statement about the code status of the deceased resident; because the other nurse worked with the resident. The Administrator, Corporate Nurse, VP Operations Nurse, and DON were notified on [DATE] at 5:00 p.m. that an Immediate Jeopardy situation was identified. During interview on [DATE] at 3:00 p.m. with the Administrator he stated that: after the IJ all staff would be trained before starting each shift on the written CPR process. Training would also include code status procedures, the dots system, and explained how the code identification system worked. He felt the IJ resulted because LVN A wrongly assumed the resident's code status and did not perform CPR. The Facility's investigation finding was that the incident was confirmed because the employee failed to provide CPR. The employee was terminated. Before the IJ, according to the Administrator, Provider responses included: in-service on CPR; re-training on abuse and neglect; and Mock Code Blue evaluations. The Administrator confirmed that there was no written policy prior to the IJ on the CPR process. He confirmed that he did not bring to the QA Committee the issue of CPR Process and Full/DNR Code Identification as a key clinical indicator requiring a Plan of Action. Interview on [DATE] 10:21 a.m. with the DON revealed she did not know whether the LVN A knew how to check the code status on the residents; we assumed the nurse would check the resident's status. Further interview with the DON revealed (after the immediate jeopardy) On admission, we will ask for code status, ask family, if unknown the resident will be coded full code. The family will be told to produce documentation that the resident should be DNR. The DON confirmed that she did not bring to the QA Committee the issue of CPR Process and Full/DNR Code Identification as a key clinical indicator requiring a Plan of Action. During interview on [DATE] at 3:41 p.m. with DON she stated that: Policy does not contain the statement to initiate CPR for a non-responsive resident until the code status is established; it is an assumption in the Process for Performing CPR. This is a process that has existed but it was not previously published at the time of the incident. The written form of the Process was done on [DATE]; but it has always been in effect. In CPR certification you are taught that the resident is full code until information shows otherwise. We will elaborate on # 2 to clearly establish to begin CPR until information shows otherwise. We will start educating staff on the written process. The written CPR Process had not been reviewed and signed by the Medical Director, Administrator, DON and Pharmacist as of [DATE] During interview on [DATE] at 3:24 p.m. with the DON she stated: In place before (prior to the IJ) was make sure code validated in chart, kard-X. Now (after the IJ), make sure upon hire we obtain CPR card, all staff trained on CPR process, where the code status are at (chart, flash cards, kard-X, MAR and closet. The DON added that the IJ resulted because LVN A assumed resident # 1 was DNR. LVN B accepted, according to the DON, LVN A's comment that resident # 1 was dead and therefore LVN B did not initiate CPR to an unresponsive resident. The DON confirmed that it was not in LVN A's scope of practice to declare a resident deceased . The DON could not provide an explanation as to why LVN A and LVN B assumed that the resident # 1's code status was DNR. Likewise, the DON could not give an explanation as to why LVN A acted beyond her scope of practice to say that resident # 1 was dead. The DON confirmed that resources and training were available to LVN A and LVN B on ascertaining the code status of resident #1. The DON further confirmed that the facility did not have in place at the time of the incident a written policy on the CPR process; especially as to when to administer CPR to an unresponsive resident when the code status was not known. During telephone interview on [DATE] at 11:05 a.m. with the Medical Director, witnessed by the DON, he stated that: I have overall medical oversight of the facility which included the CPR process. I was told the resident was dead by the DON. We do not do CPR on a dead resident. (The DON responded that the resident was declared dead by the Hospice nurse and not her). It was a concern that an issue developed over CPR; we did a quick ad-hoc QA meeting to discuss the situation and developed ways to deal with the situation The Medical Director confirmed that he did not bring to the QA Committee the issue of CPR Process and Full/DNR Code Identification as a key clinical indicator requiring a Plan of Action. During interview on [DATE] at 9:25 a.m. with the HR Manager he stated that: tracking of CPR was based on verifying the CPR card and keeping a copy on file listing expiration date. He confirmed that a copy of LVN A's card was not received until [DATE]; and given to surveyor on [DATE]. The facility submitted a plan of removal dated [DATE] at 4:53 p.m. to remove the immediacy consisting of the following actions: The following plan of action outlines immediate interventions employed by the Facility to abate any further concerns surrounding the above issue: a. Residents in the facility have the right to determine their wishes with regard to cardiopulmonary resuscitation (full Code) or a Do Not Resuscitate. Mesa Vista will follow these wishes which allows full implementation of the residents Advance Directives and promotes person-centered care. b. An audit was initiated to check resident code status and ensure correct orders are in place based on resident wishes. The audit was initiated on 10.27.17 and will be completed by 10.28.17. c. There will be at least one CPR certified licensed nurse on each shift. 1. An audit of the licensed nurse files was conducted by HR on 10.27.17 to determine their CPR certification. Those without certification will be required to produce one within 30 days. The Director of Nursing will ensure that there is at least once CPR certified licensed nurse on staff when making the schedule. The DON and Administrator will review the licensed nurse schedule on Mondays and Fridays to ensure there is a licensed nurse in the facility. i. Those responsible for nurse scheduling will have a list of CPR certified licensed nurses on hand. 2. Upon hire, licensed nurses will be given 30 days to complete their CPR certification if not already certified. HR Director will audit licensed nurse's monthly to ensure they are CPR certified. d. Mock codes will be completed on a quarterly basis to ensure staff is prepared to manage a code blue situation. 1. Mock codes started on [DATE] and were completed for all shifts post incident on [DATE] and is ongoing. 2. Next quarterly mock codes will be due in the month of [DATE] for all shifts. The quarterly mock codes will be scheduled for March, June, September and December. e. The facility will review all code status orders and initiate either a red (for DNR) or green (for full code) sheet and place it in front of the resident chart. The intent of the process is to allow staff a quick reference to know what the resident advanced directive wishes are. 1. New admits that do not have a DNR will be considered full code. f. The facility initiated a dot process on 10.27.17 to identify resident code status in their rooms, as an alternate identification place to the resident medical record/chart. A red dot will indicate the resident is a DNR and a green dot will indicate that the resident is a full code. This process will be completed by 10.28.17 and either red or green dots will be placed in all closets depending on the resident code status. 1. All facility staff (nursing, administration, dietary, housekeeping) will be in-services on the new dot process by 10.31.17. 2. Licensed nurses will be in-services on 10.28.17 to initiate the dot on new admissions or change the dots if code status is changed as they receive orders. Red and green dots will be placed at nurses stations for licensed staff to use by 10.28.17. a. Facility social worker will conduct audits on the resident dots to ensure correct code status color is in place. This audit will be done on a weekly basis for four weeks and then on a monthly basis and on an as needed basis. This audit will begin the week of 10.30.17. b. This in-service will be completed by 10.31.17. c. Administrative staff will check resident dots in the closet when they are conducting their daily quality of life rounds during the morning 7 days a week. This process will begin 10.30.17. d. CNAs will check resident closets to make sure that the dots are in place during their initial (first rounds) each day. The CNAs conduct walking rounds at the beginning of each shift. This process will begin 10.28.17 once all dots are placed. e. Licensed nurses, CNAs, dietary, housekeeping, administrative staff were in-services by administrator/DON to check code status for the resident, either using the clinical record or the dot in their closet, as soon as an unresponsive resident is found. This in-service was initiated on 10.28.17 and will be completed by 10.31.17. f. Staff will not be allowed to start their designated shift till they have been in-serviced. B. The facility electronic record system was triggered to print the code status orders on the resident MARs and Nurse MARs. a. Licensed nurses were in-serviced to review the MARs and NMARs if needed to identify resident code status if the clinical chart is not easily available on 10.28.17 by the DON. This in-service will be completed no later than 10.31.17. b. The November MARs and NMARs will have the code status printed on them. C. In the first crucial moments, when a resident is found unresponsive, without vital signs, licensed nurses will initiate CPR per AHA guidelines. a. All staff (nursing, dietary, housekeeping, administrative) will be in-services to check for the code status in the resident record/chart when an unresponsive resident is found. b. In-service was initiated by the DON on this process for licensed nurses on 10.27.17 and will be completed by 10.31.17. c. An in-service was initiated by the DON for all other staff (direct care, administration, housekeeping/laundry, dietary) D. As the administrative staff is conducting education on the POR for all staff the Administrator is checking the names of the staff against a facility list which will be completed by 10.31.17. E. The facility administrator will monitor the items listed in the plan on a monthly basis and report findings to medical director and the facility QAPI team in the QA meetings for four months and then as needed. Verification of Plan of Removal: Observation on [DATE] at 1:15 p.m. revealed the presence of at least one CPR certified staff member, LVN H on Wing A (Day Shift). Observation of nursing staff at 4:30 p.m. revealed the presence of the following qualified CPR staff: LVN I and LVN J. Review of employee files for the said staff revealed the presence of a CPR card. On-going Observation on [DATE] at 4:20 p.m. of four closets (room [ROOM NUMBER], 706, 501 and 502 (C Wing) revealed the existence of code status dots. Observation on [DATE] at 2 p.m. of CNA K and CNA L revealed that CNAs were checking the dots in the closets; room [ROOM NUMBER], 706, 501 and 502 (C Wing), A wing: 302, 305, 212, and 402 During interview on [DATE] at 1:20 p.m. with DON she stated that, no nursing staff had been hired since the date of the approved POR; but a new hire was scheduled for [DATE]. Interview on [DATE] at 1:45 p.m. with the DON revealed that a Mock Code training on the new CPR process was scheduled for December, 2017. During interview on [DATE] at 1:30 p.m. with the Social Worker she stated that, the weekly process of auditing the CPR system (SW Code sheets against dots and flash sheets on the Nurse MAR and clinical record would start the week of [DATE]. Interview on [DATE] at 2:50 p.m. with LVN W revealed if he found someone unresponsive he would assess the resident, have someone check the code status and initiate CPR, he would not wait for verification of code status. Further interview with LVN W revealed he was inserviced on the new process at 5:00 a.m. [DATE]. Interview on [DATE] at 4:27 p.m. with LVN I revealed she would initial CPR immediately if she found a resident unresponsive. Further interview revealed call would call for help and call a code. LVN I reported she was inserviced yesterday. During interview with DON on [DATE] at 1:45 p.m and ADON D at 4:30 p.m. revealed that training was in process regarding the new CPR and Code system was on-going. Interview on [DATE] at 4:35 p.m. with staff revealed that they were in-serviced on the dot system before going on shift. During interview with CNA M (evening shift) and CNA K (evening shift) revealed they received an in-service prior to going on shift. During interview on [DATE] at 4:37 p.m. with the ADON D she stated that the night shift would receive the new training on CPR and code identification. During interview on [DATE] at 2:38 p.m. with the Administrator he stated that: he will check that the POR tasks were completed; at the next QA meeting in [DATE] the POR would be formatted into an action plan; which would be part of the Plan of Correction. Record review of the facility A and C Wing Code Audit sheet revealed that the audit was completed on [DATE]. Record review of attendance sign-in sheets revealed that the facility conducted Mock Code training on [DATE] and [DATE]. Record review of two new admissions records, resident # 24 and # 25, revealed that that the full code sheet was present in the front of the chart and on the Nurse MAR [DATE]. Record reviewed revealed that the clinical record and the electronic Nurse MAR [DATE] contained the code status for the following residents: resident # 26, #4, #27, #22, #28, #29, #30, #31, and #32 While the IJ was removed on [DATE] at 5:21 p.m., the facility remained out of compliance at a level of actual harm with a scope identified as pattern until all residents were assessed and staff was in-serviced on code identification and provision of CPR. The facility's Abuse and Neglect Prohibition Policy and Procedure (undated) documented Each resident has the right to be free from mistreatment, neglect, and misappropriation. Neglect means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Injuries of an unknown origin may occur as a result of neglect. Information provided by the DON on [DATE] revealed that 62 resident were coded full code.

Based on observation, interview and record review the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical and mental well-being, in accordance with the comprehensive assessment and plan of care for 1 of 6 residents (#1) whose records were reviewed in that: CNA I repositioned Resident #1 during pericare without assistance by another staff as required based on Resident #1's MDS (minimum data set) assessment and care plan, which resulted in Resident #1 sliding off the bed, and long [MEDICATION NAME] psychological harm due to Resident #1's extreme fear of falling. This deficient practice could affect 8 residents on the skilled side who were at risk for falls and could result in long [MEDICATION NAME] psychological distress. The findings were: Review of Resident #1's medical face sheet dated 2/4/16 revealed she was admitted into the facility on [DATE]. Review of Resident #1's consolidated physician orders [REDACTED].#1's [DIAGNOSES REDACTED]. Further review revealed a treatment order dated 2/18/16 which read: clean right BKA w/wound cleanser, pat dry, apply TAO w/Max orb AG & cover w/dry drsg Q Monday & Thursday & PRN. Review of Resident #1's most recent 30 day MDS dated [DATE] revealed her BIMS was a 14 on a scale from 1-15 indicating she was alert and oriented and able to make daily decisions; she required extensive assistance by two people with bed mobility and transfers. Further review revealed Resident #1 suffered from Depression and bi-polar disease and she did not require oxygen therapy. Review of Resident #1's Care Plan updated on 3/8/16 revealed she had a [DIAGNOSES REDACTED]. Further review revealed she was morbidly obese and required total assistance with all ADLs including bed mobility due to amputation of all limbs; required transfer by 2 staff via a mechanical lift and she was a risk for falls. Review of a fall risk evaluation dated 1/31/16 revealed Resident #1's score was an 18. A score of 10 or higher indicated Resident #1 was a high risk for falling. Review of an incident report dated 3/17/16 revealed that at 10:30 p.m. Resident #1 fell in her room while she was being repositioned. It was noted: as the resident turned towards the left, lower body slid off mattress to floor. Upper body was observed face down on edge of mattress. Resident #1's pulse was 105, her respirations were 22, blood pressure was 126 over 78; her oxygen sats were 97 and her pain was 10 on a scale from 1 to 10. Review of a falls investigation worksheet revealed that on 3/17/16 Resident #1 fell while being repositioned. Resident #1 was using side rails for assistance. Resident #1 sustained a skin tear to her left lower extremity. The intervention implemented was 2 people in the room with all care that requires turning and repositioning in bed and/or transfers. Interview on 4/7/16 at 2:21 p.m. with Resident #1 revealed she slid off the bed while CNA I was providing pericare. She stated she rolled onto her left side per CNA I's instructions and when she attempted to roll back to the right side she lost her momentum and slid off the bed. She stated somehow she was able to hook her left stump onto the bed rail and was dangling off the bed; her upper body was on the bed and her lower body was hanging off the bed. She stated her knee caps hit the floor. Resident #1 stated CNA I was standing on her left side when she slid off the bed. She stated she started crying and screaming. CNA I walked out into the hallway and was crying. Resident #1 stated she kept screaming until LVN J came in, picked her up from her trunk and put her back into bed. Resident #1 was sobbing at this point. She was extremely emotional. She commented falling was her worst fear. Resident #1 stated she was so upset that LVN J had to give her oxygen until she could catch her breath. Resident #1 stated CNA I always came in with another aid and stated 2 staff always assisted during pericare or repositioning. She stated she felt more secure with 2 staff assisting because of her fear of falling. Resident #1 stated she never refused assistance from 2 staff during care. She stated she was so upset and was ready to get out of the facility. Resident #1 further stated she felt bad because she learned that LVN J hurt his back while lifting her. Interview on 4/8/16 at 12:32 p.m. with DON H revealed she met with Resident #1 for the first time after her fall on 3/17/16. DON H stated she conducted an investigation that same night and confirmed that CNA I was providing pericare and repositioning Resident #1 when she fell . She confirmed CNA I was the only one assisting the resident. She stated there was a question as to whether the resident needed assistance from 1 or 2 staff. She stated she believed the resident really required assistance by 2 staff. DON H stated when staff initially approached Resident #1, after the fall, Resident #1 denied assistance from 2 staff stating it was not necessary. However, after she talked with Resident #1, she agreed to receive assistance from 2 staff. At this point she updated the care plan to reflect the change. DON H stated the day after the fall she in serviced nursing staff and instructed them to always use 2 staff to assist Resident #1 with bed mobility. She further stated the resident's PCP came in to assess Resident #1and it was at that point that Resident #1 agreed to an X-ray. It was negative for any acute fractures. DON H stated Resident #1 asked for an MRI and her PCP stated she did not need an MRI but later agreed to a C-scan. However, Resident #1 left the facility before they could schedule the C-Scan. Interview on 4/8/16 at 2:00 p.m. with CNA I confirmed she assisted Resident #1 with pericare and repositioning on the night she slid off the bed. CNA I stated she was working on a different hall but noticed the call light had been on for at least 10 minutes and did not see any other staff available. CNA I stated she answered the call light and Resident #1 asked to get changed. Again, she stated she did not see any other staff so she helped the resident without assistance. CNA I stated Resident #1 wanted to maintain her independence and was able to assist with repositioning. CNA I stated she asked Resident #1 to roll to her left side during pericare and then asked her to roll back to her right side. She stated she was standing on Resident #1's right side when the resident tried to roll to the left side and slid off the mattress. Resident #1 somehow hooked her right stump on the bed rail and was dangling from the bed rail. CNA I stated she stepped out and yelled out for help while Resident #1 was screaming and crying uncontrollably. CNA I stated she panicked. CNA I stated that LVN J and 2 other staff responded to her call for help. LVN J came into the room, picked the resident up and put her back into bed. Resident #1 had a carpet burn on her left knee cap which was treated. She stated the resident did not want to go to the hospital. CNA I commented she felt bad and the resident had told her that falling was her worst fear. CNA I stated she was not sure whether Resident #1 was a one or two person assist with bed mobility and further stated she had provided care without assistance several times. However, confirmed she would not have been able to hold on to the resident because of her amputations and she would not have been able to keep the resident from falling due to the resident's weight. She stated she tried to apologize to the resident several times, but every time she went into the resident's room, the resident would kick her out. CNA I mentioned that initially the resident was ok with her and then several days after the incident, the resident suddenly went off on her. CNA I was visibly tearful at this point and commented she felt horrible about what happened. Interview on 4/8/16 at 3:36 p.m. with LVN J confirmed he was one of the charge nurse's on the skilled side when Resident #1 rolled off the bed. He stated she fell after the end of his shift (10 p.m.) while CNA I was providing pericare and repositioning the resident in bed. He stated he heard CNA I yelling for help from down Resident #1's hall. He stated he ran towards Resident #1's room and when he entered the room he saw her hanging off the bed holding on to the bed rail with her left stump. Resident #1 was teetering on her knee caps. LVN J stated he wrapped his arms around Resident #1 and lifted her on to the bed. He stated he did not know what else to do because she was hanging on and was afraid that the resident would let go and really hurt herself. LVN J stated Resident #1 was screaming and was very upset; she was hyperventilating so he had someone bring her oxygen. He stated they provided oxygen at 2 liters until she calmed down after about 20 minutes or so. LVN J stated Resident #1 was still very upset and CNA I was crying. LVN J further stated he believed CNA I used poor judgement in believing she could safely provide pericare and reposition Resident #1 on her own. He stated Resident #1 could help, however, she was very heavy and CNA I was tiny. He commented there was no way CNA I could have broken the fall. LVN J stated Resident #1 complained to him days later because she stated CNA I never apologized to her. Review of nurse's note dated 3/18/16 revealed that at 10:30 p.m. CNA called for help from resident's room. Resident was observed with lower body out of bed, and upper body facing down on bed. Resident was yelling for help. Resident transferred to bed x 2 person assist. PRN O2 at 2 liters provided per NC due to resident exhibiting signs of anxiety and shallow breaths, c/o pain to left lower extremity. Skin tear 1 cm x 1 cm observed. Resident assessed and PRN [MEDICATION NAME] (used for pain) administered. Resident stated not feeling the need to be transferred to the ER. Review of nurse's note written by LVN J dated 3/18/16 read: (Late Entry of 3/17/16) Pt observed hanging down from bed, attempting to hold self onto side rail, yelling (Help me, Help me) repeatedly and hyperventilating. I lifted patient around midsection and LVN K lifted pt legs and she was placed back onto air matt. Review of a psychiatric progress note dated 3/18/16 read: discussed her slide off the bed last night while being changed. She was anxious in retelling it but came to a place of resolution about it. Review of a weekly skin integrity review dated 3/18/16 revealed a left stump abrasion. Review of an X-RAY report of the left elbow dated 3/19/16 indicated two views were taken which revealed there was no evidence of acute fracture or dislocation. Review of an X-RAY report of the right knee dated 3/25/16 indicated two views were taken which revealed Resident #1 had Osteopenia and mild joint [MEDICAL CONDITION] disease. Interview on 4/11/16 at 2:30 p.m. with the ADM, DOR, and with the corporate nurse consultant revealed that on 3/16/16 Resident #1 reached her goal regarding bed mobility. The DOR stated that Resident #1 was a stand by assist by one staff for bed mobility. However, she confirmed that Resident #1's state of mind would hinder her level of participation. The DOR and nurse consultant stated Resident #1 wanted to maintain her independence as much as possible. The nurse consultant stated she helped Resident #1 once and she declined that the nurse consultant ask for another staff to assist with bed mobility. Both the DOR and the nurse consultant confirmed that Resident #1 was usually compliant or accepted assistance from staff depending on her state of mind. However, the nurse consultant confirmed that when upset, Resident #1 would decline anything and everything; her moods fluctuated drastically which was consistent with her [DIAGNOSES REDACTED]. Interview on 4/11/16 at 5:15 p.m. with LVN K, a charge nurse on the skilled side, revealed Resident #1 required extensive assistance with all ADL's and she was a 2 person assist with bed mobility. LVN K stated Resident #1 never refused care when 2 staff assisted for bed mobility. She commented that Resident #1 was particular about who assisted and would deny help from specific staff. LVN K stated Resident #1 was always compliant with care. LVN K stated she was aware of Resident #1's fall and stated Resident #1 was extremely upset after and was hyperventilating. She stated it took quite some time for her to calm down (10/15 to 20 minutes). LVN K stated when she walked into the room on the night of the incident, Resident #1's upper extremities were on the bed and her lower extremities were touching the floor. She stated that her, LVN J and LVN L lifted Resident #1 up and put her on the bed. LVN K stated one staff would not be able to keep Resident #1 in bed if she lost her balance or momentum. LVN K stated Resident #1 sustained a rug burn on her left lower extremity but it healed in 2 days. The facility took action to correct the deficiency on 3/17/16 with in-services provided to nursing staff. They were instructed that two staff assist Resident #1 with bed mobility and transfers at all times. Resident #1's care plan was updated to reflect the changes. CNA I was counseled by the facility administrator. Review of a document completed by the facility on 4/11/16 revealed there were 8 residents on the skilled side who were a risk for falls.

Based on observation, interview, and record review, the facility failed to provide necessary care and services to prevent the development of avoidable pressure ulcers for 4 Residents (Residents #4, #5, #15 and #3) of 21 residents reviewed for pressure ulcers in that; The facility failed to; 1. Prevent Resident #4 from developing a Stage III pressure sore behind his left ear caused by the nasal cannula tubing used to deliver oxygen to the resident as needed as it did not complete a timely assessment and did not follow Wound Care Nurse Practitioner orders for repositioning. 2. Prevent Resident #5 from developing a Stage III pressure sore to the Left Ishcium as it did not complete a timely assessment and did not follow Wound Care Nurse Practitioner orders for repositioning. 3. Prevent Resident # 15 from developing a Stage III pressure sore to the Coccyx and Stage II pressure sores to bilateral heels as it did not complete a timely assessment and did not follow Wound Care Nurse Practitioner orders for repositioning. 4. Prevent Resident #3 from developing an unstageable pressure sore to right posterior thigh as it did not complete a timely assessment and did not follow Wound Care Nurse Practitioner orders for repositioning. Resident #3 was highly resistant to care These deficient practices resulted in Residents #4, #5, #15 and #3 acquiring pressure sores and could affect 11 of 97 residents who had existing pressure sores and could lead to development of new pressure sores or worsening of existing pressure sores. The findings were: 1. Record review of Resident #4's face sheet dated 11/05/15 revealed he was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Further review of Resident #4's facesheet and review of clinical record revealed the resident was diagnosed with [REDACTED]. He was fed through a PEG tube observed 01/25/16 through 01/29/16 via feeding pump at 75 cc/hr. Record review of the Wound Care Specialist Nurse Practitioner Note dated 12/30/15 revealed, New problem Stage III Pressure Ulcer to left ear from 02 tubing. Reinforced off loading, repositioning. Measurements: 2 cm x1cm [MEDICAL CONDITION].cm Wound bed: Slough 10%, pink, moist. Odor/Drainage: Serous. PeriWound: Intact. Treatment: Offload, moisture control. Plan: Santyl, [MEDICATION NAME], Turn q 2 hrs, LAL mattress, Reinforced repositioning and pressure relief. Record review of the Physician's Orders dated 12/13/14 revealed the resident was placed on hospice on 12/13/14. Review of Resident #4's Consolidated Physician Orders dated January 2016 revealed an order for [REDACTED]. Observation of Resident #4 on 1/27/16 at 7:10 a.m. revealed the resident was sleeping, lying on his back. Observation of Resident #4 on 1/27/16 at 9:00 a.m. revealed the resident was sleeping, lying on his back. Observation of Resident #4 on 1/27/16 at 12:22 p.m. revealed the resident was sleeping, lying on his back. Observation of Resident #4 on 1/27/16 at 3:48 p.m. revealed the resident was sleeping on his back with a pillow propped underneath his left side, supporting his shoulder and head. Observation of Resident #4 on 1/28/16 at 8:15 a.m. revealed he was awake in bed, lying on his back, with a pillow propped underneath his left side, supporting his shoulder and head. His body was slumped toward his left side. During an interview with Wound Care LVN B on 1/26/16 at 3:45 p.m., she confirmed that the Stage III ulcer behind Resident #4's left ear was acquired at the facility and revealed that she believed this ulcer was missed by the facility staff and could have been prevented. She further revealed that with the number of people that cared for Resident #4 on a daily basis, including the hospice aides that bathed and shaved him 3x per week, it should have been noticed. She stated that she saw Resident #4 daily when she provides treatment for [REDACTED]. She further stated that due to Resident #4's poor health, he did not get out of bed and could decline rapidly. She confirmed that he was on a pressure mattress. During an interview with the Wound Care Specialist Nurse Practitioner on 1/27/16 at 10:25 a.m., she confirmed that Resident #4's Stage III pressure ulcer behind his left ear was facility acquired. She revealed that she believed it was preventable, caused by the oxygen tubing, because they didn't have the foam on the tubing. She further revealed that due to Resident #4's multiple co-morbidities, which included being pre-disposed to pressure ulcers, having an existing ulcer, and being on hospice, an ulcer could develop anywhere from three hours to three days - hard to say. Observation of Resident #4's Wound to Left Ear on 01/27/16 at 2:25 p.m. revealed a Stage III pressure ulcer to top crease of Left Ear. Wound clean, moist and dry, no drainage noted. Area not covered with a dressing. Oxygen was not on during observation. Resident #4 also had a dressing to Right buttocks / hip area dated 01/27/16. Record review of the Nurses' Note from the Wound Care LVN B dated 12/30/15 revealed the resident developed a Stage III pressure ulcer to left ear caused by nasal cannula tubing measuring 2 cm x1 cm. Wound bed had 10% slough noted. Serous drainage was noted. Santyl with [MEDICATION NAME] to wound bed was applied with instructions to cover with a dry dressing daily. Hospice was notified. Record review of Resident #4's Care Plan undated revealed pressure ulcers were addressed, including Assist resident to reposition frequently. Develop turning and repositioning plan with resident input. Review of clinical record did not reveal a turning and repositioning plan for Resident #4. Record review of Braden Scale for Predicting Pressure Sore Risk dated 1/28/16 revealed Resident #4 scored 11 with 10-12 being High Risk. + 2. Record review of Resident #5's face sheet revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the Physician's Orders dated 11/02/2015 revealed the resident was placed on hospice. Record review of Resident #5's Care Plan dated 09/18/14 did not address her immobility or high risk of developing a pressure ulcer. Record review of Braden Scale for Predicting Pressure Sore Risk dated 11/03/15 revealed Resident #5 scored 15 with 10-12 being At Risk. Review of latest Scoring dated 01/13/16 revealed Resident #5 scored 13 being Moderate Risk. This was after resident developed pressure sore. Record review of Weekly Skin Assessment noted Skin intact on 01/03/2016 and on 01/10/16 noted Skin intact with L hip (ischium) with quarter size purple area. Wound care notified and assessed . The following 2 weekly notes dated 01/17/2016 and 01/24/2016 noted an open area on Right Hip. Wound Care Nurse Practitioner Note dated 01/20/2016 noted Left Hip Deep Tissue Injury. Palliative Wound Care. Reinforced off loading, Repositioning. Notes wound is 1.0 x 1.0 x .01, pink and dry. Orders to apply Triad BID prn, Turn Q 2 and LAL mattress Reinforced repositioning and pressure relief. Record review of the Nurses' Note dated 01/08/2016 noted that she had identified a purple mark on Resident #5 ' s Left Trochanter and that this was relayed to the Wound Care LVN who assessed that day and orders were received for barrier cream to be applied Q shift. Hospice was notified. Record review of Wound Care Notes revealed a Wound Care LVN note dated 01/13/2016 (Wound 0.8x0.8x0.1) and one on 01/20/2016 (Wound [MEDICAL CONDITION]). There was no note Wound Care Note from 01/08/2016, the day the wound was identified and brought to the Wound Care Nurses' attention. Observation of Resident #5 on 1/26/2016 at 8:45 a.m. revealed the resident was sitting up in a wheelchair in the communal area in front of the TV. Observation of Resident #5 on 1/26/2016 at 10:30 a.m. revealed the resident was sitting up in a wheelchair in the communal area in front of the TV. Observation of Resident #5 on 1/26/2016 at 11:30 a.m. revealed the resident was sitting up in a wheelchair in the communal area in front of the TV. Observation of Resident #5 on 1/26/2016 at 2:00 p.m. revealed the resident was sitting up in a wheelchair alone in hallway in front of her room door. Interview on 01/26/16 at 3:00 p.m. with LVN R revealed Resident #5 had not be repositioned or put back to bed from 8:30 a.m. that morning to 2:30 p.m. that afternoon. During an interview with Wound Care LVN on 1/26/16 at 3:45 p.m., she confirmed that the Stage III ulcer on Resident #5 ' s left trochanter was acquired at the facility. She stated she assessed Resident #5 daily when she provided treatment for [REDACTED].#5's poor health, she did get out of bed to her wheelchair but required maximum assist and could decline rapidly. She confirmed that Resident #5 was on a low air loss mattress and had a pressure cushion in her wheelchair. She also stated that change of position every two hours was very important to avoid further damage to this pressure sore and to avoid any further sores from developing. She stated that she worked with the CNAs regarding this on an ongoing basis. She also confirmed there was no documentation of a turning schedule for Resident #5 and CNAs don't document when they changed a resident's position. Observation of Resident #5 on 1/26/2016 at 4:00 p.m. revealed the resident was sitting up in a wheelchair in the communal area in front of the TV. Observation of Resident #5 on 1/27/2016 at 7:15 a.m. revealed the resident was lying in bed on her Right side, she was gotten up for breakfast at 7:35 a.m. but because she was not awake and able to eat she was returned to bed at 7:50 a.m. again on her right side. Observation of Resident #5 on 1/27/2016 at 9:45 a.m. revealed the resident was lying in bed on her right side. Observation of Resident #5 on 1/27/2016 at 12:30 p.m. revealed the resident was lying in bed on her right side. Observation of Wound Care for Resident #5 on 01/28/16 at 3:15 p.m. revealed the resident was lying in bed on her right side. Stage III ulcer to Left Trochanter .5 cm x .5 cm x Unstageable. Wound clean, pink and moist. Wound was cleansed, Triad barrier Cream applied. Record review of Resident #5's Care Plan dated 01/26/16 revealed Resident #5 is palliative care and has potential for weight changes, skin breakdown and pressure ulcers. (Problem onset = 11/02/15) Interventions included Promote comfort by routine turning and repositioning. Observe for skin integrity. Record review of Resident #5's Care Plan dated 01/26/16 revealed Resident #5 had a Deep Tissue Injury to her Left Hip (Problem onset = 01/08/16). Interventions included Assist resident to reposition frequently. Develop turning and repositioning plan with resident input, Encourage weight shifts when sitting up in chair. Review of clinical record did not reveal a turning and repositioning plan for Resident #5. 3. Record review of Resident #15's face sheet, dated 01/29/16 revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #15's MDS dated [DATE] revealed a BIMS score of 7 for Resident #15 indicating moderate cognitive impairement. Record review of Nurses Note dated 11/29/15 at 11:00 a.m. revealed Open areas to coccyx with other in crack. Barrier cream applied and turn q 2 hrs. Wound care to eval and tx on Monday. Record review of Braden Scale for Predicting Pressure Sore Risk dated 12/05/16 revealed a score of 18 and a score of 17 on 01/02/16 with a score of 15-18 being At Risk. Record review of Wound Care Nurse-LVN treatment notes revealed only two notes, one dated 12/02/15 and the other 01/20/16 with the following; Left heel DTI measures 1.5 cm x 1.0 cm x 0.1 ccm; wound bed is pink and moist. serous drainage noted. Right heel DTI measures 1.5 cm x 1.2 cm wound bed is moist with slough noted .Left buttock Kennedy Ulcer (an ulcer which is characterized by rapid onset and rapid tissue breakdown) is intact .Right buttocks Kennedy Ulcer is still intact. Coccyx stage 3 is intact. Wound bed is dry and pink. Continue triad barrier cream daily. Record review of Weekly Skin Integrity Review dated 01/25/16 revealed Lt heel has foul odor. Dressing intact. No drainage. Small open wound to buttock. Observation of Wound Care on 1/28/16 at 4:00 p.m. revealed Stage III DTIs to bilateral heels. Left heel ulcer had green drainage. Kennedy Ulcers viewed on bilateral buttocks. Open area, Stage III intact to Coccyx was pink and moist without drainage. Record review of Resident #15's Care Plan dated 01/28/16 revealed pressure ulcers were addressed, including Assist resident to reposition frequently. Develop turning and repositioning plan with resident input. Review of clinical record did not reveal a turning and repositioning plan for Resident #15. 4. Review of the face sheet, dated 11/30/15 for Resident #3 revealed he was admitted on [DATE] and had a readmitted d of 8/27/15 with [DIAGNOSES REDACTED]. Record Review of Resident #3's Ulcers, Surgical Site and Treatment and Progress Record revealed pressure sore discovered on 01/11/16 with orders to Clean Right Posterior Thigh with wound cleanser, pat dry, apply santyl to wound bed and cover with dry dressing daily. Record Review of Resident #3's Braden Scale for Predicting Pressure Sore Risk dated 01/14/16 reveals a score of 16 with 15-18 indicating At Risk. Record review of Wound Care Notes revealed a Wound Care LVN note dated 01/20/2016 (Wound 4.8 cm x 4.5 cm x unstageable), wounds bed is pink and moist with 40% slough noted. Periwound denuded (lacked top layer of skin). Continue santyl with dry dressing daily. Review of the Weekly Skin Integrity Review dated 01/26/16 revealed LEFT Posterior Thigh open area, purple area to RIGHT buttock and reddness to Right leg. Tx in progress. Observation on 01/27/16 at 8:30 a.m. of Wound Care for Resident #3 revealed a Stage III wound to Right Right Posterior Thigh. Wound was clean, pink and moist. No signs of infection noted. Wound Care Nurse performed wound care and placed dressing as physician ordered. During an interview with Wound Care LVN on 1/27/16 at 8:30 a.m., she confirmed that the Unstageable ulcer on Resident #3's 'Right Posterior Thigh' was acquired at the facility. She stated she assessed Resident #3 as often as she was able but resident was frequently resistant to care of any kind. She further stated that due to Resident #3's poor hygiene and resistance to care he was at higher risk. Interview on 01/27/16 at 3:30 p.m. with Wound Care Nurse LVN revealed that she was notified of a black spot on the back of Resident #3's leg on 1/04/16. When she went to assess it the resident refused to allow her. She was going to return that day to try again but forgot. On 01/08/16 Resident #3 was in the shower and she was able to assess the area then. She stated that He knew it was there but didn't tell anyone. CNA's hadn't seen it because he refused care frequently. Wound Care note dated 01/13/16 revealed Resident #3 was seen by Wound Care Nurse Practitioner. Wound Care Nurse stated that in her opinion Resident #3's pressure sore was Unavoidable due to his compliance issues and his resistance to care. Record Review of Resident #3's Care Plan undated revealed pressure ulcer was addressed, including Assist resident to reposition frequently. Develop turning and repositioning plan with resident input. Review of clinical record did not reveal a turning and repositioning plan for Resident #3. Care Plan revealed that the facility had no active plan to address of his resistance to care in order to facilitate appropriate hygiene and wound care in order to heal his pressure sore and avoid any further pressure sore issues. Record review of the facility policy on Routine Skin Care, undated, revealed it stated, (2) Turn and position at least every two hours in bed and relieve position when in chair .(4) Off load/pad bony prominences, as necessary. CMS-672 provided by Administrator on 01/26/16 revealed 11 residents who had pressure ulcers, 6 of which were in-house acquired.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to attain the highest practicable physical well-being for 2 residents (Residents #13 and #17) of 21 residents reviewed for Pain Management, in that: 1. LVN B did not pre-medicate Resident #13 for pain before providing wound care to her right buttock and right ischium. Resident #13 experienced pain during the cleansing of the loose stool and during the wound treatment. 2. Resident #17 was not provided her scheduled [MEDICATION NAME] 50mg tablet as ordered for pain as a result Resident #17 voiced pain and discomfort. This deficient practice resulted in 2 residents suffering avoidable pain, and could affect all 21 residents reviewed for pain management. The findings were: 1. Review of Resident #13's Face Sheet reflected a [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of the Wound Care Specialist Evaluation dated 1/27/16 indicated Resident #13 had stage II pressure ulcers to the right buttock and right ischium. Review of the Care Plan (undated) revealed a problem onset dated 1/11/16 for Stage II pressure ulcers to right buttock and right ischium. The goals were for the area to be healed or improved in 90 days as evidenced by observation and documentation and that the area would remain free of infection. The wound care approaches included wound care as ordered by the physician, administer pain medications as ordered by the physician, stop treatment if resident is exhibiting pain verbally or non-verbally and administer pain medications before starting treatment if indicated. Record review of Resident #13's Physician's Orders and Review of the January 2016 MARS reflected the following medications for pain: - [MEDICATION NAME] HCL 5 mg, give 1.5 tablets every 12 hours at 9:00 a.m. and 9:00 p.m. - [MEDICATION NAME] 50mg, every 6 hours as needed for pain - Tylenol ([MEDICATION NAME]) 325mg, give 2 tablets every 4 hours, as needed, for pain. Review of the MAR from 1/1/16 -1/28/16 revealed Resident #13 received her scheduled 9:00 a.m. dose of [MEDICATION NAME] but was not medicated for pain with Tylenol during that period. [MEDICATION NAME] was not given since the day shift on 1/26/16. The pain assessment for day shift on 1/28/16 was 0. Observation of wound care on 1/28/16 at 2:05 p.m. revealed LVN B asked Resident #13 if she was having pain. The resident responded yes. LVN B asked if she received any pain medications, Resident #13 stated yes but it doesn't help. LVN B informed the resident she would check with the charge nurse to determine when she last received her medication. Upon returning, LVN B informed the resident she last received her pain medicine at 9:00 a.m. and asked if she wanted to wait until after she received a pain medication. Resident #13 informed LVN B she was incontinent of stool and to go ahead with the treatment. LVN proceeded to complete incontinent care and then provided the wound care. Resident #13 cried out numerous times throughout the incontinent/wound care that the care was causing her pain. Interview with LVN G on 1/29/16 at 3:30 p.m. revealed if she were treating a resident and they complained of pain she would stop, assess the pain and check if the resident had anything they could take for the pain. If the resident ' s scheduled medications were inadequate to control the pain, she would contact the physician. Interview with the Treatment Nurse on 1/29/16 at 3:35 p.m. revealed that Resident #13 said it would be alright to do the treatment, but that with Resident #13's discomfort she should have waited until after the resident was medicated for pain and had a chance for the medication to work. Interview with the DON on 1/29/16 at 3:40 p.m. revealed Resident #13 was paraplegic, although she wasn't certain at what level. She stated Resident #13 has been on many pain medications and a number have been discontinued. The DON stated she spoke with LVN B and she conveyed that Resident #13 gave her consent for her to proceed with the treatment. 2. Review of Resident #17's face sheet dated 10/2/15 revealed she was admitted to the facility on [DATE]. Further review of her face sheet revealed [DIAGNOSES REDACTED]. Review of Resident #17's comprehensive plan of care updated 1/28/16 revealed she had problem of alteration in comfort relating to [MEDICAL CONDITION], approaches listed administer medications as ordered. Review of physician order dated 8/27/15 revealed [MEDICATION NAME] HCL 50mg tablet, one tablet PO Q 8 hours-pain. Review of Resident #17's Quarterly MDS with an ARD of 11/2/15 revealed she was understood and could understand. Observation of Resident #17 on 1/28/16 at 2:55 p.m. revealed she was lying in bed and appeared uncomfortable. During an interview with Resident #17 on 1/28/16 at 2:55 p.m. she said that she was sitting up and had to go to bed because her leg was hurting, she said that she did not get her pain medication because the nurse said that it had not arrived yet. Review of Resident #17's MAR indicated [REDACTED]#17 did not get her pain medication. During an interview on 1/28/16 at 3:00 p.m. with RN A, who had circled her initials to indicate a missed dose of Resident #17's [MEDICATION NAME], and who was taking care of Resident #17, she said that the pharmacy had not brought in the medication and that she thought it would be there already, so Resident #17 did not get her [MEDICATION NAME] as ordered. When the surveyor inquired if there was an emergency drug kit in the facility, RN A said Oh my gosh, I did not even think about that, and proceeded to get the [MEDICATION NAME] 50 mg tablet from the drug kit to give to Resident #17. Review of the facility Policy/Procedure revised 9/14 included the following: #8. Patient/Resident should be evaluated for any needed pain medication prior to treatments (i.e. wounds) or care. 21 residents were reviewed for Pain Management.