Every finding on record at Normandy Terrace Nursing & Rehabilitation Center

Based on interview and record review, the facility failed to ensure resident care plans were reviewed and revised by the interdisciplinary team after each assessment for 1 of 3 residents (Resident # 1) reviewed for care plans. The facility failed to revise Resident #1's care plan on 07/28/2026 to reflect the resident's transfer need to use a mechanical lift for all transfers. This failure could place residents at risk of not receiving the care and services they needed.The findings included: Record review of Resident #1's face sheet dated 8/20/2026 revealed a [AGE] year-old male admitted to the facility on [DATE], re-admitted [DATE], with the diagnosis that included: chronic lymphocytic leukemia of b-cell type (slow-growing blood cancer), abnormal posture, right femur neck fracture, vascular dementia (reduced or blocked blood flow to the brain causing thinking and memory issues), and Alzheimer's disease (brain disorder that destroys memory and thinking skills). Record review of Resident #1's quarterly MDS assessment, dated 8/17/2026, revealed a BIMS score of 00, which indicated severe cognitive impairment. Section GG - Functional Abilities - Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair) score was a 1, indicating = 01. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. Record review of Resident #1's physician orders for August 2026 revealed an order dated 7/28/2026 which read, [mechanical] lift for all transfers. Record review of Resident #1's care plan, dated 08/21/2026, revealed, Staff x 1 to assist with transfer. Further review revealed the resident's care plan did not addressed the use of a mechanical lift for all transfers. During an interview with CNA B on 8/21/2026 at 8:47 a.m., CNA B stated the Kardex was where staff check and document resident care and it also indicated the type of transfer the residents required. CNA B stated the nursing department was supposed to update the Kardex information when there were any changes to residents' transfer status. CNA B stated the Kardex showed Resident #1 as a 1 person transfer. During an interview with LVN D on 8/21/2026 at 9:04 a.m., LVN D stated that updating the care plan, was an IDT team assignment, so everybody was technically responsible for updating the care plan. LVN D stated the order was written by a nurse. During an interview with RN E on 8/21/2026 at 9:09 a.m., RN E stated that updating care plans was an IDT team assignment and nurses could update the care plans if there was a change. RN E stated when an MD order was entered into the system, it was considered an acute change, which would require update to the care plan. RN E further stated care plans were also updated quarterly, annually, and if there were any significant changes to the residents' health or care. RN E stated if a resident's care plan was not updated, the Kardex would not reflect the update which would cause miscommunication in resident care being provided by floor staff. RN E stated this could cause a lack in care for the affected resident. During an interview with the DON on 8/21/2026 at 10:02 a.m., the DON stated the resident's transferring status was updated in the care plan information and should be updated by the MDS Coordinators. The DON stated if the Care Plan was not updated, it would not be reflected in the Kardex. The DON stated when the doctor's order was entered, it should have been discussed in the morning meeting and then updated with the IDT. The DON stated if the resident's care plan was not updated, it could affect resident care. Record review of the facility's policy titled, Comprehensive Care Planning, undated, revealed, . The resident care plan will be reviewed after each admission, quarterly, annually, and/or a significant change in MDS assessment, and revised based on the changing goals, preferences, and needs of the resident and in response to current interventions.

Based on interview, and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #1) reviewed for quality of care. 1.The facility failed to ensure Resident #1's transfer orders for, [mechanical] lift for all transfers, were followed as ordered by the physician on 7/28/2026. 2.CNA B failed to transfer Resident #1 using a mechanical lift transfer. These failures could place residents at risk of decline in health and well-being. Findings included: Record review of Resident #1's face sheet dated 8/20/2026 revealed a [AGE] year-old male admitted to the facility on [DATE], re-admitted [DATE], with the diagnosis that included: chronic lymphocytic leukemia of b-cell type (slow-growing blood cancer), abnormal posture, right femur neck fracture, vascular dementia (reduced or blocked blood flow to the brain causing thinking and memory issues), and Alzheimer's disease (brain disorder that destroys memory and thinking skills). Record review of Resident #1's Quarterly MDS assessment, dated 8/17/2026, revealed a BIMS score of 00, which indicated severe cognitive impairment. Section GG - Functional Abilities - Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair) score was a 1, indicating = 01. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. Record review of Resident #1's physician orders for August 2026 revealed an order dated 7/28/2026 which read, [mechanical] lift for all transfers. Record review of Resident #1's care plan, dated 08/21/2026, revealed, Staff x 1 to assist with transfer. Further review revealed the resident's care plan did not addressed the use of a mechanical lift for all transfers. During an interview with CNA C on 8/20/2026 at 10:46 a.m., CNA C stated she had transferred Resident #1 using a 1 person assist. CNA C stated she was using the information in the residents' Kardex regarding transfers. CNA C stated she transferred the resident from his wheelchair to his bed, and as she was placing the resident on the mattress, the resident grabbed her leg and caused her to place the resident in bed abruptly. CNA C stated there was no injury observed to Resident #1 and she informed LVN D of the transfer. During an interview with LVN D on 8/20/2026 at 10:59 a.m., LVN D stated CNA C had told her about the 1-person transfer of Resident #1. LVN D stated she had not assessed Resident #1 after the abrupt transfer to verify no injuries or discomfort. LVN D stated the resident was on hospice services and the resident's RP requested pain medication for the resident due to the residents' chronic pain. During an interview with the DON on 8/21/2026 at 10:02 a.m., the DON stated Resident #1 should have been assessed when the staff reported the incident. The DON stated the resident should have been assessed for an injury, if not then the residents potential injuries could not be addressed. Record review of the facility's policy titled, Documentation, undated, revealed, Documentation is the recording of all information, both objective and subjective, in the clinical record of an individual resident and or soft resident file. Special forms in the clinical record are utilized in nursing documentation, such as .assessment .

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were secured properly within 1 of 4 medication carts (medication cart on C wing) observed for medication storage. The facility failed to ensure medication cart on C wing was locked when left unattended. This failure could place residents at risk of missing or misuse of drugs by unauthorized personnel.The findings were: Observation of C wing on 08/18/2026 at 4:32 PM revealed the medications cart labeled C Wing Medication Cart 2 was left at the nurse's station unattended and unlocked with the drawers facing the hallway while residents were ambulating in the area. During an interview with Medication Aide A on 08/18/2026 at 4:37 PM, Medication Aide A revealed she left the C Wing Medication Cart 2 unlocked when she went to take a resident's blood pressure. Medication Aide A stated she had been a medication aide for 4 months and received training on locking the medication cart when she was hired as a medication aide. Medication Aide A stated it was her responsibility to ensure the medication cart was locked before she left it. Medication Aide A stated residents could get into an unlocked medications cart and could take medications that don't belong to them causing residents to get sick and overdose. During an interview with the Administrator on 08/21/2026 at 12:55 PM, the Administrator revealed medication carts were to be locked when they were unattended. The Administrator stated it was the responsibility of the staff assigned to the cart to ensure the carts were locked. The Administrator stated she did an in-service training on locking medication carts with all staff about a month ago, and staff received training on locking medication carts annually. The Administrator stated it was the responsibility of the DON to ensure staff received the training. The Administrator stated residents could get into an unlocked mediation cart and take medications that did not belong to them and it could cause the residents to become ill. During an interview with the DON on 08/21/2026 at 1:05 PM, the DON revealed medication aides and nurses were trained to lock their medication carts when they were hired and again annually. The DON stated it was the responsibility of the staff holding the keys to the cart to ensure the carts were locked when they were unattended. The DON stated if a medication cart was left unlocked when unattended residents or visitors could take medications that did not belong to them and could then make the residents ill. Record review of the facility's policy titled, Medication Storage in the Facility, dated 2025, revealed, 2. Only licensed nurses, the Consultant Pharmacist, and those lawfully authorized to administer medications (e.g. medication aides) are allowed unsupervised access to medications. Medication rooms, carts, and medication supplies are locked or attended to by persons with authorized access.

Based on interview and record review, the facility failed to provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 of 3 residents (Resident #2) reviewed for death. The facility failed to provide immediate basic life support interventions for Resident #2 upon finding Resident #2 unresponsive on [DATE], and Resident #2 was declared deceased on [DATE]. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:33 PM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of actual harm because Resident #2 expired, and the facility needed to evaluate training outcomes. Failure to provide basic life support to residents requiring emergency care could lead to death. Findings included: Record review of Resident #2's admission Record dated [DATE] reflected a [AGE] year-old female admitted to the facility on [DATE] and discharged on [DATE]. Relevant diagnoses included tracheostomy [an artificial opening in the airway to allow for oxygenation] status. Record review of Resident #2's MDS submitted [DATE] reflected Resident #2 had expired in the facility. Record review of Resident #2's progress notes reflected the following documentation from RN AB dated [DATE] at 7:24 AM: At approximately 0400hrs, resident was found in prone position [face down] on fall mat. Resident was unresponsive to verbal and painful stimuli. Resident repositioned to supine and found to have absent lung sounds and heartbeat. CPR was initiated and code blue initiated. At 0407 fire department arrived and took over CPR. Unable to revive resident after exhausting all efforts, time of death was called at 0426am by EMS and [EMS MD] on phone. [Police department] was contacted by EMS and arrived shortly thereafter. After inital [sic] [Police Department] investigation and confering [sic] with the M.E., the decision was made to end the investigation citing resident past medical history. Family member was notified at 0600 hrs, spoke to [family member] who stated funeral arrangements would be through [funeral home]. Resident was tranferred [sic] to bed, bed bath provided, and family enroute to visit. Record review of document EMS Run Report dated [DATE] at 3:59 AM reflected EMS was notified of cardiac arrest by the facility and arrived at 4:10 AM, and the resident was already receiving CPR from an additional fire department team who arrived several minutes earlier. The documentation reflected the facility staff could not relay a time at which Resident #2 was last seen at her baseline status. The documentation also reflected Resident #2's jaw showed signs of rigor [the natural stiffening of muscles that happens hours after death] when EMS attempted to place an artificial airway in Resident #2's mouth, and that Resident #2's body was very cold to the touch. In an interview with CNA AJ on [DATE] at 7:41 AM, he said he rounded on resident at approximately 11:00 PM on [DATE] and again at an unknown time after 3:00 AM on [DATE]. He said he noticed Resident #2's bed looked like it was in an elevated position, and he felt that she would benefit from a fall mat, so he left her room to obtain one and returned to put it in place. He said he then attempted to speak to Resident #2, and he determined she was unresponsive. He then attempted to perform CPR but could not effectively initiate chest compressions, so he attempted to assist her to the ground, at which time she slipped down onto the fall mat. He then left the room to obtain assistance and notify the nurse of Resident #2's condition. CNA AJ then said he whispered to RN AB that Resident #2 was dead, but RN AB did not respond or move towards Resident #2's room. He said several minutes later he again notified RN AB that he thought Resident #2 was dead, and at that time RN AB went to Resident #3's room and they initiated CPR and called EMS. He said he had a current CPR certification. In an interview with RN AB on [DATE] at 9:17 AM, he said he administered pain medication to Resident #2 around 9:30 PM on [DATE] and was unable to check on her again because he was very busy. He said CNA AJ whispered something to him at an unknown time before 4:00 AM on [DATE], but he has difficulty hearing and could not understand what CNA AJ had said. He said approximately 5-10 minutes later, CNA AJ whispered to him again, and this time he understood that CNA AJ had told him Resident #2 was not breathing. He said he went to Resident #2's room with CNA AJ and they had to reposition her onto her back from the prone position, at which time he attempted to stimulate her and obtain vital signs, but he discovered she had no heartbeat or breathing activity. He said he then left the room to obtain the crash cart but he then felt that he did not need any items from the crash cart, so he returned to Resident #2's room and CPR was initiated at that time. He was unsure of the amount of time that lapsed between CNA AJ initially attempting to notify him of Resident #2's condition and when CPR was initiated. He said he had not been given training regarding the procedure for initiating a code blue at the facility, and he had a current CPR certification. In a joint interview with the DON and ADM on [DATE] at 10:36 AM, the ADM said the incident had initially been reported to the SSA because it was reported by staff that the resident was found unresponsive on the floor, but their interview with CNA AJ revealed CNA AJ had assisted Resident #2 to the floor, so she didn't feel the incident should have been reported. The DON said the facility investigation was nearly complete and had not reflected any indications of neglect. The ADM said the facility had reviewed the camera footage and found the footage to be consistent with CNA AJ's account of the incident, but the footage was unavailable for surveyor review due to technical issues. The ADM said when she interviewed CNA AJ, he did not tell her that there was a delay in initiating assistance from the nurse, and she said she had not yet interviewed RN AB. The DON said CNA AJ should have immediately gotten assistance from the nurse upon finding Resident #2 unresponsive by shouting into the hallway. He said if RN AB did not immediately react, CNA AJ should have been more persistent with his communication to illicit a response from the nurse. The DON said she was unsure if the facility covered emergency procedures for unresponsive residents during onboarding because the Human Resources Department did all of the onboarding training, but she said her expectation was staff would immediately get help and initiate CPR/BLS if they were CPR certified, such as RN AB and CNA AJ. Record review of the facility policy titled Cardiopulmonary Resuscitation undated/provided [DATE] reflected the following: Procedure . 2. When the resident is unresponsive, immediately call for emergency help and notify staff of Code Blue. Call for emergency assistance. Ensure that the first responder calls EMS and returns to the scene with an AED (defibrillator). If you are alone and cannot alert anyone to call EMS, YOU MUST [sic] call EMS prior to beginning CPR and obtain the AED . The ADM was notified of an IJ on [DATE] at 5:33 PM and a POR was requested. The POR was accepted on [DATE] at 12:58 PM and included the following: Date [DATE]Plan of RemovalF678 CPR Staff who found the unresponsive resident were inserviced [sic] on CPR policy and Emergency Codes. Staff who found the unresponsive resident were suspended pending investigation on [DATE].The Administrator, DON, and ADON were in-serviced 1:1 on the following policies by the Regional Compliance Nurse and ADO. Completed [DATE]Abuse and Neglect Policy: Failure to start CPR on an unresponsive resident that is a full code, is neglect and could increase the chances server harm to resident including death.CPR Policy to include: Calling loudly for help when notifying staff that a resident is unresponsive in an emergency.Assess for unresponsiveness. Tap the resident's shoulder and ask the resident if he/she is alright.When the resident is unresponsive, immediately call for emergency help and notify staff of Code Blue. Call for emergency assistance. Ensure that the first responder calls EMS and returns to the scene with an AED (defibrillator). If you are alone and cannot alert anyone to call EMS, YOU MUST call EMS prior to beginning CPR and obtain the AED.Avoiding delays in responding to a code blue or leaving a resident unattended.Emergency Codes - All staff will be educated and in-serviced on emergency codesDON/Admin/HR completed a CPR certification audit of 26 nurses and 4 were unable to verify current CPR status. Nurses without current CPR status will have 10 days to complete, or be removed from staff schedule. The 4 nurses without current CPR status will only be scheduled with nurses active CPR status.DON/designee will complete monthly audits of CPR certifications to ensure all nurses have current CPR certifications.Mock Codes completed with night shift and day shift and will continue two mock code drills per shift per week for four weeks or until compliance is met. Mock drills will be completed by DON/designee. Areas for improvement will be documented on the Code Blue Record and reviewed with he staff participating in the Mock drill. Mock findings/concerns will be reviewed monthly in QAPI.The Medical Director was notified of the immediate jeopardy citation by the administrator. Completed [DATE].An ADHOC QAPI meeting was conducted with IDT Team to discuss the immediate jeopardy and plan of removal. Completed [DATE]. In-servicesThe following in-services were initiated by Administrator, Regional Compliance Nurse, ADO, DON, and ADON to all staff. All staff not present or in-serviced as of [DATE] will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All PRN, agency staff, or staff on leave will in serviced prior to assuming their next assignment. All of the following inservices were initially communicated via phone, followed by in-person prior to their next assignment-Abuse and Neglect Policy: 100% of all staff in serviced Failure [sic] to start CPR on an unresponsive resident that is a full code, is neglect and could increase the chances server harm to resident including death. CPR Policy to include: 100% of all staff inservice -calling loudly for help when when a resident is unresponsive. Tap the resident's shoulder and ask the resident if he/she is alright.When the resident is unresponsive, immediately call for emergency help and notify staff of Code Blue. Call for emergency assistance. Ensure that the first responder calls EMS and returns to the scene with crash cart and AED (defibrillator). If you are alone and cannot alert anyone to call EMS, YOU MUST call EMS prior to beginning CPR and obtain the AED.Avoiding delays in responding to a code blue or leaving a resident unattended.Emergency Codes - All staff will be educated and in-serviced on emergency codesCode Status-100% of all nurses were inserviced on where to find the code status in PCCCPR and Emergency Codes policies and procedures education will continue for all new hires and annually. Monitoring a)Mock Codes completed with night shift and day shift and will continue two mock code drills per shift per week for four weeks.b)Facility will ensure effective communication between staff during an emergency situation by completing mock code blue drills and completing staff interviews post-incident.c)Facility will ensure an unresponsive resident is not left alone by completing mock code blue drills and completing staff interviews post-incident. Verification of the POR was as follows: Record review of the facility in-service sign-in sheet titled Cardiopulmonary Resuscitation dated [DATE] reflected 78 total staff signatures. An additional staff roster attached to the sign-in sheet indicated 132 staff members received the in-service by telephone or in-person. RN AB and CNA AJ were noted to be included on the list of staff members who received the in-service. Record review of the facility in-service sign-in sheet titled Emergency Codes dated [DATE] reflected 72 total staff signatures. An additional staff roster attached to the sign-in sheet reflected 122 total staff members had received the in-service by telephone or in-person. RN AB and CNA AJ were noted to be included on the list of staff members who received the in-service. Record review of the facility document titled Employee Disciplinary Report dated [DATE] reflected RN AB had received investigatory suspension. Record review of the facility document titled Employee Disciplinary Report dated [DATE] reflected CNA AJ had received investigatory suspension. Record review of the facility in-service sign-in sheet titled In-Service Training Topic: ANE, emergency codes, and CPR policy dated [DATE] was signed as attended by the DON and ADM. Record review of a staff roster of licensed nurses reflected 26 staff members. Record review of the attached documentation reflected 22 nurses had active CPR certifications. Record review of the facility document titled CPR Certification Monthly Audit Tool reflected a blank spreadsheet created by the facility to indicate staff names, CPR certification status, and date of CPR certification expiration. In an observation on [DATE] at 7:10 PM, a code blue was observed to be in progress with six staff members participating. Record review of the facility document titled Code Blue Record reflected drills had occurred on the following dates:[DATE] at 3:05 PM with 8 staff members[DATE] at 6:15 PM with 4 staff members[DATE] at 12:05 PM with 8 staff members Record review of the facility document titled Monitoring- two code blue drills per shift per week reflected an illegible signature and date of [DATE]. Record review of the facility document document titled Self-Reporting protocol/ Ad HOC QAPI- neglect Flowsheet dated [DATE] reflected the meeting was attended by the ADM, LSW, MDS nurse, ADO, and MD (by telephone). Record review of the facility staff roster titled Abuse/Neglect policy dated [DATE] reflected 132 of 132 staff members had received the in-service. Record review of the facility staff roster titled CPR policy dated [DATE] reflected 132 of 132 staff members had received the in-service. Record review of the facility staff roster titled Emergency Codes dated [DATE] reflected 132 of 132 staff members had received the in-service. Record review of the facility in-service sign in sheet titled CODE STATUS dated [DATE] reflected 9 staff signatures. Record review of the facility document titled New hire orientation checklist reflected new hire curriculum included emergency procedures and codes. Record review of the facility document titled CPR and Emergency Code Education Checklist reflected a blank document to be used to indicate if the training was new hire orientation or annual competency and included the items CPR policy, code status, emergency codes policy, and staff responsibilities. In a joint interview on [DATE] at 2:54 PM with the DON, the ADM, and the DCS, the ADM said RN AB and CNA AJ received all applicable emergency code in-services during their notification of their suspensions that were initiated on [DATE]. The ADM said she felt that both staff members exhibited a lack of responsiveness and critical thinking skills during the incident with Resident #2, and the suspensions were ongoing pending the conclusion of the facility's investigation. The DON and ADM said they had received an-inservice from the DCS regarding the necessary in-services that would be provided to staff, and the ADM said a QAPI meeting regarding the incident had occurred on [DATE] and was attended by the MD. The ADM said the MD had no additional concerns or guidance regarding the incident. The DON and ADM said the facility policy regulation and ensured at least 1 staff member per shift had an active CPR certification, and they discovered 4 licensed nurses were unable to show evidence of current certification. The DCS said those staff members were given a deadline of ten days to obtain the documentation or certification in order to continue working. The DCS also said the facility had audited all shifts in June and [DATE] and there were no shifts in there was not a staff member present with active CPR certification. She said an additional audit had been performed to ensure the shifts for the following 10 days also included staff with active CPR certification, pending the receipt of the missing certifications from the four staff members. The ADM said the spreadsheet monitoring CPR certifications will be completed by the DON and reviewed on a monthly basis. The DON said she would collaborate with Human Resources to ensure new hires were added to the spreadsheet. The ADM said the code blue drills had been initiated, and she had participated in the role of the unresponsive resident. She said staff were responsive to the drills, and any deficiencies were coached at the time of the drill. The following staff interviews were conducted to verify in-services and/or participation in code blue drills:2 ADONsADON I said on [DATE] at 2:22 PM she had received all of the in-services related to code blue and CPR, and they had reviewed that you yell code blue into the hallway if you find a resident unresponsive, then obtain the trash cart, and do not leave the resident unattended. ADON D said on [DATE] at 2:27 PM she had received all in-services, including communication for shift report and CPR, and that you should not move a deceased resident until cleared by the ME.1 BOMBOM J said on [DATE] at 4:48 PM she had received the in-services on code blues and emergencies. She said if she found a resident unresponsive, she would call code blue, find help, and return to the resident. 12 CNAsCNA K said on [DATE] at 6:11 PM she had received all in-services, and the process was to tap shoulder, if unresponsive, holler code blue, if have to leave come back promptly. Report incidents immediately to the ADM.CNA A said on [DATE] at 6:54 PM said she had received all in-services and if she found a resident unresponsive, she would tap his shoulder and check if he's responding to her. If he didn't, she would initiate code blue and yell out to the nurse code blue and obtain the crash cart and AED and not leave the resident. She also said she had participated in a code blue drill. CNA E said on [DATE] at 6:02 PM that she had attended all in-services regarding emergencies and code blues. She said they learned to communicate to nurse and coworkers and at shift change all changes in condition, and if they found someone unresponsive, to call for help or code blue and to not leave a resident unattended. She said she had participated in a code blue drill. CNA F said on [DATE] at 2:55 PM that she had received all in-services and would call a code blue and obtain a crash cart if a resident was found unresponsive. She said she would not leave a resident unattended. CNA AP said on [DATE] at 6:00 PM that he had received all in-services, including communication. He said his responsibility was to report to the nurse and yell code blue, and stay with the resident. CNA AO said on [DATE] that she had received all in-services and that she would call for help, report to the nurse, and call 911. CNA V said on [DATE] at 6:05 PM that she had attended all of the in-services from the facility, and she would call for help from the nurse if she found a resident unresponsive and not leave a resident unattended. She said they also talked about communication to the nurse and coworkers at shift change. CNA AQ said on [DATE] at 2:59 PM she had been in-serviced about code blues, and to not leave a resident alone, and to follow the instructions listed on the badge attachment. CNA G said on [DATE] at 2:16 PM she had received all of the in-services that day, and she was to call the resident's name, check for breathing, and initiate CPR. CNA AJ said on [DATE] at 2:39 PM he had received the in-services and had learned to yell code blue if a resident was unresponsive. CNA X said on [DATE] at 2:02 PM she had received all in-services and knew to call for help down the hall if a resident was unresponsive. CNA AS said on [DATE] at 4:00 PM she had received the in-services from the facility, including the code blue procedure and to call for help if a resident was unresponsive. 7 LVNsLVN Y said on [DATE] at 12:32 PM she said attended the in-services, and they had discussed tapping an unresponsive resident to see if they're okay, to yell code blue if no response, and to stay with the resident until help arrived. LVN O said on [DATE] at 3:11 PM she received all in-services and to call code blue and share all relevant information with oncoming shift. LVN AS said on [DATE] at 2:36 PM he had attended all of the facility in-services and if a resident was unresponsive to tap should and ask if okay. No response assess breathing and pulse, call code blue/911 and then start CPRLVN AT said on [DATE] at 4:12 PM that she had received all in-services and In incident first take care of resident, check for responsiveness if none start CPR.LVN AU said on [DATE] at 2:53 PM she had attended the in-services and to call for help and start code blue, do CPR if indicated and call 911. LVN AV said on [DATE] at 3:26 PM that she had received all of the in-services, and they had learned to notify the DON or ADM of all incidents, to check responsiveness and for pulse, start CPR, and call 911. LVN Z said on [DATE] at 3:12 PM all in-services were received, and they were to yell code b lue, obtain crash cart and AED, and do not leave the resident unattended unless you are the only staff member. She said she had participated in a code blue drill. 7 RNsRN AN said on [DATE] at 2:40 PM she attended all of the in-services and to immediately call out for help from staff code blue and initiate CPR if indicated, then call 911. RN AA said on [DATE] at 3:55 PM that she attended all of the in-services and if a resident was unresponsive, to check their code status, call 911, and perform CPR until EMS took over. RN AB said on [DATE] at 2:11 PM he had been in-serviced from the facility about code blues and emergencies. He said he needed to give report to the CNA about the residents, and if a resident was unresponsive to immediately assess and determine if lifesaving measures were needed, then call code blue, have 911 called, and begin CPR. RN AW said on [DATE] at 3:15 M she had received the in-services and would announce or yell code blue, call for help, if alone call EMS before CPR, and if not alone designate someonme to call. RN AX said on [DATE] at 12:39 PM said she had been in-serviced by the facility, and if a resident was assessed to be unresponsive, call for help or activate emergency code blue response, initiate CPR if indicated and follow facility protocol until EMS arrived. RN AC said on [DATE] at 3:08 PM she had gotten all in-services, and they talked about yelling for help or yelling code blue, and that the DON, ADON, MD, RP, and shift change needed to be notified of any changes in condition or incidents. RN AK said on [DATE] at 1:59 PM she had all in-services and to call out down the hall to other staff if code blue, and to use the phone if needed. 6 Dietary Services staffDS AY said on [DATE] at 3:10 PM he had been to the in-services and to call for help or code blue get a nurse, call 911, and help where he was able if he found a resident unresponsive. DS AZ said on [DATE] at 3:08 PM she had attended the in-services and learned if she found a resident unresponsive to call for help and to not leave a resident unattended unless she was the only staff member around. DS BA said on [DATE] at 3:10 PM he had been in-serviced, and if he found an unresponsive resident, he would call for help and yell code blue, and get another coworker to stay with the resident while he looked for clinical help. DS AD said on [DATE] at 3:10 PM she had been to the in-services and she knew to call for help immediately if a resident was unresponsive. DS BB said on [DATE] at 3:10 PM he had been in-serviced, and to yell code blue if a resident was unresponsive, and to offer to get others to help once clinical staff arrived or call 911. DSM said on [DATE] at 3:10 she had assisted with ensuring the staff had been in-serviced, and if resident was unresponsive, call for help or call code blue, and offer to call 911 when clinica help arrived. 1 HRCHRC said on [DATE] at 4:48 PM she had received the in-services from the facility about emergencies and if a resident was unresponsive to check on them and call code blue and find help then return to the resident. 1 MaintenanceMaint. Dir. said on [DATE] at 5:15 PM he had gotten the in-services and he would call for help or yell code blue if he found a resident unresponsive. He said if he forgot the code name, he could use the information attached to his badge. 2 MDS nurseMDS BD said on [DATE] at 4:53 PM she had attended all in-services and learned to confirm unresponsive status of a resident and then call for help, call EMS, and start CPR. She said she had participated in a code blue drill. MDS RN said on [DATE] at 7:12 PM she had received all of the in-services and participated in a code blue drill. 1 MAMA Q said on [DATE] at 3:05 PM she had attended the in-services and learned to share all important information with coworkers on shift changes, and to see if a resident was unresponsive, and call for help or call code blue, then initiate CPR, and call 911. 1 Therapy staffThe DOR said on [DATE] at 4:45 PM she had been in-serviced about emergency procedures, and if she found a resident unresponsive, she would first check on them and see if they were responsive, if they weren't she would scream for help and call code blue, then call EMS. 1 LSWLSW said on [DATE] at 4:45 PM she had been in-serviced, and learned if she a resident was unresponsive she would first check on them and then scream for help and call code blue, then call EMS. On [DATE] at 7:52 PM, the ADM was notified the IJ was removed, however the facility remained out of compliance at a severity level of actual harm that is not immediate and a scope of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of corrective systems.

Based on observation, interview and record review, the facility failed to, based on the comprehensive assessment of a resident, ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 4 residents (Resident #1) reviewed for quality of care. The facility failed to identify and address Resident #1's fall with injury appropriately, leaving Resident #1 with a fractured hip for over 24 hours without treatment. An Immediate Jeopardy (IJ) situation was Identified on 07/13/2026. While the IJ was removed on 07/13/2026 the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the to the facility's need to evaluate the effectiveness of corrective systems. This failure could place residents at risk for unrecognized issues, including injury, and could result in uncontrolled pain, loss of the residents' highest practicable well-being, or death.The findings included: Record review of Resident #1's admission Record, dated 07/11/2026, revealed an [AGE] year-old female who admitted to the facility on [DATE], with diagnoses which included: age-related osteoporosis (occurs when bone breakdown outpaces bone growth as you age, leading to brittle, porous bones), encounter for orthopedic aftercare (a scheduled medical visit for recovery, therapy, or ongoing management following a musculoskeletal procedure), rheumatoid arthritis (a chronic autoimmune disorder where the immune system mistakenly attacks the lining of your joints), and dementia (an umbrella term for a decline in cognitive abilities-such as memory, thinking, and reasoning-severe enough to interfere with daily life). Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS score of 02, which indicated severe cognitive impairment. The resident was dependent for both bed mobility and transferring as well as having had falls since admission. Record review of Resident #1's Care Plan, dated 07/01/2026, revealed the resident was a fall risk, with multiple falls since admission to the facility. Resident #1 had, staff x1 to assist with transfers, initiated on 10/07/2025; 'requires total assist x2 staff for transfers initiated 02/27/2026; and, Hoyer lift for transfers, initiated on 03/09/2026. Record review of Resident #1's Kardex, dated 07/12/2026, revealed, Staff x1 to assist with transfers, Hoyer lift for transfers, and requires total assist x2 staff for transfers. Record review of Resident #1's MAR, dated 07/12/2026, revealed no pain medication was administered to Resident #1 after the fall on 07/06/2026. Record review of Resident #1's Progress Notes, dated 07/11/2026, revealed late entry on 07/06/2026 at 8:55 PM entered by ADON C for the resident's fall. ADON C documented Resident #1, was seen to have slipped from her chair while attempting to self-propel using a nearby banister. ADON C further documented Resident #1 had stated, leave me alone, and no, when staff attempted to lift her into her wheelchair. ADON C documented MD/NP notification on 07/06/2026 at 3:00 PM and RP notification on 07/06/2026 also at 3:00 PM. The next note in Resident #1's Progress Notes was on 07/07/2026 at 5:23 AM, LVN K documented, resident showing c/o pain to left hip shouts out and or facial grimace if left hip is touched, Resident #1 was, often confused unable to ascertain verbal pain contacted [NAME] physicians spoke to NP orders to x-ray left hip 2 views along with orders for Tylenol 650mg q 6 hrs for pain resident RP no answer left message to contact facility for patient update. prn Tylenol for pain administered. Following note documented 07/07/2026 at 4:59 PM revealed, resident noted to have fall yesterday on dayshift. Night nurse reported to NP, orders given for bilat Hip x-ray. Results showing fracture- order to send out to hospital, and PRN tramadol every 8 hours for 14 days. Progress Notes on 07/07/2026 at 5:09 PM revealed called place to ambulance company for transport with ETA of 6:30 PM to send out via stretcher. Record review of hospital discharge paperwork, dated 07/10/2026, revealed on 07/09/2026 Resident #1 had a surgical procedure related to acute intertrochanteric left hip fracture with impaction and angulation. Fracture treated with left femur cephalomedullary nail. Post-op instructions revealed orders for weight bearing as tolerated with a walker, a follow-up with orthopedic physician 2 weeks after discharge, and to keep dressing dry and intact. 393 During an interview on 07/11/2026 at 1:47 PM, MA B revealed she was on B hall on 07/06/2026 and responded to Resident #1's fall after a staff member notified her of the resident being found on the floor in the main dining room. MA B stated she believed the fall happened just before dinner and MA B arrived before the nurses and started collecting vital signs. MA B stated when staff were attempting to get Resident #1 up from the floor the resident did not want to be touched nor could she answer any questions. MA B stated Resident #1 was yelling, Stop don't do that. MA B stated ADON C was the Charge Nurse over both A and B halls on 07/06/2026. During an interview on 07/11/2026 at 1:54 PM, CNA A revealed she usually worked B hall and was on shift the day of Resident #1's fall. CNA A stated she believed Resident #1 fell before dinner. CNA A stated Resident #1 was lying flat on her back and breathing heavily but did not say she was in pain. CNA A stated she did not remember Resident #1 responding when she was lifted into her wheelchair. CNA A stated the nurses treated Resident #1 pretty much like, pick her up and put her in bed. CNA A stated the DON told her to pick up Resident #1 and put her in her chair, along with a couple of other staff, and that she, CNA A, did not see anyone get vital signs on the resident. CNA A stated Resident #1 was an assist x1 staff member, CNA A stated she put the resident back to bed by herself. CNA A said Resident #1 was changed on shift and she did not notice anything different with changing her. During an interview on 07/11/2026 at 3:31 PM, LVN K stated he came onto shift at 6:00 PM and received no shift report from ADON C or DON. LVNK stated CNA N came and told him Resident #1 looked to be in pain and something was not right. LVN K stated he went to the resident's room and did a head-to-toe assessment and found the resident's left hip to be tender to touch. LVN K stated he contacted ADON D, called the NP, who told him she was not previously notified of the fall, and Tylenol and x-rays were ordered. LVN K stated an incident in the Risk Management System had been initiated, however it was empty, with no information in it. LVN K further stated that on 07/06/2026 at 6:00 PM when he came onto shift there was no documentation related to a fall during ADON C's shift for Resident #1. During an interview on 07/11/2026 at 2:10 PM, MA F stated she was on shift for Resident #1's fall, however ADON C directed MA F to stay on the hall and not leave it and to call ADON C with any issues. MA F stated ADON C was covering both the A and B halls as the charge nurse. MA F stated ADON C, when covering both halls, stayed on A hall and directed the MA to manage the floor unless there was an emergency or major issue. MA F stated ADON C told her she was going to get Resident #1 something to, calm her down, and she was going to, handle the situation. MA F stated ADON C was aware Resident #1 was hurting but only wanted to give the resident something for agitation, not pain. MA F stated ADON C said, not to tell the next shift. MA F stated she worked with Resident #1 at their sister facility and she was never a problem. MA F stated ADON D expressed frustration to her about ADON C, and stated ADON C never documented or did what she was supposed to do. During an interview on 07/11/2026 at 2:57 PM, ADON D revealed she was off on 07/06/2026, but had returned to the facility on [DATE]. ADON D stated LVN K called her on 07/07/2026 at around 5:00 AM to ask if Resident #1 had a fall the previous day on 07/06/2026. ADON D stated she reached out in the management group chat and learned Resident #1 had a fall on 07/06/2026 around 3:00 PM. LVN K stated he notified the NP about the change in residents' condition, and the NP told him she was not previously aware of the resident's fall. The NP ordered Tylenol and x-rays. ADON D stated when the results for the x-ray came back with a fracture, the NP ordered the resident to be sent out to the hospital. ADON D stated if Resident #1 was resistant to care while lying on the floor or while the staff lifted her back into her wheelchair, it may have been due to pain. ADON D stated in their group chat, ADON C stated she notified the NP and the RP of the fall and after confronting her in the chat ADON C then changed her comment to that she must have forgotten to call right after the fall due to being so busy. During an interview on 07/11/2026 at 3:56 PM, Resident #1's Responsible Party, RP, stated she did not receive a call on 07/06/2026 regarding a fall. The RP stated she received a call on 07/07/2026 around 5:30 AM or so stating they were requesting x-rays due to pain. The RP stated she spoke with a female nurse, whose name she could not recall, who stated she was not assigned to Resident #1 but wanted to let her know the resident was being sent out to the hospital regarding her x-ray results. During an interview on 07/11/2026 at 4:15 PM, the DON and the ADMIN stated after watching the camera footage of the fall Resident #1 had, for that camera angle, was hard to determine if she fell out of her wheelchair versus sliding out of her wheelchair. The ADMIN and the DON both stated the two residents who had claimed to see the fall were not in the main dining room when the fall happened. The DON stated a nurse's note should have been completed as soon as possible and that 5 hours after the fall was too long. The ADMIN stated her expectation was that falls and other incidents were documented in chart as quick as possible. During an observation on 07/11/2026 at 4:15 PM, revealed camera footage from the main dining room showed Resident #1 in the main dining room with several unknown residents. The unknown residents were not facing Resident #1 in the camera footage. Resident #1 was observed attempting to ambulate self in the wheelchair towards a pillar in the middle of the dining room. Resident #1 was observed falling forward onto floor and the camera angle showed no staff. Resident #1's fall occurred at 3:15 PM on 07/06/2026. Two staff were observed entering the main dining room from different areas and then leaving, together, to get help. The two staff members were observed re-entering the main dining room and crossing the space, passing Resident #1 on the floor, and exiting the other side of the main dining room, together. An unknown kitchen aide was observed entering the main dining room and stood with Resident #1 while appearing to turn back towards the kitchen with hands at their mouth. MA B was observed entering the main dining room immediately after unknown kitchen aide puts hands at their mouth and appeared to call out. MA B was observed standing over Resident #1 for a second before reaching down to obtain vital signs. The DON was observed entering the main dining room with one of the two staff that left together previously in the camera footage. The DON stood over Resident #1 for a minute and then leaned over her. Staff lifted Resident #1 into wheelchairs shortly after the DON leaning over Resident #1. The two residents who claimed to have witnessed the fall were not observed in the camera footage. During an interview on 07/12/2026 at 10:22 AM, the ADMIN, DON and ADON C all stated any incident should be reported to the family and MD/NP immediately as best practice. The ADMIN, DON and ADON C stated two residents who witnessed the fall in the main dining room shared that Resident #1 slid off of her wheelchair. The ADMIN, DON and ADON C stated there were no witness statements from the residents who witnessed the fall, that was just shared with them verbally, but they stated the statements being given should have been documented in Resident #1's chart. The DON stated one of the witnessing residents stopped her in hall after the incident, around 4-4:30 PM, to tell her they saw Resident #1 trying to self-ambulate towards a pillar in her wheelchair. The ADMIN, DON, and ADON C could not recall who claimed to have spoken to the other witness for the incident, or how the other resident was involved. During an interview on 07/12/206 at 11:00 AM, the ADMIN stated that the new camera angle showed Resident #1's fall better and you could see the resident fall from her wheelchair onto her left hip before laying on her side and then onto her back. During an observation on 07/12/2026 at 11:00 AM, the camera footage revealed Resident #1 was observed attempting to self-propel to the pillar in the middle of the dining room from a different camera angle. CNA A was observed in the main dining room behind a pillar where Resident #1 was out of sight. Resident #1 was observed leaning forward and then falling directly on her left hip in a new camera angle. Resident #1 was observed laying onto the floor while CNA A was still behind the pillar, CNA A did not appear to be aware of Resident #1's fall several feet away. An unknown resident was observed getting up from her chair and moving towards CNA A behind the pillar. As the unknown resident approached CNA A, CNA E was observed entering the main dining room and noticed Resident #1 down on the ground. Both CNA A and CNA E were observed leaving Resident #1 on floor and exiting the main dining room to find assistance. CNA A and CNA E were observed both re-entering the main dining room, walking past Resident #1 on the floor, and were observed exiting the main dining room. The unknown kitchen aide came out of kitchen and turned back towards kitchen, appearing to call for assistance. MA B was observed arriving to the main dining room and leaning over Resident #1 to get vital signs. The DON entered the main dining room and started speaking to CNA E while standing near Resident #1. The DON then leaned over Resident #1 and was observed to reach down and touch Resident #1 on her right hip area and her knees. ADON C and the ADMIN were seen entering the main dining room and then staff were seen lifting Resident #1 to a sitting position and then lifting her into her wheelchair. CNA A was observed pushing Resident #1 back towards her room. The ADMIN switched the camera angle to Resident #1's hallway and CNA A was observed pushing Resident #1 to her room. During an interview on 07/12/2026 at 12:36 PM, the DON and the RCN stated Neuro checks did not just self-populate, they were under the assessments tab in the clinical record and the nurse needed to know to go open them up. The DON and RCN stated all unwitnessed falls and head injuries needed neuro checks and this information should be shared during shift change report. The DON and RNC also stated not conducting post-fall assessments and documentation could lead to a delay in care. DON stated that facility falls are not tracked by names and a report that they run just shows how many falls or falls with injury. The DON stated staff and the MDS caught the falls and that was how they tracked the residents' decline. During an interview on 07/12/2026 at 3:21 PM, MA F revealed she was directed to say Resident #1 was a x1 staff member transfer. MA F stated she thought this is crap and that she was going to be honest Resident #1 was really a x2 assist for transfers. MA F stated after Resident #1 returned from the hospital she truly was a x2 assist for everything. MA F also stated she was not aware Resident #1 had a pin put in her hip. During an interview on 07/12/2026 at 3:37 PM, CNA A stated Resident #1 was a x1 assist to transfer and CNA A had only been at the facility a couple of months and she had always been a x1 assist to transfer. CNA A stated after the fall she was told to put Resident #1 in bed by herself so she did. During an interview on 07/12/2026 at 3:45 PM, ADON D revealed Resident #1 was a x2 staff assist since return from the hospital. The resident was NWB at the hospital so they kept it NWB at the facility until therapy evaluated her and cleared her. ADON D stated she was aware they were saying that Resident #1 was x1 staff assist for transfer, but she had not transferred her alone and she always got someone else. ADON D stated Resident #1 was dead weight and heavy. ADON D stated the DON called her to tell her to back document in the clinical record late entries for all the assessments and care needed after return from the hospital, and now it was there but it was not done while she was out. During an interview on 07/13/2026 at 10:30 AM, ADON D stated she had spoken with her staff the morning of 07/07/2026 before she even spoke to ADON C and was told about a fall. Resident #1 was incontinent of bowel and bladder and would need assistance to be changed. ADON D stated Resident #1 was not combative, unless she was irritated or hurt. If Resident #1 expressed ow or no don't do that then she probably had some pain. Sometimes Resident #1 could express she was hurt or needed something and sometimes she could not. During an interview on 07/13/2026 at 10:37 AM, CNA E revealed she did come across Resident #1 on the floor in the main dining room and went to find help. CNA E stated she remembered Resident #1 said ow and no don't do that when they were picking her up to put her in her wheelchair. CNA E also remembered the DON said lets check you. During an interview on 07/13/2026 at 12:20 PM, CNA A revealed Resident #1 was changed on shift when she worked and it was like a normal change. CNA A denied noticing anything unusual. CNA A stated she is aware of the signs of pain if a resident was non-verbal or could not express pain correctly. CNA A stated she never heard anyone say to not tell the next shift about the fall. During an interview on 07/13/2026 at 12:33 PM, MA B revealed she did not see the fall and an aide came to get her as she was leaving to clock out and stated Resident #1 was on the floor. MA B stated she told aide she would get the vital signs and to go get a nurse. MA B said she leaned over her and did VS, ADON C came in and then the DON came in and then the ADMIN arrived. MA B stated she had VS and Resident #1 was still on her side. MA B thought the DON was checking the resident, the DON stated okay you can put the resident into her chair. CNA A and MA B put the resident in chair. MA B stated she walked off when the resident was put in her chair. MA B said when she looked up they were taking Resident #1 to her room and that was when they first turned Resident #1, she stated stop that leave me alone, when put in her chair she tightened up and said OW when we put her in chair. MA B stated she did work the next day, but not on Resident #1's side. MA B said when the lady came to do the x-ray and they were putting Resident #1 in bed, when they transferred her she seemed like she was in pain. Resident #1 screamed OW when they transferred her. MA B stated the resident was just different. She was up that morning on the 7th. During an interview on 07/13/2026 at 12:45 PM, MA F stated she walked down the hall on 07/06/2026 some time after Resident #1's fall and remembered seeing the resident in her room in her chair, she was not put into bed after the fall. When she asked CNA A, CNA A stated ADON C told her to put the resident in her room and she (ADON C) would get the resident something for pain. MA F stated that on 07/07/2026 when she came in, staff had already gotten Resident #1 up out of bed and put her in her wheelchair. MA F stated an overnight aide (did not recall who) told them that she was supposed to stay in bed for an x-ray. MA F stated she was directed by ADON C to not share things with other shifts or staff at times. During an interview on 07/13/2026 at 1:07 PM, LVN O revealed she was off on 07/06/2026 but worked 07/07/2026 and started shift at 11:00 AM. LVN O stated she asked the aides on the hall why Resident #1 was still in bed as that was not normal for her. ADON D stated she had a fall the previous day and the facility was waiting for x-rays. LVN O said she helped the x-ray technician with Resident #1 and LVN O could tell that something was not right, her outer left thigh and hip was swollen and looked displaced. LVN O stated during manipulation, Resident #1 was making grunting noises and crying out. During an interview on 07/13/2026 at 5:21 PM, the NP revealed she was not notified of Resident #1's fall until 07/07/2026 at around 5:00 AM. The NP stated ADON D called later that day on 07/07/206 to inform her of the x-ray results and she ordered Resident #1 to be sent out to the hospital. The NP said sometimes the facility would have two staff call her about things and other times no one called. Record review of the facility's undated Fall Policy revealed a Fall Risk Assessment will be completed on admission and after each fall, the Nurse will complete an event fall nurses note after each fall., DON or designee will be responsible for investigating all resident falls to attempt to determine the cause., vital signs and first aide measures will completed immediately and charge nurse will notify attending physician and family. Record review of the facility's undated Documentation Policy revealed the facility will ensure that information is comprehensive and timely. Policy also revealed that documentation is to be completed in timely manner and that documentation for at least 72 hours will be required for each shift.following an incident. This was determined to be an Immediate Jeopardy (IJ) on 07/13/2026 at 5:38 PM. The ADMIN was notified and provided with the IJ template on 07/13/2026 at 5:38 PM. The following Plan Of Removal was submitted by the facility and was accepted on 07/15/2026 at 2:25 PM. Facility:Date: 7/13/26Plan of RemovalF684 Quality of Care Interventions:Resident #1 was assessed by the DON for any further injuries or pain from fall on 7/6/26. No additional injuries or pain were noted. The assessment was documented in PCC. Completed 7/12/26.An audit of all residents who experienced a fall within the previous 30 days was completed by the Regional Compliance Nurse, DON, and ADON to ensure all incident reports, post fall assessments, neuro checks, and notifications to physician and responsible party were completed per facility policy. Completed 7/13/26.New Process: Effective immediately, the Administrator and DON (or designee) will be notified of all resident falls prior to the end of each shift. The DON or designee will review each fall to verify completion of the incident report, post-fall assessments, head-to-toe assessment, pain assessment, neurological assessments (when indicated), physician and responsible party notifications, and implementation of appropriate interventions. Any resident that complains of pain post fall will be sent to the emergency room to prevent a delay in treatment per MD orders. All residents' falls will be reviewed each morning during the clinical meeting to ensure all required documentation, notifications, physician orders, follow-up evaluations, care plan revisions, and interventions have been completed. Any identified concerns or deficiencies will be addressed immediately by the DON or designee. Completed 7/13/26The Administrator and DON were 1:1 in-serviced on the following by the Regional Compliance Nurse and Area Director of Operations. Completed 7/13/26.Abuse and Neglect Policy in-service will be provided to all staff to include that failure to timely assess a resident following a fall, delay in notifying the physician or responsible party, delay in obtaining treatment, or failure to implement physician orders may constitute neglect.Fall Prevention Policy in-service will be provided to all staff including documentation to be conducted after a fall to include the incident report, post fall assessment, head to toe assessment, neurological assessment, and pain assessment per policy.Neurological Assessment Policy in-service will be provided to all nurses- neurological assessments will be completed for all residents who experience an unwitnessed fall or a fall that results in the residents hitting their head or face area.Notification of Change in Condition in-service to be provided to all nurses to include notifying the physician immediately for signs and symptoms of a fracture, pain or injury after a fall for subsequent orders. All residents who complain of pain post fall will be sent to the emergency room to prevent a delay in treatment per MD orders. Also notifying the responsible party immediately after a change in condition and a fall.Shift to Shift Communication Expectations in-services to be provided to all nurses and CNAs to include any resident who experiences a fall will be included in shift-to-shift report for a minimum of 72 hours. The off-going licensed nurse will communicate the details of the fall, resident assessment, physician and responsible party notifications, pending diagnostic testing, current interventions, neuro checks (when indicated), pain status, and any changes in the resident's condition. The oncoming licensed nurse will acknowledge receipt of the report and assume responsibility for continued monitoring and completion of any outstanding interventions. The nurses will use the 24hr report in PCC for communication.5. Admin/designee will complete 10-15 abuse surveys for staff 5 days weeks x 4 weeks.6. Admin/designee will complete 10-15 abuse surveys for residents 5 days weeks x 4 weeks.7. The Medical Director was notified of the Immediate Jeopardy Citation on 7/13/26 by the Director of Nursing.8. An ADHOC QAPI meeting was conducted with the IDT Team and Medical Director to discuss the immediate jeopardy and plan of removal. Complete 7/13/26. In-servicesThe following in-services were initiated by Administrator, Regional Compliance Nurse, ADO, DON, and ADON to all staff. All staff not present or in-serviced as of 7/12/26 will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All PRN, agency staff, or staff on leave will in serviced prior to assuming their next assignment. A post-test will be provided to all staff to verify retention of education. Completion date 7/13/26. Abuse and Neglect Policy in-service will be provided to all staff to include that failure to timely assess a resident following a fall, delay in notifying the physician or responsible party, delay in obtaining treatment, or failure to implement physician orders may constitute neglect.Fall Prevention Policy in-service will be provided to all staff including documentation to be conducted after a fall to include the incident report, post fall assessment, head to toe assessment, neurological assessment, and pain assessment per policy.Neurological Assessment Policy in-service will be provided to all nurses- neurological assessments will completed for all residents who experience an unwitnessed fall or a fall that results in the resident hitting their head or face area.Notification of Change in Condition in-service to be provided to all nurses to include notifying the physician immediately for signs and symptoms of a fracture, pain or injury after a fall for subsequent orders. All residents who complain of pain post fall will be sent to the emergency room to prevent a delay in treatment per MD orders. Also notifying the responsible party immediately after a change in condition and a fall.Shift to Shift Communication Expectations in-services to be provided to all nurses and CNAs to include any resident who experiences a fall will be included in shift-to-shift report for a minimum of 72 hours. The off-going licensed nurse will communicate the details of the fall, resident assessment, physician and responsible party notifications, pending diagnostic testing, current interventions, neuro checks (when indicated), pain status, and any changes in the resident's condition. The oncoming licensed nurse will acknowledge receipt of the report and assume responsibility for continued monitoring and completion of any outstanding interventions. The nurses will use the 24hr report in PCC for communication Monitoring:DON/DESIGNEE WILL VERIFY SHIFT TO SHIFT REPORT COMPLETED PER PCC 24 HR REPORT DAILY IN STAND UP BY ENSURING NURSES SIGN OFF ON 24 HR REPORT.DON/DESIGNEE WILL VERIFY CAN SHIFT TO SHIFT REPORT DAILY IN STAND UP BY ENSURING CNAS SIGN SHIFT TO SHIFT REPORT LOG.DON/DESIGNEES WILL REVIEW RISK MANAGEMENT DAILY IN STAND UP TO ENSURE REPORT IS COMPLETED TIMELY.DON/DESIGNEE WILL REVIEW ALL EVENTS IN RISK MANAGEMENT IN STAND UP TO ENSURE POST FALL FOLLOW UP/NEUROS ARE COMPLETED.DON/DESIGNEE WILL REVIEW ALL EVENTS IN RISK MANAGEMNT IN STAND UP TO ENSURE S/SX OF PAIN WAS ASSESSED AND TRANFERED TO ER FOR FURTHER EVALUATION. Verification of the POR was as follows: Record reviews as follows:a. Record review assessment had revealed post-fall assessment for Resident #1 dated 7/6/2026 at 8:55. No other assessments were entered into PCC until 07/12/2026 when staff asked about re-admission documentation. b. Record review 30-day incident report/assessments had revealed undated print out from PCC under Risk Management listing falls within facility from 6.9.2026 to current 07/15/2026. Initials on sheets from DON next to each listing is observed to show acknowledgement of the review by the facility. c. Record review of post in-service exams with questions identifying notification after falls effective immediately, to include the DON and the Administrator. The facility created a list to review the above listed documentation which includes halls and completion dates of 7.13.2026 and 7.14.2026. d. Record review of in-services dated 7/12/2026 titled Abuse Neglect Policy, Fall Prevention Policy, Neuro Assessment Policy, Notification/Change policy, shift to shift communication expectations were signed by the ADMIN and the DON. Record reviews of in-services titled ANE dated, 7/12/2026, revealed 112 of 119 staff signed acknowledgment of receipt. e. Record review of in-services, dated 07/12/2026, documented 112 of 119 staff members received the Fall Prevention in-service. f. Record review of in-services, dated 07/12/2026, documented 27 nursing employees received the Neurological Assessment In-service. g. Record review of in-services, dated 07/12/2026, documented 27 nursing employees received the Notification of Change of Condition In-service. h. Record review of in-services, dated 07/12/2026, documented 27 nursing employees received the Shift to Shift 24-hour report In-service. i. Record review of the completion of the staff abuse surveys for 15 staff members was completed on 7.13.2026, no findings. j. Record review of the completion of the resident abuse surveys for 35 residents within the facility was completed 7.14.2026. k. Record review of the QAPI sign-in sheet, dated 7/12/2026, revealed the MD signature along with the ADMIN, DON, and other members of the management team. l. Record review of the completion of the QAPI/ADHOC meeting completed and was signed on 7.13.2026. Notes of Meeting revealed a system failure identified during abbreviated self-report survey, which resulted in an immediate need for review for this system. The action plan created due to facility failure to ensure Resident #1 had received the necessary care post unwitnessed fall, that resulted in hip fracture. Interviews are as follows: a. Interview with the DON and ADMIN regarding Intervention 1 was as follows: They assessed for pain as well as asked her, Resident #1 had dermabond to surgical site and was in good spirits. This information was documented in clinical system. No other assessment was entered into clinical system, to include re-admission from hospital on [DATE], until staff was asked about missing documentation. b. Interview with the DON and the ADMIN regarding Intervention 2 was as follows: They looked back at Risk Management for the last 30 days to make sure the event notes were there, post assessments were completed, notifications were completed, and pain was identified. They did follow up if something was missing, and now in-services should be a cleaner and smoother process. c. Interview with the DON on 7/14/2026 at 12:45 PM regarding Intervention 3 was as foll

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 of 6 residents (Residents #2 and Resident #4), and the facility failed to ensure that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled for 5 of 5 medication carts (B Hall Carts #1, #2, and #3; A Hall Cart, and C Hall Cart) reviewed for pharmacy services. The facility failed to ensure Resident #4 received ordered insulin on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE].The facility failed to ensure Resident #2 received ordered medications on [DATE] after admission to the facility on the evening of [DATE].The facility failed to ensure narcotics logs were maintained and reconciled on B Hall Carts #1, #2, and #3; A Hall Cart; and C Hall Cart. These failures could lead to residents not receiving ordered medication, residents not receiving the intended therapeutic effect of medications, or the loss or misappropriation of residents' narcotic medications. Findings included: Record review of Resident #4's admission Record, dated [DATE], revealed an [AGE] year-old female, admitted [DATE], with diagnoses that included: Type 2 Diabetes (a chronic condition where your body resists insulin or doesn't make enough of it, causing blood sugar levels to spike), Cognitive communication deficit (an impaired ability to speak, listen, read, or write caused by disrupted thinking skills—such as attention, memory, and executive function—rather than a physical speech issue) and dementia (an umbrella term for a decline in cognitive abilities—such as memory, thinking, and reasoning—severe enough to interfere with daily life). Recorder review of Resident #4's Quarterly MDS, dated [DATE], revealed a BIMS score of 00, indicating severe cognitive impairment. Record review of Resident #4's Care Plan, dated [DATE], revealed the resident had diabetes mellitus that require insulin administration and was a wander-risk. Record review of Resident #4's MAR, dated [DATE], revealed that on: -[DATE] no documentation indicating administration of 18 units of insulin being administered on the overnight shift -[DATE] no documentation indicating administration of 18 units of insulin being administered on the overnight shift -[DATE] no documentation indicating administration of 8 units of insulin being administered on the day shift -[DATE] no documentation indicating administration of 8 units of insulin being administered on the day shift -[DATE] no documentation indicating administration of 8 units of insulin being administered on the day shift -[DATE] no documentation indicating administration of 18 units of insulin being administered on the overnight shift -[DATE] no documentation indicating administration of 8 units of insulin being administered on the day shift -[DATE] no documentation indicating administration of 8 units of insulin being administered on the day shift Record review of Resident #4's Order Summary Report, dated [DATE], revealed that Resident #4 had an order for Insulin Glargine Solution 100 UNIT/ML Inject 18 unit subcutaneously one time a day in the evening for diabetes, and an order for Insulin Glargine Solution 100 UNIT/ML Inject 8 unit subcutaneously one time a day in the morning for diabetes. Record review of Resident #4's Progress Notes, dated [DATE], revealed no documentation pertaining to the missed doses of insulin. Progress Notes also revealed no hypo or hyperglycemic incidents for the resident around the times of missed insulin doses. During an interview on [DATE] at 4:15 PM, the DON revealed that she is unsure why the insulin was not documented on the MAR for the resident. The DON stated that she believed that ADON C was covering the unit those days. The facility expectation is that all medications are administered, documented that they are administered, or it is documented why the medications could not be administered. The DON stated that failure to receive insulin could result in negative outcome to the resident. Attempted to contact ADON C on [DATE] at 3:50 PM, [DATE] at 4:45 PM, and again on [DATE] at 5:15 PM. Review of facility Documentation Policy, undated, revealed that the facility will ensure that information is comprehensive and timely. Policy also revealed that documentation is to be completed in timely manner in the clinical record. Review of facility Medication Administration Policy, undated, revealed that all medications are to be documented in clinical record by right medication, right time, right does, right route, and right documentation. Policy revealed that medication 2. Record review of Resident #2's admission Record dated [DATE] reflected a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included end stage renal disease [severe kidney disease] and dependence on renal dialysis [artificial filtering of the blood by machine]. Record review of Resident #2's MDS dated [DATE] reflected Resident #2 expired at the facility. The admission MDS was in progress status during the survey. Record review of Resident #2's Order Summary Report dated [DATE] reflected the following orders: -Coreg Oral Tablet 3.125 MG (Carvedilol) Give 1 tablet by mouth two times a day for Hypertension [sic] [high blood pressure] HOLD [sic] if SBP less than 110 and/or HR: [sic] less than 60 Start Date [DATE] -Hydroxyzine HCl Tablet 25 MG Give 1 tablet by mouth every 8 hours for itching Start Date [DATE] -Lisinopril Tablet 2.5 MG Give 1 tablet by mouth one time a day for hypertension Hold [sic] for SBP less than 110/DBP less than 60/HR less than 60 Start Date [DATE] -Plavix Oral Tablet 75 MG (Clopidogrel Bisulfate) Give 1 tablet by mouth one time a day for prevent clot formation [sic] Start Date [DATE] Record review of Resident #2's MAR for [DATE] dated [DATE] reflected code UN was used by staff to indicate UNAVAILABLE (Contact the DON/ADON), and code 9 was used to indicate Other/ See Nurse Notes. The following was documented by facility staff for [DATE]: -Lisinopril Tablet 2.5 MG, code UN for morning administration documented by MA AM -Plavix Oral Tablet 75 MG, code UN for morning administration documented by MA AM -Coreg Oral Tablet 3.125 MG, code UN for morning administration documented by MA AM -Coreg Oral Tablet 3.125 MG, code UN for evening administration documented by MA AM -Hydroxyzine HCl Tablet 25 MG, code 9 documented by RN AB for 6:00 AM administration -Hydroxyzine HCl Tablet 25 MG, code UN documented by MA AM for 2:00 PM administration -Hydroxyzine HCl Tablet 25 MG, code 9 documented by RN AB for 9:00 PM administration Record review of Resident #2's progress notes did not reveal documentation from [DATE] associated with the above listed medications not administered for code 9. In an interview on [DATE] at 9:17 AM, RN AB said Resident #2 admitted to the facility on [DATE] and her medications had not yet arrived when he worked night shift on [DATE]. He said he was told by the day shift nurses that Resident #2's medication had not yet arrived and could not be taken from the emergency kit because nobody had access. He was unsure which nurse reported this to him. He said he was unsure what the facility policy was for obtaining medications for residents that are not in stock, and he said he attempted to borrow the medications from other residents' stock but was unsuccessful because he couldn't locate other residents with the same prescriptions. He said he did not have access to the facility's emergency medication storage, and he did not attempt to contact the ADON or DON because he was busy. He said he did not contact the physician to notify him/her that Resident #2 had not received her scheduled medications that day. In an interview with MA AM on [DATE] at 3:25 PM, she said she was not responsible for administering medications to Resident #2 on [DATE] because Resident #2 had a tracheostomy, so the nurse had to administer the medications. She said she signed off the medications for that shift because they appeared on her MAR task list, but she had told the nurse of the need for administration prior to signing them. She was unsure if the medications were available for administration, and she was unsure which nurse she told. In an interview with the DON on [DATE] at 10:36 AM, she said the staff should have informed her immediately that Resident #2's medication had not arrived in time for scheduled administration on [DATE]. She said she was unaware that the staff were unable to give Resident #2 her scheduled medications that day, and the medications could have been pulled from the emergency kit. She said RN AB did not have access to the emergency kit, but there was always at least one nurse during every shift who was able to log into the system to obtain medications. She said the facility policy included never using one resident's medication to administer to another resident, and the medication policies were covered with staff during orientation. She said there is not a document verifying that staff receive medication ordering and emergency medication retrieval during orientation. Record review of the facility policy titled Medication Administration and General Guidelines dated 2025, reflected the following: . 12. If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time (e.g. resident not in facility at scheduled dose time, initial dose of antibiotic), the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN documentation. The physician must be notified when a dose of medication has not been given. If an electronic medical record is being utilized than the caregiver administering the medication will enter the correct documentation that will then be electronically date/time stamped with their initials. 13. Medications supplied for one resident are never administered to another resident . A policy regarding medication ordering/ re-ordering was requested from the facility, and the facility provided a document titled Ordering and Receiving Medications from Non-Contracted Pharmacy dated 2025. Record review of this document did not reveal policy or procedure related to admission medication ordering or emergency medication supplies. 3. In an observation and record review on [DATE] at 12:22 PM, the medication cart for A Hall was observed to have a binder containing the reconciliation records for narcotic medication in the A Hall. Record review of the first page of the binder, titled Controlled Drugs- Audit Record dated [DATE] for Memory Care Station 1, reflected a form for two staff members to sign for each 12 hour shift period on a daily basis acknowledging the narcotic medications were reconciled. The following dates had incomplete documentation (4 shifts): -[DATE] 6:00 AM nurse on signature -[DATE] 6:00 AM nurse off signature -[DATE] 6:00 AM nurse on signature -[DATE] 6:00 PM nurse off signature In an observation on [DATE] at 12:26 PM, the medication cart for C Hall was also observed to have a binder containing narcotic medication reconciliation records. Record review of the first page of the binder, also titled Controlled Drugs- Audit Record dated [DATE] for Cart 1 Station C reflected 12 shifts from [DATE] through [DATE] in which the facility staff had not signed the form, including the following (13 total shifts): -[DATE] nurse off 6:00 AM -[DATE] nurse on 6:00 PM -[DATE] nurse on 6:00 AM -[DATE] nurse on 6:00 PM -[DATE] nurse on 6:00 AM -[DATE] nurse on 6:00 PM -[DATE] nurse on 6:00 AM -[DATE] nurse on and nurse off 6:00 AM -[DATE] nurse off 6:00 PM -[DATE] nurse on 6:00 AM -[DATE] nurse off 6:00 PM -[DATE] nurse on 6:00 AM -[DATE] nurse off 6:00 PM In an observation and interview on [DATE] at 1:49 PM, three medication carts located in the B hall were observed to also have binders containing narcotic medication reconciliation documents. The records contained in the binders were noted to have columns for three, eight-hour shifts, and the RDON said the facility did not utilize any MAs or nurses in eight-hour shifts during the month of [DATE]. He said the staff should have notated the correct shift start time and reconciled the cart with both staff members signing the form at the end/start of each 12-hour shift. Record review of the Controlled Drugs-Audit Record dated [DATE] contained in B hall cart #1 reflected the record with three shift columns, as previously described. The following dates from [DATE] through [DATE] contained no signatures (16 total shifts): -[DATE] nurse on and nurse off for morning shift -[DATE] nurse off for evening shift -[DATE] nurse on for evening shift -[DATE] nurse off for morning shift -[DATE] nurse on for evening shift -[DATE] nurse off for morning shift -[DATE] nurse on for morning shift -[DATE] nurse on for morning shift -[DATE] nurse on and nurse off for evening shift -[DATE] nurse on and nurse off for evening shift -[DATE] nurse on and nurse off for morning shift -[DATE] nurse off for evening shift -[DATE] nurse off for morning shift -[DATE] nurse on for evening shift -[DATE] nurse off for morning shift -[DATE] nurse off for morning shift Record review of the Controlled Drugs-Audit Record dated [DATE] contained in B hall cart #2 reflected the record with three shift columns, as previously described. The following dates from [DATE] through [DATE] contained no signatures (2 total shifts): -[DATE] nurse off and nurse on for morning shift -[DATE] nurse off for evening shift Record review of the Controlled Drugs-Audit Record dated [DATE] contained in B hall cart #3 reflected the record with three shift columns, as previously described. The following dates from [DATE] through [DATE] contained no signatures (10 total shifts): -[DATE] nurse off morning shift -[DATE] nurse off evening shift -[DATE] nurse off and nurse on morning shift -[DATE] nurse on evening shift -[DATE] nurse off morning shift -[DATE] nurse off morning shift -[DATE] nurse on evening shift -[DATE] nurse off morning shift -[DATE] nurse off morning shift -[DATE] nurse off morning shift In an interview on [DATE] at 1:55 PM, LVN Y said she always signed the narcotic book and had signed the book for hall A that morning. She said not all staff followed the facility policy of reconciling the cart with two staff members, but she made sure to follow the procedure because she did not want to be responsible for any missing medications. In an interview with the DON on [DATE] at 3:00 PM, she said the facility policy was for the staff member whose shift was ending and the staff member arriving for shift to count the narcotic medications together and both sign the audit record. She said she was unaware the records for [DATE] were incomplete, and the ADONs were responsible for ensuring the logs were complete at the end of every month. She said not signing the logs could result in missing medications, but the facility had not had any instances of missing narcotics since she had assumed the position of DON in [DATE]. Record review of the facility policy titled Controlled Medications- Administration dated [DATE] reflected the following: .8. At each shift change, a physical inventory of all controlled medications is conducted by two licensed nurses and/or one nurse and a CMA, QMAP, Med Tech or equivalent as allowed by your State regulatory agency and documented on an audit record. Alternatively, the shift change audit may be recorded on the accountability record if there is a designated column for the audit. 9. Current controlled medication accountability records and audits records are kept on the medication card, either in the MAR or in a separate folder. When completed, audit and accountability records are submitted to the Director of Nursing and kept on file for three years at the facility .

Based on interview and record review, the facility failed to ensure that all alleged violations involving neglect are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation result in serious bodily injury for 1 of 6 residents (Resident #3) reviewed for neglect. The facility failed to report the unexpected death with signs of potential neglect for Resident #3. This failure could lead to lack of oversight and neglect of residents. Findings included: Record review of Resident #3's admission Record dated [DATE] reflected a [AGE] year-old male admitted to the facility on [DATE] and discharged on [DATE]. Relevant diagnoses included cerebral infarction, unspecified (interrupted blood flow to the brain causing brain damage). Record review of Resident #3's MDS dated [DATE] reflected Resident #3 expired at the facility. Record review of Resident #3's quarterly MDS dated [DATE] reflected a BIMS score of 13, which indicated intact cognition. Section J0100 reflected Resident #3 received a scheduled pain medication regimen. Section GG0115 reflected Resident #3 had impairment to one side of both upper and lower limbs. Section N0415 reflected Resident #3 was taking opioid medication. Record review of Resident #3's Order Summary Report dated [DATE] reflected the following orders: -fentaNYL [sic] Transdermal patch 72 Hour 25 MCG/HR (Fentanyl) Apply 25 mcg/hr transdermally [sic] [to skin] one time a day every 3 day(s) for pain and remove per schedule Start date [DATE] -HYDROcodone-Acetaminophen [sic] Oral Tablet 10-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 8 hours for pain Start date [DATE] Record review of Resident #3's Care Plan Report undated/ printed [DATE], reflected the following: . Resident is a Full Code [sic] Date Initiated: [DATE] . and . The resident has a terminal prognosis and/or is receiving hospice services with [hospice provider] Date Initiated: [DATE] . Further record review of Resident #3's Care Plan Report did not reveal findings related to pain monitoring or pain medication. Record review of Resident #3's progress notes reflected the following documentation: -Progress note by LSW dated [DATE] 1:01 PM: SW contacted legal guardian to inform of incident where resident stated he was not receiving his pain medication but then resident proceeded to remove medication from his sock. Legal guardian was informed that staff has checked MAR and that resident is receiving his medications. Legal guardian states that he is concerned about this because of resident's past issues with substances. Legal guardian states he would prefer resident be put on a patch rather than oral tablets for his pain medication. SW to contact hospice for this request. -Progress note by RN AN dated [DATE] at 2:18 PM: This nurse was notified at 1326 [1:28 PM] resident was slumped over in his bed sitting at the side of the bed with visible blood at the mouth, this nurse entered the room [ROOM NUMBER] [1:28 PM] 911 services were called immediately for assistance in distress. Assistance was called for ADON, DON entered the room with crash cart resident was being suctioned when he was noted with no pulse and CPR was initiated immediately AED applied indicating no shock needed, 2 rounds of 2-minute CPR performed and then EMS arrived on seen and took over. Guardian and family were notified, MD was notified, Hospice was notified. TOD was called by EMS and [police department] @ 1357 [1:57 PM]. Police cleared resident for release to funeral home. Record review of Resident #3's Postmortem [after death] assessment dated [DATE] reflected Resident #3 was found unresponsive with no respirations or pulse while in bed. Resident #3 was pronounced and released to the funeral home on [DATE] at 5:00 PM. Record review of EMS Run Report dated [DATE] at 1:29 PM for Resident #3 reflected EMS was dispatched to the facility for reported cardiac arrest [heart not beating]. EMS performed advanced life-saving support interventions, including the administration of Naloxone (also known as narcan, a medication used to reverse the effects of opiate overdose). EMS documentation indicated the Naloxone had no effect, and the resident was unable to be resuscitated. Records from the police department were requested on [DATE] at 3:33 PM (reference number W804485-071626), but the request remained in progress as of [DATE]. In an interview with ADON D on [DATE] at 11:17 AM, she said she was present at the time Resident #3 was found unresponsive, and she was present when EMS and the police department declared Resident #3 deceased . She said the police department located a bag containing multiple pills on Resident #3's body that she identified as Resident #3's opiate pain medication. She said Resident #3 had also been discovered hiding opiate pain medication in his sock recently. She said she had notified the DON of both instances, but no investigation or action had occurred as a result of the notification. In an interview with the DON on [DATE] at 3:30 PM, she said she was aware of the incident in which Resident #3 was discovered to have hidden pain medication in his sock. She said the incident was brought to the attention of hospice, his legal guardian, and the IDT during a care plan meeting shortly after the incident. She said the determination was made to modify the pain regimen for safety and better pain control. She said she was unaware that additional pills were located on Resident #3's body after he died, and she did not feel Resident #3's death was suspicious or required reporting to the SSA because the police department had released Resident #3's body for funeral arrangements and not required an autopsy. She said she did not suspect Resident #3 had died as a result of overdose. In an interview with the ADM on [DATE] at 3:30 PM, she said she was not told by staff that Resident #3 had been in possession of suspected narcotics at the time he died. She said she had not reported Resident #3's death to the SSA because he was on hospice and because the police had released his remains without requiring an autopsy. In an interview with CNA A on [DATE] at 6:24 PM, she said she brought Resident #3 coffee at lunch time on [DATE], at which time he was acting normally. She said she found him unresponsive with blood near his nose approximately 10 minutes later. She said he displayed signs of an overdose, including drooling and a slumped position. She said she immediately notified the nurse that Resident #3 was unresponsive and looked like he had overdosed, and the nurse responded right away. She said she observed a bag of pills discovered on Resident #3's body by the police department after he died. In an interview with the MD on [DATE] at 9:10 PM, he said he was aware Resident #3 had expired and that he had been found with pills. He said he did not suspect Resident #3 died of an overdose because the Narcan was ineffective, and he suspected Resident #3 died from a heart attack. Record review of the facility's policy titled, Abuse/Neglect, undated, revealed Neglect is defined as 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. If an allegation involves serious bodily injury, the reporting of incident should be made within 2 hours of the allegation. Further review revealed, E. Reporting . 3. Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 2024-14 dated [DATE] .

Based on interview and record review, the facility failed to ensure, in response to allegations neglect, have evidence that all alleged violations are thoroughly investigated for 2 of 6 residents (Residents #2 and #3) reviewed for neglect. The facility failed to have evidence of investigation into the unexpected death with signs of potential neglect for Resident #3. The facility failed to have evidence of thorough investigation of the unexpected death with signs of potential neglect for Resident #2. These failures could lead to lack of oversight and/or neglect of residents. Findings included: 1.Record review of Resident #3's admission Record dated [DATE] reflected a [AGE] year-old male admitted to the facility on [DATE] and discharged on [DATE]. Relevant diagnoses included cerebral infarction, unspecified (interrupted blood flow to the brain causing brain damage). Record review of Resident #3's MDS dated [DATE] reflected Resident #3 expired at the facility. Record review of Resident #3's quarterly MDS dated [DATE] reflected a BIMS score of 13, which indicated intact cognition. Section J0100 reflected Resident #3 received a scheduled pain medication regimen. Section N0415 reflected Resident #3 was taking opioid medication. Record review of Resident #3's Order Summary Report dated [DATE] reflected the following orders: -fentaNYL [sic] Transdermal patch 72 Hour 25 MCG/HR (Fentanyl) Apply 25 mcg/hr transdermally [sic] [to skin] one time a day every 3 day(s) for pain and remove per schedule Start date [DATE] -HYDROcodone-Acetaminophen [sic] Oral Tablet 10-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 8 hours for pain Start date [DATE] Record review of Resident #3's Care Plan Report undated/ printed [DATE], reflected the following: . Resident is a Full Code [sic] Date Initiated: [DATE] . and . The resident has a terminal prognosis and/or is receiving hospice services with [hospice provider] Date Initiated: [DATE] . Further record review of Resident #3's Care Plan Report did not reveal findings related to pain monitoring or pain medication. Record review of Resident #3's progress notes reflected the following documentation: -LSW dated [DATE] 1:01 PM: SW contacted legal guardian to inform of incident where resident stated he was not receiving his pain medication but then resident proceeded to remove medication from his sock. Legal guardian was informed that staff has checked MAR and that resident is receiving his medications. Legal guardian states that he is concerned about this because of resident's past issues with substances. Legal guardian states he would prefer resident be put on a patch rather than oral tablets for his pain medication. SW to contact hospice for this request. -RN AN dated [DATE] at 2:18 PM: This nurse was notified at 1326 resident was slumped over in his bed sitting at the side of the bed with visible blood at the mouth, this nurse entered the room [ROOM NUMBER] [1:28 PM] 911 services were called immediately for assistance in distress. Assistance was called for ADON, DON entered the room with crash cart resident was being suctioned when he was noted with no pulse and CPR was initiated immediately AED applied indicating no shock needed, 2 rounds of 2-minute CPR performed and then EMS arrived on seen and took over. Guardian and family were notified, MD was notified, Hospice was notified. TOD was called by EMS and [police department] @ 1357 [1:57 PM]. Police cleared resident for release to funeral home. In an interview with ADON D on [DATE] at 11:17 AM, she said she was present at the time Resident #3 was found unresponsive, and she was present when EMS and the police department declared Resident #3 deceased . She said the police department located a bag containing multiple pills on Resident #3's body that she identified as Resident #3's opiate pain medication. She said Resident #3 had also been discovered hiding opiate pain medication in his sock recently. She said the DON had been notified of both instances, but no investigation or action had occurred as a result of the notification. In an interview with the DON on [DATE] at 3:30 PM, she said she was unaware that additional pills were located on Resident #3's body after he died, and she did not feel Resident #3's death was suspicious or required reporting to the SSA because the police department had released Resident #3's body for funeral arrangements and not required an autopsy. She said no further investigation regarding the circumstances of Resident #3's death had been done after he died because she was unaware of the pills. She said the facility had not performed a search of Resident #3's body or belongings after he was discovered to have hidden a narcotic pill in his sock because she felt it was a violation of his rights. She said Resident #3 could have potentially obtained the pills found on his body from a source outside of the facility because he occasionally left the faciity on pass. She said the facility did not have established monitoring in place for Resident #3 to determine if Resident #3 had returned from pass exhibiting signs or symptoms of intoxication or substance abuse, but she was not aware of any instances in which Resident #3 had seemed intoxicated or altered after returning to the facility. In an interview with the ADM on [DATE] at 3:30 PM, she said she was not told by staff that Resident #3 had been in possession of suspected narcotics at the time he died. She said the facility had not further investigated Resident #3's death because she was not aware that any potential neglect had occurred. In an interview with CNA A on [DATE] at 6:24 PM, she said she brought Resident #3 coffee at lunch time on [DATE] and found him unresponsive with blood near his nose approximately 10 minutes later. She said he displayed signs of an overdose, including drooling and a slumped position. She said she immediately notified the nurse that Resident #3 was unresponsive and looked like he had overdosed, and the nurse responded right away. She said she observed a bag of pills discovered on Resident #3's body by the police department after he died. She said she had not been questioned by the DON or ADM regarding the pills. 2. Record review of Resident #2's admission Record dated [DATE] reflected a [AGE] year-old female admitted to the facility on [DATE] and discharged on [DATE]. Relevant diagnoses included tracheostomy [an artificial opening in the airway to allow for oxygenation] status. Record review of Resident #2's MDS submitted [DATE] reflected Resident #2 had expired in the facility. Record review of Resident #2's MAR for [DATE] dated [DATE] reflected code UN was used by staff to indicate UNAVAILABLE (Contact the DON/ADON), and code 9 was used to indicate Other/ See Nurse Notes. The following was documented by facility staff for [DATE]: -Lisinopril Tablet 2.5 MG, code UN for morning administration documented by MA AM -Plavix Oral Tablet 75 MG, code UN for morning administration documented by MA AM -Coreg Oral Tablet 3.125 MG, code UN for morning administration documented by MA AM -Coreg Oral Tablet 3.125 MG, code UN for evening administration documented by MA AM -Hydroxyzine HCl Tablet 25 MG, code 9 documented by RN AB for 6:00 AM administration -Hydroxyzine HCl Tablet 25 MG, code UN documented by MA AM for 2:00 PM administration -Hydroxyzine HCl Tablet 25 MG, code 9 documented by RN AB for 9:00 PM administration Record review of Resident #2's progress notes from [DATE] did not reveal documentation from [DATE] associated with the above listed medications not administered for code 9. Further record review of Resident #2's progress notes reflected the following documentation from RN AB dated [DATE] at 7:24 AM: At approximately 0400hrs, resident was found in prone position [face down] on fall mat. Resident was unresponsive to verbal and painful stimuli. Resident repositioned to supine and found to have absent lung sounds and heartbeat. CPR was initiated and code blue initiated. At 0407 fire department arrived and took over CPR. Unable to revive resident after exhausting all efforts, time of death was called at 0426am by EMS and [EMS MD] on phone. [Police department] was contacted by EMS and arrived shortly thereafter. After inital [sic] [Police Department] investigation and confering [sic] with the M.E., the decision was made to end the investigation citing resident past medical history. Family member was notified at 0600 hrs, spoke to [family member] who stated funeral arrangements would be through [funeral home]. Resident was tranferred [sic] to bed, bed bath provided, and family enroute to visit. Record review of document EMS Run Report dated [DATE] at 3:59 AM reflected EMS was notified of cardiac arrest by the facility and arrived at 4:10 AM, and the resident was already receiving CPR from an additional fire department team who arrived several minutes earlier. The documentation reflected the facility staff could not relay a time at which Resident #2 was last seen at her baseline status. The documentation also reflected Resident #2's jaw showed signs of rigor [the natural stiffening of muscles that happens hours after death] when EMS attempted to place an artificial airway in Resident #2's mouth, and that Resident #2's body was very cold to the touch. Record review of TULIP intake #1103796 reflected the facility reported Resident #2 was found unresponsive on [DATE] , on the ground on a fall mat in the prone position at approximately 4:00 AM and facility staff initiated CPR. Resident #3 expired, and the facility had notified the MD, Resident #3's family, contacted the police department, interviewed staff, and initiated in-services regarding abuse and neglect. Record review of the facility binder identified as the investigation for intake #1103796 reflected a document titled Self-Reporting Protocol/ Ad Job QAPI- Neglect and/or Injury of Unknown Origin dated [DATE] that reflected the incident had been reported to the SSA on [DATE]. The item if camera system used and applicable to the area, review was blank. The item suspend known perpetrators immediately pending investigation was documented as completed on [DATE]. The item take statements from everyone who cares for the resident in the 24 hours preceding the discover of the injury was documented as completed on [DATE]. The item interview other interviewable residents regarding staff treatment was indicated as complete by a checkmark but no date of completion was documented. The item begin abuse/neglect in-service and/or assign an abuse related [computer] course was documented as started on [DATE] for emergency codes and cpr policy. An entry into the EMR was documented as completed on N/A and the MD was documented to have been notified on [DATE]. The document reflected because of the above actions, the likelihood for serious harm to any resident no longer exists as of [DATE] and reflected 2 code blue drills per shift per week could be performed, as well as 10 ADL actions per week to ensure sufficient staffing. The binder included written staff statements from CNA AJ dated [DATE], CNA AO dated [DATE], and LVN P dated [DATE]. In an interview with CNA AJ on [DATE] at 7:41 AM, he said he rounded on resident at approximately 11:00 PM on [DATE] and again at an unknown time after 3:00 AM on [DATE]. He said he noticed Resident #2's bed looked like it was in an elevated position, and he felt that she would benefit from a fall mat, so he left her room to obtain one and returned to put it in place. He said he then attempted to speak to Resident #2, and he determined she was unresponsive. He then attempted to perform CPR but could not effectively initiate chest compressions, so he attempted to assist her to the ground, at which time she slipped down onto the fall mat. He then left the room to obtain assistance and notify the nurse of Resident #2's condition. CNA AJ then said he whispered to RN AB that Resident #2 was dead, but RN AB did not respond or move towards Resident #2's room. He said several minutes later he again notified RN AB that he thought Resident #2 was dead, and at that time RN AB went to Resident #3's room and they initiated CPR and called EMS. In an interview with RN AB on [DATE] at 9:17 AM, he said Resident #2 had not received any medications on [DATE] except her pain medication because the medications had not been delivered. He said he did not notify the doctor or facility leadership of the missed doses. He said he administered the pain medication to Resident #2 around 9:30 PM on [DATE] and was unable to check on her again because he was very busy. He said CNA AJ whispered something to him at an unknown time before 4:00 AM, but he has difficulty hearing and could not understand what CNA AJ had said. He said approximately 5-10 minutes later, CNA AJ whispered to him again, and this time he understood that CNA AJ had told him Resident #2 was not breathing. He said he went to Resident #2's room with CNA AJ and they had to reposition her onto her back from the prone position, at which time he attempted to stimulate her and obtain vital signs, but he discovered she had no heartbeat or breathing activity. He said he then left the room to obtain the crash cart but he then felt that he did not need any items from the crash cart, so he returned to Resident #2's room and CPR was initiated at that time. He was unsure of the amount of time that lapsed between CNA AJ initially attempting to notify him of Resident #2's condition and when CPR was initiated. He said he had not been given training regarding the procedure for initiating a code blue at the facility. In a joint interview with the DON and ADM on [DATE] at 10:36 AM, the ADM said the incident had initially been reported to the SSA because it was reported by staff that the resident was found unresponsive on the floor, but their interview with CNA AJ revealed CNA AJ had assisted Resident #2 to the floor, so she didn't feel the incident should have been reported. She said the facility investigation was nearly complete and had not reflected any indications of neglect. She said the facility had reviewed the camera footage and found the footage to be consistent with CNA AJ's account of the incident, but the footage was unavailable for surveyor review due to technical issues. She said when she interviewed CNA AJ, he did not tell her that there was a delay in initiating assistance from the nurse. She said she had not yet interviewed RN AB, and she was unaware RN AB had left the room again prior to initiating CPR. She said she was aware Resident #2 had not received any of her scheduled medication on [DATE] but had not yet interviewed staff to determine the cause. In an interview with the DCS on [DATE] at 11:30 AM, the DCS said she had assisted the facility with investigating the death of Resident #2. She said she had not yet interviewed RN AB as part of the investigation, but RN AB would be suspended beginning [DATE] until the investigation was complete. Review of facility Abuse/Neglect Policy, undated, revealed that Neglect is defined as 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. If an allegation involves serious bodily injury, the reporting of incident should be made within 2 hours of the allegation. Further review revealed: .4. With an allegation of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property, the employee will immediately be suspended pending an investigation. The employee will have an opportunity to present a written statement to answer the allegation(s) of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property 6. The Abuse Preventionist and/or administrator will conduct a thorough investigation of the incident(s). A copy of the written report will accompany any personnel action deemed necessary .

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable and, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 2 of 5 medication carts (A Hall cart and C Hall cart) reviewed for storage of drugs and biologicals.The facility failed to ensure the carts for A Hall and C Hall were locked and secured or labeled and dated.This failure could place residents at risk of medication misuse, medication errors, drug diversion or harm due to accidental ingestion of unprescribed medications.The findings include:1. During an observation on 07/11/2026 at 11:37 AM, revealed the medication cart on A Hall, secured unit, was left unlocked and unattended. The medication cart was against the nurses station with drawers facing out towards residents. Three unknown resident ambulated within 10 feet of the unlocked medication cart. MA Q exited from a resident room several doors down from the nurses station and approached the medication cart. MA Q noticed the cart was unlocked and rushed to secure the medication.During an interview on 07/11/2026 at 1139 AM, MA Q stated she should not leave the medication cart unlocked and she was running around like crazy and must have missed it. MA Q stated the medication cart should be locked if she was not using it and residents could be negatively affected by the medication cart being unlocked as they could take medications that they were not prescribed. MA Q stated that she did not have a charge nurse on her hall so she was doing everything.2. During an observation on 07/16/2026 at 6:03 AM, medication cart on C hall was left unlocked and unattended. The medication cart was halfway down the hallway, facing outward. Two unknown aides were in a room two doors down transferring a resident. RN AW exited a room several doors down from the medication cart. There were no residents near the medication cart.During an interview on 07/16/2026 at 6:05 AM, RN AW stated the policy was that the medication carts were to be locked when staff walked away and that the negative outcome for residents could be they take something that was not prescribed. During an interview on 07/16/2026 at 2:57 PM, ADON D stated medication carts should be locked when staff were not next to them. The negative outcome could be a resident taking something they were not prescribed and being injured. 3. During an observation on 07/17/2026 at 12:07 PM, revealed the medication cart on A hall had one bottle of Latanoprost eye drops without an open date on the bottle or box and two bottles of Fluticasone nasal spray without an open date on the bottles or boxes.During an interview on 07/17/2026 at 12:07 AM, LVN Y stated all three bottles on the medication cart should have an open date either on the bottle or on the box. LVN Y stated failure to do this could affect medication potency and hinder affects to residents utilizing the medications.During an interview on 07/17/2026 at 5:35 PM, the DON stated all medication carts should be locked, medications labeled, medications signed out, and medications monitored per policy or professional standards to prevent accidents to residents.Record review of the facility's undated, Medication Storage in the Facility Policy, reflected all medications should be stored safely, securely and properly following manufacturer's recommendations or those of the supplier. Policy also revealed that medication rooms, carts and medication supplies are locked or attended to by persons with authorized access and that medications should have open dates ,or use by dates, where

Based on observation, interview, and record review, the facility failed to provide necessary services to maintain good grooming, personal hygiene for residents who were unable to carry out activities of daily living for 3 of 5 residents (Residents #1, #2, and #3) reviewed for ADLs. 1. The facility failed to ensure Resident #1 received scheduled showers on 6/13/2026, 6/16/2026, 6/18/2026, 6/20/2026, 6/23/2026, 6/25/2026. 2. The facility failed to ensure Resident #2 received scheduled showers on 6/13/2026, 6/16/2026, 6/18/2026, 6/20/2026, 6/23/2026, 6/25/2026, 6/27/2026, 6/30/2026. 3. The facility failed to ensure Resident #3 received scheduled showers on 6/15/2026, 6/19/2026, 6/22/2026, 6/24/2026, 6/26/2026. These failures could place residents at risk of skin breakdown, infection, and contribute to feelings of poor self-esteem and hopelessness.The findings included: 1. Record review of Resident #1's admission record, dated 7/2/2026, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which include: multiple sclerosis (autoimmune disease that affects the central nervous system, leading to damage of the myelin sheath that protects nerve fibers, resulting in a range of physical and cognitive symptoms), hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (often resulting from a stroke leading to one-sided paralysis or weakness), and muscle weakness unspecified. Record review of Resident #1's quarterly MDS assessment, dated 6/2/2026, revealed a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. Further review revealed the resident had impairment on both sides of the upper extremity (shoulder, elbow, wrist, hand) and lower extremity (hip, knee, ankle, foot) and required substantial/maximal assistance for sit to stand and dependent chair/bed-to-chair transfer. Record review of Resident #1's undated care plan revealed a focus area for the following: The resident had hemiplegia/hemiparesis with the intervention assist with ADLs/mobility as needed initiated on 11/18/2025. The resident has an ADL self-care performance deficit with the intervention Bathing: requires staff x2 for assistance initiated on 11/18/2025. Record review of Resident #1's EMR bathing task sheet revealed no baths/showers were recorded on the EMR bath task record and 6/12/2026 showed an entry of not applicable. Baths or refusals were missing on the EMR for the dates of 6/13/2026, 6/16/2026, 6/18/2026, 6/20/2026, 6/23/2026, 6/25/2026, 6/27/2026, and 6/30/2026. Record review of Resident #1's bathing schedule in the shower sheet binder revealed scheduled bathing days were Tuesday, Thursday, Saturday during the 3-11 shift. No shower sheets were provided for 6/13/2026, 6/16/2026, 6/18/2026, 6/20/2026, 6/23/2026, and 6/25/2026. During an observation and interview on 6/30/2026 at 4:35 PM, Resident #1 was sitting in bed and appeared clean. Resident #1 stated There are some things that can be better. I wasn't told when I could take a shower. I was told 3 days a week. I asked what days. Finally told Monday-Wednesday-Friday. Then I was told Tuesday-Thursday-Saturday. I never got a shower. I went 3-4 weeks without taking a shower. When I was able to, the shower chair was broke. I have taken 4 showers in the time I have been here. I spoke to (the ADMIN), spoke to the State. I am currently only taking a shower 1 times a week. The CNAs would say I am the only one here, so I can't give you a shower. The CNA said they needed to send someone to help me. Last shower was last Saturday. I usually get them in the evenings. 2. Record review of Resident #2's admission record, dated 7/1/2026, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included: end stage renal disease (final stage of chronic kidney disease, where the kidneys can no longer function adequately to sustain life without treatment), unspecified visual loss, neuralgia and neuritis (nerve pain and inflammation of the nerve), unspecified, muscle weakness (generalized). Record review of Resident #2's quarterly MDS, dated [DATE], revealed a BIMS score of 14 out of 15, which indicated the resident was cognitively intact. Further review revealed the resident required substantial/maximal assistance for sit to stand and partial/moderate assistance for chair/bed-to-chair transfer. Record review of Resident #2's undated care plan revealed focus areas for the following: The resident has actual impairment to skin integrity r/t trauma to left knee, trauma to left foot with the intervention Keep skin clean and dry initiated on 5/20/2026. The resident has an ADL self-care performance deficit, with interventions including, Bathing: requires staff x1-2 for Part(ial)/mod(erate) assistance initiated on 3/11/2026 and revised on 3/18/2026. Record review of Resident #2's EMR bathing task sheet revealed no baths/showers were recorded on the EMR bath task record and 6/20/2026 showed an entry of Not Applicable. Baths or refusals were missing on the EMR for the dates of 6/13/2026, 6/16/2026, 6/18/2026, 6/20/2026, 6/23/2026, 6/25/2026, 6/27/2026, and 6/30/2026. Record review of Resident #2's bathing schedule in the shower sheet binder revealed scheduled bathing days were Tuesday, Thursday, Saturday during the 3-11 shift. The shower sheets provided by ADON D revealed that Resident #1 received a bath on 7/1/2026. No shower sheets were provided for 6/13/2026, 06/16/2026, 06/18/2026, 06/20/2026, 06/23/2026, 06/25/2026, 6/27/2026, 6/30/2026. During an observation and interview on 7/1/2026 at 12:47 PM, Resident #2 was sitting in his wheelchair in his room. He appeared clean and no odors were noted. Resident #2 stated, I have not had a shower for 3 months. I refuse care because they don't take care of me. 3. Record review of Resident #3's admission record, dated 7/2/2026, revealed a [AGE] year-old male readmitted to the facility on [DATE], with an original admission date of 12/21/2022, with diagnoses which included: hemiplegia and hemiparesis following cerebral infarction primary admitting dx affecting left non-dominant side (often resulting from a stroke leading to one-sided paralysis or weakness), unspecified lack of coordination, muscle weakness (generalized), and neuralgia and neuritis, unspecified (nerve pain and inflammation of the nerve), unspecified, muscle weakness (generalized). Record review of Resident #3's quarterly MDS, dated [DATE], revealed a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. Further review revealed the resident had impairment on one side of the upper extremity (shoulder, elbow, wrist, hand) and lower extremity (hip, knee, ankle, foot) and required substantial/maximal assistance for sit to stand and was dependent chair/bed-to-chair transfer. Record review of Resident #3's undated care plan revealed focus areas for the following: The resident has an ADL self care performance deficit, hx of CVA with left hemiparesis. with the interventions Bathing: requires staff x1 for assistance, initiated on 9/3/2025 and Bathing: The resident requires extensive assist from staff participation with bathing initiated on 9/3/2025. Record review of Resident #3's EMR bathing task sheet revealed the resident received a shower on 7/1/2026 and refused a bath on 6/17/2026. The EMR showed an entry 6/24/2026 of not applicable. Baths or refusals were missing on the EMR for the dates of 6/15/2026, 6/19/2026, 6/22/2026, 6/24/2026, 6/26/2026, and 6/29/2026. Record review of Resident #3's bathing schedule in the shower sheet binder revealed scheduled bathing days were Monday, Wednesday, Friday during the 3-11 shift. The shower sheets provided by ADON D revealed that Resident #3 refused a bath/shower on 6/17/2026 and received a bath/shower on 6/29/2026 and 7/1/2026. No shower sheets were provided for 6/15/2026, 6/19/2026, 6/22/2026, 6/24/2026, 6/26/2026. During an observation and interview on 6/30/2026 at 5:01 PM, Resident #3 was lying in bed watching TV. He stated, The morning shift said I refused a shower, but I never do. I am scheduled Monday-Wednesday-Friday. During an interview on 6/30/2026 at 4:56 PM, CNA A revealed that a shower list is used to determine residents that are scheduled to receive shower each day. She stated that shower sheets are completed, the nurse reviews the shower sheet, and then we (CNAs) enter them into POC. She said that a shower sheet is still filled out if the resident refused, the nurse signs it, and we enter it (refusal) into POC. During an interview on 7/2/2026 at 3:30 PM, CNA B revealed that residents are showered 3 times a week. She stated that she knew which residents to showering by checking the shower book or the nurses let me know which residents need a shower. She said the records they are required to keep are The shower sheet for each resident. If they refuse, I tell the nurse. I also tell them (resident) I can make time later if they'd like. Every shift I fill out the POC with showers provided. She revealed that shower sheets are maintained in the binder at the nurse's station. And POC is on any computer. She said when a resident refuses a shower, (I) let the nurse know. I write a shower sheet and write refused. I also enter (the refusal) into POC. She said I make as much time as I can to complete the showers. I will let the resident know I am passing the task to the next shift. Sometimes there are only two CNAs, and we do not have enough staff to complete all showers. During an interview on 7/1/2026 at 3:15 PM, LVN C stated If a resident refuses (a shower), I can't say that it is always recorded. They may record it in their POC, but I don't go thru and check to see what's documented. She said of her responsibilities for showers, I don't do showers, I give out assignments with the room numbers, I look at the census and divide the daily duties by the number of CNAs. My responsibility is my nursing duties. She stated if a resident refuses a shower, I talk to the res and try to encourage them, but at the end of the day the client has a right to elect to not shower. Documentation is the next thing. During an interview on 7/1/2026 at 3:44 PM, ADON D revealed that shower schedules are A-beds are completed by the 7AM-3PM shift, B-beds are completed by the 3PM-11PM shift, and residents are on a Monday/Wednesday/Friday or Tuesday/Thursday/Saturday schedule. She said the bathing task is In POC for CNAs to view. Kardex for all staff to view. Sheets in the shower books. And some have it written on the bulletin board. The CNAs are required to fill out a sheet. The ADONs review the sheets and refusals. The CNAs report to the charge nurse. The charge nurse alerts ADONs to refusals. The ADONs make the schedule and not the charge nurse. During an interview on 7/2/2026 at 3:18 PM, the DON stated her responsibility regarding showers was To ensure overall that they are getting done. The ADONs are ultimately responsible for seeing they are happening on their halls. She said the records that are a part of the program are Shower sheets at every nurse's station and the POC. She stated regarding review of the shower records, I have been pulling them up and with the ADONs to make sure they are correct or not. I am not going to lie; there are some that are missed. I instructed the ADONs to get with the CNAs for the missed showers. Record review of the facility's policy titled, Bath, Tub/Shower, with no revision date noted, revealed the following: Bathing by tub bath or shower is done to remove soil, dead epithelial cells, microorganisms from the skin, and body odor to promote comfort, cleanliness, circulation, and relaxation.The frequency and type of bathing depends on resident preference, skin condition, tolerance and energy level.Although a daily bath or shower is preferred and necessary for some, the aging skin can be maintained by bathing every two days or with partial bathing as needed . The resident will experience improved comfort and cleanliness by bathing.The resident will maintain intact skin integrity.The resident will be free from soil, odor, dryness, and pruritus following bathing.The resident will receive assistance with bathing according to their resident centered plan of care.

Based on observation, interview, and record review, the facility failed to provide necessary services to maintain good grooming, personal hygiene for residents who were unable to carry out activities of daily living for 3 of 6 Residents (Residents #1, #2, and #3) reviewed for quality of life. 1. The facility failed to ensure Resident #1 received scheduled showers on 04/22/2026, 04/27/2026, 05/1/2026, 05/4/2026, 05/6/2026, 05/8/2026, and 05/13/2026. 2. The facility failed to ensure Resident #2 received scheduled showers on 04/25/2026, 04/28/2026, 05/9/2026, and 05/12/2026. 3. The facility failed to ensure Resident #3 received scheduled showers on 04/22/2026, 04/27/2026, 05/8/2026, 05/13/2026, and 5/15/2026. These failures could affect any resident and contribute to feelings of poor self-esteem and hopelessness.The findings included: 1. Record review of Resident #1's admission record, dated 05/18/2026, revealed a [AGE] year-old male readmitted to the facility on [DATE], with an original admission date of 06/03/2022, with diagnoses which include: unspecified dementia, unspecified severity, with other behavioral disturbance (cognitive decline accompanied by behavioral disturbances such as sleep issues), vascular dementia, unspecified severity, with other behavioral disturbance (cognitive decline accompanied by behavioral disturbances such as agitation, depression or anxiety) and hemiplegia and hemiparesis following cerebral infraction affecting right dominant side (often resulting from a stroke leading to one-sided paralysis or weakness). Record review of Resident #1's MDS assessment, dated 07/08/2025, revealed a BIMS score of 3 out of 15, which indicated severe cognitive impairment. Further review revealed the resident needed substantial/maximal assistance to shower/bathe self and was independent for tub/shower transfers. Record review of Resident #1's care plan, last revised on 02/20/2026, revealed a focus area for the following: The resident has a ADL self-care performance deficit r/t confusion, dementia, hemiplegia, impaired balance, ambulates without assistance device, revised on 04/25/2025, with interventions including, Bathing/Showering: the resident requires moderate by 1 staff with showering 3 times weekly and as necessary, revised on 04/09/2024. Record review of Resident #1's task record revealed the residents scheduled bathing days as Tuesdays, Thursdays, and Saturdays. Review of the task record set for a 30-day look back period reflected the following dates as marked as not applicable; 04/22/2026, 04/27/2026, 05/1/2026, 05/4/2026, 05/6/2026, 05/8/2026, and 05/13/2026. During an observation and interview on 05/18/2026 at 11:50 a.m., Resident #1 was sitting in bed and appeared clean. Resident #1 stated the staff did not shower him but instead he showered himself. Resident #1 could not recall the last time they had showered him. Resident #1 stated they did like to shower. 2. Record review of Resident #2's admission record, dated 05/18/2026, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included: multiple sclerosis, unspecified (neurological disorder where the immune system attacks apart of the nerve cells), hemiplegia and hemiparesis following cerebral infraction affecting left non-dominant side (often resulting from a stroke leading to one-sided paralysis or weakness), and muscle weakness. Record review of Resident #2's MDS, dated [DATE], revealed a BIMS score of 15 out of 15, which indicated the resident's cognition was intact for daily decision-making skills, and did not have an indication of the assistance level Resident #2 required for shower/bathing nor tub/shower transfers. Record review of Resident #2's care plan, last revised on 01/14/2026, revealed a focus area for the following: The resident has a ADL self-care performance deficit, initiated on 11/18/2025, with interventions including, bathing: requires staff x2 for assistance, initiated on 11/18/2025. Record review of Resident #2's task record revealed no indication of the resident's shower schedule. Review of the task record set for a 30-day look back period reflected the following dates as marked as not applicable; 04/25/2026, 04/28/2026, 05/9/2026, and 05/12/2026. During an observation and interview on 05/18/2026 at 10:43 a.m. Resident #2 was in his wheelchair and appeared disheveled. Resident #2 stated he thought his shower days were Monday, Wednesday, and Friday. Resident #2 stated he was lucky if he got one shower a week and thought the last shower he got was last Thursday, 05/14/2026. Resident #2 stated he never refused a shower and if he did not get one it was because of the facility being short staffed. Resident #2 stated he would ask for showers and not get one. 3. Record review of Resident #3's admission record, dated 05/18/2026, revealed a [AGE] year-old female readmitted to the facility on [DATE], with an original admission date of 10/14/2021, with diagnoses which included: restless legs syndrome (neurological disorder that causes an irresistible urge to move legs), muscle wasting and atrophy, not elsewhere classified, multiple sites (refers to loss of muscle mass and strength at an unspecified site), and muscle weakness. Record review of Resident #3's MDS, dated [DATE], revealed a BIMS score of 12 out of 15, which indicated the resident's cognition was intact for daily decision-making skills, and did not have an indication of the assistance level Resident #3 required for shower/bathing nor tub/shower transfers. Record review of Resident #3's care plan, last revised on 10/06/2025, revealed a focus area for the following: The resident has a ADL self-care performance deficit r/t impaired balance, pain in lower extremity, revised on 03/26/2024, with interventions including, bathing/showering: resident prefers to bath independently, revised on 11/24/2025. Record review of Resident #3's task record revealed the residents scheduled bathing days as Monday, Wednesday, and Friday. Review of the task record set for a 30-day look back period reflected the following dates as marked as not applicable; 04/22/2026, 04/27/2026, 05/8/2026, 05/13/2026, and 5/15/2026. During an observation and interview on 05/18/2026 at 10:11 a.m. Resident #3 was sitting in her wheelchair in the hallway and appeared clean. Resident #3 stated she was supposed to get showers on Monday's, Wednesday's, and Friday's and received a shower on 05/15/2026 but before then it had been about two weeks since the last shower. Resident #3 stated staff told her they did not have any help when Resident #3 did not receive showers. Resident #3 stated they did not feel safe showering alone and that was why they waited for staff to be available. During an interview on 05/19/2026 at 12:42 p.m., CNA A stated residents should be receiving three showers a week based off their bathing schedule. CNA A stated residents were not receiving their showers due to short staffing. CNA A stated resident shower days were based off of the hall they were in and if their room number was even or odd. CNA A stated residents had complained about not receiving showers and when it was brought up to management the CNAs would provide them with a shower then. CNA A stated if not applicable had been marked on a resident's shower sheet they were not sure why other than the CNA did not get to the resident's shower that day. CNA A stated Resident #3 had not raised any concerns regarding showers to staff, the resident had not refused showers in the past, and the CNA provided the resident with showers. CNA A further stated Resident #1 needed assistance with showers, did not refuse showers, and was provided with showers. CNA A stated if a resident did not get their weekly showers, it could cause skin infections. During an interview on 05/19/2026 at 2:02 p.m., LVN B stated residents should be receiving three showers a week. LVN B stated residents were not receiving three showers a week due to staffing. LVN B stated it had been brought up to management, and they were told the nurses needed to step in and help. LVN B stated they were told the facility was trying to hire people. LVN B stated if a resident had a complaint regarding not getting showered, they would do it. LVN B stated the CNAs were supposed to use the shower sheets to document, but some CNAs had told them when a resident did not get showered, but some CNAs did not. LVN B stated Resident #2 received showers but did not know why they were not being documented. LVN B stated if a resident did not get their weekly showers, it could cause skin breakdown and/or personal humiliation. During an interview on 05/19/2026 at 5:09 p.m., the DON stated residents should be receiving a minimum of three showers weekly, either on Monday, Wednesday, Friday or Tuesday, Thursday, and Saturday. The DON stated they had been actively working to hire more staff. The DON stated they were unsure of why CNAs were marking not applicable on shower sheets due to the shower sheets having other options to mark instead such as resident refused or resident not available. The DON stated she had been aware of the complaints made by residents regarding not receiving showers. The DON stated if a resident did not receive their showers it could lead to UTIs, fungal rashes, and all different skin issues or infections. Record review of the facility's policy titled, Bath, Tub/Shower, with no revision date noted, revealed the following: Bathing by tub bath or shower is done to remove soil, dead epithelial cells, microorganisms from the skin, and body odor to promote comfort, cleanliness, circulation, and relaxation.The frequency and type of bathing depends on resident preference, skin condition, tolerance and energy level.Although a daily bath or shower is preferred and necessary for some, the aging skin can be maintained by bathing every two days or with partial bathing as needed . The resident will experience improved comfort and cleanliness by bathing.The resident will maintain intact skin integrity.The resident will be free from soil, odor, dryness, and pruritus following bathing.The resident will receive assistance with bathing according to their resident centered plan of care.

Based on observation, interviews, and record review, the facility failed to provide treatment and care in accordance with the comprehensive person-centered care plan and in accordance with professional standards of practice for 1 of 6 residents (Resident #4) reviewed for quality of care. The facility failed to ensure Resident #4 received wound care on 04/01/2026, 04/03/2026, 04/05/2026, 04/06/2026, 04/07/2026, 04/08/2026, 04/09/2026, 04/10/2026, 04/11/2026, 04/12/2026, 04/13/2026, 04/15/2026, 04/16/2026, 04/20/2026, 04/20/2026, 04/24/2026, 04/30/2026, 05/06/2026, 05/08/2026, 05/09/2026, 05/10/2026, 05/13/2026, 05/04/2026, and 05/18/2026. These failures could affect residents who receive wound care treatments by placing them at risk for receiving inadequate treatments resulting in the worsening of the wounds.The findings include: Record review of Resident #4's face sheet, dated 05/20/2026, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included: type 2 diabetes mellitus with hyperglycemia (insulin resistance and high blood sugar levels) and pressure ulcer of right heel, stage 4 (full-thickness wound that exposes muscle, tendon, or bone). Record review of Resident #4's MDS, dated [DATE], revealed a BIMS score of 14 out of 15, which indicated the resident's cognition was intact for daily decision-making skills. The MDS indicated Resident #4 had 1 stage 4 pressure ulcer in Section M-Skin conditions under M0300. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage. Record review of Resident #4's weekly ulcer assessment dated [DATE] revealed a stage 4 ulcer to the right heel, present upon admission, with dimensions of length 2.5cm by width 2.5cm by depth 0.2cm, with no odor or drainage, and with current wound treatment as clean with NS, pat dry, apply calcium alginate, cover with border gauze and secure with gauze bandage roll. Apply boots and off load, air mattress. Record review of Resident #4's wound care physicians' initial wound evaluation and management summary, dated 03/25/2026, revealed a stage 4 pressure wound of the right heel, full thickness with dimensions length 2.5 cm width 2.5 cm and depth 0.2 cm and no signs of infection. Record review of Resident #4's wound care physicians' wound evaluation and management summary, dated 04/24/2026, revealed a stage 4 pressure wound of the right heel, partial thickness, with dimensions length 2.5 cm width 2.5 cm and depth 0.1c m and no signs of infection. The evaluation stated the wound had improved evidenced by decreased depth and decreased necrotic tissue. Record review of Resident #4's wound care physicians' wound evaluation and management summary, dated 05/20/2026, revealed the stage 4 pressure wound of the right heel, full thickness was changed to a diabetic wound of the right heel, full thickness, with dimensions length 1.0 cm width 2.0 cm and depth 0.1 cm and no signs of infection. The evaluation stated the wound had improved evidenced by decreased surface area. Record review of Resident #4's care plan, last revised on 04/23/2026, revealed a focus area for the following: The resident has a pressure ulcer to right heel, with a revised date of 04/16/2026, with interventions including, follow facility protocols for treatment of injury, and, treatment as ordered, with a revised date of 04/16/2026. Record review of Resident #4's order summary, dated 05/19/2026, reflected the following: - Wound care: stage 4 ulcer: clean with NS, pat dry, apply calcium alginate and apply dry dressing. PRN, one time a day for pressure injury, with an order date 03/23/2026 with no end date.- May have pressure relieving mattress, every day shift, with an order date 03/23/2026 with no end date.- Zinc Oral Tablet (Zinc) give 220 mg by mouth one time a day for wound healing related to pressure ulcer of right heel, stage 4, with an order date of 03/23/2026 with no end date.- Vitamin C oral tablet 500 mg (ascorbic acid) give 1 tablet by mouth in the morning for wound healing related to pressure ulcer of right heel stage 4, with an order date of 03/23/2026 with no end date.- Protein Oral Liquid (protein), give 30 ml by mouth three time a day for wound healing related to pressure ulcer of right heel, stage 4, with an order date of 03/24/2026 with no end date. Record review of Resident #4's April WAR indicated no documentation of wound care for the following dates: 04/01/2026, 04/03/2026, 04/05/2026, 04/06/2026, 04/07/2026, 04/08/2026, 04/09/2026, 04/10/2026, 04/11/2026, 04/12/2026, 04/13/2026, 04/15/2026, 04/16/2026, 04/20/2026, 04/20/2026, 04/24/2026, and 04/30/2026. Record review of Resident #4's May WAR indicated no documentation of wound care for the following dates: 05/06/2026, 05/08/2026, 05/09/2026, 05/10/2026, 05/13/2026, 05/04/2026, 05/18/2026. During an interview on 05/18/2026 at 3:48 p.m., the DON stated they currently did not have a treatment nurse and the nurses assigned to the floor were responsible for providing the residents with wound care treatment. The DON stated the nurses knew they were responsible for providing wound care to the residents who required it. The DON stated the ADON was responsible for overlooking wound care while their facility did not have a wound care nurse. During an interview on 05/19/2026 at 2:02 p.m., LVN B stated the floor nurses were responsible for wound care. LVN B stated they were supposed to be checking the resident's administration record everyday to know who required wound care. LVN B stated they were supposed to be documenting wound care on the residents' WAR or TAR. LVN B stated no one had been ensuring the wound care was completed. During an interview on 05/19/2026 at 4:08 p.m., ADON D stated she would round with the wound care practitioner when they were at the facility. ADON D stated the nurses on the floor were responsible for providing wound care to residents. ADON D stated nurses knew which residents required wound care because she told them to check orders every time they came in, especially because they facility did not have a wound care nurse. ADON D stated no one was checking to make sure wound care was provided to residents. ADON D stated if residents were not provided with wound care as ordered their wounds could get worse and the residents could have an overall decline. ADON D stated no wounds had gotten worse to their knowledge. During an interview on 05/19/2026 at 4:55 p.m., Wound Care Physician E stated the facility regularly communicates with them regarding wound care and they were made aware of issues, if any, that would arise. Wound Care Physician E stated she gave orders to the facility regarding treatment and participated in care planning. Wound Care Physician E stated they were not aware of any issues with any wounds at the facility. During an interview on 05/19/2026 at 5:09 p.m., the DON stated it appeared that Resident #4 did not receive wound care for the right heel based off of Resident #4's WAR. The DON stated Resident #4's wound had not gotten worse. The DON stated if wound care was not provided as ordered it could possibly lead to the wound getting worse or hospitalization. During an interview on 05/20/2026 at 11:02 a.m., LVN B stated they were familiar with Resident #4 and were a regular nurse on Resident #4's hall. LVN C stated she knew he had a wound but thought it had been resolved. LVN C stated she could not recall providing wound care treatment to Resident #4's right heel. During an interview on 05/20/2026 at 11:10 a.m., LVN C stated they were familiar with Resident #4 and were a regular floor nurse on Resident #4's hall. LVN C stated the floor nurses were responsible for the residents' wound care and LVN C personally provided wound care for the residents who required wound care treatment. LVN C stated they checked residents' WARs and TARs anytime they were working and that was how they knew who required wound care. LVN C stated they had provided wound care to Resident #4's right heel the morning of 05/20/2026 and the resident's right heel did not look infected. LVN C stated they were not aware of if any other nurses had been providing wound care to Resident #4. LVN C stated they documented when they provided wound care to Resident #4 in the resident's WAR or TAR. LVN C stated the risk of not providing wound care could be the wound getting worse or infection. During an interview and observation on 05/20/2026 at 11:38 a.m., Resident #4 had a what appeared to be a clean white bandage over their right heel with a date of 05/21/2026. Resident #4 stated they received wound care treatment but not daily. Resident #4 stated their wound sometimes hurt but it appeared to be healing. Resident #4 stated he was not sure how often the wound care was supposed to be completed. During an interview on 05/20/2026 at 11:59 a.m., ADON D stated they were aware of Resident #4's right heel pressure wound. ADON D stated they were not aware of Resident #4's lack of wound care treatment. ADON D stated ADON E had informed them on 05/15/2026 that the wound to Resident #4's right heel had been resolved. During an interview on 05/20/2026 at 12:51 p.m., Wound Care Physician E stated they were familiar with Resident #4's right heel wound. Wound Care Physician E stated the wound had decreased in size since Resident #4 arrived at the facility and that they had no concerns with the wound deteriorating. Wound Care Physician E stated they had received a picture from facility staff on 05/15/2026 which showed Resident #4's wound dimensions as length 1.5 cm by width 2.3 cm. Wound Care Physician E stated if wound care was not provided as ordered then the wound could deteriorate. During an interview on 05/20/2026 at 3:55 p.m., ADON G stated they took a picture of Resident #4's right heel wound on 04/24/2026 and that was the last time ADON G saw Resident #4's wound. ADON G stated Resident #4's right heel wound appeared yellowish, not open and no pink area on 04/24/2026. ADON G stated if wound care was not provided as ordered the wound could further break down. During an interview on 05/20/2026 at 4:38 p.m., LVN C stated if they did not document in Resident #4's WAR or TAR regarding the resident's wound care to the right heel it could have been due to either not getting around to documenting the care, or that they did not get to the wound care and would report that to the nurses coming in for the next shift. During an interview and observation on 05/20/2026 at 5:00 p.m., Wound Care Physician F performed a wound care observation and assessment on Resident #4's right heel wound. Wound Care Physician F stated the wound was open and not necrosed, and the wound measured at length 1.0 cm, width 2.0 cm, and width 0.1 cm. Wound Care Physician F stated Resident #4's wound looked really healthy and would be changing the pressure wound to a diabetic wound instead. Wound Care Physician F stated the wound had improved by 68% since the last time Resident #4 had been seen by the wound care company. Record review of the LVN B and LVN C's Nurse Proficiency audit, with no date, revealed both had been checked off as satisfactory for treatment procedures. Record review of the facility's policy titled, Pressure Injury: Prevention, Assessment and Treatment, revision date 05/25/2025, revealed: 7. Nursing Care plan. 2. Under Nursing intervention physician ordered treatments.

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 2 of 6 residents (Residents #4 and #5) reviewed for accuracy of records: 1. Nursing staff failed to document accurate weekly skin assessments and weekly ulcer assessments for Resident #4 from March to May 2026 when it was documented the resident had no skin breakdown when the resident had a wound to the right heel. 2. Nursing staff failed to document weekly skin assessments for Resident #5 for May 2026. 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: 1. Record review of Resident #4's face sheet, dated 05/20/2026, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included: type 2 diabetes mellitus with hyperglycemia (insulin resistance and high blood sugar levels) and pressure ulcer of right heel, stage 4 (full-thickness wound that exposes muscle, tendon, or bone). Record review of Resident #4's MDS, dated [DATE], revealed a BIMS score of 14 out of 15, which indicated the resident's cognition was intact for daily decision-making skills. The MDS indicated Resident #4 had 1 stage 4 pressure ulcer in Section M-Skin conditions under M0300. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage. Record review of Resident #4's care plan, last revised on 04/23/2026, revealed a focus area for the following: The resident has a pressure ulcer to right heel, with a revised date of 04/16/2026, with interventions including, follow facility protocols for treatment of injury, and treatment as ordered, with a revised date of 04/16/2026. Record review of Resident #4's weekly ulcer assessment record was as follows:-Weekly ulcer assessment on 03/23/2026 documented a stage 4 right heel pressure wound with measurements length 2.5cm width 2.5cm and depth 0.2cm.- Weekly ulcer assessment on 03/31/2026 documented a stage 4 right heel pressure wound with measurements length 2.5cm width 2.5cm and depth 0.2cm.- Weekly ulcer assessment on 04/07/2026 documented a stage 4 right heel pressure wound with measurements length 1.6cm width 2.0cm and depth 0.2cm.-Weekly ulcer assessment on 04/14/2026 documented a stage 4 right heel pressure wound with measurements length 1.0cm width 2.0cm and depth 0.2cm.- Weekly ulcer assessment on 04/21/2026 documented a stage 4 right heel pressure wound with measurements length 0.5cm width 2.0cm and depth 0.2cm.- Weekly ulcer assessment on 04/28/2026 documented a stage 4 right heel pressure wound with measurements length 0.5cm width 2.0cm and depth 0.2cm.- Weekly ulcer assessment on 05/05/2026 documented a stage 4 right heel pressure wound with measurements length 0.2cm width 0.2cm and depth 0.1cm.- Weekly ulcer assessment on 05/12/2026 documented the stage 4 right heel pressure wound as closed and intact- Weekly ulcer assessment on 05/19/2026 documented a stage 4 right heel pressure wound with measurements length 1.5cm width 2.3cm and depth 0.1cm. Record Review of Resident #4's weekly skin assessments record was as follows:-Weekly skin assessment on 03/30/2026 documented no skin tears, bruises or ulcers.- Weekly skin assessment on 03/31/2026 documented no skin tears, bruises or ulcers.- Weekly skin assessment on 04/08/2026 documented a pressure ulcer.- Weekly skin assessment on 04/16/2026 documented no skin tears, bruises or ulcers.- Weekly skin assessment on 05/19/2026 documented a pressure ulcer. 2. Record review of Resident #5's face sheet, dated 05/20/2026, revealed a [AGE] year-old male readmitted to the facility on [DATE], with an original admission date of 11/06/2025, with diagnoses which included: pneumonitis due to inhalation of food and vomit (foreign substances enter lungs leading to inflammation and respiratory distress), muscle weakness, unspecified lack of coordination (signs of poor motor control), unspecified intellectual disabilities (developmental disorders characterized by significant limitations in intellectual and adaptive functioning). Record review of Resident #5's MDS, dated [DATE], revealed a BIMS score of 99 out of 15, which indicated the resident's cognition was severely impaired. Record review of Resident #5' s care plan, last revised on 05/05/2026, revealed a focus area for the following: The resident has potential for pressure ulcer development: impaired mobility, bowel and bladder incontinence, with a revised date of 01/07/2026, with interventions including, follow facility protocols/policies for the prevention/treatment of skin breakdown, with a revised date of 11/16/2025. Record review of Resident #5's weekly skin assessment record was as follows:- Weekly skin assessment on 05/06/2026 documented no skin tears, bruises, or ulcers.- Weekly skin assessment on 05/19/2026 documented a pressure ulcer. During an interview on 05/18/2026 at 3:48 p.m., the DON stated the facility did not have a treatment nurse therefore the floor nurses were responsible for weekly skin and ulcer assessments. The DON stated ADON D was responsible for ensuring weekly skin and ulcer assessments were completed when they did not have a treatment nurse. During an interview of 05/19/2026 at 2:02 p.m., LVN B stated the floor nurses were responsible for completing weekly skin assessments. LVN B stated she had not gotten to a number of skin assessments the week of 05/18/2026. LVN B stated she tried to ensure they got done. LVN B stated the risk of not completing weekly skin or ulcer assessments could be skin breakdown. During an interview on 05/19/2026 at 4:08 p.m., ADON D stated the floor nurses were responsible for completing residents' weekly skin and ulcer assessments, and the nurses were to check residents electronic record regarding if a skin assessment was due. ADON D stated they were not checking to see if skin assessments or ulcer assessments were being completed. ADON D stated the risk of not completing weekly skin assessments or ulcer assessments could be moisture associated skin damage could worsen into a pressure wound. ADON D stated to her knowledge no wounds have gotten worse. During an interview on 05/19/2026 at 5:09 p.m., the DON stated residents should be getting a weekly skin assessment. The DON stated each nurses' station had a schedule of skin assessments due for their residents. The DON stated weekly skin and ulcer assessments should be accurate and complete. The DON stated if weekly skin and ulcer assessments were not completed there could be a risk of not knowing if a wound were to develop on a resident. During an interview on 05/20/2026 at 11:10 a.m., LVN C stated the nurses were responsible for weekly skin assessments. LVN C stated they received reminders in the facility's EMR system for residents with skin assessments due. LVN C stated the risk of not completing weekly skin assessments could be a wound getting worse. During an interview on 05/20/2026 at 3:27 p.m., ADON D stated they were told by the DON to catch up on Resident #4's skin and ulcer assessments. ADON D stated that for some of Resident #4's ulcer assessments she did not have the wounds measurements so she would put the same measurements as the previous assessment because no one was measuring the wound. ADON D stated she had a couple of measurements from the previous treatment nurse and sometimes she received measurements from ADON G. ADON D stated she could not provide dates of when she received previous measurements of Resident #4's wound and what dates she had not received measurements for the wound. During an interview on 05/20/2026 at 3:55 p.m., ADON G stated the nurses on the floor measure the residents' wounds and give them to ADONG G who then gives them to ADON D. ADON G stated the nurses take measurements of the residents' wounds when ADON D asks for them. ADON G stated she could not provide the previous dates and measurements taken for Resident #4. ADON G stated ADON D is the one who completes weekly ulcer assessments. ADON G stated the risk of not completing weekly skin or ulcer assessments could be further breakdown. Record Review of the facility's policy titled, Pressure Injury: Prevention, Assessment and Treatment, revision date 05/25/2025, revealed: Assessment: 1. All residents should have a skin assessment on a weekly basis completed in [the facility's EMR system]. 2. If a resident has any type of ulcer (pressure injury, arterial, venous, diabetic) an ulcer assessment should be completed at least weekly. Record review of the facility's policy titled, Documentation, with no date, revealed: Goal 1. The facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets. 2. The facility will ensure that information is comprehensive and timely and properly signed.

Based on interview and record review, the facility failed to ensure the resident has the right to be informed of, and participate in, his or her treatment, including; the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers for 2 of 5 residents (Residents #2 and #3) reviewed for the right to be informed of, and participate in treatment.1.The facility failed to obtain signed consents for 2 anti-psychotic medications for Resident #2.2.The facility failed to obtain a signed consent for an anti-psychotic medication for Resident #3.These failures could place residents at risk for inaccurate documentation of clinical records and misuse of psychotropic medication that could result in diminished quality of care.The findings included:1.Record review of Resident #2's face sheet dated 4/24/2026, revealed a [AGE] year-old female admitted to the facility on [DATE] with the diagnoses which included: Parkinson's, chronic obstructive pulmonary disease (progressive inflammatory lung disease that restricts airflow), dementia, psychotic disorder with delusions, schizoaffective disorder (a chronic mental health condition combining schizophrenia ( hallucinations, delusions) symptoms with mood disorders -mania or depression), and major depressive disorder. Further review revealed Resident #2 was her own RP.Record review of Resident #2's Care Plan dated 2/24/2026 revealed the resident was care planned for verbally abusive with staff, fall risk, inappropriate sexual comments to male staff, and for receiving antipsychotics and antidepressant medications.Record review of Resident #2's quarterly MDS dated [DATE] revealed the resident had a BIMS score of 5, indicative of severe cognitive deficit. She needed one person assist with ADLs, had psych diagnoses, and coded for psychotropic medications.Record review of Resident #2's physician orders dated 2/16/2026, revealed the resident had orders for Ativan 0.5 mg p.o. daily in the evening (for agitation) with a start date of 2/16/2026; Oxcarbazepine 300 mg- 2 tablets p.o. daily in the evening (for psychotic disorder with delusions) with start date 2/16/2026; and Nuplazid 34 mg- 1 tablet p.o. daily in the morning (for psychosis) with start date 2/17/2026. None of the medication orders had stop dates.2.Record review of Resident #3's face sheet dated 4/23/2026 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: dementia, depression, and anxiety disorder. Record review of Resident #3's Care Plan dated 4/7/2026 revealed the resident was care planned for falls, aggression, and elopement risk.Record review of Resident #3's admission MDS BIMS assessment dated [DATE] revealed the resident had a BIMS score of 3 indicative of severe cognitive deficit coded for anxiety and antipsychotic medication.Record review of Resident #3's physician order dated 4/22/2026 revealed orders for: - Ativan 0.5 mg 1 tab p.o. every 24 hours and prn with a stop date of 5/6/2026- Ativan 0.5 mg 1 tablet twice daily for anxiety with a start date on 4/15/2026 and a stop date on 4/29/2026. Observation on 4/23/2026 at 10:56 AM revealed Resident #3 was in a smaller dining room on the Secured Unit. Further observation revealed Resident #3 appeared drowsy, nodding, and her speech was slurred. During an interview with Resident #3's RP on 4/23/2026 at 10:59 AM, Resident #3's RP stated, when they put her on the medication, it helped to calm Resident #3's behavior, but hopefully, once Resident #3 got used to the new medication, she won't be as drowsy. Resident #3's RP further stated, they felt Resident #3 was aggressive because it was all new to her- the facility and the people.During an interview on 4/23/2026 at 3:10 PM the DON checked the EHR for physician orders and consents for Resident #2 and Resident #3. The DON showed the EHR with physician orders and electronic consents, to the investigator, but no copies of signed consents in the EHR for either resident. The DON said signed consents were not needed for Ativan used for anti-anxiety. The DON said there was a consent in the electronic medical record and there was not a need for a signed consent by the resident or RP because the consent was in the EHR and generated by the EHR. During an interview on 4/24/2026 at 9:20 AM Resident #2 said she did not mind the medications she took, and she said she knew what they were. She stated, it helps me act right! It's good!During an interview on 4/24/2026 at 12:30PM the ADM said all anti-psychotic medications that were to be administered to a resident needed to have a written and signed consent before it could be administered to the resident.During an interview on 4/24/2026 at 5:00PM, the DON said it was important to have a signed consent to ensure a resident's family understood the side effects and why the resident would receive the medications, and that they were okay with the resident receiving the medication. Record review of Psychotropic Medication Consent V-5 in the EHR revealed instructions that stated, With all new orders for PSYCHOACTIVE medication, review with resident and or Responsible Party, the reason, expected benefit(s), side effects and course of treatment. PRINT A COPY AND HAVE RESIDENT/RESPONSIBLE PARTY GIVING OR DENYING CONSENT, SIGN AND SEND TO MEDICAL RECORDS. COMPLETE A SEPARATE CONSENT FOR EACH MEDICATION PRESCRIBED.Record review of facility policy titled, Psychotropic Medication dated 2/12/2025 stated A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: Anti-psychotic, Anti-depressant, Anti-anxiety, and Hypnotic.

Based on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 2 residents (Resident #1) reviewed receiving nebulizer treatments. The facility failed to ensure Resident #1's face mask and tubing were stored properly to prevent contamination when the resident's unprotected face mask and tubing were observed lying on the resident's bedside table next to their bed. This failure could put residents receiving medication via nebulizer and face masks at risk for cross-contamination and respiratory infection. The findings included: Record review of Resident #1's face sheet, dated 04/23/2026, reflected a [AGE] year old male with current admission date of 08/22/2025 with diagnoses which included: hemiplegia (paralysis affecting one side of the body) and hemiparesis (weakness affecting one side of the body) following cerebral infarction (stroke) affecting left non-dominant side, chronic obstructive pulmonary disease (a group of lung diseases that make it hard to breathe) and essential hypertension (high blood pressure). Record review of Resident #1's quarterly MDS, dated [DATE], revealed Resident #1's BIMS score of 15 which indicated intact cognitive status. Record review of Resident #1's physician orders dated 04/23/2026, revealed orders for: Oxygen LPM: 2 Via: nasal cannula as needed for shortness of breath and Albuterol Sulfate Inhalation Nebulization Solution 1.25MG/3ML (Albuterol Sulfate) 1 vial inhale orally via nebulizer every 6 hours as needed for Cough/Congestion, with a start date of 03/18/2026 and no end date. Record review of Resident #1's comprehensive care plan, initiated 09/03/2025, revealed: The resident has Emphysema/COPD and has SOB while lying flat. Prefers to keep HOB elevated when in bed, intervention, Give oxygen therapy as ordered by the physician, intervention, Head of bed to be elevated (semi-Fowlers to fowlers) or out of bed upright in a chair during episodes of difficulty breathing (Dyspnea) Report to nurse if increased difficulty breathing, intervention, Monitor/document for anxiety. Offer support, encourage resident to vent frustrations, fears. Reassure. Give PRN medications for anxiety as ordered. Monitor and report to nurse for s/sx of acute respiratory insufficiency: Anxiety, Confusion, Restlessness, SOB at rest, Cyanosis, Somnolence. Monitor/document/report to MD PRN any s/sx of respiratory infection: Fever, Chills, increase in sputum (document the amount, color and consistency), chest pain, increased difficulty breathing (Dyspnea), increased coughing and wheezing. Observation on 04/23/2026 at 10:54 a.m. revealed Resident #1 was seated in a wheelchair in the resident's room. Further observation revealed there was an unprotected face mask and tubing on the resident's bedside table attached to nebulizer machine on top of a personal refrigerator. There were no receptacles observed in the room in which to store the tubing or face mask. During an interview with Resident #1 on 04/23/2026 at 10:54 a.m., Resident #1 stated, I have COPD and that mask is for my treatment. During an interview with LVN A on 04/23/2026 at 11:25 a.m., LVN A stated the tubing and face mask were for Resident #1's nebulizer. LVN A stated oxygen tubing and face masks should be bagged to prevent contamination. LVN A stated the face mask and tubing were brand new and had been replaced that morning after a deep cleaning of the room and the staff did not have time to put them into bags yet. During an interview with the DON on 04/23/2026 at 1:30 p.m., the DON stated the expectation was that respiratory equipment such as tubing, masks, and nasal cannulas should be placed in a plastic bag when not in use and changed out weekly, and that placing the equipment in a bag was to avoid cross-contamination and potential respiratory infection. During an interview with MA B on 04/24/2026 at 12:55 p.m., MA B stated, if oxygen tubing, nasal cannulas, or masks were not in a bag, they should be switched out to avoid contamination. During an interview with RN D on 4/24/2026 at 1:52 p.m., RN D stated respiratory tubing, or masks should always be bagged when not in use to prevent infection. Record review of the facility's policy titled, Oxygen Administration, undated, revealed, Goals: 3. The resident will be free from infection. Procedure: 10. Change the tubing (including any nasal prongs or mask) that is in use on one patient when it malfunctions or becomes visibly contaminated, however; the policy did not address storing of respiratory tubing or masks, and DON was unable to provide a policy related to storing respiratory equipment.

Based on observation, interviews, and record review, the facility failed to ensure the environment was as free of accident hazards as is possible and each resident receives adequate supervision to prevent accidents for 1 of 1 resident (Resident #1) reviewed for accidents hazards and supervision: Resident #1 left the facility without supervision or staff knowledge on 3/19/26 from 11:35 p.m. to 11:57 p.m. Resident #1 was found approximately 0.1 miles away at a local fast-food restaurant. This failure could place residents at risk of accidents that could result in serious injury, harm, impairment, or death.The findings included: Record review of Resident #1's face sheet dated 3/20/26 reflected a [AGE] year old female admitted to the facility on [DATE] with diagnoses that included cerebral infarction (stroke, caused by loss of blood flow to part of the brain), COPD (Chronic Obstructive Pulmonary Disease; long-term lung condition that makes it hard to breathe), abnormal posture, muscle weakness, lack of coordination, dementia with agitation, heart failure, asthma, and fracture to the right wrist. Record review of Resident #1's most recent quarterly MDS assessment dated [DATE] reflected the resident had adequate vision, was cognitively intact for daily decision-making skills, and was independent with mobility. Record review of Resident #1's comprehensive care plan dated 1/13/26 reflected that the resident had impaired cognitive function or impaired thought processes related to disease process, forgetful at times, and dementia with agitation. Record review of Resident #1's Elopement Risk assessment dated [DATE] reflected the resident ambulated independently or with a device, understood and verbalized acceptance of the need for nursing home care, was cognitively consistent and reasonable with decision-making skills, did not have previous attempts of leaving her own residence/facility, recognized stop lights and signs, knew precautions when crossing streets, and knew the location of current residence. Record review of Resident #1's hospital visit summary dated 3/19/26 and time stamped 12:27 a.m., reflected the resident was transferred to the hospital by EMS for an unwitnessed fall at 7:00 p.m. and the resident complained of right sided head pain. The report reflected Resident #1 had a chest x-ray, a CT of the abdomen and pelvis, and a CT of the head all showing negative results. Record review of Resident #1's progress note dated 3/19/26, time stamped 6:45 a.m. and authored by LVN A revealed Resident #1 was seen in her room during the medication pass around 9:40 p.m., was alert and oriented and expressing grievance that she was supposed to be in a private room. LVN A documented he had talked to the Administrator about Resident #1's grievance. LVN A documented he then received a call from an EMS and was asked if Resident #1 lived in the facility. LVN A documented he instructed staff to go to Resident #1's room to look for her and was informed she was not in her room. LVN A documented he walked to the corner and Resident #1 was acting confused and denied knowing who LVN A was. LVN A documented that the resident was transferred to the emergency department related to confusion. LVN A documented that the nurse in the emergency department stated Resident #1 reported she had fallen at 7:00 p.m. and had hit her head. LVN A documented that Resident #1 returned to the facility at 4:00 a.m. (3/20/26) and apologized to LVN A for leaving. Record review of Resident #1's electronic record reflected the resident did not have any documented falls since the time of admission, 10/21/25. Resident #1's electronic record reflected the resident admitted to the facility on [DATE] with a diagnosis of right radius closed fracture with routine healing. During an interview on 3/20/26 at 8:14 a.m., the Administrator stated Resident #1 eloped from the facility at 11:35 p.m. on 3/19/26 and was transferred back to the facility from the hospital on 3/20/26 at 4:30 a.m. The Administrator stated, Resident #1 was observed on the video surveillance camera using the keypad to input the door code to the front entry to open the door. The Administrator stated Resident #1 had a history of going out to the local fast-food restaurant but was always accompanied by staff. The Administrator stated Resident #1 was upset because she had a roommate and wanted her own room. The Administrator stated Resident #2 was moved into Resident #1's room because she required closer monitoring and Resident #1 was offered to be moved to another room but Resident #1 rejected the idea. The Administrator stated, Resident #1 was unsupervised for about 20 minutes from 11:35 p.m. and up until LVN A received the phone call from EMS at 11:55 p.m. The Administrator stated Resident #1 was upset because another resident was placed in her room, and Resident #1 didn't sign out, she didn't tell anybody, and she somehow got the code to leave the facility. During an observation and interview on 3/20/26 at 9:00 a.m., Resident #1 was seen sitting up on the side of the bed with a walker in front of her. Resident #1 was observed with a wrist immobilizer to her right wrist, due to past injury. Resident #1 stated she was able to ambulate with the walker to go to the bathroom or to get something out of her closet and could stand long enough to do it. Resident #1 stated she used to have frequent blackouts when she lived at home but stated she could not remember the events from 3/19/26 in which she walked out of the facility and was found at the local fast-food restaurant. Resident #1 stated she was upset because they put a lady in her room when the Administrator had promised she would not have a roommate. Resident #1 stated she did not remember leaving the facility and stated, I was told I pushed the buttons on the door, but I don't even know the code, but I guess I got it open by pushing a bunch of numbers. Resident #1 stated nobody had given her the code to the front door and had only left the facility for doctor appointments, or when she obtained permission to go with family or friends. Resident #1 stated she recalled LVN A giving her medications at 8:00 p.m. (3/19/26), then she fell asleep and could not remember anything else. During an observation and interview on 3/20/26 at 10:08 a.m., Resident #1's room was located on B Hall next to the shower room and toilet on the right, and the nurse's station was next to the shower room on the left. The Administrator stated, according to his estimation, Resident #1's room was approximately 15 yards (45 feet) from her room to the dining room and a total of approximately 100 yards (300 feet) from her room to the facility front door [85 yards or 255 feet from the dining room to the front door of the facility]. Observation from Resident #1's room in the B Hall required Resident 1 to walk past three resident rooms, into the dining room, and then to the front lobby to gain access to the front door. The Administrator stated, Resident #1 was seen on the facility camera footage walking from her room, through the dining room, and to the lobby and was clearly not stumbling. During an interview on 3/20/26 at 10:16 a.m., Resident #2 stated she was moved to a room closest to the dining room because of issues related to difficulty with walking. Resident #2 stated she was moved to the same room as Resident #1 and was told by Resident #1 that she (Resident #1) wanted the room to herself and had been promised to have the room to herself. Resident #2 stated she received medications on 3/19/26 at approximately 8:30 p.m. and recalled Resident #1 had received her medication at the same time. Resident #2 stated Resident #1 did not say anything to her about leaving or about having the code, or getting the code to the door, other than she wanted the room to herself. Resident #2 stated she didn't usually go to sleep until 10:30 p.m. but recalled Resident #1 leaving the room at around 8:30 p.m. when medications were given, but was not in the room when I went to sleep. Resident #2 stated she was sure she went to sleep at 10:30 p.m. because that was the time she turned off her tv. Resident #2 stated, typically nobody checks on me after the last medication. I leave my door open a little bit if I need to get their attention. Observation of the facility video footage on 3/20/26 at 10:35 a.m. revealed Resident #1 was observed in the B Hall unit accompanied by CNA B and CNA C on 3/19/26 from 11:00 p.m. to 11:15 p.m. in the shower room. Resident #1 was observed exiting the shower room at approximately 11:30 p.m. with CNA C and Resident #1 was seen using her walker to go back into her room. The facility video footage shows there were two aides (CNA B and CNA C), one unidentified housekeeping staff, LVN A and LVN D in the unit. At approximately 11:35 p.m., Resident #1 was observed at the front door, activating the code on the keypad and exiting onto the sidewalk. The facility video footage showed LVN A walk out of the facility from the front door at 12:00 a.m. An attempt at a telephone interview with CNA B on 3/20/26 at 11:22 a.m. was unsuccessful. An attempt at a telephone interview with CNA C on 3/20/26 at 11:24 a.m. was unsuccessful. An attempt at a telephone interview with LVN D on 3/20/26 at 11:25 p.m. was unsuccessful. During a telephone interview on 3/20/26 at 11:29 a.m., LVN A stated he had administered medications to Resident #1 at approximately 9:40 p.m., and recalled the resident being upset because she had Resident #2 for a roommate. LVN A stated he told Resident #1 he would make her grievance known to the Administrator and placed a call to the Administrator at approximately 9:30 p.m., with Resident #1 witnessing the telephone exchange, and told the resident the Administrator would look into the matter of having a private room. LVN A stated Resident #1 seemed satisfied and never indicated to me that she was planning on making a run for it. LVN A stated he continued with medication pass and CNA B and CNA C assisted Resident #1 into the shower room. LVN A stated he received a phone call at approximately 11:58 p.m. from EMS staff about Resident #1 and asked LVN D to go to the resident's room to see if she was there. LVN A stated he was told by LVN D that Resident #1 was not in her room. LVN A stated it took him approximately 3 minutes to get from the facility to the local fast-food restaurant where Resident #1 was found. LVN A stated when he arrived at the local fast-food restaurant, Resident #1 was observed sitting on a stretcher and she acted like she didn't know me. LVN A stated, Resident #1 told him she had fallen and hit her head at 7:00 p.m. LVN A stated, if Resident #1 had fallen we would have known, and there was no way she would have been able to get up by herself. She has a lot of attention seeking. LVN A stated EMS staff took Resident #1 to the hospital because she appeared confused. LVN A stated he did not now how Resident #1 obtained the code to the front door but she is very observant. LVN A stated the facility had a lot of observant patients, a lot of smokers, and it's been a battle trying to keep the door codes a secret. Record review of the facility policy titled Resident Rights, undated reflected in part, .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, including those specified in this policy.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, recognizing each resident's individuality.Safe environment - The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored properly in the cart for 1 of 3 medication carts (300 hallway medication cart) reviewed for storage: he facility failed to ensure Resident #2's insulin Lispro was stored appropriately in a locked medication cart. This failure could place residents at risk of not receiving prescribed medications as ordered and drug diversions. The findings included: Record review of Resident #2's face sheet dated 3/18/26 reflected a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included type 1 diabetes (a chronic autoimmune disease in which the body's immune system destroys the insulin-producing cells of the pancreas, leading to an absolute deficiency of insulin), and dependence on renal dialysis (medical treatment that replaced some functions of the kidneys when they are no longer able to work effectively). Record review of Resident #2's most recent MDS assessment dated [DATE] reflected the resident was cognitively intact for daily decision-making skills and was treated with insulin. Record review of Resident #2's Order Summary Report dated 3/18/26 reflected the following:- Insulin Lispro Subcutaneous Solution Pen-injector 100 unit/ML, inject 4 units subcutaneously as needed for Diabetes before each session of dialysis with order date 3/3/26 and no end date.-Insulin Lispro Subcutaneous Solution Pen-injector 100 unit/ML, inject as per sliding scale subcutaneously with meals for diabetes with order date 3/5/26 and no end date. During an observation on 3/18/26 at 2:15 p.m., three medication carts on the 300 Hall were seen next to each other in front of the nurse's station facing the hallway. The middle medication cart was observed with an insulin Lispro pen on top of the medication cart counter with a pharmacy label with Resident #2's name. During an interview on 3/18/26 at 2:17 a.m., LVN E stated she had obtained the insulin Lispro pen for Resident #2 and stated she had given the resident a dose of insulin at approximately 11:30 a.m. and stated she had written the open date on the insulin cap with a black marker. LVN E stated she believed Resident #2's insulin Lispro pen may have been left on top of the medication cart by the previous shift because the medication cart counter where the insulin pen was seen was not hers. LVN E stated she could not recall if she had forgotten to lock the insulin pen in her medication cart. LVN E stated, all medications should always be locked in the medication cart because somebody could take it and if used could cause a drug reaction and it could also cause hypoglycemia (low blood sugar). During an interview on 3/18/26 at 3:02 p.m., the DON stated medications, including insulin, should be locked in the medication cart immediately after use. The DON stated, if someone took it, and it did not belong to them, they could inject themselves not knowing what it was and they could become hypoglycemia, or the insulin pen could go missing, or if the patient did take it and they were not diabetic, they could fall into a coma. The DON stated that an unlocked insulin pen was considered a safety concern. The DON stated, only nursing staff were allowed to administer insulin to the residents. Record review of the facility document titled Medication Storage in the Facility, dated 2025 reflected in part, .Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.

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 6 residents (Resident #3) reviewed for accuracy of records: The facility failed to document wound care treatments on the TAR for Resident #3 on 3/1/25, 3/6/26, 3/7/26, 3/11/26, 3/13/26, 3/14/26, 3/15/26, and 3/16/26. 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 included: Record review of Resident #3's face sheet dated 3/19/26 reflected a [AGE] year-old male admitted to the facility on [DATE], and re-admitted on [DATE] with diagnoses that included diabetes, muscle weakness, lack of coordination, retention of urine, and pain. Record review of Resident #3's most recent quarterly MDS assessment dated [DATE] reflected that the resident was cognitively intact for daily decision-making skills and was at risk for pressure ulcer/injury. Record review of Resident #3's Order Summary Report dated 3/19/26 reflected the following:- Apply TRIAD to buttocks one time a day for wound healing with order date 2/15/26 and no end date. Record review of Resident #3's MAR for March 2026 reflected the following:- Apply TRIAD to buttocks one time a day for wound healing. The TAR was missing documentation for the TRIAD treatment for Resident #3 on 3/1/25, 3/6/26, 3/7/26, 3/11/26, 3/13/26, 3/14/26, 3/15/26, and 3/16/26. Record review of Resident #3's comprehensive care plan with revision date 10/9/25 reflected the resident was at risk for alteration in skin integrity related to impaired mobility with interventions that included to use lifting device, draw sheet, etc. to reduce friction. During an interview on 3/17/26 at 4:12 p.m., Resident #3 stated he had complained about the nursing staff not administering medications for his blood pressure. Resident #3 stated he had been receiving a treatment to his buttocks with a cream every morning, and was sure of that because he did not want the area to get worse. Resident #3 stated he often refused to take medications and stated he was part of the problem. During an interview on 3/19/26 at 2:34 p.m., the ADON stated Resident #3 often refused medications and the expectation was for nursing staff to document on the MAR/TAR when a medication was refused. The ADON stated, when a resident refused medications, the MAR/TAR prompted the nurse to input a numeric code which indicated if the resident refused, or if the resident was not in the building, but the MAR/TAR should not have any blanks because it could be interpreted as the medication not being given or treatment not being done. The ADON stated the nurse who documented on the MAR/TAR should also be auditing the document daily. The ADON stated, any medications or treatments not documented on the MAR/TAR were reviewed the following day during the morning meeting. The ADON stated, I know in the nursing world, if it wasn't documented it wasn't done. The ADON stated, in Resident #3's case, she was aware he often refused medications, but the treatment of the buttocks with TRIAD was something he did not refuse. During an interview on 3/19/26 at 4:20 p.m., LVN E stated the floor nurses were responsible for providing treatments to those residents who had physician's orders for wound care. LVN E stated there should not be any blank spaces on the MAR/TAR because it looked like the medication or treatment was not given or done. LVN E stated if treatment was not done as ordered, the area could deteriorate. LVN E stated, documentation of the situation whether the medication was refused, not given, or withheld should be documented at that time. During a joint interview with the Administrator and DON on 3/20/26 at 12:54 p.m., revealed the DON stated, it was her expectation that there should not be any blanks on the MAR/TAR because it could be considered the medication was missed or the treatment was not done. The Administrator stated it was important to keep an accurate medication record otherwise there could be mistakes due to double dosing or frequency isn't maintained. The DON and the Administrator stated the clinical management team generated a report that flagged missed medications that were reviewed daily. The DON stated, she and nursing management audited the MAR/TAR for missing documentation. The DON stated, in Resident #3's case, he had a history of medication refusals, but there was no way Resident #3 refused the TRIAD treatment to his buttocks. The DON stated, it was her expectation, once a medication or treatment was completed, it would be documented immediately after completed. Record review of the facility document titled, Documentation, undated reflected in part, .Documentation is the recording of all information, both objective and subjective, in the clinical record of an individual resident and or soft resident file. It may include observations, investigations, and communications of the residents involving care and treatments. It has legal requirements regarding accuracy and completeness, legibility and timing. Special forms in the clinical record are utilized in nursing documentation, such as.nursing progress notes.medication sheets.The facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets.The facility will ensure that information is comprehensive and timely and properly signed.

Based on observations, interviews, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of needs and preferences for three (3) of twelve (12) residents (Resident #1, Resident #2, Resident #3) reviewed for reasonable accommodation of needs. 1. The facility failed to ensure the call light system in Resident #1's room was in a position accessible to the resident on 02/20/2026.2. The facility failed to ensure the call light system in Resident #2's room was in a position accessible to the resident on 02/20/2026.3. The facility failed to ensure the call light system in Resident #3's room was in a position accessible to the resident on 02/23/2026. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.The findings included: 1. Record review of Resident #1's admission Record, dated 02/20/2026, revealed an [AGE] year-old female admitted on [DATE]and re-admitted on [DATE]. Record review of Resident #1's Diagnosis Report, dated 02/23/2026, revealed diagnoses including unspecified dementia (a decline in cognitive function, impacting memory, thinking, behavior, and the ability to perform everyday activities), unspecified lack of coordination, and unspecified osteoarthritis (a condition where the protective layer that cushions the ends of the bones wears down over time leading to pain, stiffness, and reduced mobility). Record review of Resident #1's Annual MDS, dated [DATE], reflected Resident #1 had a BIMS score of 7, indicating she was severely cognitively impaired. She used a wheelchair, required setup or clean-up assistance with toileting hygiene, and was independent for her mobility needs. Record review of Resident #1's Care Plan, undated and accessed 02/20/2026 at 03:07 p.m., reflected Resident #1 had a problem related to diagnoses of dementia and impaired cognition causing the resident to sometimes not understand staff and family, date initiated and revised 02/07/2025. An intervention included Ensure/provide a safe environment: Call light in reach, ., date initiated 02/07/2025. Resident #1 had an ADL Self Care Performance Deficit (a condition where an individual has difficulty performing self-care activities such as dressing, grooming, and toileting due to physical or mental impairment), date initiated 01/06/2025. An intervention included Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed., date initiated 01/06/2025. During an observation and attempted interview on 02/20/2026 at 10:16 a.m., Resident #1, was observed lying in her bed with a walker at bedside, located close to the room door. Her call light was observed wrapped and hooked onto the wall situated behind Resident #1's headboard and towards the center of the room, away from the room door. Resident #1 stated she just got here when asked how long she had lived at the facility and when asked if she could reach her call light, she was observed to reach over her shoulder but could not touch the call light. Resident #1 stated she did not know how long her call light was in that position. Resident #1 did not answer when asked how she felt about the call light being out of reach or if she used it. During an observation and interview on 02/20/2026 at 10:18 a.m., MA A was observed standing at a medication cart two (2) doors down from Resident #1's room. MA A stated Resident #1 had moved onto her current hall around three (3) days prior but had been a resident at the facility for a while. MA A stated Resident #1 was able to perform some self-care activities independently and used a walker for mobility; however, she needed some assistance and cueing for certain tasks. MA A stated Resident #1 was confused and needed redirection. MA A stated Resident #1 did use her call light. MA A stated Resident #1's current roommate would sometimes pack up all the possessions in the room and might have possibly put Resident #1's call light on the wall. MA A stated staff were to give the call light back to Resident #1 and clip it onto Resident #1's bed. MA A stated the call light was supposed to be within Resident #1's reach. She stated staff were supposed to check throughout the day, during the two-hour rounds, and when she was passing medications to ensure the call lights were within reach of the residents. MA A stated she had observed the call light having been hooked on the wall that morning, 02/20/2026 and had not placed it at Resident #1's bedside due to providing care to another resident. 2. Record review of Resident #2's admission Record, dated 02/20/2026, revealed an [AGE] year-old female admitted on [DATE] and re-admitted on [DATE]. Record review of Resident #2's Diagnosis Report, dated 02/23/2026, revealed diagnoses including neurocognitive disorder with Lewy bodies (a brain disorder caused by a gradual buildup of proteins in the brain resulting in cognitive decline, movement difficulties, and visual hallucinations), lack of coordination, and anxiety disorder ( a mental health condition characterized by excessive, uncontrollable worry about everyday issues, affecting daily functioning and quality of life). Record review of Resident #2's Quarterly MDS, dated [DATE], reflected Resident #2 was unable to complete the BIMS interview and was moderately impaired regarding making decisions for tasks of daily life and required cues or supervision. She used a wheelchair and was dependent on an assistant for moving from sitting to lying, from lying to sitting on the side of the bed, and from transferring to and from bed to a chair. Record review of Resident #2's Care Plan, undated and accessed 02/20/2026 at 01:12 p.m., reflected Resident #2 had an ADL Self Care Performance Deficit, date initiated 07/05/2022 and revised on 02/28/2025. An intervention included Encourage the resident to use bell to call for assistance, date initiated 01/06/2025. Resident #2 had oxygen therapy (the administration of supplemental oxygen to someone who cannot get enough oxygen naturally) as needed, date initiated 03/30/2023 and revised on 09/20/2023. An intervention included Provide reassurance and allay (relieve or alleviate) anxiety (a feeling of worry or nervousness): Have an agreed-on method for the resident to call for assistance (e.g., call light, bell)., date initiated 03/30/2023. During observations on 02/20/2026 at 10:25 a.m. and 10:47 a.m., Resident #2, was observed in her bed asleep. Her call light was observed to be lying under her bed and against the wall. Resident #2 was unrousable and did not wake up enough to follow directions or attempt to demonstrate if she could have reached the call light. During an observation and interview on 02/20/2026 at 10:49 a.m., CNA B and CNA C stated Resident #2 did not use her call light. CNA B walked to Resident #2's bed, pick up the call light, and clip it onto the bed within Resident #2's reach. CNA B and CNA C stated the call light was on the floor, out of reach, and stated that though Resident #2 did not use the call light, it was still supposed to be within the resident's reach. 3. Record review of Resident #3's admission Record, dated 02/23/2026, revealed a [AGE] year-old female admitted on [DATE]. Record review of Resident #3's Diagnosis Report, dated 02/23/2026, revealed diagnoses including cerebral palsy (a condition caused from damage or abnormal development to a part of the brain which is responsible for muscle movement and leads to movement disorders and may result in developmental delays and sensory impairments), severe intellectual disabilities (a condition characterized by significant limitations in intellectual functioning such as reasoning, problem solving, planning and learning), and lack of coordination. Record review of Resident #3's Quarterly MDS, dated [DATE], reflected Resident #3 was rarely or never understood. She used a wheelchair and was dependent for her mobility needs. Record review of Resident #3's Care Plan, undated and accessed 02/23/2026 at 11:00 a.m., reflected Resident #3 had a communication problem, was non-verbal, had a diagnosis of cerebral palsy, and made sounds or gestures, date initiated 04/05/2023 and revised on 08/13/2024. An intervention included Ensure/provide a safe environment: Call light in reach. During an observation and interview on 02/23/2026 from 08:51 a.m. to 09:25 a.m., Resident #3, was initially observed in bed asleep. During medication administration, she woke up and was observed to be non-verbal. Upon entering Resident 3's room, her call light was observed to be out of Resident #3's reach, wrapped and hooked onto the wall situated along the wall toward the center of the room, past Resident 3's footboard. At 09:20 a.m., LPN D stated she did not know why Resident #3's call light was hooked onto the wall. LPN D stated she did not have a chance to check Resident #3's room earlier that morning. LPN D stated Resident #3 normally did not use or could not use the call light, but it was usually clipped to Resident #3's bed. LPN D stated housekeeping, night shift, or anyone could have put the call light there. LPN D stated the call light having been out of Resident #3's reach could definitely impact her if Resident #3 was able to use it. LPN D clipped the call button to the bed prior to leaving the room. During an interview on 02/23/2026 at 04:00 p.m., the DON stated she had always been taught that call lights were to be in reach of the residents. The DON stated the expectation was for call lights to be in reach of the residents. She stated the impact of a call light out of reach was that it could result in the residents' needs not being addressed in a timely manner. She stated at shift change or start of shift, the nurses were expected to check the more critical residents, and the CNAs, should have been completing a walkthrough on all their assigned residents, which would include checking the location of the call lights. The DON stated the facility did not have a policy on call lights. During an interview on 02/23/2026 at 04:27 p.m., the ADMIN stated his expectation was for the call lights to be within reach of the residents. He stated that even if a resident was comatose, the call light should still be within reach. He stated the impact on a resident of a call light having been out of reach was that they resident might not be able to have timely assistance. Record review of the facility's policy, Fall Policy, undated, reflected: Preventing falls requires an interdisciplinary program that focuses on modifying the extrinsic factors, correcting intrinsic factors, and educating the resident and family.Environmental .- Position call bells within reach.

Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments and permit only authorized personnel to have access to the keys for one (1) of twelve (12) residents (Resident #4) reviewed for medication storage. The facility failed to ensure Resident #4 did not have two (2) velphoro oral tablets (a phosphate binder, a medication used to control phosphorus levels in the blood) at the bedside. This deficient practice could place residents at risk of medication misuse or drug diversion.The findings included: Record review of Resident #4's admission Record, dated 02/20/2026, revealed a [AGE] year-old male admitted on [DATE] and re-admitted on [DATE]. Record review of Resident #4's Diagnosis Report, dated 02/23/2026, revealed diagnoses including end stage renal disease (the final stage of chronic kidney disease, where the kidneys lose nearly all their ability to filter waste in the blood), and dependence on renal dialysis (condition where patients are reliant on dialysis treatment due to the inability of their kidneys to adequately filter waste from the blood). Record review of Resident #4's Quarterly MDS, dated [DATE], reflected Resident #4 had a BIMS score of 15.0, indicating he was cognitively intact. He had range of motion impairment on one side for his upper extremities and both sides for his lower extremities, used a wheelchair, and was dependent on assistance when transferring to and from a bed to a chair. Record review of Resident #4's Order Summary Report, dated 02/20/2026, reflected the order Velphoro Oral Tablet Chewable 500 MG (Sucroferric Oxyhydroxide) Give 2 tablet [sic] by mouth with meals related to END STAGE RENAL DISEASE give [sic] with meals. May crush, chew or swallow, noted as active and dated as ordered 10/10/2025. There was not an order stating Resident #4 could self-medicate. Record review of Resident #4's Self Medication Program Assessment of Skills, effective date 01/23/2025, reflected Resident #4 was Fully Capable of demonstrating the correct route of medication(s) administration, knowledge of dose (strength) of medication(s), correct frequency (time) of medication(s), could verbalize the basic reason why he was taking the medication, and the knowledge of common side effects of his medication. Record review of Resident #4's Care Plan, undated and accessed 02/20/2026 at 12:36 p.m., reflected Resident #4 had impaired cognitive function/dementia (a decline in cognitive function, impacting memory, thinking, behavior, and the ability to perform everyday activities) or impaired thought processes as evidenced by a BIMS score of 8.0, date initiated and revised on 12/25/2024. An intervention included Engage the resident in simple, structured activities that avoid overly demanding tasks., date initiated 12/25/2024. There was not a focus or intervention stating Resident #4 could self-medicate. Observation and interview on 02/20/2026 at 10:28 a.m., two 2 orangish-brown, disk-like pills were observed in a disposable plastic cup on Resident #4's side table. Resident #4 stated he had just come back to his room from dialysis (provided in the facility). He stated the pills were his binders (phosphate binders) for his dialysis. He stated that they [did not identify staff member(s)] gave it to him this morning, 02/20/2026. He stated, those I chew, referring to the binders, and the rest they watch me, referring to the other medications he was administered. During an interview on 02/20/2026 at 10:51 a.m., MA E stated she did not administer Resident #4 his medications yet that morning, 02/20/2026. She stated staff were supposed to watch residents take their medications. During an interview on 02/20/2026 at 10:52 a.m., RN F stated the impact for Resident #4 if he did not want to take his phosphate binder, was that his phosphate levels could be high. She stated the dialysis staff took their own labs on the dialysis residents and they would notice if Resident #4's phosphate levels were high. RN F stated the phosphate binders were supposed to be watched by staff when administered and swallowed. During an interview on 02/23/2026 at 04:00 p.m., the DON stated her expectation, if a resident refused to take a medication during administration, was for the staff to take the medication back and never leave a medication at a resident's bedside. She stated if a resident had a high enough BIMS, the resident would need to be assessed prior to being permitted to self-administer medications. She stated, as far as she was aware, the facility did not have any residents that were allowed to self-administer medications. She stated if a resident voiced that they wanted to self-administer medications, an assessment would have to be completed, the task could be care-planned with the resident, and the task would reflect on the resident's care plan. She stated the impact of a medication having been left at a resident's bedside was that the resident could overmedicate by taking the medication too close to the administration of the same medication from a different shift, double up on the phosphate binder, or another resident could find and take the medication, thinking the medication was candy or something. During an interview on 02/23/2026 at 04:27 p.m., the ADMIN stated that if Resident #4 was assessed to be capable of self-medicating, he should still have been care planned for that task. He stated his expectation was for a mention of self-medication to be the resident's care plan. The ADMIN stated that he would defer to the clinical staff to theorize on the impact a medication could have if left at a resident's bedside. Record review of the facility's policy, Medication Administration and General Guidelines, dated 2025, reflected: PolicyMedications are administered as prescribed, in accordance with State Regulations using good nursing principles and practices and only by persons legally authorized to do so.Procedure1. Medications are prepared, administered, and recorded only by licensed nursing, medical, pharmacy, or other personnel authorized by state laws and regulations to administer medications.4. Residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with policy and procedure for self-administration of medications.Checklist for completing proper steps in the administration of medications .- Observes the resident take the medications. Record review of the facility's policy, Self-Administration of Medications by Residents Policy, undated, reflected: Each resident who desires to self-administer medication is permitted to do so if the facility's interdisciplinary team and/or facility policy allows or has determined that the practice would be safe for the resident and other residents of the facility.Procedure1. Each resident is offered the opportunity to self-administer his or her medications during the routine assessment by the facilities interdisciplinary team.2. If the resident desires to self-administer medications an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility.3. The interdisciplinary team determines the residents' ability to self-administer medications by means of completing the Self Administration of Medication assessment in PCC.4. The results of the interdisciplinary team assessment are recorded.8.The resident requests each dose from the medication nurse, who provides the medication to the resident in the unopened package for the resident to self-administer. The nurse then records such self-administration on the MAR in the manner described above.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 1 residents (Resident #1) reviewed for accidents and supervision in that: The facility failed to supervise Resident #1 who eloped from the facility on 08/16/25 and was gone from the facility for more than nine hours and found in a closed car and had sustained a heat stroke. The non-compliance was identified as PNC. The Immediate Jeopardy (IJ) began on 08/16/2025 and ended on 08/16/2025. The facility had corrected the non-compliance before the survey began on 08/17/2025. This deficient practice could place residents who were elopement risks at-risk of harm, serious injury, or death. The findings included: Review of Resident's #1 face sheet, dated 8/17/25, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included: multiple sclerosis (a condition in which nerve damage affects the communication between the brain and body), type 2 diabetes mellitus (a condition in which the body's blood sugar was not controlled), and unspecified dementia (a condition in which there is a decline in cognition). Record review of Resident #1's quarterly MDS assessment, dated 7/29/25, revealed a blank BIMS score, indicating the resident could not complete the interview. The MDS revealed that Resident #1 was ambulatory and had wandering behavior. Record review of Resident #1's elopement assessment, dated 1/16/25, revealed Resident #1 had the potential for wandering behavior and was at risk for elopement. Record review of Resident #1's care plan, initiated on 1/16/25, revealed Resident #1 had an identified risk for elopement behavior. The interventions for elopement behavior included close supervision, reporting of risk factor such as wandering behavior and requests to leave the facility to the MD, and increased monitoring. The care plan for Resident #1 was updated on 8/16/25 to include the elopement incident. Record review of Physician Order Summary, dated 8/16/25, revealed Resident #1 was taking Depakote Sprinkles 125 mg for (General Anxiety Disorder), Humalog SQ 100 unit/ML for (Diabetes Mellitus), Metformin HCI 500 MG for (Diabetes Mellitus) and Lantus SQ 300 unit for (Diabetes Mellitus). Record review of the facility incident report, dated 8/16/25, revealed Resident #1 eloped from the facility at 5:10 am and that staff first learned of the incident at 7:30 am and a search on the secure unit was initiated with a Code Orange being called at 9:00 am. Record review of the National Weather Service weather data (https://www.weather.gov/wrh/Climate?wfo=ewx) for 8/16/2025 revealed a high temperature that day of 98 degrees Fahrenheit. Record review of the employee statement from CNA P, dated 8/16/25, revealed she said she took out the trash on the secure unit side door shortly after 11:10 pm on 8/15/25 and made sure the door was locked. Record review of the employee statement from LVN B, dated 8/16/25, revealed he said he took out the trash on the morning of 8/16/25 thru the gate in the courtyard and made sure the courtyard gate was closed. The actual time in the morning was not specified on the statement. Observation of the facility's camera footage revealed Resident #1 exiting the secure unit thru the side door on 8/16/25 at 5:04 am and thru the courtyard gate at 5:10 am. Record review of the facility's actual elopement exercise for Resident #1 revealed the drill was initiated on 8/16/25 at 7:30 am and cleared at 2:55 pm. During an interview with Family Member A on 8/17/25 at 8:00 am, Family Member A stated Resident #1 had gotten out of the facility's secure unit door shortly after 5:00 am on 8/16/25 and was not located until 2:30 pm on 8/16/25. Family Member A stated Resident #1 was found by family members inside of a closed car on a private residence that was one block from the facility. Family Member A stated Resident #1 was then transported to the hospital from this location. Family Member A stated Resident #1 would be returned to the same nursing home facility. During an interview with hospital RN B on 8/17/25 at 9:00 am, hospital RN B stated Resident #1 was admitted to the hospital with a diagnosis of heat stroke. Hospital RN B stated Resident #1 would be given IV fluids along with Magnesium, Potassium, and Electrolytes. During an interview with Resident #1 on 8/17/25 at 9:10 am at her hospital room she stated she did not know where she was currently at or what had happened to her on 8/16/25. During an interview with Family Member C on 8/17/25 at 9:15 am, Family Member C stated she was told by the facility administrator that the side door on the secure unit apparently had a malfunction in its locking mechanism which allowed for Resident #1 to be able to leave the facility. Family Member C stated she was told by the Administrator the cameras on the secure unit were not fully operational at the time of Resident #1's elopement on 08/16/25. Family Member C stated Resident #1 would be returning to the same nursing facility upon hospital discharge. Record review of the facility's staff checklist in-service log dated 8/16/25 revealed that 100 percent of the staff had received the in-service on abuse/neglect, elopement protocol, and ensuring exit doors and gates were locked. Record review of the facility's secure unit resident head count form dated 8/17/25 revealed the protocol for the charge nurse on the secure unit conducting the resident head count. Record review of the facility's secure unit resident rounding form completed by Nurses and CNA staff revealed that the form is completed at the end of the shift. Record review of the facility's care plan listing report revealed that all of the residents on the secure unit had their care plan updated on 8/16/25 for elopement status. Record review of the facility's elopement policy in the Nursing Policy and Procedure Manual WA-03-2.0 revealed the intervention steps for staff to take in conducting an internal and external search for a missing resident as well as the need for staff to manually check all exit doors and outside gates for closure and alarm viability. Record review of the facility's Code Orange Drill Elopement Guide that was undated revealed the steps and notifications that staff are to follow when searching for a missing resident. Record review of the facility's process change form dated 8/16/25 revealed the following updates:a. The side door on the secure unit used by Resident #1 to exit the facility is now permanently secured and closed.b. All secure unit door codes were changed.c. Nurse will conduct hourly resident head counts on the unit.d. CNA and Nursing staff will complete resident head counts at the end of their respective 8 hour and 12-hour shifts.e. The Maintenance Director or designated person (Manager on Duty for the weekends) will check all exit doors and outside gates for alarm viability twice a day).f. Nursing staff completed elopement assessments on all residents.g. Care plans were updated for all residents on elopement risks.h. A spring was added on the outside court- yard gate to increase the automatic closure ability of the gate.i. The elopement policy, abuse/neglect policy, and door/gate closure protocol were reviewed with 100 percent of the staff. Record review of the facility's maintenance log exit door check completed on 8/18/25 at 8:30 am revealed all facility exit doors were alarmed. During an interview with the DON on 8/17/25 at 10:15 am, the DON stated that she believed Resident #1 was able to exit the secure unit thru a side door that had a malfunction on the locking mechanism. The DON stated Resident #1 was last seen on the secure unit at 4:00 am and the resident had a habit of wandering into other resident rooms. The DON stated the facility staff began an internal search of the facility for Resident #1 on 08/16/25 at 7:30 am and the official Code Orange was called at 9:00 am. The DON stated 100 percent of the facility's staff had been in-serviced on 8/16/25 on the elopement protocol which included the steps to undertake to complete an internal and external search for missing resident. The DON stated that the in-service also included the need to staff to manually check all facility exit doors and outside gate to ensure that they were closed and alarmed. During an interview with the Administrator on 8/17/25 at 8/17/25 at 11:20 am, the Administrator stated he felt the locking mechanism on the side door on the secure unit malfunctioned which allowed Resident #1 to exit the building. The Administrator stated that courtyard gate was not properly secured which allowed Resident #1 to go thru that gate to the outside. The Administrator stated that he believed a nurse working on a different unit had left the courtyard gate open and that nurse was suspended. The Administrator stated that Resident #1 was last seen on the secure unit at 4:00am and had a habit of wandering into other resident rooms. The Administrator stated that the facility staff began an internal search for Resident #1 on 8/16/25 at 7:30 am and the official Code Orange was called at 9:00 am. The Administrator stated the facility had new cameras installed and the cameras on the secure unit were recording but the playback from the cameras was not fully operational until 8/17/25. The Administrator stated 100 percent of the facility's staff had been in-serviced on 8/16/25 on the elopement protocol which included the steps to undertake to complete an internal and external search for missing resident. The Administrator stated that the in-service also included the need to staff to manually check all facility exit doors and outside gate to ensure that they were closed and alarmed. During an interview with the Maintenance Director on 8/17/25 at 12:20 pm, the Maintenance Director stated he was not sure how Resident #1 had exited the building thru the side door on the secure unit. He stated that he had checked that exit door on 8/15/25 and the alarm was functioning properly. The Maintenance Director stated during the elopement search on 8/16/25 he checked both the side door of the secure unit in which Resident #1 had exited the building as well as the courtyard gate and both were closed and alarmed. During an interview with CNA D on 8/17/25 at 1:15 pm, CNA D stated she had assisted in the elopement search for Resident #1. CNA D stated she had been re-in-serviced on abuse/neglect and elopement protocol including the steps to take to conduct an internal and external search for a missing resident as well as manually checking all exit doors and outside gates to be sure they were closed and alarmed. During an interview with LVN E on 8/17/25 at 1:20 pm, LVN E stated she had assisted in the elopement search for Resident #1. LVN E stated she had been re-in-serviced on abuse/neglect and elopement protocol including the steps to take to conduct an internal and external search for a missing resident as well as manually checking all exit doors and outside gates to be sure they were closed and alarmed. During an interview with ADON F on 8/17/25 at 1:35 pm, ADON F stated she had assisted in the elopement search for Resident #1. ADON F stated she had been re-in-serviced on abuse/neglect and elopement protocol including the steps to take to conduct an internal and external search for a missing resident as well as manually checking all exit doors and outside gates to be sure they were closed and alarmed. ADON F stated during the elopement search she had gone to the side door on the secure unit, and it was properly locked. During an interview with CNA G on 8/17/25 at 1:40 pm, CNA G stated she had assisted in the elopement search for Resident #1. CNA G stated she had been re-in-serviced on abuse/neglect and elopement protocol including the steps to take to conduct an internal and external search for a missing resident as well as manually checking all exit doors and outside gates to be sure they were closed and alarmed. During an interview with Housekeeper H on 8/17/25 at 1:50 pm, Housekeeper H stated she had assisted in the elopement search for Resident #1. Housekeeper H stated she had been re-in-serviced on abuse/neglect and elopement protocol including the steps to take to conduct an internal and external search for a missing resident as well as manually checking all exit doors and outside gates to be sure they were closed and alarmed. During an interview with LVN I on 8/17/25 at 2:00 pm, LVN I stated she had worked as the Charge Nurse during the night shift on 8/16/25 and did not observe Resident #1 leave the unit. LVN I stated she had not participated in the elopement search but had been re-in-serviced on abuse/neglect, elopement protocol including the steps to take to conduct an internal and external search for a missing resident as well as manually checking all exit doors and outside gates to be sure they were closed and alarmed. During an interview with RN J on 8/17/25 at 2:20 pm, RN J stated she had assisted in the elopement search for Resident #1. RN J stated that she had been re-in-serviced on abuse/neglect and elopement protocol including the steps to take to conduct an internal and external search for a missing resident as well as manually checking all exit doors and outside gates to be sure they were closed and alarmed. During an interview with CNA K on 8/17/25 at 2:25 pm, CNA K stated she had been re-in-serviced on abuse/neglect and elopement protocol including the steps to take to conduct an internal and external search for a missing resident as well as manually checking all exit doors and outside gates to be sure they were closed and alarmed. During an interview with RN L on 8/17/25 at 2:30 pm, RN L stated she had been re-in-serviced on abuse/neglect and elopement protocol including the steps to take to conduct an internal and external search for a missing resident as well as manually checking all exit doors and outside gates to be sure they were closed and alarmed. During an interview with CNA M on 8/17/25 at 2:35 pm, CNA M stated she had been re-in-serviced on abuse/neglect and elopement protocol including the steps to take to conduct an internal and external search for a missing resident as well as manually checking all exit doors and outside gates to be sure they were closed and alarmed. During an interview with CNA N on 8/17/25 at 2:40 pm, CNA N stated she had been re-in-serviced on abuse/neglect and elopement protocol including the steps to take to conduct an internal and external search for a missing resident as well as manually checking all exit doors and outside gates to be sure they were closed and alarmed. During an interview with CNA O on 8/17/25 at 2:45 pm, CNA O stated she had been re-in-serviced on abuse/neglect and elopement protocol including the steps to take to conduct an internal and external search for a missing resident as well as manually checking all exit doors and outside gates to be sure they were closed and alarmed. CNA O stated she had worked on the night shift in which Resident #1 had eloped on 8/16/25. CNA O stated she did not remember when she had last seen Resident #1 but that it could have been at 4:00 am, whenever Resident #1 received incontinent care in her room. During an observation with the Administrator and Maintenance Director on 8/18/25 from 8:05 am until 8:30 am all of the facility's exit doors and outside gates were checked for closure and alarm viability and found to be in good working order. The Administrator and Maintenance Director stated that all facility exit doors and outside gates would be checked twice a day seven days a week for closure function and alarm viability. Record review of the facility's policy titled, Nursing Policy and Procedure Manual TG 03-1.0, undated, revealed that Neglect; is the failure of the facility, it's 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.

Based on observation, interview, and record review, the facility failed to ensure each resident receives adequate supervision to prevent accidents for 1 of 6 residents (Resident #1), reviewed for quality of care. The facility failed to supervise Resident #1 who eloped out of a side door of the facility on 2/17/25 at approximately 7:12 p.m. without staff knowledge, through a side door that the alarm had been turned off on and was found ambulating down the sidewalk approximately 400 feet from the facility. An Immediate Jeopardy was identified as past noncompliance on 4/23/25. The IJ began on 2/17/25 and ended on 2/18/25. The facility had corrected the noncompliance before the survey began. This failure could put residents at risk of accidents, and could result in serious injury, harm, impairment, and death. The findings were: Record review of Resident #1's face sheet dated 4/22/25 revealed the resident was a [AGE] year-old female initially admitted to the facility on [DATE] with readmission on 1/10/25. The resident's diagnoses included non-traumatic subarachnoid hemorrhage, unspecified (bleeding in the space below one of the thin layers that cover and protect your brain not caused by caused by, or associated with trauma), schizoaffective disorder (mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania), muscle weakness, and other abnormalities of gait and mobility (abnormal walking pattern and the ability to move freely, coordination). Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed the resident had a BIMS score of 3 out of 15 indicating the resident was severely cognitively impaired. The resident had no behaviors and no wandering. The resident used a walker and was independent for lying to sitting on side of bed, required supervision, or touching assistance to stand, transfer, and walk 150 feet. Record review of Resident #1's undated care plan revealed a focus initiated on 2/18/25 for the resident to reside in the secure unit due to elopement, and the resident had an actual elopement. Interventions included encourage the resident to participate in activities and monitor for statements of wanting to go home or leave the facility and wandering, and to stay with the resident and notify the charge nurse if exit seeking. (There were no focus's for wandering or exit seeking prior to this incident). Record review of Resident #1 Elopement risk assessment, dated 1/11/25, had a score of 0 indicating the resident was not an elopement risk. (1-9 not a risk, 10 or greater is an elopement risk). Record review of the facility PIR for intake #565261 dated 2/24/25 revealed on 2/17/25 at approximately 7:12 p.m. the facility was notified Resident #1 had left the building by another resident sitting outside. The DON went out the front door and noted the resident walking with her walker on the sidewalk on the same side of the street as the facility walking towards local chicken restaurant next door to the facility. The DON caught up to Resident #1 at approximately 7:20 pm as she was walking down the sidewalk. The DON stayed with the resident and staff brought a wheelchair for the resident and she was back in the facility at 7:28 pm. The resident stated she was going home. The resident was assessed by the DON to have no injuries. The resident was placed on 1:1 supervision until she was moved to the secure unit. The MS checked all facility doors on 2/17/25 at approximately 8:20 p.m. and found the double doors by the B wing by the dining room were not functioning properly and were immediately fixed. Record review of Resident #1's event nurses' note for elopement dated 2/17/25 by the DON revealed she was notified by receptionist Resident #1 had left the building through double doors and was not out of the building more than 15 minutes. The Resident's physician who was also the facility Medical Director and the resident's RP were notified and the resident was moved to the secure unit. Record review of Resident #1's progress notes revealed a nurses' note dated 2/17/25 at 7:56 p.m. by the DON she was notified by the receptionist Resident #1 was outside the facility and she observed her walking on the sidewalk on the same side of the street as the facility and she was redirected back to the facility with no visible injuries. In an observation and interview on 4/22/25 at 11:10 a.m. Resident #1 was lying in bed on top of her covers and was dressed in a t-shirt and pants. Facility staff had assisted Resident #1's roommate and was leaving the room. Resident #1 was alert and oriented to person only. Resident #1 was unable to answer questions about the elopement. The resident stated she was happy living here and liked to watch the birds through the windows, felt safe, and liked the staff pointing to a staff member at the doorway and calling her by the wrong name and stated, she's good people and smiled. The resident was able to communicate well in English despite preferring Spanish. In an interview on 4/22/25 at 3:05 p.m. The DON stated on 2/17/25 at approximately 7:12 p.m. the receptionist was notified by another resident that was sitting outside that Resident #1 had been walking up the sidewalk on the side of the kitchen and lobby but still in front of the facility due to the shape of the building. The DON stated she immediately went out the front door and observed the resident walking on the sidewalk with her walker headed towards local chicken restaurant on the right next door to the facility. The DON stated she was unsure of the timeframes but it did not take her long to catch up to the resident. The DON stated Resident #1 was still in front of the facility on the edge of the property line when she caught up with her. The DON stated the resident did not cross the driveway into the local chicken restaurant that interrupted the sidewalk immediately after the facility fence line. The DON stated she pulled out her phone and called staff who brought out a wheelchair and she brought Resident #1 back inside the facility by wheelchair without resistance or issues. The DON stated Resident #1 had told her she was going home. The DON stated she assessed Resident #1 and she had no injuries. The DON stated she had notified the physician and RP and received verbal consent from the resident's RP to move the resident to the secure unit and the resident was moved that same evening, not sure of the time. The DON stated ADM D was notified and the MS came to the facility at about 8:20 p.m. and checked all the facility doors and found something wrong with the double doors between B wing and the dining room and they were immediately fixed and all doors rechecked and were working properly and all door codes were changed as well. The DON stated she started in-servicing staff the same night on 2/17/25 on ANE, Elopement response policy/code orange, and staff were not allowed to work until training was completed. The DON stated Resident #1 was not an elopement risk prior to this incident the resident would go places in the facility but did not attempt to elope. In an observation and interview on 4/23/25 at 12:30 p.m. the MS stated when he was checking the door alarms on the night of 2/17/25 he found the double doors between B hall and the dining room were not alarmed and had been turned off. He showed me the red stop sign box attached to the doors with a key slot and the words off and on next to the key slot. The key slot was turned to the on position. The MS demonstrated without disarming the alarm that a key had to be inserted to turn it from on to off and vice versa. The MS stated all the nurses had keys to turn the alarm off as well as himself and he was unsure of who else had keys. The MS then showed me the secondary alarms that were placed on all facility exit doors and the secure unit on 2/18/25 and stated they cannot be turned off and the alarms sound the entire time the doors were open. This was demonstrated by opening the secure unit doors after entering the code to enter, an alarm sounded until the door was closed. In an interview on 4/23/25 at 5:00 p.m. the ADM C stated he was not the Administrator at the time of this incident and was hired about 4 weeks ago, around 3/14/25. The ADM C stated he had continued with the elopement plan of action and had further trained staff on ANE and notifications to be made. In an interview on 4/25/25 3:05 p.m. the MS stated he knew the door alarms were working as they had been checked that day on 2/17/25. The alarmed door that was turned off was what the facility calls the kitchen staff emergency exit. The MS stated the front facility entrance already had a secondary alarm. The MS stated the push button release for the front entrance door was relocated on 2/18/25 to a hidden place inside the receptionist desk and mounted in place with screws and the drawer is locked and the receptionist has the key. Review of the facility policy on elopement prevention revised January 2023 indicated under environmental modification . 4. Use door alarms or monitoring devices to notify staff when residents try to leave the facility. It was determined the failure placed Resident #1 in an IJ situation on 4/23/25. The ADM C was notified on 4/23/25 at 3:18 p.m., that a PNC IJ had been identified due to the above failure. The facility implemented the following interventions: 1. Resident #1 was placed on 1:1 monitoring and then moved to the secure unit on 2/17/25. 2. All facility doors were checked and all alarms were verified to be on and working on 2/17/25. 3. The DON began in-servicing all staff on 2/17/25 for ANE, elopement response policy/code orange, elopement prevention policy, and door alarm safety, and staff were not allowed to work until training was completed. 4. On 2/17/25 at 8:50 pm an off-cycle QAPI by phone was conducted with the DON and Medical Director. 5. On 2/18/25 an ADHOC QAPI review of corrective action plan was conducted. 6. All new staff to be in-serviced during orientation and agency staff to have training prior to working if used. 7. On 2/18/25 Elopement risk assessments were completed and evaluated for changes on all residents in the facility. 8. On 2/18/25 secondary alarms were placed on all alarmed doors that cannot be turned off. 9. Door alarm checks daily and as needed 5 times weekly x 4weeks. 10. 5 staff members to be interviewed 3 times weekly on elopement prevention and response 5 times weekly for 4 weeks. Review of facility signature sheet for ADHOC QAPI meeting on 2/18/25 had 14 attendees and included the facility Medical Director, corporate compliance nurse, DON, ADON, director of rehabilitation, MDS nurse, SW, housekeeping, dietary, and nursing staff. Record review of elopement drills revealed drills were completed on 2/18/25, 2/21/25, 2/20/25, 2/28/25, and 3/19/25. Review of facility staff list revealed 8 newly hired staff from 2/17/25 to 4/23/25 employee files reviewed revealed they were ADM C, staff PP, QQ, RR, CNA SS, staff TT, UU, and CNA VV. The orientation training packet was included and signed by each staff for ANE, elopement response policy, elopement prevention policy, door alarms, and elopement drills training was completed. In interviews conducted on 4/24/25 starting at 11:27 p.m. to 4/25/25 at 12:22 a.m., 11 interviews of the night shift staff RN CC, LVN NN, LVN P, LVN DD, LVN Z, CNA X, CNA II, CNA S, CNA JJ, CNA R, and CNA U stated they had been trained on ANE, elopement response policy, elopement prevention policy, door alarms, and elopement drills and were able to state appropriate responses. During these interviews LVN NN, RN CC, CNA S, and CNA II stated they had been participants in elopement drills recently. Record review of the facility door alarm check log completed by MS or maintenance staff revealed they were completed daily on all wings on 2/17/25 through 2/24/25, 2/24/25 (different time) through- 2/27/25, 3/2/25, 3/10/25 through 3/14/25, 3/17/25 through 3/21/25, 3/24/25 through 3/28/25, 3/31/25 through 4/4/25, and 4/7/25 through 4/11/25. In an interview on 4/22/25 at 4:09 p.m. LVN E (6a-6p) stated she had been trained on ANE, elopement response policy, elopement prevention policy, door alarms, and elopement drills and was able to state appropriate responses. In interviews conducted on 4/23/24 starting at 10:30 a.m. to 11:20 a.m. staff from shifts (7a-3p)- AA, Q, OO, FF, W, EE (6a-6p)- BB, LVN KK (8a-5p)- HH, MM, RN V, RN LL, and Y all stated they had been trained on ANE, elopement response policy, elopement prevention policy, door alarms, and elopement drills and were able to state appropriate responses. In an interview on 4/23/25 at 10:03 a.m. RN I (6a-6p) stated she had been trained on ANE, elopement response policy, elopement prevention policy, door alarms, and elopement drills and was able to state appropriate responses. In an interview on 4/23/25 at 3:26 p.m. the SW (8a-5p) stated he had been trained on ANE, elopement response policy, elopement prevention policy, door alarms, and elopement drills and was able to state appropriate responses. In an interview on 4/23/25 at 5:10 p.m. CNA O (3p-11p) stated she had been trained on ANE, elopement response policy, elopement prevention policy, door alarms, and elopement drills and was able to state appropriate responses. In an interview on 4/24/25 at 11:43 a.m. staff M (8a-5p) stated she had been trained on ANE, elopement response policy, elopement prevention policy, door alarms, and elopement drills and was able to state appropriate responses. In an interview on 4/24/25 at 12:04 p.m. RN L (6a-6p) stated she had been trained on ANE, elopement response policy, elopement prevention policy, door alarms, and elopement drills and was able to state appropriate responses. In an interview on 4/24/25 at 12:15 p.m. CNA H (3p-11p) stated she had been trained on ANE, elopement response policy, elopement prevention policy, door alarms, and elopement drills and was able to state appropriate responses. In an interview on 4/24/25 at 12:50 p.m. LVN J (6a-6p) stated she had been trained on ANE, elopement response policy, elopement prevention policy, door alarms, and elopement drills and was able to state appropriate responses. In an interview on 4/24/25 at 1:15 p.m. CNA T (7a-3p) stated she had been trained on ANE, elopement response policy, elopement prevention policy, door alarms, and elopement drills and was able to state appropriate responses. In an interview on 4/24/25 at 3:30 p.m. CNA N (3p-11p) stated she had been trained on ANE, elopement response policy, elopement prevention policy, door alarms, and elopement drills and was able to state appropriate responses. In an interview on 4/25/25 at 11:22 a.m. LVN GG (6a-6p) stated she had been trained on ANE, elopement response policy, elopement prevention policy, door alarms, and elopement drills and was able to state appropriate responses.

38511 Based on interview and record review, the facility failed to ensure the residents had the right to be free from abuse, neglect and misappropriation of property for 2 of 6 residents (Residents #2 and #3) reviewed for abuse, in that: 1. The facility failed to protect Resident #2 from physical abuse when Resident #1 grabbed, scratched and hit Resident #2 during a smoke break on [DATE]. The facility failed to respond to develop a plan of care, behavior monitoring, interventions or train staff on behaviors to prevent further abuse. 2. The facility failed to protect Resident #3 from physical and psychological abuse when Resident #1 repeatedly hit Resident #3 in the face and head and scratched him on [DATE] which resulted in swelling, redness, bruising to Resident #3's left eye, scratches to his face, neck, chest and arms and trauma. On [DATE] Resident #1 was arrested and charged with a class three felony for abuse of an elderly and currently resided in a local jail waiting indictment. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 8:17 p.m. While the IJ was removed on [DATE] at 6:57 p.m., the facility remained out of compliance at a scope of pattern and a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy because of the facility's need to monitor the implementation of the plan of removal. These deficient practices could affect all residents and place them at risk for abuse, trauma, psychosocial harm, injuries, hospitalization and/or death. The findings included: 1. Record review of form 3613-A Provider Investigative Report dated [DATE] revealed the facility self-report of a resident-to-resident altercation and listed it as incident category other. The report indicated on [DATE] at 4:00 p.m., Resident #1 was found rummaging through another resident's purse during smoke break. Resident #2 intervened to remove the purse from Resident #1. Resident #1 slowly inched his way to Resident #2 striking him several times which resulted in scratches to neck, chest, bilateral arms (both arms) and ripping a small hole in Resident #2's shirt. A former Administrator (Administrator AA) marked the investigation as inconclusive. The facility documented their response as self-report protocols, in-service and re-education of staff initiated for abuse/neglect policy and an AD HOC QAPI meeting held. Record review of Resident #1's face sheet, dated [DATE], revealed a [AGE] year-old male admitted on [DATE] with diagnoses which included: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, schizophrenia and depression. Record review of Resident #1's hospital records for admission to the facility, dated [DATE], revealed Diagnosis, Assessment and Plan revealed [AGE] year-old male NF resident with history significant for schizophrenia, cirrhosis of the liver, behavior disorder and dementia brought to the ED for further evaluation of altered mental status. The physician documented he reviewed the electronic medical records from the previous NF that showed Resident #1 had a history of dementia, major depressive disorder, schizoaffective disorder, anxiety disorder, behavioral disturbance and epilepsy. On page 39 of hospital document titled discharge planning: revealed hospital case manager documented Resident #1's previous NF declined to accept Resident #1 back to their facility because they were concerned about the safety of the other residents. Record review of Resident #1's Admission MDS, dated [DATE], revealed a BIMS score of 12 which indicated a moderate cognitive impairment without behaviors or evidence of acute change in mental condition. Resident #1's functional status was listed as dependent on staff for ADL care, use of a wheelchair without assessment of transferring or walking functionality. Record review of Resident #1's Nurse Progress Note, dated [DATE] documented by RN C, revealed Resident #1 was seated in his wheelchair in the TV room .noted to have his right hand in a brown backpack on the sofa area. Seen with a soda and 1 dinner item. Verified the bag belonged to a staff (unspecified). Resident #1 advised not to take belongings of other. He stated he understood. Record review of Resident #1's Nurse Progress Noted, dated [DATE], revealed Resident #1 observed entering other resident's room and eating his jalapeno pork skins. Redirected to TV room and reminded not to enter other rooms. Resident pleasant and denies altered mental status. Record review of Resident #1's Physician's Progress Note, dated [DATE], revealed Nurses report some behaviors including going into other resident rooms and taking their things, requesting a visit for psychiatric services. Record review of Resident #1's Care Plan, last revised on [DATE], revealed Resident #1 required anti-psychotic and anti-depressant medications with interventions which included: monitor/record occurrence of target behavior systems (specify: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others, etc.) and document per facility protocol. The care plan did not address any resident behaviors or behavior management. Record review of Resident #1's Nurse Progress Notes, dated [DATE], revealed Resident #1 entered other resident rooms and eats their snacks. Record review of Resident post-incident assessment, dated [DATE], revealed the AD came to nurses' station to inform nurse of an altercation between Resident #2 and another resident that occurred during smoke break. Resident #2 assessed and had noticeable random scratches to neck, chest, bilateral arms and had a torn shirt at the neckline. Resident had no complaints of pain. The assessment noted Resident #2 statement of the event He picked up her purse and hid it and I got it back and gave it back to resident's owner (sic) and the (sic) just started hitting and scratching me! Record Review of Resident #1's Nurse Progress Notes, dated [DATE], revealed LVN B documented that staff (unnamed) reported to nurse that Resident #1 had a physical altercation with another resident while in the smoking area. When asked what happened, Resident #1 stated He started it. Staff reported that Resident #1 had picked up a purse and was getting into it when another resident [Resident #2] took it from him. Resident #1 then stood up and began to hit and scratch the other resident causing scratches and a small bruise under the right eye, redness to the scratched areas and a torn shirt. The residents were separated, and Resident #1 was brought inside. He had no visible injuries. Record review of Resident #1's [DATE] MAR/TARs revealed no evidence of behavior monitoring. Record review of Resident #1's Psychological Initial Assessment, dated [DATE] (after incident with Resident #2 but before the incident with Resident #3), revealed diagnoses treating was antisocial personality disorder. Reason for referral: agitation, irritability, anger, paranoia, physical aggression. RN reports Resident #1 had been stealing from other patients at times and also becomes aggressive. Risk of aggression: None. Insight: Fair. Judgement: Fair. Short term memory: mildly impaired. Long-Term memory: intact. This document was signed by the psychological services physician. Record review of Resident #1 Psychological Services Progress Note, dated [DATE] (after incident with Resident #2 but before incident with Resident #3), revealed aggressive behavior was listed as none. Patient was polite. Patient reports having nothing to talk about and having no problems, struggles or worries. Patient displays depressive symptoms. This document was signed by psychological services LPC. Record review of Resident #2's face sheet, dated [DATE], revealed a [AGE] year-old male admitted on [DATE] with diagnoses which included: sequelae of cerebral infarction, hemiplegia (stroke with resulting paralysis on one side of the body) affecting right dominant side and schizoaffective disorder bipolar type and mild neurocognitive disorder due to known physiological condition with behavioral disturbance. Record review of Resident #2's Care Plan, last revised on [DATE], revealed the resident had wandering behaviors. No other behaviors were part of the plan of care. Record review of Resident #2's Nurse Progress Notes, dated [DATE], revealed Resident #2 was involved in an altercation during smoke break with Resident #1. Resident #2 was not faulted for the incident. Resident #1 was found rummaging through another resident's purse (unnamed). Resident #2 intervened to remove the purse from Resident #1. Resident #1 slowly inched his way to Resident #2, striking him several times, scratching him and ripping a small hole in his shirt. AA D (Activity Assistance D) and Laundry Attendant E peacefully diffused the incident, separating bath parties, Charge nurses notified, DON notified of incident. Documented by AA D. Record review of Resident #2's Psychiatric Clinical Treatment Plan, dated [DATE], revealed he was assessed for current mood and anxiety symptoms to ascertain current emotional functioning and process thoughts and feelings relative to recent physical altercation with another resident. The assessment listed his anxiety was moderate and rated as increased, his emotional withdrawal was listed as moderate and rated as increased, hostility was labeled as moderate and rated as increased and tension was labeled as moderate and rated as increased. The assessment noted he was moderately cognitively impaired. Record review of Resident #2's Quarterly MDS, dated [DATE], revealed a BIMS score of 6 which indicated a severe cognitive impairment, with continuously present behaviors which included inattention, disorganized thinking and altered level of consciousness but no physical, verbal or other behaviors exhibited. Resident #2's functional status was recorded as independent with walking and transferring. During an interview on [DATE] at 11:01 a.m., AA D stated he was responsible for supervising smoke break ([DATE]) when the incident between Resident #1 and Resident #2 occurred. He stated he believed it was the 4:00 p.m. smoke break but could not be certain. He stated another staff in housekeeping (identified as LA E) was also there taking her own personal break. AA D stated it started when one of the female residents left the smoking area because she said it was too hot and she wanted to go back inside where it was cooler, but she left her purse behind on the floor. AA D stated he saw Resident #1 bend over and go through something on the floor. He stated before he could get to Resident #1, he saw Resident #2 grab a purse from Resident #1. Resident #2 then handed the purse to him (AA D). AA D stated, after Resident #2 handed him the purse, both residents sat back down and resumed the smoke break. He stated a little bit later, Resident #1 was quiet and calm but started inching closer and then suddenly took some swipes at Resident #2 but made no contact. AA D stated Resident #1 then grabbed Resident #2 by his shoulder, scratching him in the process. AA D stated both staff immediately pulled the two residents apart and both calmed down quickly. AA D stated Resident #1 stopped his aggressive behavior. AA D stated there had been no other altercations between the two residents who both attended every smoke break. He stated they had never exhibited any aggressive behaviors before. AA D stated he had been told by the nurse (unknown) on Resident #1's unit that Resident #1 had a history of stealing but was not told of any aggressive behaviors. He stated he had been in-serviced on abuse/neglect, reporting and treating residents with respect. He stated he was working on an on-going computerized training program for dementia residents called [NAME] which he believed stood for personal assistance care training. He stated he had not received any facility in-service or training on dealing with physical aggression or behavioral interventions. During an interview on [DATE] at 11:25 a.m., Resident #2 stated he remembered the incident with the purse ([DATE]). He stated he grabbed the purse from that other resident (Resident #1) because it did not belong to him. Resident #2 pointed to his right shoulder and chest indicating where he had been scratched by Resident #1. He stated he feels fine, no pain. Resident #2 stated he thought Resident #1 left because he had not seen him and there were no further incidents with the resident. He stated he felt safe at the facility. During an interview on [DATE] at 11:29 a.m., LVN B stated Resident #1 was very hard to understand. She stated Resident #1 could be aggressive, but she had never had any problems with him. She stated when he would get upset, she would talk to him to calm him down. LVN B stated Resident #1 did have a bad habit of going into other residents' rooms and stealing and he smoked a lot. LVN B stated she was informed he had an altercation with another resident in the smoking area. She stated she could not remember when this occurred or whom the other resident was. She stated she didn't remember a lot about the resident but does remember he could be talked down. LVN B stated for interventions she just kept an eye on him and tried to keep him separated to keep other residents safe. LVN B stated Resident #1 was not like that all the time, just certain things would make him agitated. She stated Resident #1 did not go up to people with no reason. LVN B stated she does not recall if anyone in management gave her any interventions or instructions. LVN B stated she was not sure anything was in his care plan about it. After looking at his care plan, LVN B stated there was nothing in Resident #1's care plan about his klepto or behaviors. LVN B stated she doesn't really use care plans for resident care . She stated she gets to know the residents and their personality and that was how she knows how to care for them. LVN B stated she was trained to separate residents who had conflict and then assess them, speak to both parties and then let the DON and Administrator know and also report to the RP. Record review of Resident #15's face sheet, dated [DATE], revealed an admitted [DATE] and a readmitted [DATE] with diagnoses which included: Alzheimer's disease, recurrent depressive disorders and unsteadiness on feet. Record review of Resident #15's Annual MDS, dated [DATE], revealed a BIMS score of 12 which indicated a moderate cognitive impairment. During an interview on [DATE] at 10:48 a.m., Resident #15 stated Resident #1 had sticky fingers (slang term to indicate someone who steals). Resident #15 stated Resident #1 would go into other residents' rooms and had stolen many things. He stated Resident #1 stole some $1 bills from his wallet in his room . He stated he told staff (unknown) and was told to keep his wallet put away and not in the open. He stated it was a resolved issue, but he was glad Resident #1 was gone. Resident #15 stated Resident #1 did not belong at the facility. He stated he had not witnessed any aggression or abuse. He stated he felt safe at the facility. During an interview on [DATE] at 11:00 a.m., CNA G stated she had not witnessed him be mean to residents. She stated she never worked directly with Resident #1. but he was mean (to staff). She stated when she went to check on him, he would tell her to get out and did not want help. She stated she had not received any training on resident behaviors. She stated she did not get any training following either incident with Resident #1. She stated if a resident had a behavior or acted aggressive, she would just go get the nurse to intervene. CNA G stated if she witnessed resident's arguing she would get in between them and try to get the aggressor away and let the nurse know. She stated if she saw a physical incident, she would go get help. She stated she was taught to tell the charge nurse and then let the administrator know if she saw abuse. Record review of Resident #4's face sheet, dated [DATE], revealed an admitted [DATE] and readmitted [DATE] with diagnoses which included: end stage renal disease with dependence on renal dialysis, major depressive disorder single episode moderate and generalized anxiety disorder. Record review of Resident #4's Quarterly MDS, dated [DATE], revealed a BIMS score of 00 which indicated a score could not be obtained. During an interview on [DATE] at 11:08 p.m., MA P stated Resident #1 demeanor was quiet. She stated he mumbled a lot. She stated she was in the building following Resident #1's altercation in the smoking area. She stated after the altercation he kept saying I am going to fuck you up. She stated the staff talked to him to get him to calm down and she told him it was considered assault what he did. She stated prior to this event she had never seen him with anger issues. MA P stated Resident #1 was a klepto (used as a slang word in this context, which is a shortened version of the word kleptomania, not the actual diagnosis of a mental health disorder. Kleptomania is a mental health disorder where a person feels an uncontrollable urge to steal things.). She stated he particularly targeted Resident #4's room for stealing. MA P stated Resident #4 went to dialysis three days a week and was gone from the facility a lot. She stated Resident #1 would go into Resident #4's room and steal his stuff. She stated after the second or third time the staff told the DON, and nothing was done. MA P stated the DON said she would speak to him (Resident #1) and the DON told the staff to watch him but nothing changed. MA P stated the CNA's had to handle it themselves. She stated they tried to keep an eye on Resident #1, and she kept Resident #4's door shut. She stated they would also give Resident #4's iPad to the nurses to lock up in their cart when Resident #4 was away. MA P stated she had received behavior training in [DATE]. She stated it was a computer-based training. She stated the training discussed how to interact with residents and how to report behaviors. She stated she was told to intervene and redirect and how to identify aggression when it first started. She stated she was also trained on abuse and was told to report abuse to the charge nurse, then the ADON and DON. Record review of Resident #53's face sheet, dated [DATE], revealed an admitted [DATE] and readmitted [DATE] with diagnosis which included: quadriplegia (paralysis of all 4 extremities), major depressive disorder and nicotine dependence. Record review of Resident #53's Annual MDS, dated [DATE], revealed a BIMS score of 15 which indicated the resident was cognitively intact. During an interview on [DATE] at 11:31 a.m., Resident #53 stated he had witnessed the incident involving Resident #1 and Resident #2 ([DATE]). He stated they were all out smoking as usual when a female resident started moving herself in her wheelchair towards the door to go back inside and dropped her purse on the ground. He stated the female resident did not appear to be know she had dropped her purse. Resident #53 stated he saw Resident #1 go towards the purse and start going through it. He stated he then saw Resident #2 get up and grab the purse, hand it to AA D and then sit back down. Resident #53 stated Resident #1 did not do anything at first, he was quiet. He stated a few minutes later he saw Resident #1 scoot his wheelchair towards Resident #2 and then grab his shirt and started hitting him. Resident #53 stated AA D pulled Resident #1 off Resident #2. He stated they (staff) took Resident #1 back inside. Resident #53 stated he felt safe and would tell staff if anyone threatened or hurt him. During an interview on [DATE] at 12:49 p.m., the DON and Regional Compliance Nurse stated the interim Administrator was not in the building. They stated the Administrator was the Abuse Coordinator and staff were trained to report abuse to the Administrator. During an interview on [DATE] at 1:45 p.m., LA E stated she was present during the altercation between Resident #1 and Resident #2 smoke break. She stated she thought it was the 1:30 p.m. smoke break but could not be certain. She stated she was there on her own personal smoke break. She stated she and AA D were talking when she saw a female resident go inside, wheeling herself in her wheelchair, but dropped her purse along the way. She stated AA D had gone to let the female resident inside, when she saw Resident #1 move toward the purse. She stated Resident #2 grabbed the purse from Resident #1 and handed it back to AA D. LA E stated Resident #1 was quiet for about 5 minutes and then started pushing himself in his wheelchair towards Resident #2. She stated as Resident #1 got closer to Resident #2, she saw Resident #1 saying something, like a whisper. She stated she could not hear what he was saying, but Resident #2 leaned forward to hear him. LA E stated Resident #1 stood up and grabbed Resident #2's shirt and started to hit him. She stated she did not know Resident #1 could stand before this occurred. She stated AA D moved Resident #1 away and she moved Resident #2 away and calmed him down by telling him it was going to be okay. LA E stated Resident #1 was moved inside and everyone calmed down. She stated she had not witnessed any other aggressive incidents between residents during smoke breaks and had not witnessed any other incidents involving Resident #1. LA E stated when she was first hired, she received training in abuse/neglect. She described abuse/neglect as a worker hitting a resident or not attending to their needs or even when two residents fought. She stated she was taught to report abuse/neglect immediately to the Administrator. She stated she had not received any training on how to deal with resident behaviors or fights. She stated she just followed her instinct to pull them apart when it happened. LA E stated she was frightened by Resident #1, but then was surprised when she saw both Resident #1 and Resident #2 together the next day at smoke break. She stated they acted like nothing had happened. 2. Record Review of Form 3613-A Provider Investigative Report dated [DATE] revealed the former Administrator self-reported resident-to-resident [abuse] under the category other for an incident that occurred on [DATE] at 5:50 p.m. between Resident #1 and Resident #3, The report indicated Resident #1 and #3 had a verbal altercation that lead to a physical altercation in which Resident #1 punched Resident #3 in the face while he was lying down and resulted in bruising under Resident #3's right eye, swelling aside {sic} of the right eye, and a scratch to the side of the right eyebrow. The report indicated the residents were separated and the aggressor (Resident #1) was placed on 1:1 supervision until police arrived and he was arrested. The investigative findings were listed as confirmed with a note that the aggressor (Resident #1) remained in jail at the time of the report and would not be allowed to return to the facility. The facility was conducting ongoing staff in-service on abuse, neglect and exploitation. Record review of Resident #1's Nurse Progress Notes, dated [DATE] at 5:45 p.m., ADON A documented while sitting in the dining room a CNA notified her that Resident #1 and another resident [Resident #3] had a verbal altercation. She told the CNA to move Resident #1 out of the room and the CNA agreed and stated okay. ADON A indicated she came back from the dining room and was at the nurses' station at 6:15 p.m., while the CNA was moving belongings into another room, she heard a scream for help and all staff ran to the room. ADON A documented Resident #1 was standing over [Resident #3] and throwing punches at the other resident's face. The CNA tried to stop Resident #1 as he continued to punch the other resident in the face. ADON A documented she grabbed Resident #1 by his shirt and pulled him off the other resident causing ADON A and Resident #1 to fall over the wheelchair. Resident #1 was breathing hard and was visibly mad at [Resident #3]. ADON A and the CNA assisted Resident #1 off the floor and back to his wheelchair and removed him from the room. He tried to go back into the room and continue to fight [Resident #3]. ADON A documented she told Resident #1 that she would call the police if he did not stop and he replied I don't care .ADON A notified the DON who stated to call 911. ADON A then notified Resident #1's physician who also stated to call 911. ADON A documented she called 911 and EMS to evaluation the other resident [Resident #3]. A report was made and (police) officers handcuffed Resident #1 while in the wheelchair and escorted him out of the building. Record review of Resident #1's Nurse Progress Notes, dated [DATE], at 8:22 p.m., ADON A documented Resident's #1's guardian was made aware that Resident #1 was arrested by police for attacking another resident [Resident #3] while the other resident was in bed and was currently at the magistrate's office. Record review of Resident #3's face sheet, dated [DATE], revealed a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] and readmitted [DATE] with diagnoses which included: senile degeneration of brain (dementia), schizoaffective disorder bipolar type (mental health disorder) and acquired absence of right leg below knee. Record review of Resident #3's Annual MDS, dated [DATE], revealed a BIMS of 5 which indicated a severe cognitive impairment with no behavior symptoms. A review of Resident #3's functional status revealed he used a wheelchair, was unable to walk or transfer himself and was totally dependent of staff for movement and ADL care. Record review of Resident #3's Care Plan, last revised on [DATE], revealed had a history of depression and impaired cognitive function related to dementia with impaired thought process with interventions which included monitor for changes in mood, discuss concerns for confusion and use task segmentation to support short term memory deficits. There were no behaviors documented in the plan of care. Record review of Resident #3's TAR for [DATE] revealed behavior monitoring with no behaviors documented on [DATE] (date of incident) or multiple days before and after the incident. Record review of Resident #3's Event Nurse's Note, dated [DATE], revealed Resident #1 was standing over the resident and was throwing punches at the other [Resident #3] face. An assessment was completed with notes of bruising under the right eye, swelling to the right cheek and scratch on the side of the right elbow. Tylenol was administered to Resident #3 for pain. Resident #3's physician was notified, and neuro checks were completed for 72 hours. Record review of Resident #3's Nurse Progress Notes, dated [DATE] documented by ADON A, revealed she was notified of a verbal altercation between Resident #1 and Resident #3 by a CNA. She instructed the CNA to move this resident (unspecified) out of the room and the CAN agreed and said OKAY. While sitting at the nurses' station after coming back from the dining room, she heard a scream for help and all staff ran to the room. She noted Resident #1 standing over Resident #3 throwing punches at his face. The CNA tried to stop the resident and he continued to punch .ADON A grabbed the resident (Resident #1) by the shirt and pulled the resident off the other resident causing them to fall over the wheelchair. After removing Resident #1 from the room, she notified Resident #3's physician and made her aware of the bruising under the right eye, swelling aside (sic) of the right eye, and scratch to the side of the right eyebrow. The physician did a video call with DON and resident (Resident #3), new order neuro's x 72 hours. Record review of Resident #3's Nurse Progress Notes, dated [DATE], revealed Resident #3 was alert and oriented to person, place but not day or time of day. Bruising noted around right orbital fossa (right eye). When asked what happened (sic) That guy that takes me stuff beat me up. I was telling him to stay out of my stuff (sic) he started hitting me. I tried to fight but I (sic) couldn't. The nurses took him away (sic) I am okay now. (sic) Record review of a local police report, dated [DATE], revealed Resident #1 was arrested and charged with Class 3 Felony Texas Penal Code 22.04 (A) (Injury to a child, elderly individual, or disabled individual). The report indicated the police responded to the NF for an assault in progress call. Upon arrival ADON A advised that Resident #1 and Resident #2 shared a room. ADON A advised Resident #3 was bedridden and could not get up on his own and Resident #1 used a wheelchair but could walk from time to time. She reported to police that Resident #1 and Resident #2 got into a verbal argument and Resident #1 had been removed from the room. She stated Resident #1 later returned to the room and she heard a disturbance. She stated when she went into the room, she observed Resident #1 standing over Resident #3's bed, punching Resident #3 multiple times. ADON A advised that her and other nurses had to physically pull Resident #1 away from Resident #3. The police report indicated police contacted Resident #3 who stated he was lying in bed when Resident #1 came into the room. Resident #3 stated they were arguing over whose diaper was changed first. Resident #3 stated Resident #1 went over to his bed and began punching him multiple times. The police officer documented he observed that Resident #3 had a black eye and that his eye was slightly swollen. EMS responded to the scene. The report indicated Resident #1 told police Resident #3 was talking shit about his family member who was deceased . Resident #1 admitted to assaulting Resident #3. The report indicated due to the victim (Resident #3) being [AGE] years of age, the suspect (Resident #1) was placed under arrest, transported to the city detention center and booked. During an interview on [DATE] at 10:47 a.m., Resident #1's legal guardian stated Resident #1 had been arrested at the NF was still in the local jail, charged with a third-degree felony with intent to cause bodily injury. The guardian stated when he had visited with Resident #1 in the past he always presented as very passive. The guardian stated that historically he was very aggressive. He stated he was unsure if the current NF was aware of Resident #1's history of aggression. He stated Resident #1 was discharged from the previous NF for aggression. He stated the previous NF took it upon themselves to discharge Resident #1 from their facility. He stated Resident #1 ended up at a local hospital and the hospital placed Resident #1 at the current NF. The legal guardian stated the incident that ended with Resident #1 in jail was not his first incident at the current NF. He stated he was notified of the incidents but was not given specific details. During an interview on [DATE] at 12:01 p.m., Resident #3's RP described Resident #3 as happy-go-lucky. She stated he liked to talk to people and touch them. She stated when people would pass by, he would hold his hand out to be touched. She stated Resident #3 did have a touch of dementia and had recently had a decline which worried her. She stated he never had any anger management problems. The RP stated staff from the facility had called her and told her Resident #3 had an altercation with a roommate. She stated she was told the roommate attached him while he was laying down and he suffered a black eye. She stated she did not see the eye or the bruises because she had not been able to visit during that time. She stated she did talk to him on the phone about the incident. The RP stated Resident #3 made a joke about it, in a macho sort of way. She stated he did not say anything else to her about the incident. She stated she worried about him. During an interview on [DATE] at 10:05 p.m., Resident #3 stated he remembered the incide [TRUNCATED]

38511 Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 3 of 4 residents (Residents #1, #2, and #3) reviewed for care plans, in that: 1. Facility failed to develop a person-centered care plan with interventions that addressed Resident #1's diagnoses of mental illness including depression, schizophrenia, dementia or antisocial personality disorder, and behaviors which included stealing, agitation, and aggression. 2. The facility failed to develop a person-centered care plan with interventions that addressed Resident #2's behaviors, specifically associated around smoke breaks, refusal of medications and mental illness or his altercation with Resident #1 associated with a smoke break and interventions to keep him safe from future events. 3. The facility failed to develop a person-centered care plan that addressed Resident #3's behaviors of screaming and crying out and cussing and his diagnosed mental illness, or his altercation with Resident #1 and follow up care for emotional evaluation/PTSD. An IJ was identified on 8/09/2024. The IJ template was provided to the facility on [DATE] at 8:17 p.m. While the IJ was removed on 8/11/2024 at 6:57 p.m., the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because of the facility's need to monitor the implementation of the plan of removal. These deficient practices could affect residents and place them at risk for not having their needs and preferences met. The findings included: 1. Record review of Resident #1's face sheet, dated 8/08/2024, revealed a [AGE] year-old male admitted on [DATE] with diagnoses which included: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, schizophrenia (mental health disorder) and depression. Record review of Resident #1's hospital records for admission to the facility, dated 6/14/2024, revealed Diagnosis, Assessment and Plan revealed [AGE] year-old male NF resident with history significant for schizophrenia, cirrhosis of the liver, behavior disorder and dementia brought to the ED for further evaluation of altered mental status. The physician documented he reviewed the electronic medical records from the previous NF that showed Resident #1 had a history of dementia, major depressive disorder, schizoaffective disorder, anxiety disorder, behavioral disturbance and epilepsy. Record review of Resident #1's admission MDS, dated [DATE], revealed a BIMS score of 12 which indicated a moderate cognitive impairment without behaviors or evidence of acute change in mental condition. The MDS assessment revealed related care area (CAA) triggers included cognitive loss/dementia, behaviors were not triggered on the assessment. Record review of Resident #1's Nurse Progress Note, dated 6/18/2024, revealed Resident #1 observed entering other resident's room and eating his jalapeno pork skins. Redirected to TV room and reminded not to enter other rooms. Resident pleasant and denies altered mental status. Record review of Resident #1's Nurse Progress Note, dated 6/20/2024, documented by RN C revealed Resident #1 was seated in his wheelchair in the TV room .noted to have his right hand in a brown backpack on the sofa area. Seen with a soda and 1 dinner item. Verified the bag belonged to a staff (unspecified). Resident #1 advised not to take belongings of other. He stated he understood. Record review of Resident #1's Physician's Progress Note, dated 6/25/2024, revealed Nurses report some behaviors including going into other resident rooms and taking their things, requesting a visit for psychiatric services. Record review of Resident #1's Care Plan, last revised on 6/25/2024, revealed Resident #1 required anti-psychotic and anti-depressant medications with interventions which included: monitor/record occurrence of target behavior systems (specify: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others, etc.) and document per facility protocol. The care plan did not address any resident behaviors or behavior management. Record review of Resident #1's Nurse Progress Notes, dated 7/01/2024, revealed Resident #1 entered other resident rooms and eats their snacks. Record review of Resident post-incident assessment, dated 7/04/2024, revealed the AD came to nurses' station to inform nurse of an altercation between Resident #2 and another resident that occurred during smoke break. Resident #2 assessed and had noticeable random scratches to neck, chest, bilateral arms and had a torn shirt at the neckline. Resident had no complaints of pain. The assessment noted Resident #2 statement of the event He picked up her purse and hid it and I got it back and gave it back to resident's owner (sic) and the (sic) just started hitting and scratching me! Record Review of Resident #1's Nurse Progress Notes, dated 7/04/2024, revealed LVN B documented that staff (unnamed) reported to nurse that Resident #1 had a physical altercation with another resident while in the smoking area. Staff reported that Resident #1 had picked up a purse and was getting into it when another resident [Resident #2] took it from him. Resident #1 then stood up and began to hit and scratch the other resident causing scratches and a small bruise under the right eye, redness to the scratched areas and a torn shirt. Record review of Resident #1's Psychological Initial Assessment, dated 7/10/2024 (after incident with Resident #2 but before the incident with Resident #3), revealed diagnoses treating was antisocial personality disorder. Reason for referral: agitation, irritability, anger, paranoia, physical aggression. RN reports Resident #1 had been stealing from other patients at times and also becomes aggressive. Record review of Resident #1 Psychological Services Progress Note, dated 7/17/2024 (after incident with Resident #2 but before incident with Resident #3), revealed patient displays depressive symptoms. Record review of Resident #1's Nurse Progress Notes dated 7/23/2024 at 5:45 p.m., ADON A documented while sitting in the dining room a CNA notified her that Resident #1 and another resident [Resident #3] had a verbal altercation. She told the CNA to move Resident #1 out of the room and the CNA agreed and stated okay. ADON A indicated she came back from the dining room and was at the nurses' station at 6:15 p.m., while the CNA was moving belongings into another room, she heard a scream for help and all staff ran to the room. ADON A documented Resident #1 was standing over [Resident #3] and throwing punches at the other resident's face. The CNA tried to stop Resident #1 as he continued to punch the other resident in the face. ADON A documented she grabbed Resident #1 by his shirt and pulled him off the other resident causing ADON A and Resident #1 to fall over the wheelchair. Resident #1 was breathing hard and was visibly made at [Resident #3]. ADON A and the CNA assisted Resident #1 off the floor and back to his wheelchair and removed him from the room. He tried to go back into the room and continue to fight [Resident #3]. ADON A documented she told Resident #1 that she would call the police if he did not stop and he replied I don't care .ADON notified the DON who stated to call 911. ADON then notified Resident #1's physician who also stated to call 911. ADON A documented she called 911 and EMS to evaluation the other resident [Resident #3]. A report was made and (police) officers handcuffed Resident #1 while in the wheelchair and escorted him out of the building. Record review of a local police report dated 7/23/2024 revealed Resident #1 was arrested and charged with Class 3 Felony Texas Penal Code 22.04 (A) (Injury to a child, elderly individual, or disabled individual). Resident #1 admitted to assaulting Resident #3. The report indicated due to the victim (Resident #3) being [AGE] years of age, the suspect (Resident #1) was placed under arrest, transported to the city detention center and booked. During an interview on 8/07/2024 at 11:01 a.m., AA D stated he was responsible for supervising smoke break (7/04/2024) when the incident between Resident #1 and Resident #2 occurred. AA D stated it started when one of the female residents left the smoking area because she said it was too hot and she wanted to go back inside where it was cooler, but she left her purse behind on the floor. AA D stated he saw Resident #1 bend over and go through something on the floor. He stated before he could get to Resident #1, he saw Resident #2 grab a purse from Resident #1. Resident #2 then handed the purse to him (AA D). AA D stated, after Resident #2 handed him the purse, both residents sat back down and resumed the smoke break. He stated a little bit later, Resident #1 was quiet and calm but started inching closer and then suddenly took some swipes at Resident #2 but made no contact. AA D stated Resident #1 then grabbed Resident #2 by his shoulder, scratching him in the process. AA D stated both staff immediately pulled the two residents apart and both calmed down quickly. AA D stated Resident #1 stopped his aggressive behavior. AA D stated there had been no other altercations between the two residents who both attended every smoke break. He stated they had never exhibited any aggressive behaviors before. AA D stated he had been told by the nurse (unknown) on Resident #1's unit that Resident #1 had a history of stealing but was not told of any aggressive behaviors. During an interview on 8/09/2024 at 11:08 p.m., MA P stated she was in the building following Resident #1's altercation in the smoking area (with Resident #2). She stated after the altercation he kept saying I am going to fuck you up. She stated the staff talked to him to get him to calm down and she told him it was considered assault what he did. MA P stated Resident #1 was a klepto (used as a slang word in this context, which is a shortened version of the word kleptomania, not the actual diagnosis of a mental health disorder. Kleptomania is a mental health disorder where a person feels an uncontrollable urge to steal things.). She stated after the second or third time the staff told the DON, and nothing was done. MA P stated the DON said she would speak to him (Resident #1) and the DON told the staff to watch him but nothing changed. MA P stated the CNA's had to handle it themselves. She stated they tried to keep an eye on Resident #1, and she kept Resident #4's door shut. During an interview on 8/09/2024 at 11:29 a.m., LVN B stated Resident #1 could be aggressive, but she had never had any problems with him. LVN B stated Resident #1 did have a bad habit of going into other residents' rooms and stealing and he smoked a lot. LVN B stated she was informed he had an altercation with another resident in the smoking area. She stated she could not remember when this occurred or whom the other resident was. LVN B stated for interventions she just kept an eye on him and tried to keep him separated to keep other residents safe. LVN B stated she was not sure anything was in his care plan about it. After looking at his care plan, LVN B stated there was nothing in Resident #1's care plan about his klepto or behaviors/mental illness. LVN B stated she doesn't really sue care plans for resident care. She stated she gets to know the residents and their personality and that was how she knows how to care for them. LVN B stated charge nurses do not alter care plans and she was not sure who was responsible. During an interview on 8/09/2024 at 1:45 p.m., LA E stated she was present during the altercation between Resident #1 and Resident #2 smoke break. She stated she thought it was the 1:30 p.m. smoke break but could not be certain. She stated she was there on her own personal smoke break. She stated she and AA D were talking when she saw a female resident go inside, wheeling herself in her wheelchair, but dropped her purse along the way. She stated AA D had gone to let the female resident inside, when she saw Resident #1 move toward the purse. She stated Resident #2 grabbed the purse from Resident #1 and handed it back to AA D. LA E stated Resident #1 was quiet for about 5 minutes and then started pushing himself in his wheelchair towards Resident #2. She stated as Resident #1 got closer to Resident #2, she saw Resident #1 saying something, like a whisper. She stated she could not hear what he was saying, but Resident #2 leaned forward to hear him. LA E stated Resident #1 stood up and grabbed Resident #2's shirt and started to hit him. During an interview on 8/07/2024 at 10:47 a.m., Resident #1's legal guardian stated Resident #1 had been arrested at the NF was still in the local jail, charged with a third-degree felony with intent to cause bodily injury. The legal guardian stated the incident that ended with Resident #1 in jail was not his first incident at the current NF. He stated he was notified of the incidents but was not given specific details. 2. Record review of Resident #2's face sheet dated 8/10/2024 revealed a [AGE] year-old male admitted on [DATE] with diagnosis which included: schizoaffective disorder bipolar type (mental illness with features of both schizophrenia and bipolar mood disorder with symptoms that include mania and heightened emotion). Major depressive disorder recurrent, generalized anxiety disorder, paranoid schizophrenia, paraphilia (preference for or obsession with unusual sexual practices) and mild neurocognitive disorder due to known physiological condition with behavioral disturbance (behavioral and psychological symptoms of dementia. Record review of Resident #2's Care Plan last revised on 4/29/2024 revealed the resident had wandering behaviors and exit seeking behaviors and resided in the locked unit. The care plan also addressed the use of antidepressant and anti-anxiety medication. The care plan did not address dementia or cognitive deficits related to understanding/communication, it did not address his mental health diagnoses and how to relate/approach/interventions for depression and anxiety and it did not address mental illness of schizoaffective disorder with bipolar symptoms and it did not address paraphilia or any behavior monitoring. The care plan also did not address Resident #2's altercation with another resident (Resident #1) with interventions to prevent recurrence. Record review of Resident #2's progress note, dated 6/20/2024, revealed Resident #2 actively involved in smoke break. He receives 5 smoke breaks daily. Behaviors (unspecified) present before the start of smoke break, nurse is aware. Record review of Resident #2's progress note, dated 6/21/2024, revealed he was refusing medications. Record review of Resident #2's progress note, dated 6/23/2024, revealed Resident refused all his medications this shift. Record review form 3613-A Provider Investigative Report, dated 7/04/2024, revealed the facility self-report a resident-to-resident altercation and listed it as incident category other. The report indicated on 7/04/2024 at 4:00 p.m., Resident #1 was found rummaging through another resident's purse during smoke break. Resident #2 intervened to remove the purse from Resident #1. Resident #1 slowly inched his way to Resident #2 striking him several times which resulted in scratches to neck, chest, bilateral arms (both arms) and ripping a small hole in Resident #2's shirt. A former Administrator (Administrator AA) marked the investigation as inconclusive. The facility documented their response as self-report protocols, in-service and re-education of staff initiated for abuse/neglect policy and an AD HOC QAPI meeting held. Record review of Resident #2's Nurse Progress Notes, dated 7/04/2024, revealed Resident #2 was involved in an altercation during smoke break with Resident #1. Resident #2 was not faulted for the incident. Resident #1 was found rummaging through another resident's purse (unnamed). Resident #2 intervened to remove the purse from Resident #1. Resident #1 slowly inched his way to Resident #2, striking him several times, scratching him and ripping a small hole in his shirt. AD (Activity Assistance D) and laundry attendant (LA-E) peacefully diffused the incident, separating bath parties, Charge nurses notified, DON notified of incident. Documented by AA D. Record review of Resident #2's Psychiatric Clinical Treatment Plan, dated 7/10/2024, revealed he was assessed for current mood and anxiety symptoms to ascertain current emotional functioning and process thoughts and feelings relative to recent physical altercation with another resident. The assessment listed his anxiety was moderate and rated as increased, his emotional withdrawal was listed as moderate and rated as increased, hostility was labeled as moderate and rated as increased and tension was labeled as moderate and rated as increased. The assessment noted he was moderately cognitively impaired. Record review of Resident #2's progress notes, dated 7/28/2024, revealed Resident #2 upset, yelling, being aggressive when told there was no one to take them to smoke. Resident yelling, cursing and demanding to smoke. Resident easily redirected to room. Record review of Resident #2's quarterly MDS, dated [DATE], revealed a BIMS score of 6 which indicated a severe cognitive impairment, with continuously present behaviors which included inattention, disorganized thinking and altered level of consciousness but no physical, verbal or other behaviors exhibited. Resident #2's functional status was recorded as independent with walking and transferring. 3. Record review of Resident #3's face sheet, dated 8/08/2024, revealed a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] and readmitted [DATE] with diagnoses which included: senile degeneration of brain (dementia), schizoaffective disorder bipolar type (mental health disorder), and anxiety disorder. Record review of Resident #3's Annual MDS, dated [DATE], revealed a BIMS of 5 which indicated a severe cognitive impairment with no behavior symptoms. Record review of Resident #3's Care Plan, last revised on 5/13/2024, revealed there were no behaviors documented in the plan of care and no interventions for behaviors. The Care Plan also did not address his mental health diagnosis of schizoaffective disorder bipolar type or diagnoses of anxiety. The care plan did not address Resident #3's altercation with another resident and/or interventions for potential PTSD. Record review of Resident #3's progress note dated 7/02/2024 revealed the resident was yelling Let me off this bus. During an interview on 8/09/2024 at 11:57 a.m., the MDS Coordinator stated she began working at the facility on 6/24/2024. She stated there were a lot of assessments (MDS) that were getting behind and since she was new some people in management had been helping her when she asked. She stated when a resident first admitted to the facility the admitting nurses completed a baseline care plan and then she does an admission assessment where she looks at the care plan. She stated she does care plans associated with assessments and the nurses were supposed to do acute care plans. She stated anything not acute and associated with an assessment would be her responsibility. She stated once admitted a comprehensive care plan should be completed by day 21. She stated she reviews all sorts of records for her assessments/care plans including admission records, history and physicals, therapy, nursing documentation, CNA documentation. She then does an interview with the resident or family member, social services, any ancillary services, and reviews dietary notes and assessments. She stated she took in all that knowledge for the MDS assessment and the care plan that followed. She stated she does not complete a physical examination of the resident. She stated she was taught that was not her role. She stated her role was to code what was documented by other nurses. She stated she was unsure if Resident #1's care plan was a baseline care plan or a comprehensive care plan. She stated she had not seen the facilities baseline care plans since she started working at the facility and did not know if the comprehensive was built on the baseline. She stated Resident #1 should have had a comprehensive care plan and acknowledge Resident #1, #2 and #3 were incomplete mental illness nor behaviors were care planned and it was her responsibility. She stated as of this interview, it was the first time she had looked at Resident #1's care plan. The MDS Coordinator stated when she went to write his care plan Resident #1 had already been discharged (7/23/2024) and she had not admitted him. She stated Resident #1 was not part of her assignment and was not on her radar. She stated she did not know who was responsible for completing Resident #1's care plan. The MDS Coordinator stated Resident #2 and Resident #3 did not have care plans that addressed their mental illness, behaviors or interventions. She stated the care plans of all residents should address their mental illness with interventions, not just management of their medication. She stated the facility used to have another MDS Coordinator, but she no longer worked at the facility. She stated she did not really have an assignment, she just worked on whomever was next. She stated Resident #1 was not due for a care plan. The MDS Coordinator stated she had heard about Resident #1's fight where he hit someone while they were in bed (Resident #3). She stated she did not realize there was a previous fight (Resident #2). She stated she did not remember and was not sure but she stated the two people were in the first fight were separated and were not in direct contact with each other so she could not say she would have put that in the resident's care plans. She stated she could not judge what she did not know. She stated it would have been important to add to the care plan so people could be aware Resident #1 was violent. The MDS Coordinator stated she had a lot of MDS assessments to complete and was getting behind. The MDS Coordinator stated she was aware there was a resident at the facility with stealing behaviors because she heard about it during morning meeting, but she did not know it was Resident #1. She stated they might have mentioned Resident #1's name during morning meeting but she was not good with names and could not remember. She stated multiple residents and behaviors were discussed during morning meetings. The MDS Coordinator stated Resident #1's stealing behaviors had not been care planned. The MDS Coordinator stated it was important for residents' behaviors and mental illness to be care planed because it was a behavior and that was reason alone. She stated they should have been care planned but she was completely overwhelmed by the RUGS/MDS system. She stated she was mostly focused on completing assessments and not on the care plans. . During an interview on 8/09/2024 at 11:19 p.m., CNA J stated Resident #1 had a temper and was always stealing money, tennis shoes and food, mostly from Resident #4. CNA J stated he stole tennis shoes from another resident (unknown name) and stole money from another resident. CNA J stated she told ADON A about the stealing and Resident #1 denied it. CNA J stated there was nothing on his Kardex (care plan) about his behaviors. During an interview on 8/09/2024 at 2:56 p.m., the SW stated he did have influence on the care plan and the social worker role was to add interventions especially if it was a social work goal or change in condition. He stated at this facility they documented interventions into the facility investigation incident report but not into the care plan. He said the incident is documented in a binder and not in a residents medical record. He stated he was told by a former administrator (unknown name, not current administrator) not to document behaviors in the care plan. He stated his role at the facility was case management. He stated Resident #3 did not have any behaviors that he was aware of but was grumpy at times. The SW stated the facility did not get much information about him initially because it was an emergency placement. He stated they reviewed the hospital records, and sometimes later, not at admission, they reviewed the records from his previous NF placement. The SW stated the records indicated he had a habit of theft, and he was moved from his last NF placement because he had an altercation at the NF and was either sent to jail or to the hospital. The SW stated the facility got Resident #1 from the hospital. He stated when he reviewed the reports from the previous facility the altercation was a physical altercation with unknown injuries. He stated other residents at the facility were telling him he was stealing. Staff were also reporting he was stealing. The SW stated Resident #1's behaviors were discussed during morning meetings. He stated the discussions were around what he had done. He stated they talked about what he had stolen, and which residents were accusing him of stealing. He stated they also discussed the incident between Resident #1 and #2. When asked if they discussed interventions to keep the other resident's safe the SW stated they encouraged other residents to keep their personal items put away. The SW stated Resident #1 did not have access to Resident #2 because Resident #2 resided in the locked unit and during smoke breaks, they encouraged them to sit farther away from each other. During an interview on 8/09/2024 at 4: 44 p.m., the DON said behaviors were discussed during morning meeting, and it was her expectation for the MDS Coordinator to document them in the residents' care plans. She stated behaviors were also discussed during evening stand down meetings (end of day meetings). The DON stated Resident #1's care plans should have been documented by a former MDS Coordinator. After reviewing the termination date of the former MDS Coordinator (6/22/2024), the DON stated she was not sure who was responsible. She stated she might have been a gap between, or one (MDS Coordinator) might of have in orientation for a few days. She stated right now the facility only had one MDS Coordinator. The DON stated the charge nurses completed the initial care plan and periodically reviewed the care plans as needed. She stated the care plan was part of the POC and Kardex for CNA's to review for care. She stated the staff should document behaviors in their notes, including CNA's who document in POC. The DON stated it was important for resident behaviors and mental illness to be care planned so they didn't have what they currently have going on (in reference to the investigation of the resident-to-resident abuse). She stated when Resident #1 first arrived at the facility he was fine. She stated he was going out for cigarette breaks. She stated on one of those smoke breaks Resident #1 found a purse and was going through it. She stated another resident, Resident #2 intervened and took the purse away. The DON stated Resident #1 retaliated by scratching Resident #2 all up on his arms and neck. The DON stated after this incident occurred, they kept an eye on Resident #1 during smoke breaks and in other areas. The DON stated most of the time Resident #1 was in a good mood. She stated Resident #1 thought everything belonged to him, which meant he stole items. She stated anything left out; he would take. The DON stated a CNA left her bag out and Resident #1 ate her lunch. The DON stated for interventions people were told to put things away and they monitored Resident #1. She stated monitored meant they just watched him through the day. The DON stated she did not think there was a place for staff to document the monitoring. The DON stated Resident #1 did not have any orders for behavior monitoring. She stated they were not doing behavior monitoring because the incident between Resident #1 and Resident #2 was a first-time occurrence and the incident was provoked by Resident #2 when he removed the purse from Resident #1. The DON stated she had not expected behaviors from Resident #1. She stated they were just watching him, not monitoring for behaviors. The DON stated the first time she became aware of the stealing behaviors was when Resident #1 stole the purse and when he stole the CNA's bag. The DON stated she did consider stealing a behavior, but they were just monitoring him as part of the incident reporting and not as part of Resident #1's medical record. The DON stated they had discussed behaviors during morning meetings and had expected the MDS Coordinator to document it in the care plan. The DON stated she expected the charge nurses to review the care plan upon admission and then periodically. She stated the care plan was part of POC and on the Kardex for the CNA's. The DON stated she would expect staff to respond to behaviors by following their dementia training which was to allow the resident space and allow them to calm down. The DON stated the facility was working on dementia training currently and it was not completed. The DON stated she expected the CNAs to report behaviors to the charge nurse and she expected the charge nurses to use basic nursing knowledge to intervene and was not based on interventions documented in a plan of care. The DON stated the staff should have taken Resident #2 out separately from Resident #1. She stated this was a verbal agreement with staff and not part of the care plan. The DON stated, IF I took something your you, you would probably act up too. It was an expected behavior. When asked about the other residents' safety the DON stated she did not feel like other residents were at risk The DON stated she had been monitoring UDAs for behaviors and had not seen any behaviors documented. When asked how she would see a UDA for behaviors if they were not monitoring for behaviors, she stated the ADON's look for behaviors in the medical record and she does the same. She stated if she saw a behavior in the medical record, she would tell the ADON to go check on it. During an interview on 8/12/2024 at 1:10 p.m., the Administrator stated she had been out of the facility from the time of surveyor arrival (8/07/2024) until today. She stated she was the interim Administrator until the facility could find a permanent Administrator. She stated she was hired on 7/20/2024 after the incidents between Resident #1 and #2 had occurred. She stated when she arrived, she did review and discuss the resident-to-resident altercations with the DON prior to surveyor arrival. The Administrator stated the nursing staff, SW and activities were responsible for the resident care plans. She stated all of them could alter/update the care plan. She stated the MDS Coordinator and IDT team provided oversight to ensure accurate and complete care plans. The Administrator stated the ADON and DON were responsible for monitoring nursing staff. She stated the DON could delegate quite a bit of her duties if needed. The Administrator stated the facility prevented harm by reviewing resident history, observation of resident behaviors. She stated everyone was responsible for resident safety. Record review of a facility policy, titled Behavior management Policy last revised April 19, 2005, revealed: Policy: Behavior management includes the management of anger, confusion, hallucination, and other behavior by utilizing techniques such as area limitation, self-responsibility, group interactions, limit setting, and behavior modifications depending on individual needs. Procedures: 15. Develop and facilitate a behavior modification program .19. Document behavior modification on the interdisciplinary plan of care. Monitor effectiveness of interventions. Record review of a facility policy, titled Comprehensive Care Planning (undated) revealed: The facility will develop and [TRUNCATED]

Based on interviews and record review, the facility failed to consult with the resident's physician when there is a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 (Resident #2) of 7 residents reviewed for resident rights. The facility failed to notify Resident #2's physician of her change of condition on [DATE]. Resident #2 continued to have these symptoms and was sent out to the hospital on [DATE]. On [DATE] at 4:30 pm an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm that was not an immediate jeopardy due to the facility continuing to monitor the implementation the effectiveness of their Plan of Removal. This failure could affect residents by placing them at risk for a delay in medical treatment, decline in health, and death. Findings included: Record review of Resident #2's Admission Record, dated [DATE], revealed Resident #2 was originally admitted to the facility on [DATE] with the most recent readmission on [DATE]. The diagnoses included: Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), acute kidney failure (condition in which kidneys suddenly are unable to filter waste from blood), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), and dementia (group of thinking and social symptoms that interferes with daily functioning). Record review of Resident #2's Quarterly MDS assessment, dated [DATE], revealed Resident #2 had a BIMS score of 6 (suggesting severe impairment). Record review of Resident #2's Order Summary included: Behavior Monitoring Enter the code - 0. None 1. Panic 2. Agitated 3. Angry 4. Anxiety 5. Biting 6. Compulsive 7. Crying 8. Pacing 9. Screaming/yelling 10. Pull IV line/tubes 11. Poor eye contact 12. Depressed/withdrawn 13. Extreme fear 14. False beliefs 15. Fighting 16. Finger painting feces 17. Hallucinations/paranoia/delusion 18. Head banging 19. Insomnia 20. Jittery 21. Kicking 22. Noisy 23. Pinching 24.Restless 25. Scratching 26. Slapping 27. Suspiciousness 28. Throwing objects 29. Wandering 30. Other see progress notes; every shift, if any behaviors are noted, document details in a progress note. Record review of Resident #2's April TAR revealed: Behavior Monitoring Enter the code - 0. None 1. Panic 2. Agitated 3. Angry 4. Anxiety 5. Biting 6. Compulsive 7. Crying 8. Pacing 9. Screaming/yelling 10. Pull IV line/tubes 11. Poor eye contact 12. Depressed withdrawn 13. Extreme fear 14. False beliefs 15. Fighting 16. Finger painting feces 17. Hallucinations/paranoia/delusion 18. Head banging 19. lnsomnia 20. Jittery 21. Kicking 22. Noisy 23. Pinching 24. Restless 25. Scratching 26. Slapping 27. Suspiciousness 28. Throwing objects 29. Wandering 30. Other see progress notes every shift If any behaviors are noted, document details in a progress note. Further review of this document revealed: [DATE] - [DATE]: 0 (None) [DATE] - [DATE]: 19 (Insomnia) [DATE] and [DATE]: 4 and 13 (Anxiety and Extreme fear) [DATE] and [DATE]: 0 (None) [DATE] and [DATE]: 1 and 4 (Panic and Anxiety) Resident #2's April TAR also revealed: Side Effects - Enter the code - 0. None 1. Dystonia 2. Dry mouth 3. Constipation/urinary retention 4. Hypotension 5. Drowsiness/Sedation 6. Dizziness 7. Arrhythmias 8. Tardive dyskinesia 9. Rash 10. Headache 11. Urine retention 12. Weak 13. Cogwheel rigidity 14. Tremor 15. Appetite change 16. Insomnia 17. Confusion 18. Sore throat 19. Seizure 20. Photo-sensitivity 21. Suicidal Ideations 22.GI disturbance 23. Ataxia every shift If any side effects are noted, document details in a progress note. Further review of this document revealed: [DATE] - [DATE]: 0 (None) [DATE]: 5 (Drowsiness) [DATE]: 14 (Tremor) [DATE] - [DATE]: 0 (None) [DATE]: 8 and 14 (Tardive Dyskinesia and Tremor) [DATE] and [DATE]: 14 (Tremor) [DATE] and [DATE]: 0 (None) [DATE]: 6, 14, and 16 (Dizziness, Tremor, and Insomnia) [DATE]: 14 and 16 (Tremor and Insomnia) Record review of Resident #2's Progress Notes revealed: Effective Date: [DATE] 13:25 [1:25 pm] .Note Text: This nurse was called to resident room to assist with a transfer back to w/c from the bed. Once resident was in her w/c her eyes became fixated and shallow breathing. Resident then took her last breath and was placed on the floor. Another CNA went to call for help. This resident is a full code. CPR was initiated, with AED, ambu bag with 02 at 15L. 911 was called, family in hallway. Resident now breathing with a strong heartbeat [sic] EMS arrived and placed resident on stretcher, resident still incoherent. Resident was sent to [hospital] with RP at her side.MD, DON, and administrator aware. Author: [LVN B] . Record review of Resident #2's SBAR, dated [DATE], revealed Resident #2 had mental, functional, and neurological status change, with heightened emotional status of anxiety, panic, dizziness, fear, body was shaking, trembling, perspiring, VS were BP ,d+[DATE], Pulse ,d+[DATE], and respirations 28, symptoms started [DATE]. Record review of Resident #2's SBAR, dated [DATE], revealed Resident #2 had functional status change, needed more assistance with ADLs, falls, weakness, and was diaphoretic (sweating), VS were BP ,d+[DATE], Pulse 92, and respirations 20, symptoms started [DATE]. Further review of this documentation revealed the MD or NP were notified on [DATE] and RP was notified on [DATE]. Review of Resident #2's EMR revealed there was no documentation stating the MD/NP was notified of Resident #2's change in condition on [DATE]. Record review of Resident #2's hospital record, dated [DATE], revealed: .brought to the ED via EMS with reports of altered mental status. Per the ED physician the nursing facility reported that the patient was unresponsive, so EMS was called. The nurse at the outside facility started CPR .Upon arrival to the ED of EMS the patient was found to be hypotensive [low blood pressure] and tachycardic [elevated heart rate] .Initially on arrival the patient was unresponsive .ASSESSMENT/PLAN: 1. Sepsis .2. Acute encephalopathy .3. Dehydration .4. AKI . During interview on [DATE] at 9:38 am, RN A said, on [DATE] at approximately 10:00 am, Resident #2 was sitting in the dining room holding on very tightly to the table and the pillar and said she did not want to be left alone. RN A obtained VS and said the abnormal VS (BP ,d+[DATE], Pulse ,d+[DATE], and respirations 28) on [DATE] triggered the SBAR. RN A further stated she notified the MD about Resident #2's change in condition after completing the SBAR on [DATE] and did not receive any new orders from the MD. RN A said she must have documented the communication with the MD in a progress note. During interview on [DATE] at 11:57 am, the MD, she was not notified of the change in condition for Resident #2 on [DATE]. The MD said had she been notified; she would have sent Resident #2 to the hospital. The MD further stated there was a possibility the change in condition Resident #2 experienced on [DATE] may have led to the hospitalization on [DATE]. During interview on [DATE] at 4:09 pm, the DON said she was aware of the SBAR for [DATE] and had briefly read it. She further stated RN A reported that on [DATE] Resident #2 had gripped the table and was shaking, and RN A notified the MD. She further stated she was not aware of the symptoms listed on the SBAR for Resident #2 or the lack of documentation regarding notification or follow up to the MD/NP on [DATE] regarding Resident #2. The DON said she expected nurses to contact the MD once the resident was stabilized if there was a change in condition and document on the SBAR what the MD said. The DON further stated she audited resident records at least once a week, reviewed all the nurses notes every morning on Tuesday - Friday, and the 72-hour report on Monday mornings. The DON said she was not aware there were no progress notes for [DATE]. The DON said during her observations Resident #2 was fine but did not remember the exact date of the observation. During interview on [DATE] at 10:27 am, LVN D said Resident #2 had some neurological changes, excessive shaking, and trembling between [DATE] and [DATE]. LVN D further stated Resident #2 was more incontinent and needed more help with ADLs during this time, and on [DATE]. During interview on [DATE] at 10:30 am, CNA C said between [DATE] and [DATE], Resident #2 was shaking a lot, holding on to the table thinking she was going to fall, and was saying the police were coming. CNA C further stated Resident #2 was having delusions and kept saying I'm falling, I'm falling. During interview on [DATE] at 1:30 pm, the NP said she was not notified of the change in condition for Resident #2 on [DATE]. The NP further stated the facility was responsible for notifying the MD/NP of changes in resident condition so that they could intervene if needed. The NP further stated, had she been notified, she would have sent Resident #2 to the hospital. Record review of facility policy, titled Notifying the Physician of Changes in Status and revised [DATE], stated: The nurse will notify the physician immediately with significant changes in status . This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 4:26 pm. The ADO and the DON were notified. The ADO and the DON were provided with the IJ template on [DATE] at 4:30 pm. The following POR submitted by the facility was accepted on [DATE] at 1:06 pm and reflected the following: [Facility] [DATE] Quality Assurance Problem: Facility failed to notify Physician/NP of resident change in condition. Interventions: The following in-services were initiated by the DON and the ADON on [DATE]. Any staff member not present or in-serviced on [DATE] will not be allowed to assume their duties until in-serviced. - In-service completed with the DON and the ADONs by the ADO and the RCN on [DATE] regarding reviewing and monitoring documentation in PCC to include review of the SBAR, and PCC clinical alerts. Licensed Nurses Certified Nurse Aides In-service licensed nursing staff to the following in the event of a resident change in condition: - Promptly and correctly assessing a resident when a change of condition has been identified / reported. - Unless it was an emergency situation, assessing a resident's change in condition and document change using a SBAR, so that all necessary information was communicated to the physician or nurse practitioner. The completion of the SBAR included documentation of the notification to the physician and any new orders, if any, the physician provided. - If an emergency situation, stabilize the resident as much as possible and notify 911. Notify the physician after transfer. - Initiate any orders provided. - Promptly and correctly assessing a resident when a change of condition has been [sic] identified. Communication of change in condition to other nurses, med aides, and nurse aides will occur during shift-to-shift change report. Documentation of change in condition will occur on the 24-hour report in PCC. In-service initiated for Certified Nurse Aides on [DATE] by the DON on the following: Any non-licensed nursing staff not present or in-serviced on [DATE] will not be allowed to assume their duties until in-serviced. - CNAS will verbally communicate any resident change of condition as well as document the change under point of care in PCC. - An adhoc QAPI meeting was conducted on [DATE] regarding this plan and monitoring. - The medical director [Medical Director] was notified of this plan and monitoring on [DATE]. Monitoring: The DON / designee will monitor PCC Dashboard alert documentation for all residents at least 5 times per week to ensure any potential change of condition has been addressed and the physician was notified timely. The DON / designee will ask 10 nursing staff (including at least 6 nurses) per week what they would do if a resident had a change of condition, or it was reported to them that a resident had a change in condition. All monitoring noted above will continue for at least 4 weeks. The QAPI Committee will review the findings and make changes to this plan as needed. The DON/designee will review all SBARs 5 times a week for 4 weeks and periodically there after to ensure all resident change in condition have been addressed. Verification of POR: Record review of facility's sign-in sheets on of [DATE] revealed 65 out of 65 nursing staff (100%) were in-serviced in-person, via text, and via telephone. Record review of facility's in-service Training Attendance Roster, Topic: Reviewing and Monitoring Documentation in PCC, dated [DATE], revealed it was completed by the ADO; Attendees: the DON, LVN D, and LVN H. In interviews between [DATE] at 5:13 pm and [DATE] at 11:34 am, with 4 nursing staff on the 6 am - 6 pm shift (2 RNs and 2 LVNs), 4 nursing staff on the 6 pm - 6 am shift (2 RNs and 2 LVNs), 6 CNAs on the 7 am - 3 pm shift, 4 CNAs on the 3 pm - 11 pm shift, and 5 CNAs on the 11 pm - 7 am shift, staff said they had been in-serviced regarding communication of changes of condition between shifts and to the charge nurse, documentation of SBAR, and notification of changes in resident condition to the MD. During interview on [DATE] at 5:13 pm, LVN A said she received an in-service on [DATE] that included when to complete an SBAR, what it entails (documentation, calling the MD), when to report changes in condition, documenting changes and notifying the MD, and documenting new orders. During interview on [DATE] at 5:16 pm, RN D said she received in-service on [DATE] that included SBAR, changes in condition, identifying changes and need for SBAR, full documentation of the SBAR and notification to the MD, family, and the DON. Communicating with our peers, and shift report. During interview on [DATE] at 5:22 pm, CNA E said she received an in-service on [DATE] that included changes for the residents, reporting changes, such as bruises or wounds, to the nurse and documentation of any changes in POC. During interview on [DATE] at 5:24 pm, CNA F said she received an in-service on [DATE] that included telling the nurse, the DON, or Administrator if we see anything like skin tears or bruising and documentation of changes in POC. During interview on [DATE] at 5:25 pm, LVN F said she received an in-service on [DATE] that included SBAR, changes in condition, calling the MD, documentation, notifying family, calling 911 for emergencies and contacting the RP. Documentation of the SBAR, such as what was going on, the change in condition, notifying the MD and documenting what the MD said regarding orders or what they want us to do, sometimes its medication or monitoring. During interview on [DATE] at 5:29 pm, CNA G said she received an in-service on [DATE] that included notifying the nurse if we see any signs of decline and documenting those changes in POC. During interview on [DATE] at 5:30 pm, CNA H said she received an in-service on [DATE] that included reporting any changes in condition or declines to the nurse and documentation in POC. During interview on [DATE] at 5:34 pm, RN B said she received in-service on [DATE] that included SBAR, calling the MD, the family, and contacting the Medical Director. She stated if the MD did not answer the medical director should be notify, and to notify the resident, family, and the medical director, if needed of new orders. CNAs were supposed to let us know if there were changes in condition, such as: loose stools, pain, fever, bruises, falls, decreases in appetite, and they document those changes in PCC. For emergencies, assess the resident, complete an SBAR, document any new orders, and make notifications. If we need to call 911, call them, document, and notify everyone. It also included the 24-report, which was a communication sheet used during shift change. During an interview on [DATE] at 2:01 am, LVN G said she received an in-service on [DATE] that included recording changes in condition, who to call if there were changes, what to do, notifying the MD, family, and stabilizing the resident. During an interview on [DATE] at 2:03 am, CNA I said she received an in-service on [DATE] that included reporting any changes in resident condition to the nurse and documenting in POC. During an interview on [DATE] at 2:04 am, CNA J said she received an in-service on [DATE] that included reporting of abuse/neglect, reporting any changes in condition to the nurse, and documenting changes in POC. During an interview on [DATE] at 2:06 am, RN F said she received an in-service on [DATE] that included contacting the MD when there were changes in condition, documentation of the changes, and completing the SBAR. During an interview on [DATE] at 2:07 am, CNA K said she received an in-service on [DATE] that included reporting any changes in condition to the nurse and documenting them in POC. During an interview on [DATE] at 2:10 am, RN G said she received an in-service on [DATE] that included how to complete an SBAR and notifying the MD. During an interview on [DATE] at 2:13 am, LVN H said she received an in-service on [DATE] that included SBAR, assessing the resident with changes in condition, notifying the MD, initiating new orders, communication of changes to nurses, Mas, and CNAs during shift report and documentation. During an interview on [DATE] at 2:14 am, CNA L said she received an in-service on [DATE] that included abuse, documentation of changes in condition, reporting to the nurse, and documenting in the POC. During an interview on [DATE] at 2:16 am, CNA M said she received an in-service on [DATE] that included abuse/neglect, documenting changes in condition, and communicating changes to the nurse. During an interview on [DATE] at 11:30 am, CNA N said she received an in-service on [DATE] that included if she saw something, such as skin tears, or if someone was hurt it should be reported to the nurse and documented. During an interview on [DATE] at 11:31 am, CNA O said she received an in-service on [DATE] that included if something happened to the residents or if there was a change in their condition, it should be reported to the nurses and then documented in the POC kiosk. When they shower the residents, if they saw anything, like a bruise, document it and report it to the nurse. During an interview on [DATE] at 11:34 am, CNA R said she received an in-service on [DATE] that included reporting changes in resident condition, such as bruising or changes in health, to the nurse, and documented in POC. During an interview on [DATE] at 11:36 am, CNA S said she received an in-service on [DATE] that included patient care, reporting changes in condition, skin, or health, to the nurses. During an interview on [DATE] at 11:40 am, the DON said she provided an in-service starting on [DATE] that included all nurses and CNAs. Topics included proper documentation and notification of SBARs regarding changes in resident condition and CNAs reporting changes to the nurses and documenting changes in POC. The DON further stated she completed a review of all resident SBARs for the months of April, May, and [DATE] and no concerns were identified. During an interview on [DATE] at 11:46 am, CNA B said she received an in-service on [DATE] that included reporting changes in resident condition to the nurse and documentation of changes in POC. During an interview on [DATE] at 11:47 am, CNA Q said she received an in-service on [DATE] that included a text message to receive an in-service before she started her shift on [DATE] at 7:00 am. She further stated on [DATE] she was told to report any changes that she had not seen before while caring for a resident to the nurse and document the change in Care Tracker/POC. Record review of facility policy, titled Notifying the Physician of Changes in Status and revised [DATE], revealed on was present and in effect. The ADO and the DON were informed the Immediate Jeopardy (IJ) was removed on [DATE] at 1:06 pm. The facility remained out of compliance at a severity of potential for more than minimal harm that was not an immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 2 residents (Resident #1) reviewed for accidents and supervision, in that: Resident #1 eloped from the facility on 02/21/2024 and again on 03/04/2024. The facility failed to prevent Resident #1 from eloping on 2/21/24. Resident #1 eloped again when he was not being monitored on 3/4/24. An Immediate Jeopardy (IJ) was identified as past non-compliance on 04/18/2024. The non-compliance began on 02/21/2024 and ended on 03/05/2024. The facility had corrected the non-compliance before the survey began. This deficient practice could place residents who were elopement risks at-risk of harm, serious injury, or death. The findings were: Record review of Resident #1's face sheet, dated 04/18/2024, revealed the resident was admitted to the facility on [DATE] with diagnoses including: unspecified dementia (memory loss), alcohol dependence, epilepsy (a condition that causes frequent seizures) and depression. Further review revealed the resident was discharged from the facility on 4/11/2024 to home, and the resident's family member was the resident's Responsible Party. Record review of Resident #1's Admission MDS, dated [DATE], revealed the resident had a BIMS score of 6 which indicated a sever cognitive impairment. Further review revealed resident did not have any behavioral issues, his level of ambulation was independent. Record review of Resident #1' doctor orders, dated 2/20/2024, revealed the resident was admitted to the secured unit upon admission. Record review of Resident #1's progress notes, dated 02/21/2024, revealed the resident had eloped from the facility via his bedroom window on 2/20/2024 at 5:05 p.m Further review revealed the resident had eloped from the facility by pulling out the glass windowpane from the window frame, and he was found walking back to the facility with beer and cigarettes. Record review of Resident #1's doctor orders, dated 2/21/2024, revealed the resident was placed on 15-minute checks. Record review of Resident #1's progress notes, dated 03/04/2024, revealed Resident #1 eloped on 03/04/2024 at 5:00 p.m Further review revealed the resident had eloped by breaking a window in another resident's room and was found sitting at a bus stop that was down the street from the facility. The resident returned to the facility with staff. Record review of Resident #1' doctor orders, dated 3/5/2024, revealed the resident was placed on 1:1 while in his room. Record review of Resident #1's care plan, dated 03/06/2024, revealed the facility implemented elopement precautions with interventions: the resident was placed on 1:1 observation while in his room and visual checks every 15 minutes checks when he was not in his room. Further review of other interventions also included: redirection, distraction, offering the resident a beer, inquiring as to why the resident wants to leave, phoning the resident's wife to speak to him to discourage the resident from eloping. During an interview with LVN B on 4/17/2024 at 9:40 a.m., LVN B stated Resident #1 was, very difficult to care for. LVN B further stated the resident would threaten staff when he was redirected from attempting to elope. During an interview with the DON on 4/17/2024 at 1:10 p.m., the DON stated that when it became apparent Resident #1 was missing on 2/20/2024 and 3/4/2024 the facility enacted their elopement response policy which included calling a code, Orange, notifying staff, performing a search of the facility and surrounding areas, assessing the resident once found and making notifications. The DON stated the resident had been discharged home after it was deemed safer for the resident. During an interview with CNA C on 04/18/2024 at 11:23 a.m., CNA C stated she was assigned to work on the resident hall where Resident #1 resided. CNA C stated Resident #1 would often verbalize that if he wanted to leave the facility, no one could stop him. During an interview with ADON A, the Unit Manager for the secure unit, on 04/18/2024 at 2:05 p.m., ADON A stated after Resident #1's first elopement on 02/21/2024 one of the interventions the facility implemented was changing the resident's room to a room across the hall from his original room. ADON A stated Resident #1's room, upon admission, had a window which faced the street, however, after the elopement on 02/21/2024 the resident was moved to a room with a window facing the facility's courtyard. ADON A further stated when the resident eloped on 03/04/2024 he went to another resident's room which had a window facing the street. During an interview with Resident #1's Responsible Party on 4/18/2024 at 4:08 p.m., Resident #1's Responsible Party stated the resident was doing fine at home, and he did not try to leave the house. The resident's Responsible Party stated that when the facility notified her of the resident's second elopement, she began going to the facility daily and stayed with the resident. Resident #1's Responsible Party further stated she was trying to find another, more appropriate facility for the resident as she had medical issues which would not allow her to care for the resident. The Administrator and DON were notified on 4/18/2024 at 6:53 p.m., that a past non-compliance IJ situation had been identified due to the above failures. The facility course of action prior to surveyor entrance included: Observations made by staff on the secured unit on 4/16/2024 at 10:11 a.m., showed that the door code, locking mechanism and door alarm were functioning properly. Observations made by staff on the secured unit on 4/17/2024 at 9:38 am, showed that the door code, locking mechanism and door alarm were functioning properly. Observations made by staff on the secured unit on 4/18/2024 at 2:03 p.m., showed that the door code, locking mechanism and door alarm were functioning properly. During an interview with the DON on 04/16/2024 at 12:15 p.m., the DON stated that Resident #1 no longer resided at the facility. During an interview with the DON on 04/17/2024 at 1:45 p.m., the DON stated the two in-service trainings for staff were developed and presented to staff as a result of Resident #1's elopement incidents on 02/21/2024 and 03/04/2024. Record review of the facility's training documentation revealed an in-service titled Elopement Response given by DON on 03/06/2024, which indicated that all 101 staff at the facility had been in-serviced regarding elopements. Summary: Staff must intervene when a resident attempts to elope, must notify Administrator, DON and ADONs and search must be conducted until the resident is found. Record review of document titled, Missing Resident/Elopement Monitoring, was completed 2/28/2024 through 3/31/2024 and included checking that the locking mechanism or alarm function properly, changing the secured unit door code, performing spot checks on Resident #1. Record review of an in-service training, dated 3/5/2024, related to Elopement Response revealed 101 of 101 staff member signatures. Interviews with 12 employees who consisted of RNs, LVNs, CNAs, Housekeeping, Activities and Dietary from 4/17/2024 at 10:30 a.m. to 4/18/2024 at 1:30 p.m. revealed they had received in-services on Elopement Response. All were able to state the key elements of the elopement policy, which include: If a resident is discovered missing: - Immediate search of the resident in resident rooms, bathrooms, showers, closets, recreation areas, outside area - Notify charge nurse/DON - Call Code Orange - Specifically, to the secure unit, since they know what the residents on the unit look like, describe what the resident looks like to staff outside the unit - After 30 minutes, if the resident had not been located, call the police, RP If a resident is observed trying to leave: - Attempt to stop the resident. Speak in a calm voice to the resident. - Get help if needed. - Tell another staff member to inform the charge nurse/DON.

Based on observations, interviews, records reviews, facility's policy review, the facility failed to provide one of three sampled residents (Resident (R)4) adequate supervision to prevent R4 from breaking a window on 06/27/21 at 11:00 AM and threatening staff with a piece of broken glass; choking a staff member on 07/01/21 at 5:31 AM; hitting R5 on 07/07/21 at 2:57 AM which caused R5 to be transferred to the hospital for a bleeding head wound that required medical treatment; and on 07/08/21 at 7:55 PM, threw a cup at another resident. The aggressive behavior exhibited by R4 placed himself and other residents at risk for serious injury, serious harm, serious impairment, and/or death. An Immediate Jeopardy (IJ) situation was determined to have existed on 6/27/21. It was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. Findings include: Review of R4's Electronic Medical Record (EMR) Face sheet found under the Face Sheet tab revealed R4 was admitted to the facility on [DATE] at 7:30 PM with diagnoses including [CONDITION(S)], anxiety, and paranoid [CONDITION(S)]. Review of the EMR Progress Notes dated 06/24/21 at 10:20 PM under the Progress Notes tab, revealed R4 was wandering in the hallway, attempted to strike staff in the main facility hallway, and exited out the facility door. Staff was with R4 when he exited the building and staff had difficulty redirecting R4 back into the facility. On 06/24/21 at 11:28 PM, R4 was moved to the secure unit. The nurse placed the resident on 15-minute checks. Review of R4's EMR under the Care Plan tab revealed that the facility failed to develop and implement a baseline care plan so that staff would know the type of supervision to provide R4. Review of the EMR Progress Notes dated 06/27/21 at 11:00 AM, revealed R4 broke a window in a resident room and held a large piece of glass in his hand as he threatened a nurse with the glass. R4 was sent to the hospital for examination on 06/28/21 at 1:42 PM. R4 returned from the hospital on 6/28/21 at 4:24 PM. Review of R4's Elopement Risk Monitoring Log, a facility document to indicate 15-minute checks, revealed the facility started the 15-minute checks on 6/28/21 at 1:30 PM when the resident returned from the hospital. Even though there was a form, there was no documentation on the form of the 15-minute checks. During an interview on 09/14/21 at 03:06 PM, the Corporate Regional Director of Clinical Operations/Acting Director of Nursing (DON) confirmed that there was no other documentation of 15-minute checks for R4 and confirmed there were no changes made to R4's care plan. Review of R4's EMR Progress Notes dated 07/01/21 at 5:31 AM, revealed R4 slept 1-2 hours and had a venipuncture that morning that was unsuccessful. R4 then walked down the hallway, put a choke hold on a staff member and held her from behind, threw a picture frame at staff, and went into a resident's room with two females present and refused to leave the female residents' room. Staff called 911 and the Administrator. The police assessed R4 and remained with him until the ambulance arrived for hospital transport. The progress notes lacked evidence of when R4 returned to the facility. Review of R4's Elopement Risk Monitoring Log for 15- minute checks document indicated the facility documented 15-minute checks beginning on 07/01/21 at 06:00 PM. There were no changes made to R4's care plan to indicate the type of supervision nursing staff were to provide. Review of R4's EMR Progress Notes dated 07/01/21 at 12:58 PM revealed, The physician (physician not named) was notified of the incidents involving R4 and the emergency room transfers. Notified the physician that the resident was not admitted on either ER [emergency room ] visits. The provider directed the facility to call Senior Psychiatric Services and the facility Medical Director. Message was left for the Medical Director requesting return call asking why R4 was not admitted . R4 remains on every 15-minute checks. Review of R4's EMR Progress Note dated 07/02/21 documented R4 was transported to appointment at the Crisis Center for mental health assessment at 9:00 AM. At 4:10 PM, R4 was transferred to a hospital for medical clearance examination from the Crisis Center. The facility received a call at 5:10 PM that while R4 was at the hospital for the medical clearance examination, R4 left the hospital Against Medical Advice (AMA) and was considered a missing person. R4 was found by the police, returned to the hospital, and the hospital determined R4 did not meet criteria for in-patient psychiatric services. On 07/02/21 at 8:51 PM, R4 returned to the facility by ambulance. The Elopement Risk Monitoring Log dated 07/01/21 documented the facility began 15-minute checks at 6:00 PM, prior to the resident's return to the facility. There were no changes made to the care plan to indicate what type of supervision to provide for R4. Review of R4's EMR Progress Notes section revealed that there were no progress notes dated 07/03/21. R4's clinical record indicated that on 07/04/21 and 07/05/21, there were no aggressive behaviors documented. There were no behaviors documented on 07/06/21. Review of R4's EMR Progress Notes dated 07/07/21 at 2:57 AM, documented R4 was ambulating in the hallway as was R5. R4 struck R5 with his towel wrapped fist. The facility separated the residents. R4 and R5 were sent to the hospital. R5 was examined and had diagnostic testing including a CT (computed tomography) scan. R5 had a wound to the back of his head that required a staple. Review of R4's EMR Progress Notes indicated that R4 returned to the facility on [DATE] at 9:00 AM. R4 was placed on one to one (1:1) staff observation. The EMR Progress Notes indicated that Senior Psychiatric Services saw R4 on 07/07/21 at 3:06 PM and made medication changes including adding [MEDICATION(S)] (antianxiety medication) 1 milligram (mg) twice a day. Review of R4's Elopement Risk Monitoring Log indicated the resident was observed at 1:00 PM and every 15 minutes that day. Review of R4's care plan revealed the intervention of 1:1 observation was added on 07/07/21. Review of R4's EMR Progress Notes dated 07/08/21 at 7:55 PM, indicated that with the 1:1 staff member walking behind the resident, R4 threw a cup at another resident, had clenched fists, and made verbal threats. At 8:00 PM, the police and DON were notified. At 8:15 PM, the police officers arrived and arrested R4. The facility failed to provide evidence of the 1:1 supervision. Review of the facility's policy titled Care Plans with an effective date of 06/2021 revealed Policy: Care plans will be developed for all patients and resident based upon the RAI (Resident assessment Instrument) manual guidelines. Care plans are developed by the interdisciplinary team and revised as needed according to resident and patient status or change. Review of the facility's 24-Hour Report/Change of Condition Reports for Station/Wing A revealed notes which indicated R4 was admitted on [DATE], without mention of the elopement attempt or move to the secure unit. On 6/30/21 the 24-Hour Report/Change of Condition Report revealed R4 remained on 15 minutes checks. On 07/05/21, the 24-Hour Report/Change of Condition Report indicated the resident was to be monitored for aggressive behaviors. The report failed to communicate to the oncoming shifts the level of supervision to be provided for R4. Review of R4's care plan with the Corporate Regional Director of Clinical Operations/Acting DON on 09/16/21 at 10:40 AM, he confirmed that the care plan's area of focus was Alzheimer's or related dementia created on 06/30/21 (6 days after admission and had interventions added that included 1. Allow resident to walk throughout the unit. The area of focus, I sometimes have behaviors which include hitting during care, Kicking. tearing things up (sic). The care plan was updated on 07/16/21 with 7/1/21 Resident attacked nurse and 07/07/21Resident attacked another resident causing injury, placed on 1:1 observation. The Corporate Regional Director of Clinical Operations/Acting DON confirmed that R4's care plan was updated eight days after discharge on 07/08/21. Continued interview on 09/16/21 at 10:40 AM, the Corporate Regional Director of Clinical Operations/Acting DON confirmed that resident's behaviors were to be documented on the MAR. The Corporate Regional Director of Clinical Operations/Acting DON confirmed that R4's June and July 2021 MARs lacked documentation of behaviors and that R4's care plan was not updated following the resident breaking the glass and failed to provide R4's baseline care plan, which was to be initiated at admission and updated as resident needs and care change. The Corporate Regional Director of Clinical Operations/Acting DON further stated that the DON would instruct the staff on the type of supervision on a case-by-case manner. The Corporate Regional Director of Clinical Operations/Acting DON confirmed the facility process does not include documentation of what the staff was instructed regarding R4's supervision needs. The Corporate Regional Director of Clinical Operations/Acting DON stated that the 1:1 supervision would be documented in the progress notes and that staff are not required to sign for providing the 1:1 level of care. The Corporate Regional Director of Clinical Operations/Acting DON confirmed that the facility uses the 24-hour report as the method of communicating information between shifts for staff. The facility's Process/Decision-Tree diagram titled Support Process dated 02/2019 for Behavioral Expressions Observed was provided by the Corporate Regional Director of Clinical Operations/Acting DON on 09/16/21 at 10:40 AM. He confirmed that the facility lacked documentation of staff trained in the process outlined in the decision-tree and stated that he had not been trained in the process to use the decision-tree. The Corporate Regional Director of Clinical Operations/Acting DON confirmed the facility lacked documentation that the facility followed the decision-tree process for R4's behavioral assessment and care planning process. Interview with the Memory Care Director/Licensed Vocational Nurse (LVN) 7 on 09/16/21 at 2:00 PM, revealed she was not employed by the facility at the time R4 was a resident. She stated that, if there was a resident that required additional staff time to provide care or ensure safety, the Administrator would be notified. The Memory Care Director 7 stated currently there were no residents requiring 1:1 supervision or 15-minute checks. Interview with an LVN 8 on 09/16/21 at 2:05 PM, revealed that she was working while R4 was a resident. LVN 8 stated she did not recall what level of supervision R4 required and stated, He was scary. LVN 8 also stated that R4's behaviors were unpredictable. Interview with the Corporate Regional Director of Clinical Operations/Acting DON on 09/16/21 at 10:40 AM, he stated the facility does not have a policy for close supervision, 15-minute checks or 1:1 observation. He stated that it is the nurses' discretion as to what level of supervision is to be provided and confirmed there was no documentation to demonstrate the level of supervision R4 was provided. The Administrator, and the Corporate Regional Director of Clinical Operations/Acting DON were notified on 9/16/21 at 6:30 p.m., that a past non-compliance IJ situation had been identified due to the above failures. It was determined these failures placed residents in an IJ situations on 6/27/21. The facility implemented the following interventions: Immediate Action On 06/24/21, day of admission to the facility, after R4 eloped from the facility, R4 was moved to the facility's secure unit to prevent future elopements and was placed on 15-minute checks. On 06/27/21, after R4 broke a window and used a piece of glass to threaten a nurse, R4 was transferred to the hospital. Upon return from the hospital, the facility resumed 15-minute checks. On 07/01/21, R4 placed a staff member in a choke hold, R4 was transferred to the hospital and upon return, 15-minute checks were resumed. On 07/02/21, R4 was seen by the Crisis Center for Mental Health. On 07/07/21, R4 attacked R5 with his fist. R4 and R5 were sent to the hospital. R5 required medical care. Upon R4's return from the hospital, the physician added two psychoactive medications and the facility initiated 1:1 supervision. On 07/08/21, R4 threw a cup and made verbal threats to a resident. The police were called. R4 was arrested and discharged from the facility on 07/08/21. Action taken: Review of R4's care plan on 09/16/21 at 10:40 AM with the Corporate Regional Director of Clinical Operations/Acting DON, he confirmed that the care plan with focus area Alzheimer's or related dementia was revised on 07/16/21. Completion Date: 07/16/21

Based on observation, interview and record review the facility failed to ensure residents were free from neglect for 1 of 6 residents reviewed for neglect (Resident 1) in that: The facility failed to prevent maggots from forming on Resident #1's peg tube stoma and vaginal region which resulted in Resident #1 being sent to the hospital for maggots in the stoma site. An Immediate Jeopardy situation was identified on 06/08/2017. The Immediate Jeopardy was removed on 06/09/2017. The facility remained out of compliance at a scope of pattern and severity at actual harm due to the facility's need to complete staff training. This deficient practice could result in 6 residents, who were identified as having a peg tube in place, from developing maggot formation. The findings were: Review of Resident #1's face sheet, dated 06/08/2017, revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly MDS dated , 04/14/2017, revealed in section B, Resident #1 was not able to speak and was not able to make self understood. The MDS revealed, Resident #1 was not able to participate in the BIMS (Brief Interview for Mental Status) interview and was identified as having a severely impaired cognition. Further review of the MDS revealed Resident #1 required extensive, 2 person assist for hygiene and toilet use. Review of Resident #1's plan of care with a problem onset date of 02/09/2015 revealed a problem area which stated, I have a PEG tube for nutritional support and medication administration. The approach for staff to provide care stated for Resident #1 to have peg site care daily. Review of Resident #1's physician orders [REDACTED].#1's peg tube stoma. Review of the treatment administration record for June 2017 revealed nursing instructions to provide care for Resident #1's peg tube stoma site which stated, cleanse peg tube site every shift. Further review of the treatment administration record did not specify if the stoma site was to be covered with a gauze dressing. Record review of a nursing assessment report from the facility, dated 06/02/2017, revealed Resident #1 received a bed bath and there was no indication of problem areas identified. Record review of the facility's nursing notes, dated 06/04/2017 at 10:36 a.m. revealed by the floor nurse, When administering medications and cleaning site when noticed maggots in dressing and dressing had brownish color drainage with smell, also noticed maggots were coming out of peg tube site. Further review of the progress notes revealed on 06/04/2017 at 12:17 p.m., Pt. to stretcher and left facility .new dressing in peg tube site, no drainage noticed coming out from site and maggot continue to noticed inside peg tube site. Record review of the ambulance records dated, 06/04/2017 at 12:47 p.m., revealed initial vital signs with a note stating, peg tube bleeding with purulent drainage/maggots. Record review of the hospital emergency department note, dated 06/04/2017 at 12:54 p.m., performed by the emergency department physician revealed the resident, arrives in the ED (emergency department) presenting with drainage of puss and maggots from her PEG tube. Further review of the emergency department report revealed, patient presents to the ED from NH (nursing home) for evaluation of PEG tube due to maggots seen inside stoma of patient's G tube as well as discharge from ostomy site. Patient's exam with poor hygiene, I visualized multiple maggots crawling in and around her G tube stoma and on gastrostomy tube itself. Record review of the hospital record history and physical dated, 06/04/2017 revealed the hospital physician staff did not utilize her peg tube for feedings and instead used IV (intravenous fluids) fluids for maintenance until the resident had the peg tube exchanged. Further review of the document revealed on page 2: Skin Peg tube with maggots present. Record review of the hospital operative report, dated 06/05/2017, performed by a [MEDICATION NAME] revealed Resident #1 underwent an EGD (Esophagogastroduodenoscopy is a test to examine the lining of the esophagus, stomach, and first part of the small intestine) along with her peg tube being removed on 06/05/2017. Further review of the operative report stated on page 1: Picture documentation of the gastrostomy site along with specimens was collected from the gastrostomy tube along with maggot that was located in the site. Interview and observation of Resident #1 at the hospital on [DATE] at 10:21 a.m. with Hospital RN R confirmed Resident #1 was admitted on [DATE] from the emergency department to a medical surgical floor. Hospital RN R stated Resident #1 has been NPO (nothing by mouth) and had her peg tube removed on 06/05/2017. Hospital RN R stated Resident #1 is pending a new peg tube placement once the site of the previous peg tube placement had healed. Hospital RN R stated maggots were still present in the stoma site as of 06/05/2017. Hospital RN R further stated that at the time of the [MEDICATION NAME] consult, pericare was performed for Resident #1 and maggots were observed coming from the vaginal area. According to http://www.rnceus.com/mag/magcyc.html, Depending on the fly species and the environmental temperature, larvae hatch within 8 to 24 hours. The eggs hatch into small larvae that look like small translucent grains of rice. The larvae are about 1 to 2 mm in length at 1 day. The maggots release [MEDICATION NAME] enzymes into their surrounding environment, and this allows them to consume the semi-liquid material. According to http://texasinsects.tamu.edu/cimg243.html, Female flies of other species may glue their eggs to the hosts ' body after which the hatching larva tunnels inside. In other species, eggs are inserted directly into the hosts ' body by the female. Once inside the body of the host, one or more larvae can develop through several stages (instars) for 4 to 14 days. They emerge from the host to pupate inside their last larval skin (puparium). Adults emerge 1 to 2 weeks later. Depending on species one or more generations occur per year. According to https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 63/, Summary: Myiasis is defined as the infestation of live vertebrates (humans and/or animals) with dipterous larvae. In mammals (including humans), dipterous larvae can feed on the host's living or dead tissue, liquid body substance, or ingested food and cause a broad range of infestations. A lack of hygiene in the presence of an open wound, are the most important predisposing factors, especially those with the inability to discourage flies from depositing eggs or larvae, also makes humans prone to wound infestation. Local destruction, invasion into deep tissues, and secondary infection are possible complications of myiasis, especially where obligatory parasites are concerned. Interview on 06/07/2017 at 11:37 a.m. with the DON revealed she was notified on 06/04/2017 via a mobile text message that the floor nurses discovered what appeared to be maggots inside Resident #1's peg tube stoma site. The DON stated she could not get confirmation of what exactly was found inside the stoma site but stated the physician ordered the resident to the hospital for evaluation. The DON stated a facility supervisor, LVN O, did speak with hospital staff on 06/06/2017 where they confirmed Resident #1 had maggots and the peg tube was removed. The DON further stated all staff had received training on peg tube stoma care since the facility got confirmation from the hospital on [DATE] of Resident #1 having maggots in the peg tube stoma site. The surveyor requested copies of the inservice training and who had received the training for review but did not receive the information. Interview on 06/07/2017 at 1:20 p.m. with LVN O revealed she was notified via a mobile text message that the floor nurse stated Resident #1 had what looked like maggots in her peg tube stoma site. LVN O stated that the facility received confirmation on 06/06/2017 that Resident #1 did have maggots. LVN O further stated once the confirmation of maggots was received all residents with a peg tube then received orders for dressing changes and had tubing and bedside syringes replaced. LVN O stated Resident #1's roommate had a lot of personal items inside her room and had at times seen flies inside Resident #1's room. LVN O stated she was not sure if Resident #1's roommate's clutter was cause for the flies to be present in their shared room. LVN O stated she had not received training on peg tube stoma care instructions as of the date of the interview. Interview and observation on 06/07/2017 at 1:43 p.m. with Housekeeping D revealed housekeeping was told to clean Resident #1's room. Housekeeping D stated she was cleaning because she heard something about bugs in the room. Interview on 06/07/2017 at 2:08 p.m. with the administrator revealed he was notified on 06/04/2017 of Resident #1 being transferred to the hospital for evaluation. The administrator stated he was told only that there were complications with the Resident #1's peg tube. The administrator further stated he did not think anything else about it until the facility was notified by hospital staff on 06/06/2017 that Resident #1 had maggots in her peg tube stoma. The administrator stated this incident did not fit his definition of neglect and was not sure if nursing staff had performed an investigation into the matter of Resident #1 having maggots inside of the peg tube stoma. The surveyor again requested copies of the inservice the DON reported the staff had received regarding peg tube stoma. Interview on 06/07/2017 at 3:10 p.m. with LVN C revealed she was the nurse on duty who first saw Resident #1's peg tube with maggots in the stoma site. LVN C stated she was giving Resident #1's medications in the morning at 10:00 a.m. and noticed Resident #1's peg tube dressing gauze was soiled with a brown substance. LVN C then removed the dressing and saw several maggots in the stoma site. LVN C stated the ambulance arrived at 12:17 p.m. for transport to the hospital and at that time Resident #1 still had maggots in her stoma site. LVN C stated she provided care for Resident #1 on 06/02/2017 - 06/04/2017 and noticed flies and gnats in Resident #1's room on 06/02/2017 and 06/03/2017. LVN C further stated Resident #1's roommate had, a bunch of stuff in their room that has flies and gnats in the room. LVN C further stated on 05/29/2017 she had observed Resident #1's stoma site was open to air and did not have a gauze dressing in place. Interview on 06/07/2017 at 3:59 p.m. outside of Resident #1's room with the contracted pest control manager revealed he was contacted on 06/04/2017 by the facility maintenance director to visit the facility for inspection and removal of pests in the facility. The contracted pest control manager stated the room belonging to Resident #1 had a live plant inside the room and further stated the live plants could contribute to pest gathering. Interview on 06/07/2017 at 6:30 p.m. with CNA E revealed she cared for Resident #1 on the night shift on 06/03/2017 but stated she did not provide pericare for Resident #1. CNA E stated she did not recall a dressing gauze being in place for Resident #1's peg tube stoma. CNA E stated she saw flies and gnats in Resident #1's room when she did two hour checks for Resident #1. CNA E further stated she had seen gnats and flies land on Resident #1's roommates food and bedside table. CNA E stated she had not received training since Resident #1 was transferred to the hospital regarding peg tube stoma care on 06/04/2017. Interview on 06/07/2017 at 6:42 p.m. with LVN G revealed she was a nurse on the overnight shift in the wing Resident #1 resided in prior to Resident #1 being sent to the hospital on [DATE]. LVN G stated she could not recall if Resident #1 had gauze dressing covering the stoma site when she assisted in providing care for Resident #1. LVN G further stated she had not received peg tube stoma care training since Resident #1 was transferred to the hospital on [DATE]. Interview on 06/07/2017 at 7:15 p.m. with LVN H revealed she was the direct care nurse on the overnight shift, 06/03/2017, for Resident #1 on the evening prior to Resident #1 being sent to the hospital. LVN H stated she administered medications to Resident #1 per peg tube between 8:00 p.m. and 9:00 p.m. LVN H stated she noticed Resident #1's dressing gauze was soiled with a brown substance, LVN H stated she wiped off the brown substance but, did not see anything coming out of it. LVN H stated she did not see maggots and did not investigate the soiled dressing because she has seen brown soiled stains on Resident #1's dressing before. LVN H stated she did not provide pericare to Resident #1 on the overnight shift. LVN H stated the last time she observed Resident #1's peg tube stoma site was at midnight, 06/04/2017, and did not observe any additional stains or drainage. LVN H stated she used a 4 inch X 4 inch gauze to cover Resident #1's stoma site. LVN H confirmed Resident #1's roommate had a fly swatter in her room to kill flies and bugs. LVN H further stated Resident #1's roommate had a live plant with standing water in it. LVN H stated she always saw gnats in Resident #1's room. LVN H further stated she had not been an inservice training regarding peg tube stoma care as of the date of the interview. Interview on 06/08/2017 at 9:25 a.m. with the District Facility Manager revealed the facility staff were working until midnight on 06/07/2017 to provide deep cleaning to resident rooms due to pest control issues. Observation and Interview on 06/08/2017 at 9:55 a.m. with Resident #1's roommate, inside her bedroom confirmed the flyswatter on her bedside table was for bugs. The live plant was still present on a bedside table next to Resident #1's roommate. Interview on 06/08/2017 at 10:02 a.m. with LVN K revealed she was working on the unit Resident #1 resided on the day Resident #1 was sent to the hospital. LVN K stated she was not assigned to provide direct care for Resident #1 only that she assisted with the assessment of Resident #1; when LVN C discovered maggots in Resident #1's stoma. LVN K confirmed there were maggots present in the stoma site. LVN K further stated she had not received inservice training regarding peg tube stoma care as of the date of the interview. Interview on 06/08/2017 at 2:19 p.m. with CNA N revealed she was the CNA assigned to provide direct care for Resident #1 on the 11:00 p.m to 7:00 a.m. shift of 06/03/2017. CNA N stated she performed 2 hour checks for Resident #1. CNA N stated she could not recall if she provided pericare for Resident #1 on the shift from 06/03/2017 through 06/04/2017. CNA N stated she constantly saw gnats in Resident #1's room and confirmed Resident #1's roommate had a flyswatter at her bedside table. CNA N further stated she had not received inservice training regarding care or observation of peg tube stoma care as of the date of the interview. Record review of the undated facility audit tool titled, Care of a Gastrostomy or Jejunostomy Tube Competency Audit listed a 14 step guide for caring for ostomy sites. Step 1 revealed, Determined whether exit site was left to open air or if dressing was indicated, checked order. Step 5. Assessed exit site for evidence of excoriation, drainage, infection or bleeding. Step 6. Cleansed skin around site with water and soap using gauze. Step 9. Placed drain-gauze over external bar or disc if dressing was ordered. The Administrator, Corporate Nurse and DON were notified on 06/08/2017 at 4:30 p.m. that an Immediate Jeopardy situation was identified. The facility's Plan of Removal was reviewed and accepted on 06/09/2017 at 12:10 p.m. and included the following: Step 1- Immediate interventions initiated for resident identified: a. Resident provided with peg tube cleaning b. Resident assessed for any other signs and symptoms of distress or pain. c. Resident transferred to Emergency Department d. Nurse practitioner and responsible party notified. e. Administrator, DNS, and ADNS notified of Peg tube concerns f. Room was deep cleaned Step 2. What immediate actions were taken to identify all residents potentially affected? a. All residents with stoma sites assessed for drainage or other adverse signs and symptoms with no other negative findings See attached Care Audit of a Gastrostomy or Jejunostomy Tube Competency. b. Tube feeding site (stoma) care education provided to all nursing team members. c. All physician orders [REDACTED]. d. Nursing staff educated regarding stoma site cleaning and management with return demonstration. e. Environmental rounds conducted. f. Pest control for immediate visit and treatment. g. Administrator and DNS (Director of Nursing Services) were educated on regulation of immediate investigation and report to state agency of any abuse and/or neglect allegation. h. Peri care re-education and audits conducted. i. Hand hygiene re-education and audits conducted. j. ADL audits conducted. Step 3. What system changes were made/modified? a. DNS/ADNS/Wound Nurse or designees to conduct wound care assessments and observations 2 times a week for 4 weeks. b. Environmental round assignments given to all department leaders to be conducted with communication back to Administrator or designee during Stand Up (daily internal meetings) c. Family communication letter to be sent on 06/09/2017 regarding environmental care. d. Resident council to be conducted on 06/08/2017 to discuss storage of food and plants. e. Pest control company contracted to continue with weekly visits for two weeks and then monthly as well as intermittent as needed. f. Inservice education will be continued until all team members have been trained. Step 4. Continued Quality Assurance audits implemented to ensure enhanced system compliance? a. Results of all environmental observations and audits will be shared at stand up and then monthly for three months and then quarterly. On 06/09/2017 the surveyor confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy. 1 RN, 11 LVNs, and 6 CNAs were interviewed and said they had received in-service training. Licensed nursing staff training included peg tube stoma care which included return demonstration. The management nursing staff also stated they were to conduct environmental rounds and to report any evidence of pest control to the facility maintenance director, environmental rounds also included observing for food left out in resident rooms. Licensed nursing staff as well as CNA staff also stated they received training on hand hygiene as well as pericare training. Record review of the audit tools mentioned in step 2 of the plan of removal revealed a 14 step audit tool for nursing staff to review and document. The Corporate Nurse stated the audit tools will be placed in a separate chart for residents identified with a stoma site. The Corporate Nurse further stated this audit tool acts as the facility's policy and procedure regarding stoma care. On 06/09/2017 at 6:10 p.m. the Administrator was informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at scope of pattern and severity of actual harm because the facility had not had time to monitor and evaluate the effectiveness of the Plan of Removal. Review of the facility's Abuse Policy, dated 02/2017, revealed Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish or emotional distress. Information provided by the facility on 06/07/2017 revealed there were 6 residents with peg tubes residing in the facility.

Based on observation, interview and record review the facility failed to ensure residents were free from neglect for 1 of 6 residents reviewed for neglect (Resident 1) in that: The facility failed to prevent maggots from forming on Resident #1's peg tube stoma and vaginal region which resulted in Resident #1 being sent to the hospital for maggots in the stoma site. An Immediate Jeopardy situation was identified on 06/08/2017. The Immediate Jeopardy was removed on 06/09/2017. The facility remained out of compliance at a scope of pattern and severity at actual harm due to the facility's need to complete staff training. This deficient practice could result in 6 residents, who were identified as having a peg tube in place, from developing maggot formation. The findings were: Review of the facility's Abuse Policy, dated 02/2017, revealed Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish or emotional distress. Review of Resident #1's face sheet, dated 06/08/2017, revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly MDS dated , 04/14/2017, revealed in section B, Resident #1 was not able to speak and was not able to make self understood. The MDS revealed, Resident #1 was not able to participate in the BIMS (Brief Interview for Mental Status) interview and was identified as having a severely impaired cognition. Further review of the MDS revealed Resident #1 required extensive, 2 person assist for hygiene and toilet use. Review of Resident #1's plan of care with a problem onset date of 02/09/2015 revealed a problem area which stated, I have a PEG tube for nutritional support and medication administration. The approach for staff to provide care stated for Resident #1 to have peg site care daily. Review of Resident #1's physician orders [REDACTED].#1's peg tube stoma. Review of the treatment administration record for June 2017 revealed nursing instructions to provide care for Resident #1's peg tube stoma site which stated, cleanse peg tube site every shift. Further review of the treatment administration record did not specify if the stoma site was to be covered with a gauze dressing. Record review of a nursing assessment report from the facility, dated 06/02/2017, revealed Resident #1 received a bed bath and there was no indication of problem areas identified. Record review of the facility's nursing notes, dated 06/04/2017 at 10:36 a.m. revealed by the floor nurse, When administering medications and cleaning site when noticed maggots in dressing and dressing had brownish color drainage with smell, also noticed maggots were coming out of peg tube site. Further review of the progress notes revealed on 06/04/2017 at 12:17 p.m., Pt. to stretcher and left facility .new dressing in peg tube site, no drainage noticed coming out from site and maggot continue to noticed inside peg tube site. Record review of the ambulance records dated, 06/04/2017 at 12:47 p.m., revealed initial vital signs with a note stating, peg tube bleeding with purulent drainage/maggots. Record review of the hospital emergency department note, dated 06/04/2017 at 12:54 p.m., performed by the emergency department physician revealed the resident, arrives in the ED (emergency department) presenting with drainage of puss and maggots from her PEG tube. Further review of the emergency department report revealed, patient presents to the ED from NH (nursing home) for evaluation of PEG tube due to maggots seen inside stoma of patient's G tube as well as discharge from ostomy site. Patient's exam with poor hygiene, I visualized multiple maggots crawling in and around her G tube stoma and on gastrostomy tube itself. Record review of the hospital record history and physical dated, 06/04/2017 revealed the hospital physician staff did not utilize her peg tube for feedings and instead used IV (intravenous fluids) fluids for maintenance until the resident had the peg tube exchanged. Further review of the document revealed on page 2: Skin Peg tube with maggots present. Record review of the hospital operative report, dated 06/05/2017, performed by a [MEDICATION NAME] revealed Resident #1 underwent an EGD (Esophagogastroduodenoscopy is a test to examine the lining of the esophagus, stomach, and first part of the small intestine) along with her peg tube being removed on 06/05/2017. Further review of the operative report stated on page 1: Picture documentation of the gastrostomy site along with specimens was collected from the gastrostomy tube along with maggot that was located in the site. Interview and observation of Resident #1 at the hospital on [DATE] at 10:21 a.m. with Hospital RN R confirmed Resident #1 was admitted on [DATE] from the emergency department to a medical surgical floor. Hospital RN R stated Resident #1 has been NPO (nothing by mouth) and had her peg tube removed on 06/05/2017. Hospital RN R stated Resident #1 is pending a new peg tube placement once the site of the previous peg tube placement had healed. Hospital RN R stated maggots were still present in the stoma site as of 06/05/2017. Hospital RN R further stated that at the time of the [MEDICATION NAME] consult, pericare was performed for Resident #1 and maggots were observed coming from the vaginal area. According to http://www.rnceus.com/mag/magcyc.html, Depending on the fly species and the environmental temperature, larvae hatch within 8 to 24 hours. The eggs hatch into small larvae that look like small translucent grains of rice. The larvae are about 1 to 2 mm in length at 1 day. The maggots release [MEDICATION NAME] enzymes into their surrounding environment, and this allows them to consume the semi-liquid material. According to http://texasinsects.tamu.edu/cimg243.html, Female flies of other species may glue their eggs to the hosts ' body after which the hatching larva tunnels inside. In other species, eggs are inserted directly into the hosts ' body by the female. Once inside the body of the host, one or more larvae can develop through several stages (instars) for 4 to 14 days. They emerge from the host to pupate inside their last larval skin (puparium). Adults emerge 1 to 2 weeks later. Depending on species one or more generations occur per year. According to https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 63/, Summary: Myiasis is defined as the infestation of live vertebrates (humans and/or animals) with dipterous larvae. In mammals (including humans), dipterous larvae can feed on the host's living or dead tissue, liquid body substance, or ingested food and cause a broad range of infestations. A lack of hygiene in the presence of an open wound, are the most important predisposing factors, especially those with the inability to discourage flies from depositing eggs or larvae, also makes humans prone to wound infestation. Local destruction, invasion into deep tissues, and secondary infection are possible complications of myiasis, especially where obligatory parasites are concerned. Interview on 06/07/2017 at 11:37 a.m. with the DON revealed she was notified on 06/04/2017 via a mobile text message that the floor nurses discovered what appeared to be maggots inside Resident #1's peg tube stoma site. The DON stated she could not get confirmation of what exactly was found inside the stoma site but stated the physician ordered the resident to the hospital for evaluation. The DON stated a facility supervisor, LVN O, did speak with hospital staff on 06/06/2017 where they confirmed Resident #1 had maggots and the peg tube was removed. The DON further stated all staff had received training on peg tube stoma care since the facility got confirmation from the hospital on [DATE] of Resident #1 having maggots in the peg tube stoma site. The surveyor requested copies of the inservice training and who had received the training for review but did not receive the information. Interview on 06/07/2017 at 1:20 p.m. with LVN O revealed she was notified via a mobile text message that the floor nurse stated Resident #1 had what looked like maggots in her peg tube stoma site. LVN O stated that the facility received confirmation on 06/06/2017 that Resident #1 did have maggots. LVN O further stated once the confirmation of maggots was received all residents with a peg tube then received orders for dressing changes and had tubing and bedside syringes replaced. LVN O stated Resident #1's roommate had a lot of personal items inside her room and had at times seen flies inside Resident #1's room. LVN O stated she was not sure if Resident #1's roommate's clutter was cause for the flies to be present in their shared room. LVN O stated she had not received training on peg tube stoma care instructions as of the date of the interview. Interview and observation on 06/07/2017 at 1:43 p.m. with Housekeeping D revealed housekeeping was told to clean Resident #1's room. Housekeeping D stated she was cleaning because she heard something about bugs in the room. Interview on 06/07/2017 at 2:08 p.m. with the administrator revealed he was notified on 06/04/2017 of Resident #1 being transferred to the hospital for evaluation. The administrator stated he was told only that there were complications with the Resident #1's peg tube. The administrator further stated he did not think anything else about it until the facility was notified by hospital staff on 06/06/2017 that Resident #1 had maggots in her peg tube stoma. The administrator stated this incident did not fit his definition of neglect and was not sure if nursing staff had performed an investigation into the matter of Resident #1 having maggots inside of the peg tube stoma. The surveyor again requested copies of the inservice the DON reported the staff had received regarding peg tube stoma. Interview on 06/07/2017 at 3:10 p.m. with LVN C revealed she was the nurse on duty who first saw Resident #1's peg tube with maggots in the stoma site. LVN C stated she was giving Resident #1's medications in the morning at 10:00 a.m. and noticed Resident #1's peg tube dressing gauze was soiled with a brown substance. LVN C then removed the dressing and saw several maggots in the stoma site. LVN C stated the ambulance arrived at 12:17 p.m. for transport to the hospital and at that time Resident #1 still had maggots in her stoma site. LVN C stated she provided care for Resident #1 on 06/02/2017 - 06/04/2017 and noticed flies and gnats in Resident #1's room on 06/02/2017 and 06/03/2017. LVN C further stated Resident #1's roommate had, a bunch of stuff in their room that has flies and gnats in the room. LVN C further stated on 05/29/2017 she had observed Resident #1's stoma site was open to air and did not have a gauze dressing in place. Interview on 06/07/2017 at 3:59 p.m. outside of Resident #1's room with the contracted pest control manager revealed he was contacted on 06/04/2017 by the facility maintenance director to visit the facility for inspection and removal of pests in the facility. The contracted pest control manager stated the room belonging to Resident #1 had a live plant inside the room and further stated the live plants could contribute to pest gathering. Interview on 06/07/2017 at 6:30 p.m. with CNA E revealed she cared for Resident #1 on the night shift on 06/03/2017 but stated she did not provide pericare for Resident #1. CNA E stated she did not recall a dressing gauze being in place for Resident #1's peg tube stoma. CNA E stated she saw flies and gnats in Resident #1's room when she did two hour checks for Resident #1. CNA E further stated she had seen gnats and flies land on Resident #1's roommates food and bedside table. CNA E stated she had not received training since Resident #1 was transferred to the hospital regarding peg tube stoma care on 06/04/2017. Interview on 06/07/2017 at 6:42 p.m. with LVN G revealed she was a nurse on the overnight shift in the wing Resident #1 resided in prior to Resident #1 being sent to the hospital on [DATE]. LVN G stated she could not recall if Resident #1 had gauze dressing covering the stoma site when she assisted in providing care for Resident #1. LVN G further stated she had not received peg tube stoma care training since Resident #1 was transferred to the hospital on [DATE]. Interview on 06/07/2017 at 7:15 p.m. with LVN H revealed she was the direct care nurse on the overnight shift, 06/03/2017, for Resident #1 on the evening prior to Resident #1 being sent to the hospital. LVN H stated she administered medications to Resident #1 per peg tube between 8:00 p.m. and 9:00 p.m. LVN H stated she noticed Resident #1's dressing gauze was soiled with a brown substance, LVN H stated she wiped off the brown substance but, did not see anything coming out of it. LVN H stated she did not see maggots and did not investigate the soiled dressing because she has seen brown soiled stains on Resident #1's dressing before. LVN H stated she did not provide pericare to Resident #1 on the overnight shift. LVN H stated the last time she observed Resident #1's peg tube stoma site was at midnight, 06/04/2017, and did not observe any additional stains or drainage. LVN H stated she used a 4 inch X 4 inch gauze to cover Resident #1's stoma site. LVN H confirmed Resident #1's roommate had a fly swatter in her room to kill flies and bugs. LVN H further stated Resident #1's roommate had a live plant with standing water in it. LVN H stated she always saw gnats in Resident #1's room. LVN H further stated she had not been an inservice training regarding peg tube stoma care as of the date of the interview. Interview on 06/08/2017 at 9:25 a.m. with the District Facility Manager revealed the facility staff were working until midnight on 06/07/2017 to provide deep cleaning to resident rooms due to pest control issues. Observation and Interview on 06/08/2017 at 9:55 a.m. with Resident #1's roommate, inside her bedroom confirmed the flyswatter on her bedside table was for bugs. The live plant was still present on a bedside table next to Resident #1's roommate. Interview on 06/08/2017 at 10:02 a.m. with LVN K revealed she was working on the unit Resident #1 resided on the day Resident #1 was sent to the hospital. LVN K stated she was not assigned to provide direct care for Resident #1 only that she assisted with the assessment of Resident #1; when LVN C discovered maggots in Resident #1's stoma. LVN K confirmed there were maggots present in the stoma site. LVN K further stated she had not received inservice training regarding peg tube stoma care as of the date of the interview. Interview on 06/08/2017 at 2:19 p.m. with CNA N revealed she was the CNA assigned to provide direct care for Resident #1 on the 11:00 p.m to 7:00 a.m. shift of 06/03/2017. CNA N stated she performed 2 hour checks for Resident #1. CNA N stated she could not recall if she provided pericare for Resident #1 on the shift from 06/03/2017 through 06/04/2017. CNA N stated she constantly saw gnats in Resident #1's room and confirmed Resident #1's roommate had a flyswatter at her bedside table. CNA N further stated she had not received inservice training regarding care or observation of peg tube stoma care as of the date of the interview. Record review of the undated facility audit tool titled, Care of a Gastrostomy or Jejunostomy Tube Competency Audit listed a 14 step guide for caring for ostomy sites. Step 1 revealed, Determined whether exit site was left to open air or if dressing was indicated, checked order. Step 5. Assessed exit site for evidence of excoriation, drainage, infection or bleeding. Step 6. Cleansed skin around site with water and soap using gauze. Step 9. Placed drain-gauze over external bar or disc if dressing was ordered. The Administrator, Corporate Nurse and DON were notified on 06/08/2017 at 4:30 p.m. that an Immediate Jeopardy situation was identified. The facility's Plan of Removal was reviewed and accepted on 06/09/2017 at 12:10 p.m. and included the following: Step 1- Immediate interventions initiated for resident identified: a. Resident provided with peg tube cleaning b. Resident assessed for any other signs and symptoms of distress or pain. c. Resident transferred to Emergency Department d. Nurse practitioner and responsible party notified. e. Administrator, DNS, and ADNS notified of Peg tube concerns f. Room was deep cleaned Step 2. What immediate actions were taken to identify all residents potentially affected? a. All residents with stoma sites assessed for drainage or other adverse signs and symptoms with no other negative findings See attached Care Audit of a Gastrostomy or Jejunostomy Tube Competency. b. Tube feeding site (stoma) care education provided to all nursing team members. c. All physician orders [REDACTED]. d. Nursing staff educated regarding stoma site cleaning and management with return demonstration. e. Environmental rounds conducted. f. Pest control for immediate visit and treatment. g. Administrator and DNS (Director of Nursing Services) were educated on regulation of immediate investigation and report to state agency of any abuse and/or neglect allegation. h. Peri care re-education and audits conducted. i. Hand hygiene re-education and audits conducted. j. ADL audits conducted. Step 3. What system changes were made/modified? a. DNS/ADNS/Wound Nurse or designees to conduct wound care assessments and observations 2 times a week for 4 weeks. b. Environmental round assignments given to all department leaders to be conducted with communication back to Administrator or designee during Stand Up (daily internal meetings) c. Family communication letter to be sent on 06/09/2017 regarding environmental care. d. Resident council to be conducted on 06/08/2017 to discuss storage of food and plants. e. Pest control company contracted to continue with weekly visits for two weeks and then monthly as well as intermittent as needed. f. Inservice education will be continued until all team members have been trained. Step 4. Continued Quality Assurance audits implemented to ensure enhanced system compliance? a. Results of all environmental observations and audits will be shared at stand up and then monthly for three months and then quarterly. On 06/09/2017 the surveyor confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy. 1 RN, 11 LVNs, and 6 CNAs were interviewed and said they had received in-service training. Licensed nursing staff training included peg tube stoma care which included return demonstration. The management nursing staff also stated they were to conduct environmental rounds and to report any evidence of pest control to the facility maintenance director, environmental rounds also included observing for food left out in resident rooms. Licensed nursing staff as well as CNA staff also stated they received training on hand hygiene as well as pericare training. Record review of the audit tools mentioned in step 2 of the plan of removal revealed a 14 step audit tool for nursing staff to review and document. The Corporate Nurse stated the audit tools will be placed in a separate chart for residents identified with a stoma site. The Corporate Nurse further stated this audit tool acts as the facility's policy and procedure regarding stoma care. On 06/09/2017 at 6:10 p.m. the Administrator was informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at scope of pattern and severity of actual harm because the facility had not had time to monitor and evaluate the effectiveness of the Plan of Removal. Information provided by the facility on 06/07/2017 revealed there were 6 residents with peg tubes residing in the facility.

Based on observation, interview and record review the facility failed to provide care in accordance with professional standards of practice and the comprehensive care plan for 1 of 6 residents (Resident #1) reviewed for quality of care in that: The facility failed to prevent maggots from forming on Resident #1's peg tube stoma which resulted in Resident #1 being sent to the hospital for maggots in the stoma site. An Immediate Jeopardy situation was identified on 06/08/2017. The Immediate Jeopardy was removed on 06/09/2017. The facility remained out of compliance at a scope of pattern and severity at actual harm due to the facility's need to complete staff training. This deficient practice could result in 6 residents, who were identified as having a peg tube in place, from developing maggot formation. The findings were: Review of Resident #1's face sheet, dated 06/08/2017, revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly MDS dated , 04/14/2017, Resident #1 was not able to speak and was not able to make self-understood. The MDS further revealed Resident #1 was not able to participate in the BIMS (Brief Interview for Mental Status) interview and was identified as having a severely impaired cognition. Further review of section G revealed Resident #1 required extensive, 2 person assist for hygiene and toilet use. Review of Resident #1's plan of care with a problem onset date of 02/09/2015 revealed a problem area which stated, I have a PEG tube for nutritional support and medication administration. The approach for staff to provide care stated for Resident #1 to have peg site care daily. Review of Resident #1's physician orders [REDACTED].#1's peg tube stoma. Review of the treatment administration record for June 2017 revealed nursing instructions to provide care for Resident #1's peg tube stoma site which stated, cleanse peg tube site every shift. Further review of the treatment administration record did not specify if the stoma site was to be covered with a gauze dressing. Record review of a nursing assessment report from the facility, dated 06/02/2017, revealed Resident #1 received a bed bath and there was no indication of problem areas identified. Record review of the facility's nursing notes, dated 06/04/2017 at 10:36 a.m. revealed by the floor nurse, When administering medications and cleaning site when noticed maggots in dressing and dressing had brownish color drainage with smell, also noticed maggots where coming out of peg tube site. Further review of the progress notes revealed on 06/04/2017 at 12:17 p.m., Pt. to stretcher and left facility .new dressing in peg tube site, no drainage noticed coming out from site and maggot continue to notice inside peg tube site. Record review of the ambulance records dated, 06/04/2017 at 12:47 p.m., revealed initial vital signs with a note stating, peg tube bleeding with purulent drainage/maggots. Record review of the hospital emergency department note, dated 06/04/2017 at 12:54 p.m., performed by the emergency department physician revealed the resident, arrives in the ED (emergency department) presenting with drainage of puss and maggots from her PEG tube. Further review of the emergency department report revealed, Patient presents to the ED from NH (nursing home) for evaluation of PEG tube due to maggots seen inside stoma of patient's G tube as well as discharge from ostomy site. Patient's exam with poor hygiene, I visualized multiple maggots crawling in and around her G tube stoma and on gastrostomy tube itself. Record review of the hospital record history and physical dated, 06/04/2017 revealed the hospital physician staff did not utilize her peg tube for feedings and instead used IV (intravenous fluids) fluids for maintenance until the resident had the peg tube exchanged. Further review of the document revealed on page 2: Skin Peg tube with maggots present. Record review of the hospital operative report, dated 06/05/2017, performed by a [MEDICATION NAME] revealed Resident #1 underwent an EGD (Esophagogastroduodenoscopy is a test to examine the lining of the esophagus, stomach, and first part of the small intestine) along with her peg tube being removed on 06/05/2017. Further review of the operative report stated on page 1: Picture documentation of the gastrostomy site along with specimens was collected from the gastrostomy tube along with maggot that was located in the site. Interview and observation of Resident #1 at the hospital on [DATE] at 10:21 a.m. with Hospital RN R confirmed Resident #1 was admitted on [DATE] from the emergency department to a medical surgical floor. Hospital RN R stated Resident #1 has been NPO and had her peg tube removed on 06/05/2017. Hospital RN R stated Resident #1 is pending a new peg tube placement once the site of the previous peg tube placement has healed. Hospital RN R stated maggots were still present in the stoma site as of 06/05/2017. Hospital RN R further stated that at the time of the [MEDICATION NAME] consult, pericare was performed for Resident #1 and maggots were observed coming from the vaginal area. According to http://www.rnceus.com/mag/magcyc.html, Depending on the fly species and the environmental temperature, larvae hatch within 8 to 24 hours. The eggs hatch into small larvae that look like small translucent grains of rice. The larvae are about 1 to 2 mm in length at 1 day. The maggots release [MEDICATION NAME] enzymes into their surrounding environment, and this allows them to consume the semi-liquid material. According to http://texasinsects.tamu.edu/cimg243.html, Female flies of other species may glue their eggs to the hosts' body after which the hatching larva tunnels inside. In other species, eggs are inserted directly into the hosts' body by the female. Once inside the body of the host, one or more larvae can develop through several stages (instars) for 4 to 14 days. They emerge from the host to pupate inside their last larval skin (puparium). Adults emerge 1 to 2 weeks later. Depending on species one or more generations occur per year. Interview on 06/07/2017 at 11:37 a.m. with the DON revealed she was notified on 06/04/2017 via a mobile text message that the floor nurses discovered what appeared to be maggots inside Resident #1's peg tube stoma site. The DON stated she could not get confirmation of what exactly was found inside the stoma site but stated the physician ordered the resident to the hospital for evaluation. The DON stated a facility supervisor, LVN O, did speak with hospital staff on 06/06/2017 where they confirmed Resident #1 had maggots and the peg tube was removed. The DON further stated all staff had received training on peg tube stoma care since the facility got confirmation from the hospital on [DATE] of Resident #1 having maggots in the peg tube stoma site. The surveyor requested copies of the inservice training and who had received the training for review and was not provided with the information. Interview on 06/07/2017 at 1:20 p.m. with LVN O revealed she was notified via a mobile text message on 06/04/2017 that the floor nurse stated Resident #1 had what looked like maggots in her peg tube stoma site. LVN O stated that the facility received confirmation on 06/06/2017 that Resident #1 did have maggots. LVN O further stated once the confirmation of maggots was received all residents with a peg tube then received orders for dressing changes and had tubing and bedside syringes replaced. LVN O stated Resident #1's roommate had a lot of personal items inside her room and had at times seen flies inside Resident #1's room. LVN O stated she was not sure if Resident #1's roommate's clutter was cause for the flies to be present in their shared room. LVN O stated she had not received training on peg tube stoma care instructions as of the date of the interview. Interview and observation on 06/07/2017 at 1:43 p.m. with Housekeeping D revealed housekeeping were told to clean Resident #1's room. Housekeeping D stated she was cleaning because she heard something about bugs in the room. Interview on 06/07/2017 at 2:08 p.m. with the administrator revealed he was notified on 06/04/2017 of Resident #1 being transferred to the hospital for evaluation. The administrator stated he was told only that there were complications with the Resident #1's peg tube. The administrator further stated he did not think anything else about it until the facility was notified by hospital staff on 06/06/2017 that Resident #1 had maggots in her peg tube stoma. The administrator stated this incident did not fit his definition of neglect and was not sure if nursing staff had performed an investigation into the matter of Resident #1 having maggots inside of the peg tube stoma. The surveyor again requested copies of the inservice the DON reported the staff had received regarding peg tube stoma. Interview on 06/07/2017 at 3:10 p.m. with LVN C revealed she was the nurse on duty who first saw Resident #1's peg tube with maggots in the stoma site. LVN C stated she was giving Resident #1's medications in the morning at 10:00 a.m. and noticed Resident #1's peg tube dressing gauze was soiled with a brown substance, LVN C then removed the dressing and saw several maggots in the stoma site. LVN C stated the ambulance arrived at 12:17 p.m. for transport to the hospital and at that time Resident #1 still had maggots in her stoma site. LVN C stated she provided care for Resident #1 on 06/02/2017 - 06/04/2017 and noticed flies and gnats in Resident #1's room on 06/02/2017 and 06/03/2017. LVN C further stated Resident #1's roommate had, a bunch of stuff in their room that has flies and gnats in the room. LVN C further stated on 05/29/2017 she had observed Resident #1's stoma site was open to air and did not have a gauze dressing in place. Interview on 06/07/2017 at 3:59 p.m. outside of Resident #1's room with the contracted pest control manager revealed he was contacted on 06/04/2017 by the facility maintenance director to visit the facility for inspection and removal of pests in the facility. The contracted pest control manager stated the room belonging to Resident #1 had a live plant inside the room and further stated the live plants could contribute to pest gathering. Interview on 06/07/2017 at 6:30 p.m. with CNA E revealed she cared for Resident #1 on the night shift on 06/03/2017 but stated she did not provide pericare for Resident #1. CNA E stated she did not recall a dressing gauze being in place for Resident #1's peg tube stoma. CNA E stated she saw flies and gnats in Resident #1's room when she did two hour checks for Resident #1. CNA E further stated she had seen gnats and flies land on Resident #1's roommate's food and bedside table. CNA E stated she had not received training since Resident #1 was transferred to the hospital regarding peg tube stoma care on 06/04/2017. Interview on 06/07/2017 at 6:42 p.m. with LVN G revealed she was a nurse on the overnight shift in the wing Resident #1 resided in prior to Resident #1 being sent to the hospital on [DATE]. LVN G stated she could not recall if Resident #1 had gauze dressing covering the stoma site when she assisted in providing care for Resident #1. LVN G further stated she had not received peg tube stoma care training since Resident #1 was transferred to the hospital on [DATE]. Interview on 06/07/2017 at 7:15 p.m. with LVN H revealed she was the direct care nurse on the overnight shift, 06/03/2017, for Resident #1 on the evening prior to Resident #1 being sent to the hospital. LVN H stated she administered medications to Resident #1 per peg tube between 8:00 p.m. and 9:00 p.m. LVN H stated she noticed Resident #1's dressing gauze was soiled with a brown substance, LVN H stated she wiped off the brown substance but, did not see anything coming out of it. LVN H stated she did not see maggots and did not investigate the soiled dressing because she has seen brown soiled stains on Resident #1's dressing before. LVN H stated she did not provide pericare to Resident #1 on the overnight shift. LVN H stated the last time she observed Resident #1's peg tube stoma site was at midnight, 06/04/2017, and did not observe any additional stains or drainage. LVN H stated she used a 4 inch X 4 inch gauze to cover Resident #1's stoma site. LVN H confirmed Resident #1's roommate has a fly swatter in her room to kill flies and bugs. LVN H further stated Resident #1's roommate had a live plant with standing water in it. LVN H stated she always sees gnats in Resident #1's room. LVN H further stated there had not been an inservice training regarding peg tube stoma care as of the date of the interview. Interview on 06/08/2017 at 9:25 a.m. with the District Facility Manager revealed the facility staff were working until midnight on 06/07/2017 to provide deep cleaning to resident rooms due to pest control issues. Observation and Interview on 06/08/2017 at 9:55 a.m. with Resident #1's roommate, inside her bedroom confirmed the flyswatter on her bedside table was for bugs. The live plant was still present on a bedside table next to Resident #1's roommate. Interview on 06/08/2017 at 10:02 a.m. with LVN K revealed she was working in the unit Resident #1 resided in on the day Resident #1 was sent to the hospital. LVN K stated she was not assigned to provide direct care for Resident #1 only that she assisted with the assessment of Resident #1 when LVN C discovered maggots in Resident #1's stoma. LVN K confirmed there were maggots present in the stoma site. LVN K further stated she had not received inservice training regarding peg tube stoma care as of the date of the interview. Interview on 06/08/2017 at 2:19 p.m. with CNA N revealed she was the CNA assigned to provide direct care for Resident #1 on the 11:00 p.m. to 7:00 a.m. shift of 06/03/2017. CNA N stated she performed 2 hour checks for Resident #1. CNA N stated she could not recall if she provided pericare for Resident #1 on the shift from 06/03/2017 through 06/04/2017. CNA N stated she constantly sees gnats in Resident #1's room and confirmed Resident #1's roommate has a flyswatter at her bedside table. CNA N further stated she had not received inservice training regarding care or observation of peg tube stoma care as of the date of the interview. Record review of the facility audit tool titled, Care of a Gastrostomy or Jejunostomy Tube Competency Audit listed a 14 step guide for caring for ostomy sites. Step 1 revealed, Determined whether exit site was left to open air or if dressing was indicated, checked order. Step 5. Assessed exit site for evidence of excoriation, drainage, infection or bleeding. Step 6. Cleansed skin around site with water and soap using gauze. Step 9. Placed drain-gauze over external bar or disc if dressing was ordered. The Administrator, Corporate Nurse and DON were notified on 06/08/2017 at 4:30 p.m. that an Immediate Jeopardy situation was identified. The facility's Plan of Removal was reviewed and accepted on 06/09/2017 at 12:10 p.m. and included the following: Step 1- Immediate interventions initiated for resident identified: a. Resident provided with peg tube cleaning b. Resident assessed for any other signs and symptoms of distress or pain. c. Resident transferred to Emergency Department d. Nurse practitioner and responsible party notified. e. Administrator, DNS, and ADNS notified of Peg tube concerns f. Room was deep cleaned Step 2. What immediate actions were taken to identify all residents potentially affected? a. All residents with stoma sites assessed for drainage or other adverse signs and symptoms with no other negative findings See attached Care Audit of a Gastrostomy or Jejunostomy Tube Competency. b. Tube feeding site (stoma) care education provided to all nursing team members. c. All physician orders [REDACTED]. d. Nursing staff educated regarding stoma site cleaning and management with return demonstration. e. Environmental rounds conducted. f. Pest control for immediate visit and treatment. g. Administrator and DNS (Director of Nursing Services) were educated on regulation of immediate investigation and report to state agency of any abuse and/or neglect allegation. h. Peri care re-education and audits conducted. i. Hand hygiene re-education and audits conducted. j. ADL audits conducted. Step 3. What system changes were made/modified? a. DNS/ADNS/Wound Nurse or designees to conduct wound care assessments and observations 2 times a week for 4 weeks. b. Environmental round assignments given to all department leaders to be conducted with communication back to Administrator or designee during Stand Up (daily internal meetings) c. Family communication letter to be sent on 06/09/2017 regarding environmental care. d. Resident council to be conducted on 06/08/2017 to discuss storage of food and plants. e. Pest control company contracted to continue with weekly visits for two weeks and then monthly as well as intermittent as needed. f. Inservice education will be continued until all team members have been trained. Step 4. Continued Quality Assurance audits implemented to ensure enhanced system compliance? a. Results of all environmental observations and audits will be shared at stand up and then monthly for three months and then quarterly. On 06/09/2017 the surveyor confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy. 1 RN, 11 LVNs, and 6 CNAs were interviewed and said they had received in-service training. Licensed nursing staff training included peg tube stoma care which included return demonstration. The management nursing staff also stated they were to conduct environmental rounds and to report any evidence of pest control to the facility maintenance director, environmental rounds also included observing for food left out in resident rooms. Licensed nursing staff as well as CNA staff also stated they received training on hand hygiene as well as pericare training. Record review of the audit tools stated in mentioned in step 2 of the plan of removal revealed a 14 step audit tool for nursing staff to review and document. The Corporate Nurse stated the audit tools will be placed in a separate chart for residents identified with a stoma site. The Corporate Nurse further stated this audit tool acts as the facility's policy and procedure regarding stoma care. On 06/09/2017 at 6:10 p.m. the Administrator was informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at scope of pattern and severity of actual harm because the facility had not had time to monitor and evaluate the effectiveness of the Plan of Removal. Information provided by the facility on 06/07/2017 revealed there were 6 residents with peg tubes residing in the facility.

Based on observation, record review, and interview, the facility failed to ensure residents were free from neglect and receive assistive devices to prevent accidents, for 1 Resident (Resident #11) of 14 residents reviewed for falls in that: 1. Resident #11 sustained an avoidable injury resulting in bruising to right side of her chin (approximately 2 inches round) and sustaining a laceration (approximately 1-1 1/2 inches) across the bridge of her nose and a nose fracture with bruising around her eyes. Resident #11 was sent to the hospital emergency room for treatment. 2. The facility did not follow up or assess Resident #11 after being informed the wheelchair was not fitted for her size and height. 3. The facility did not inform the survey team, Resident #11 had fallen from her wheelchair and harm remained in place for 5 days before replacing the whelchair. 4. The facility failed to thoroughly investigate probable causes and did not report the incident to the Texas Department of Aging and Disability Services (DADS) as required. An Immediate Jeopardy (IJ) situation was identified on 05/12/2017. The Immediate Jeopardy was removed on 05/13/2017. The facility remained out of compliance at isolation, actual harm due to the facility's need to complete in-service training and evaluate effectiveness of the corrective system. This deficient practice placed 10 residents living in the Lighthouse (Secured Unit), using a wheelchair and a history of falls at risk for neglect. The findings were: Record review of Resident #11's Electronic Face Sheet dated 05/09/ , revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #11's Quarterly MDS (ARD Date of 04/14/2017) revealed the resident scored 99 (unable to complete the interview) on the BIMS and had to be assessed by staff. The resident had short and long term memory problems and her cognitive skills for daily decision making, were severely impaired. Review of Resident #11's functional status revealed the resident required extensive assistance of one person for bed mobility, transferring, eating, toileting and hygiene and limited assistance to ambulate. The resident was not steady and needed staff to stabilize the resident for balance with an assistive device when walking, turning, moving and changing from surface to surface for transferring. Resident #11 required a wheelchair to self mobilize for long distances. Record review of Resident #11's Fall History from the Incident Log dated 05/12/2017, revealed the resident had fallen 1 time from her wheelchair on 10/31/2016 as she was being escorted to the bathroom and the resident was using her legs to help push herself as she ambulated and the resident fell face front and was sent out to the hospital to be assessed and treated. Record review of Resident 11's Resident Incident Reports dated 01/29/2017, 03/19/2017 and the one for 05/11/2017 all indicated under Medical risk factors possibly related to the incident: had documented the resident had a fall history, inability to understand directions. Record review of Resident #11's Plan of Care (no date), but a Problem Onset: 03/09/2016, stated in part: I am at risk for falls and have a history of falls. Fall: 09-27-2016, 10-24-2016, 10-31-16, 3-19-17. Goal and Target Date: I will not have any unidentified complications r/t (related to) being at risk for falls 07/17/17. Approaches: Refer me to PT evaluation as needed 09-27-16, Observe for changes in my condition that may warrant increased supervision/assistance and notify the physician, I use a wheelchair for long distance mobility, encourage to wear non-skid shoes/socks when out of bed. Further review of the Plan of Care revealed the resident was on Hospice Care since 07/2016 and had not been updated to reflect the resident was now on a different hospice, which was bought out by the new hospice. There was no indication in the Plan of Care indicating PT had been contacted to assess the resident's falls or the resident was on a fall risk program. Interview with Resident #11's primary care physician on 05/12/2017 at 10:30 a.m. and 11:00 a.m. revealed Resident #11 had never fallen from the wheelchair before and last saw her on 04/27/2017 she was sitting back in the wheelchair and her feet touching the floor. The primary physician also stated If the resident does not sit back in the wheelchair and her feet do not touch the floor and she is scooting forward to the end of her chair for her feet to touch the floor it could be an inappropriate wheelchair. It all depends on the resident and circumstances. The physician made the comment she was never called about the wheelchair not fitting the resident. Review of the last Progress Note by Resident #11's primary physician dated 04/27/2017 revealed in part: the resident was on a different Hospice for CAD ([MEDICAL CONDITION]) Resident #11 was found half asleep when we entered the room sitting on the edge of her bed precariously Musculoskeletal, Decreased Mobility, Painful Movement, poor strength, Proximal Weakness, Distal Muscle Weakness, LE (lower extremity) WEAKNESS, WILL SELF TRANSFER TO THE WC (wheelchair) There were no progress notes indicating the resident was observed sitting in her wheelchair. Observation of Resident #11 on 05/09/2017 at 3:47 p.m. revealed she was moving down the hall in her wheelchair. Resident #11 stopped and talked with the surveyor and began to tell the surveyor her feet would not touch the floor. Further observation revealed Resident #11's feet were dangling approximately 6 inches off the floor. Resident #11 told the surveyor the only way she could walk with her feet in the wheelchair was to scoot up to the edge of the wheelchair to place her feet flat on the floor. The surveyor observed the resident scooting to the front edge of the chair to plant her feet flat on the floor and lean forward to ambulate using her feet. The surveyor went to the nurses desk and talked with ADON C and MDS Coordinator F on 05/09/2017 at 3:55 p.m. and informed them of the concerns of Resident #11's wheelchair not fitting her correctly, indicating the chair was too high for her and her feet dangled approximately 6 inches off the floor when she sat all the way back in the chair. The surveyor also informed ADON C and MDS Coordinator F, when Resident #11 wanted to ambulate with her feet, she would scoot to the front edge of the wheelchair and bend over and could fall out of the chair or the chair could roll out from under her and fall. The surveyor was told by ADON C and MDS Coordinator F, the wheelchair was from Hospice and they would call Hospice to let them know. Again this surveyor restated her concern for Resident #11 and both ADON C and MDS Coordinator F indicated they would take care of it. Observation of Resident #11 on 05/10/17 at 9:30 a.m. and at 12:00 noon in the dining room revealed the resident was sitting in her wheelchair at the table eating. Resident was still in the same wheelchair. Observation on 05/11/2017 at 11:27 a.m. revealed Resident #11 was sitting in the dining room at the dining table. The resident was in the same wheelchair. Interview with the DON on 05/12/2017 at 10:05 a.m. concerning if the facility had a Fall Program revealed there was a Fall Committee consisting of the DON, Nurse Consultant and MDS Coordinator and they met once a week to review falls. The DON indicated in the Lighthouse (secured unit) all the residents were fall risks. The DON stated the ADON identified who was a fall risk and on the Admission form it identifies who is a fall risk. The DON stated the company will not let them use the falling star. The CNA's know who is a fall risk when the charge nurse gives them report. If the resident is a fall risk it is placed on the resident's plan of care. Observation on 05/12/2017 at 2:10 p.m. revealed Resident 11 was lying in bed with a large bruise (approximately 2 inches round) to the right side of her chin and a laceration approximately 1 to 1 1/2 inches across the bridge of her nose with 3 stitches and bruising was starting around her eyes. The surveyor asked the RP (who was in the room) what had happened and the RP informed the surveyor, Resident #11 fell out of her wheelchair the day before (05/11/2017) around 2:00 p.m. and the emergency room doctor told the RP Resident #11 had a fractured nose. On 05/12/2017 at 2:16 p.m. observation revealed the same wheelchair which was a concern was in Resident #11's room. Observation on 05/12/2017 at 2:47 p.m. revealed Resident #11 was being pushed down the hall by her family member in the same wheelchair and Resident #11's feet were dangling. The resident was sitting all the way back in the chair. Interview with ADON C, on 05/12/2017 at 2:50 p.m., confirmed Resident #11 had fallen out of her wheelchair the day before (05/11/2017). Further interview with ADON C reconfirmed she was on duty when this surveyor approached her and MDS Coordinator F and was concerned that Resident #11's feet were too high off the floor and the resident scoots to the front edge of the wheelchair to walk and could fall out. Review of the Facility Resident Incident Report for Resident #11, provided by ADON C on 05/12/2017 at 2:50 p.m. revealed the Incident Report was incomplete and the Post Fall/Trauma Report had not been completed. ADON C stated she was not able to contact the LVN who was on duty at the time of the incident to complete the report. Observation and interview of the RP of Resident #11 on 05/12/2017 at 3:20 p.m. revealed Resident #11 sitting in her wheelchair at the edge and trying to move in the chair. Resident #11 was observed bending forward and moving backwards and forwards (rocking motion), trying to move the chair and move her feet. Interview with ADON C on 05/12/2017 at 3:20 p.m. revealed the wheelchair in Resident #11's room was provided by hospice and got the chair when she went on hospice. Resident #11 was observaed at this same time trying to transfer from her wheelchair to her bed and was stopped by ADON C. ADON C stated Resident #11 had not tried to transfer herself before. Observation on 05/12/2017 at 3:27 p.m. revealed Physical Therapy (PT) came into Resident #11's room to check for a lower chair. Interview with PT BB on 05/12/2017 at 3:27 a.m. revealed everyday they get reports of falls. PT BB continued to reveal Resident #11 was taken off hospice so there was an order for [REDACTED]. Interview with ADON C, on 05/12/2017 at 3:35 p.m. confirmed she had not called Hospice and there was no documentation in Resident #11's electronic medical record indicating Hospice had been called concerning the wheelchair or the fall of 05/11/2017. Record review of Resident #11's Electronic Departmental Notes dated 05/12/2017 at 3:37 p.m. revealed notes were documented from 05/03/2017 at 10:20 a.m. to 05/12/2017 at 10:10 a.m., there was no documentation indicating Resident #11's wheelchair was assessed for appropriateness by any facility staff member after the surveyor brought the safety concern to ADON C and MDS Coordinator F or after the fall from the wheelchair. Interview with the Clinical Manager of the Hospice Company on 05/12/2017 at 4:10 p.m., revealed from 05/07/2017 to 05/12/2017 the Nurses Notes and the Call Log did not indicate there was a request for a wheelchair change for Resident #11. Further interview with the Clinical Manager revealed if the resident fell they should have called them and reported the fall. Interview with the Hospice Nurse on 05/12/2017 at 4:35 p.m. revealed the Hospice Nurse was not notified until 05/12/2017 at 10:30 a.m. when Resident #11's RP informed him no one had notified him of the wheelchair concern. A copy of Resident #11's revised Plan of Care for a recent fall dated 05/12/2017 presented by the facility Nurse Consultant on 05/12/2017 at 4:44 p.m. revealed she just updated the Plan of Care, revealing a plan of care for recent fall and read in part Resident observed on floor on hallway lighthouse unit. resident sustained [REDACTED]. Goal, Resident will be free of complications related to fall Approach, 1. Notify MD (Resident's Primary Physician was notified) 5. Notify PT/OT of resident's fall (Incident Report opened) 7. Order X rays if indicated (Checked in ER) .10. Complete Post Fall Risk (assessed by Unit Manager/ADON at time of incident .11. Sent to ER (stitches in place to bridge of nose, bruising and swelling noted to chin) .12. PT to screen . Interview with the Director of Nurses (DON) on 05/12/2017 at 5:00 p.m. revealed she was informed of Resident #11's fall right after it had happened and was told Resident #11 flipped out of her wheelchair. The DON stated after she found out the Hospice Company had been bought out by another Hospice Company, she stated she called the new Hospice company and let them know Resident #11 had fallen. The DON further stated she was not aware a surveyor had a concern about the wheelchair until after the resident had fallen and was told the surveyor had talked to ADON C and MDS Coordinator F on 05/11/2017 prior to the fall. The surveyor informed the DON she talked to ADON C and MDS Coordinator F on 05/09/2017 at 3:55 p.m. The DON stated she had questioned ADON C as to why they had not contacted the therapy department for them to check out or get another wheelchair and was informed by ADON C she wanted to let Hospice know about the wheelchair first. The DON revealed she was not aware the wheelchair Resident #11 fell out of was still being used by the resident. Observation on 05/12/2017 at 6:07 p.m. of the video presented by the Administrator of Resident #11 falling out of her wheelchair on 05/11/2017 at 2:45 p.m. revealed the resident going down the long hall in the Lighthouse holding onto the handrails and pulling herself along. CNA W was observed coming out of a room and was standing behind Resident #11's wheelchair and the wheelchair turning, but because of the distance from the camera the images were blurred and could not see if CNA W touched or pushed Resident 11's wheelchair or if Resident 11 was sitting completely back in her wheelchair. Interview with CNA W and review of a statement received from the CNA on 05/12/2017 at 6:15 p.m. revealed in her statement Resident #11 was at the back door yelling so I redirected her to Activity Room. She came back down the hall and I was going to redirect her back again I had my hands on the wheelchair Resident #11 was sitting halfway on the chair feet not touching the ground. With my hands still on the wheelchair I heard the maintenance man yell out to the residents please I'm painting, so I took my eyes off of Resident #11 and was paying attention to the other residents and all I heard was a loud noise and Resident #11 was on the ground. Review of the facility Falls Policy Guidelines dated 04/2017 revealed in part the following : Purpose: To establish a process that identifies risk and establishes interventions to mitigate the occurrence of falls. A fall is an unintentional change in position coming to rest on the ground, floor, or next lower surface either unassisted or assisted. Process: On Admission, newly admitted or readmitted residents are assessed for fall risk. When a risk factor for falls is identified a corresponding intervention addressing that risk factor is developed. When the risk is identified the intervention is documented on the care plan .Post Fall: .A fall huddle is called to help in investigating circumstances around the fall and help determine immediate interventions, the post fall evaluation is completed to assist in developing and implementing interventions to prevent future falls, the fall event and intervention is recorded on the 24 Hour Report, patient's care plan . Tools, Page 2 of 4, If the fall occurred from chair/wheelchair evaluate reason for fall in order to choose appropriate intervention- ex .leaning too far forward, sliding out of chair, etc Seat chair evaluation for positioning devices: Evaluate wheelchair for appropriate size, need for footrests, or need to have wheelchair locked/unlocked for safety, dropseat in wheelchair if necessary, assess for anxiety/behaviors-involve Social Services for interventions, auto lock breaks . Record review of 2 work orders presented to the surveyor on 05/12/2017 at 11:03 p.m. revealed the following information in part: Work Order 1- WORK ORDER DETAILS FOR FACILITY, Work Order #2157 by MDS Coordinator F indicating to drop wheelchair seat on A wing, room [ROOM NUMBER]B, Priority: Medium, Opened Date: 05/09/2017 at 3:53 PM CT, Status: Open Work Order 2- WORK ORDER DETAILS FOR FACILITY, Work Order #2157 by MDS Coordinator F indicating the same information as the first work order except, Opened Date: 05/09/2017 at 3:53 PM CT, Status: Closed. Interview with Maintenance D on 05/12/2017 at 11:05 p.m. revealed he did not know anything about the work order or checking on Resident #11's wheelchair. He stated he had never seen Resident #11's wheelchair before. He stated he had not gotten Resident #11 a new wheelchair. Interview with Maintenance E on 05/12/2017 at 11:08 p.m. revealed he had the two above letters (work orders) on his computer and had looked at Resident #11's wheelchair for the first time earlier today (05/12/2017) and he passed it on to therapy. Maintenance E stated the priority to check out the wheelchair was medium meaning he had 24 to 48 hours to look at it and if it needed to be looked at sooner then, someone should have told him. Interview with Maintenance Z on 05/13/2017 at 12:40 p.m. revealed if a work order came in he would fix the problem. Stated he had not seen a work order for Resident #11's wheelchair to be fixed. He stated he heard the fall and heard the yell. Interviews were conducted with LVNs and CNAs working in the Lighthouse on 05/13/2017 from 12:35 p.m. to 1:45 p.m. and they confirmed Resident 11's feet have always dangled when she sat back in the wheelchair and had to come up to the edge of the wheelchair to place her feet on the floor to propel herself. Interview with LVN U on 05/13/2017 at 12:35 p.m. revealed Resident #11's tip toes were the only thing touching the floor and the resident scooted up to the front of the wheelchair when ambulating, when the family was visiting she would sit to the back of the wheelchair and her feet would dangle. She stated she did not notify Hospice of wheelchair problem. Interview with LVN V on 05/13/2017 at 12:45 p.m. revealed Resident #11 propeled herself with her feet. She never saw the resident with her back up against the wheelchair. She never saw the resident try and get up. LVN V stated she did not notify Hospice of the wheelchair problem. Interview with CNA W on 05/13/2017 at 1:05 p.m. revealed Resident #11's feet never touched the floor and she sat on the edge of the wheelchair to walk with her feet. Interview with CNA X on 05/13/2017 at 1:11 p.m. revealed Resident #11 sometimes sat back in her wheelchair but she stated she had to sit right up on the edge of her wheelchair for her feet to touch the floor. If she sat all the way back her feet dangle. Interview with MA P on 05/13/2017 at 1:45 p.m. revealed Resident #11 sat partly on the edge of her wheelchair to push herself with her feet. Interview with LVN M on 05/13/2017 at 4:20 p.m. revealed Resident #11 propelled herself with her feet, but was not able to say whether resident had her back against the wheelchair or up front in her wheelchair when she propelled herself and she stated she did not notify Hospice about the resident's wheelchair. Record review of the Emergency/Urgent Care Report from the hospital dated 05/11/2017 at 17:55 CDT (5:55 p.m.) revealed on page 25 of 25, Computed Tomography, Report stated in part Report, CT SCAN OF THE BRAIN WITHOUT INTRAVENOUS CONTRAST: Acute head injury in a fall with head pain FINDINGS: There is a laceration over the nasal bones with nasal bone fractures . Record review of the facility Abuse Policy dated 02/2017 states in part: . Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish or emotional distress Policy Statement: It is the policy of the center to take appropriate steps to prevent the occurrence of . neglect, and to ensure that all alleged violations of Federal or State Laws which involve . neglect, are reported immediately to the Administrator/Director of Nursing of the center The Administrator/Director of Nursing will direct a thorough investigation of each such alleged violation The Director of Nursing in conjunction with other clinicians shall initiate or revise a care plan to reflect the resident/patent's condition and measures to be taken to prevent recurrence, where appropriate. Appropriate steps shall be taken to prevent recurrence of the incident. This may include in-services or other measures as appropriate. The steps taken should be documented Documentation: Documentation in the medical record shall be made where necessary for continuity of care for the resident/patient The administrator was notified on 5/12/17 at 6:25 p.m. of the Immediate Jeopardy for the above failure and a Plan of Removal was requested. The facility's Plan of Removal was provided by the administrator and accepted on 5/13/17 and included the following steps to be taken by the facility: STEP 1 What immediate interventions were initiated or resident identified? Immediate assessment of resident: First aid provided by licensed and registered nurses MD and RP notified on 5/11/17 Orders obtained for in-house treatment Per family request, resident sent to ER for evaluation on 5/11/17 and returned on 5/11/17 PT screened on 5/12/17 DNS notified hospice on 5/12/17 Initiated on 5/11/17 and completed on 5/12/17: DNS/Designee DOR/Designee Audits will be reviewed at QAPI meetings. Once it has been determined that enhanced system interventions and monitoring has been made, the frequency of the auditing process will be determined. STEP 2 What immediate actions were taken to identify all residents potentially affected? What continued and immediate interventions were implemented for identified residents? Director of Rehab and administrative nurses initiated an immediate review of residents that self-propel via wheelchair to ensure proper fit and maximum independence All identified residents were able to safely maneuver and navigate obstacles without difficulty Initiated and completed on 5/12/17: DOR/Designee, DNS/Designee Audits will be reviewed at QAPI meetings. Once it has been determined that enhanced system interventions and monitoring has been made, the frequency of the auditing process will be determined. STEP 3 What system changes were made / modified? All residents, upon admission or a change in physical function and/or mobility, will be referred to therapy for wheelchair positioning and screening if appropriate. Residents noted with difficulty maneuvering and navigating obstacles when in the wheelchair will be referred to therapy for re-evaluation of seating and positioning. All new admissions and residents with change in condition will be discussed at Daily Clinical Start-Up. DOR/Designee will assess residents' mobility status and need for wheelchair evaluation or reevaluation What systemic education was completed to enhance knowledge development of staff? Team members educated on: prevention of resident abuse and neglect, prevention of falls and follow-up, identification of appropriate residents' wheelchair seating identification and follow-up process for any residents experiencing difficulty maneuvering and navigating obstacles when in the wheelchair Team members not currently present will be educated prior to next scheduled shift New team members will receive education during new-hire orientation On-going Administrator/Designee, DNS/Designee, DOR/Designee Audits will be reviewed at QAPI meetings. Once it has been determined that enhanced system interventions and monitoring has been made, the frequency of the auditing process will be determined. STEP 4 Continued Quality Assurance audits implemented to ensure enhanced system compliance? DNS/DOR or their designees will make wheelchair rounds to audit proper positioning and maneuvering 4x/week x 3 months and then weekly thereafter. Wheelchair positioning evaluations and re-evaluations will be discussed and audited for completion at Daily Stand down or by next Daily Start-Up by the DNS/Designee. Results of all audits will be shared at monthly QAPI x3 months. On-going Administrator/Designee, DNS/Designee, DOR/Designee Audits will be reviewed at QAPI meetings. Once it has been determined that enhanced system interventions and monitoring has been made, the frequency of the auditing process will be determined. Observation of Resident #11 on 05/13/2017 at 4:25 revealed the resident was sitting in a different wheelchair. The resident was sitting back in the wheelchair with her feet flat on the floor. Resident #11 stated This chair fits me good. Whatever you do don't let anyone take this chair away from me. On 05/13/2017 the surveyors confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: Interviews with 14 CNAs, 1 Restorative Aide and 2 Medication Aides who said they had been trained on wheelchair safety, and if they saw a resident with their feet dangling or were having a problem with their wheelchair to let the nurse know. These CNAs, Restorative Aide and Medication Aides represented all shifts. Interviews with 8 LVNs and 2 RNs revealed they had been trained to ensure the resident was positioned correctly in their wheelchair and if the wheelchair was appropriate for the resident and if not to notify physical therapy to have the resident and/or wheelchair evaluated. The LVNs and RNs represented all shifts. Review of the In-services dated 05/12/2017 and 05/13/2017, revealed staff were in-serviced concerning falls and inappropriate wheelchairs and safety. On 05/13/2017 at 4:38 p.m., the Administrator was informed the Immediate Jeopardy was removed, however, the facility remained out of compliance at a pattern, actual harm, due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The DON indicated on 05/12/2017 there were 10 residents living in the Lighthouse who used a wheelchair and had a history of [REDACTED].

Based on observation, record review, and interview, the facility failed to implement written policies that prohibit and prevent neglect and ensure residents received adequate assistance devices to prevent accidents, for 2 Resident (Resident #5 and #11) of 14 residents reviewed for falls. 1. Resident #11 sustained an avoidable injury resulting in bruising to right side of her chin (approximately 2 inches round) and sustaining a laceration (approximately 1-1 1/2 inches) across the bridge of her nose and a nose fracture with bruising around her eyes. Resident #11 was sent to the hospital emergency room for treatment. 2. The facility did not follow up or assess Resident #11 after being informed the wheelchair was not fitted for her size and height. 3. The facility did not inform the survey team, Resident #11 had fallen from her wheelchair and harm remained in place for 5 days before replacing the whelchair. 4. The facility failed to thoroughly investigate probable causes and did not report the incident to the Texas Department of Aging and Disability Services (DADS) as required. An Immediate Jeopardy (IJ) situation was identified on 05/12/2017. The Immediate Jeopardy was removed on 05/13/2017. The facility remained out of compliance at isolated, actual harm due to the facility's need to complete in-service training and evaluate effectiveness of the corrective system. This deficient practice placed 10 residents living in the Lighthouse (Secured Unit), using a wheelchair and a history of falls at risk for abuse/neglect. The findings were: Record review of the facility Abuse Policy dated 02/2017 states in part: . Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish or emotional distress Policy Statement: It is the policy of the center to take appropriate steps to prevent the occurrence of . neglect, and to ensure that all alleged violations of Federal or State Laws which involve . neglect, are reported immediately to the Administrator/Director of Nursing of the center The Administrator/Director of Nursing will direct a thorough investigation of each such alleged violation The Director of Nursing in conjunction with other clinicians shall initiate or revise a care plan to reflect the resident/patent's condition and measures to be taken to prevent recurrence, where appropriate. Appropriate steps shall be taken to prevent recurrence of the incident. This may include in-services or other measures as appropriate. The steps taken should be documented Documentation: Documentation in the medical record shall be made where necessary for continuity of care for the resident/patient Record review of Resident #11's Electronic Face Sheet dated 05/09/ , revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #11's Quarterly MDS (ARD Date of 04/14/2017) revealed the resident scored 99 (unable to complete the interview) on the BIMS and had to be assessed by staff. The resident had short and long term memory problems and her cognitive skills for daily decision making, were severely impaired. Review of Resident #11's functional status revealed the resident required extensive assistance of one person for bed mobility, transferring, eating, toileting and hygiene and limited assistance to ambulate. The resident was not steady and needed staff to stabilize the resident for balance with an assistive device when walking, turning, moving and changing from surface to surface for transferring. Resident #11 required a wheelchair to mobilize. Record review of Resident #11's Fall History from the Incident Log dated 05/12/2017, revealed the resident had fallen 10 times prior to 05/11/2017 and 1 time from her wheelchair on 10/31/2016 as she was being escorted to the bathroom and the resident was using her legs to help push herself as she ambulated and the resident fell face front and was sent out to the hospital to be assessed and treated. Record review of Resident 11's Resident Incident Reports dated 01/29/2017, 03/19/2017 and the one for 05/11/2017 all indicated under Medical risk factors possibly related to the incident: had documented the resident had a fall history, inability to understand directions. Record review of Resident #11's Plan of Care (no date), but a Problem Onset: 03/09/2016, stated in part: I am at risk for falls and have a history of falls. Fall: 09-27-2016, 10-24-2016, 10-31-16, 3-19-17. Goal and Target Date: I will not have any unidentified complications r/t (related to) being at risk for falls 07/17/17. Approaches: Refer me to PT evaluation as needed 09-27-16, Observe for changes in my condition that may warrant increased supervision/assistance and notify the physician, I use a wheelchair for long distance mobility, encourage to wear non-skid shoes/socks when out of bed. Further review of the Plan of Care revealed the resident was on Hospice Care since 07/2016 and had not been updated to reflect the resident was now on a different hospice, which was bought out by the new hospice. There was no indication in the Plan of Care indicating PT had been contacted to assess the resident's falls or the resident was on a fall risk program. Interview with Resident #11's primary care physician on 05/12/2017 at 10:30 a.m. and 11:00 a.m. revealed Resident #11 had never fallen from the wheelchair before and last saw her on 04/27/2017 she was sitting back in the wheelchair and her feet touching the floor. The primary physician also stated If the resident does not sit back in the wheelchair and her feet do not touch the floor and she is scooting forward to the end of her chair for her feet to touch the floor it could be an inappropriate wheelchair. It all depends on the resident and circumstances. The physician made the comment she was never called about the wheelchair not fitting the resident. Review of the last Progress Note by Resident #11's primary physician dated 04/27/2017 revealed in part: the resident was on a different Hospice for CAD ([MEDICAL CONDITION]) Resident #11 was found half asleep when we entered the room sitting on the edge of her bed precariously Musculoskeletal, Decreased Mobility, Painful Movement, poor strength, Proximal Weakness, Distal Muscle Weakness, LE (lower extremity) WEAKNESS, WILL SELF TRANSFER TO THE WC (wheelchair) There were no progress notes indicating the resident was observed sitting in her wheelchair. Observation of Resident #11 on 05/09/2017 at 3:47 p.m. revealed she was moving down the hall in her wheelchair. Resident #11 stopped and talked with the surveyor and began to tell the surveyor her feet would not touch the floor. Further observation revealed Resident #11's feet were dangling approximately 6 inches off the floor. Resident #11 told the surveyor the only way she could walk with her feet in the wheelchair was to scoot up to the edge of the wheelchair to place her feet flat on the floor. The surveyor observed the resident scooting to the front edge of the chair to plant her feet flat on the floor and lean forward to ambulate using her feet. The surveyor went to the nurses desk and talked with ADON C and MDS Coordinator F on 05/09/2017 at 3:55 p.m. and informed them of the concerns of Resident #11's wheelchair not fitting her correctly, indicating the chair was too high for her and her feet dangled approximately 6 inches off the floor when she sat all the way back in the chair. The surveyor also informed ADON C and MDS Coordinator F, when Resident #11 wanted to ambulate with her feet, she would scoot to the front edge of the wheelchair and bend over and could fall out of the chair or the chair could roll out from under her and fall. The surveyor was told by ADON C and MDS Coordinator F, the wheelchair was from Hospice and they would call Hospice to let them know. Again this surveyor restated her concern for Resident #11 and both ADON C and MDS Coordinator F indicated they would take care of it. Observation of Resident #11 on 05/10/17 at 9:30 a.m. and at 12:00 noon in the dining room revealed the resident was sitting in her wheelchair at the table eating. Resident was still in the same wheelchair. Observation on 05/11/2017 at 11:27 a.m. revealed Resident #11 was sitting in the dining room at the dining table. The resident was in the same wheelchair. Interview with the DON on 05/12/2017 at 10:05 a.m. concerning if the facility had a Fall Program revealed there was a Fall Committee consisting of the DON, Nurse Consultant and MDS Coordinator and they met once a week to review falls. The DON indicated in the Lighthouse (secured unit) all the residents were fall risks. The DON stated the ADON identified who was a fall risk and on the Admission form it identifies who is a fall risk. The DON stated the company will not let them use the falling star. The CNA's know who is a fall risk when the charge nurse gives them report. If the resident is a fall risk it is placed on the resident's plan of care. Observation on 05/12/2017 at 2:10 p.m. revealed Resident 11 was lying in bed with a large bruise (approximately 2 inches round) to the right side of her chin and a laceration approximately 1 to 1 1/2 inches across the bridge of her nose with 3 stitches and bruising was starting around her eyes. The surveyor asked the RP (who was in the room) what had happened and the RP informed the surveyor, Resident #11 fell out of her wheelchair the day before (05/11/2017) around 2:00 p.m. and the emergency room doctor told the RP Resident #11 had a fractured nose. On 05/12/2017 at 2:16 p.m. observation revealed the same wheelchair which was a concern was in Resident #11's room. Observation on 05/12/2017 at 2:47 p.m. revealed Resident #11 was being pushed down the hall by her family member in the same wheelchair and Resident #11's feet were dangling. The resident was sitting all the way back in the chair. Interview with ADON C, on 05/12/2017 at 2:50 p.m., confirmed Resident #11 had fallen out of her wheelchair the day before (05/11/2017). Further interview with ADON C reconfirmed she was on duty when this surveyor approached her and MDS Coordinator F and was concerned that Resident #11's feet were too high off the floor and the resident scoots to the front edge of the wheelchair to walk and could fall out. Review of the Facility Resident Incident Report for Resident #11, provided by ADON C on 05/12/2017 at 2:50 p.m. revealed the Incident Report was incomplete and the Post Fall/Trauma Report had not been completed. ADON C stated she was not able to contact the LVN who was on duty at the time of the incident to complete the report. Observation and interview of the RP of Resident #11 on 05/12/2017 at 3:20 p.m. revealed Resident #11 sitting in her wheelchair at the edge and trying to move in the chair. Resident #11 was observed bending forward and moving backwards and forwards (rocking motion), trying to move the chair and move her feet. Interview with ADON C on 05/12/2017 at 3:20 p.m. revealed the wheelchair in Resident #11's room was provided by hospice and got the chair when she went on hospice. Resident #11 was observaed at this same time trying to transfer from her wheelchair to her bed and was stopped by ADON C. ADON C stated Resident #11 had not tried to transfer herself before. Observation on 05/12/2017 at 3:27 p.m. revealed Physical Therapy (PT) came into Resident #11's room to check for a lower chair. Interview with PT BB on 05/12/2017 at 3:27 a.m. revealed everyday they get reports of falls. PT BB continued to reveal Resident #11 was taken off hospice so there was an order for [REDACTED]. Interview with ADON C, on 05/12/2017 at 3:35 p.m. confirmed she had not called Hospice and there was no documentation in Resident #11's electronic medical record indicating Hospice had been called concerning the wheelchair or the fall of 05/11/2017. Record review of Resident #11's Electronic Departmental Notes dated 05/12/2017 at 3:37 p.m. revealed notes were documented from 05/03/2017 at 10:20 a.m. to 05/12/2017 at 10:10 a.m., there was no documentation indicating Resident #11's wheelchair was assessed for appropriateness by any facility staff member after the surveyor brought the safety concern to ADON C and MDS Coordinator F or after the fall from the wheelchair. Interview with the Clinical Manager of the Hospice Company on 05/12/2017 at 4:10 p.m., revealed from 05/07/2017 to 05/12/2017 the Nurses Notes and the Call Log did not indicate there was a request for a wheelchair change for Resident #11. Further interview with the Clinical Manager revealed if the resident fell they should have called them and reported the fall. Interview with the Hospice Nurse on 05/12/2017 at 4:35 p.m. revealed the Hospice Nurse was not notified until 05/12/2017 at 10:30 a.m. when Resident #11's RP informed him no one had notified him of the wheelchair concern. A copy of Resident #11's revised Plan of Care for a recent fall dated 05/12/2017 presented by the facility Nurse Consultant on 05/12/2017 at 4:44 p.m. revealed she just updated the Plan of Care, revealing a plan of care for recent fall and read in part Resident observed on floor on hallway lighthouse unit. resident sustained [REDACTED]. Goal, Resident will be free of complications related to fall Approach, 1. Notify MD (Resident's Primary Physician was notified) 5. Notify PT/OT of resident's fall (Incident Report opened) 7. Order X rays if indicated (Checked in ER) .10. Complete Post Fall Risk (assessed by Unit Manager/ADON at time of incident .11. Sent to ER (stitches in place to bridge of nose, bruising and swelling noted to chin) .12. PT to screen . Interview with the Director of Nurses (DON) on 05/12/2017 at 5:00 p.m. revealed she was informed of Resident #11's fall right after it had happened and was told Resident #11 flipped out of her wheelchair. The DON stated after she found out the Hospice Company had been bought out by another Hospice Company, she stated she called the new Hospice company and let them know Resident #11 had fallen. The DON further stated she was not aware a surveyor had a concern about the wheelchair until after the resident had fallen and was told the surveyor had talked to ADON C and MDS Coordinator F on 05/11/2017 prior to the fall. The surveyor informed the DON she talked to ADON C and MDS Coordinator F on 05/09/2017 at 3:55 p.m. The DON stated she had questioned ADON C as to why they had not contacted the therapy department for them to check out or get another wheelchair and was informed by ADON C she wanted to let Hospice know about the wheelchair first. The DON revealed she was not aware the wheelchair Resident #11 fell out of was still being used by the resident. Observation on 05/12/2017 at 6:07 p.m. of the video presented by the Administrator of Resident #11 falling out of her wheelchair on 05/11/2017 at 2:45 p.m. revealed the resident going down the long hall in the Lighthouse holding onto the handrails and pulling herself along. CNA W was observed coming out of a room and was standing behind Resident #11's wheelchair and the wheelchair turning, but because of the distance from the camera the images were blurred and could not see if CNA W touched or pushed Resident 11's wheelchair or if Resident 11 was sitting completely back in her wheelchair. Interview with CNA W and review of a statement received from the CNA on 05/12/2017 at 6:15 p.m. revealed in her statement Resident #11 was at the back door yelling so I redirected her to Activity Room. She came back down the hall and I was going to redirect her back again I had my hands on the wheelchair Resident #11 was sitting halfway on the chair feet not touching the ground. With my hands still on the wheelchair I heard the maintenance man yell out to the residents please I'm painting, so I took my eyes off of Resident #11 and was paying attention to the other residents and all I heard was a loud noise and Resident #11 was on the ground. Review of the facility Falls Policy Guidelines dated 04/2017 revealed in part the following : Purpose: To establish a process that identifies risk and establishes interventions to mitigate the occurrence of falls. A fall is an unintentional change in position coming to rest on the ground, floor, or next lower surface either unassisted or assisted. Process: On Admission, newly admitted or readmitted residents are assessed for fall risk. When a risk factor for falls is identified a corresponding intervention addressing that risk factor is developed. When the risk is identified the intervention is documented on the care plan .Post Fall: .A fall huddle is called to help in investigating circumstances around the fall and help determine immediate interventions, the post fall evaluation is completed to assist in developing and implementing interventions to prevent future falls, the fall event and intervention is recorded on the 24 Hour Report, patient's care plan . Tools, Page 2 of 4, If the fall occurred from chair/wheelchair evaluate reason for fall in order to choose appropriate intervention- ex .leaning too far forward, sliding out of chair, etc Seat chair evaluation for positioning devices: Evaluate wheelchair for appropriate size, need for footrests, or need to have wheelchair locked/unlocked for safety, dropseat in wheelchair if necessary, assess for anxiety/behaviors-involve Social Services for interventions, auto lock breaks . Record review of 2 work orders presented to the surveyor on 05/12/2017 at 11:03 p.m. revealed the following information in part: Work Order 1- WORK ORDER DETAILS FOR FACILITY, Work Order #2157 by MDS Coordinator F indicating to drop wheelchair seat on A wing, room [ROOM NUMBER]B, Priority: Medium, Opened Date: 05/09/2017 at 3:53 PM CT, Status: Open Work Order 2- WORK ORDER DETAILS FOR FACILITY, Work Order #2157 by MDS Coordinator F indicating the same information as the first work order except, Opened Date: 05/09/2017 at 3:53 PM CT, Status: Closed. Interview with Maintenance D on 05/12/2017 at 11:05 p.m. revealed he did not know anything about the work order or checking on Resident #11's wheelchair. He stated he had never seen Resident #11's wheelchair before. He stated he had not gotten Resident #11 a new wheelchair. Interview with Maintenance E on 05/12/2017 at 11:08 p.m. revealed he had the two above letters (work orders) on his computer and had looked at Resident #11's wheelchair for the first time earlier today (05/12/2017) and he passed it on to therapy. Maintenance E stated the priority to check out the wheelchair was medium meaning he had 24 to 48 hours to look at it and if it needed to be looked at sooner then, someone should have told him. Interview with Maintenance Z on 05/13/2017 at 12:40 p.m. revealed if a work order came in he would fix the problem. Stated he had not seen a work order for Resident #11's wheelchair to be fixed. He stated he heard the fall and heard the yell. Interviews were conducted with LVNs and CNAs working in the Lighthouse on 05/13/2017 from 12:35 p.m. to 1:45 p.m. and they confirmed Resident 11's feet have always dangled when she sat back in the wheelchair and had to come up to the edge of the wheelchair to place her feet on the floor to propel herself. Interview with LVN U on 05/13/2017 at 12:35 p.m. revealed Resident #11's tip toes were the only thing touching the floor and the resident scooted up to the front of the wheelchair when ambulating, when the family was visiting she would sit to the back of the wheelchair and her feet would dangle. She stated she did not notify Hospice of wheelchair problem. Interview with LVN V on 05/13/2017 at 12:45 p.m. revealed Resident #11 propeled herself with her feet. She never saw the resident with her back up against the wheelchair. She never saw the resident try and get up. LVN V stated she did not notify Hospice of the wheelchair problem. Interview with CNA W on 05/13/2017 at 1:05 p.m. revealed Resident #11's feet never touched the floor and she sat on the edge of the wheelchair to walk with her feet. Interview with CNA X on 05/13/2017 at 1:11 p.m. revealed Resident #11 sometimes sat back in her wheelchair but she stated she had to sit right up on the edge of her wheelchair for her feet to touch the floor. If she sat all the way back her feet dangle. Interview with MA P on 05/13/2017 at 1:45 p.m. revealed Resident #11 sat partly on the edge of her wheelchair to push herself with her feet. Interview with LVN M on 05/13/2017 at 4:20 p.m. revealed Resident #11 propelled herself with her feet, but was not able to say whether resident had her back against the wheelchair or up front in her wheelchair when she propelled herself and she stated she did not notify Hospice about the resident's wheelchair. Record review of the Emergency/Urgent Care Report from the hospital dated 05/11/2017 at 17:55 CDT (5:55 p.m.) revealed on page 25 of 25, Computed Tomography, Report stated in part Report, CT SCAN OF THE BRAIN WITHOUT INTRAVENOUS CONTRAST: Acute head injury in a fall with head pain FINDINGS: There is a laceration over the nasal bones with nasal bone fractures . The administrator was notified on 5/12/17 at 6:25 p.m. of the Immediate Jeopardy for the above failure and a Plan of Removal was requested. The facility's Plan of Removal was provided by the administrator and accepted on 5/13/17 and included the following steps to be taken by the facility: STEP 1 What immediate interventions were initiated or resident identified? Immediate assessment of resident: First aid provided by licensed and registered nurses MD and RP notified on 5/11/17 Orders obtained for in-house treatment Per family request, resident sent to ER for evaluation on 5/11/17 and returned on 5/11/17 PT screened on 5/12/17 DNS notified hospice on 5/12/17 Initiated on 5/11/17 and completed on 5/12/17: DNS/Designee DOR/Designee Audits will be reviewed at QAPI meetings. Once it has been determined that enhanced system interventions and monitoring has been made, the frequency of the auditing process will be determined. STEP 2 What immediate actions were taken to identify all residents potentially affected? What continued and immediate interventions were implemented for identified residents? Director of Rehab and administrative nurses initiated an immediate review of residents that self-propel via wheelchair to ensure proper fit and maximum independence All identified residents were able to safely maneuver and navigate obstacles without difficulty Initiated and completed on 5/12/17: DOR/Designee, DNS/Designee Audits will be reviewed at QAPI meetings. Once it has been determined that enhanced system interventions and monitoring has been made, the frequency of the auditing process will be determined. STEP 3 What system changes were made / modified? All residents, upon admission or a change in physical function and/or mobility, will be referred to therapy for wheelchair positioning and screening if appropriate. Residents noted with difficulty maneuvering and navigating obstacles when in the wheelchair will be referred to therapy for re-evaluation of seating and positioning. All new admissions and residents with change in condition will be discussed at Daily Clinical Start-Up. DOR/Designee will assess residents' mobility status and need for wheelchair evaluation or reevaluation What systemic education was completed to enhance knowledge development of staff? Team members educated on: prevention of resident abuse and neglect, prevention of falls and follow-up, identification of appropriate residents' wheelchair seating identification and follow-up process for any residents experiencing difficulty maneuvering and navigating obstacles when in the wheelchair Team members not currently present will be educated prior to next scheduled shift New team members will receive education during new-hire orientation On-going Administrator/Designee, DNS/Designee, DOR/Designee Audits will be reviewed at QAPI meetings. Once it has been determined that enhanced system interventions and monitoring has been made, the frequency of the auditing process will be determined. STEP 4 Continued Quality Assurance audits implemented to ensure enhanced system compliance? DNS/DOR or their designees will make wheelchair rounds to audit proper positioning and maneuvering 4x/week x 3 months and then weekly thereafter. Wheelchair positioning evaluations and re-evaluations will be discussed and audited for completion at Daily Stand down or by next Daily Start-Up by the DNS/Designee. Results of all audits will be shared at monthly QAPI x3 months. On-going Administrator/Designee, DNS/Designee, DOR/Designee Audits will be reviewed at QAPI meetings. Once it has been determined that enhanced system interventions and monitoring has been made, the frequency of the auditing process will be determined. Observation of Resident #11 on 05/13/2017 at 4:25 revealed the resident was sitting in a different wheelchair. The resident was sitting back in the wheelchair with her feet flat on the floor. Resident #11 stated This chair fits me good. Whatever you do don't let anyone take this chair away from me. On 05/13/2017 the surveyors confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: Interviews with 14 CNAs, 1 Restorative Aide and 2 Medication Aides who said they had been trained on wheelchair safety, and if they saw a resident with their feet dangling or were having a problem with their wheelchair to let the nurse know. These CNAs, Restorative Aide and Medication Aides represented all shifts. Interviews with 8 LVNs and 2 RNs revealed they had been trained to ensure the resident was positioned correctly in their wheelchair and if the wheelchair was appropriate for the resident and if not to notify physical therapy to have the resident and/or wheelchair evaluated. The LVNs and RNs represented all shifts. Review of the In-services dated 05/12/2017 and 05/13/2017, revealed staff were in-serviced concerning falls and inappropriate wheelchairs and safety. On 05/13/2017 at 4:38 p.m., the Administrator was informed the Immediate Jeopardy was removed, however, the facility remained out of compliance at a pattern, actual harm, due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The DON indicated on 05/12/2017 there were 10 residents living in the Lighthouse who used a wheelchair and had a history of [REDACTED].

Based on observation, record review, and interview, the facility failed to ensure residents received adequate assistance devices to prevent accidents, for 2 Resident (Resident #5 and #11) of 14 residents reviewed for falls. 1. Resident #11 sustained an avoidable injury resulting in bruising to right side of her chin (approximately 2 inches round) and sustaining a laceration (approximately 1-1 1/2 inches) across the bridge of her nose and a nose fracture with bruising around her eyes. Resident #11 was sent to the hospital emergency room for treatment. 2. The facility did not follow up or assess Resident #11 after being informed the wheelchair was not fitted for her size and height. 3. The facility did not inform the survey team, Resident #11 had fallen from her wheelchair and harm remained in place for 5 days before replacing the whelchair. 4. The facility failed to thoroughly investigate probable causes and did not report the incident to the Texas Department of Aging and Disability Services (DADS) as required. An Immediate Jeopardy (IJ) situation was identified on 05/12/2017. The Immediate Jeopardy was removed on 05/13/2017. The facility remained out of compliance at isolated, actual harm due to the facility's need to complete in-service training and evaluate effectiveness of the corrective system. This deficient practice placed 10 residents living in the Lighthouse (Secured Unit), using a wheelchair and a history of falls at risk for neglect and 3 residents living on the 200 hall at risk for greater injuries due to fall mats not being placed. The findings were: Record review of Resident #11's Electronic Face Sheet dated 05/09/ , revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #11's Quarterly MDS (ARD Date of 04/14/2017) revealed the resident scored 99 (unable to complete the interview) on the BIMS and had to be assessed by staff. The resident had short and long term memory problems and her cognitive skills for daily decision making, were severely impaired. Review of Resident #11's functional status revealed the resident required extensive assistance of one person for bed mobility, transferring, eating, toileting and hygiene and limited assistance to ambulate. The resident was not steady and needed staff to stabilize the resident for balance with an assistive device when walking, turning, moving and changing from surface to surface for transferring. Resident #11 required a wheelchair to self mobilize for long distances. Record review of Resident #11's Fall History from the Incident Log dated 05/12/2017, revealed the resident had fallen 1 time from her wheelchair on 10/31/2016 as she was being escorted to the bathroom and the resident was using her legs to help push herself as she ambulated and the resident fell face front and was sent out to the hospital to be assessed and treated. Record review of Resident 11's Resident Incident Reports dated 01/29/2017, 03/19/2017 and the one for 05/11/2017 all indicated under Medical risk factors possibly related to the incident: had documented the resident had a fall history, inability to understand directions. Record review of Resident #11's Plan of Care (no date), but a Problem Onset: 03/09/2016, stated in part: I am at risk for falls and have a history of falls. Fall: 09-27-2016, 10-24-2016, 10-31-16, 3-19-17. Goal and Target Date: I will not have any unidentified complications r/t (related to) being at risk for falls 07/17/17. Approaches: Refer me to PT evaluation as needed 09-27-16, Observe for changes in my condition that may warrant increased supervision/assistance and notify the physician, I use a wheelchair for long distance mobility, encourage to wear non-skid shoes/socks when out of bed. Further review of the Plan of Care revealed the resident was on Hospice Care since 07/2016 and had not been updated to reflect the resident was now on a different hospice, which was bought out by the new hospice. There was no indication in the Plan of Care indicating PT had been contacted to assess the resident's falls or the resident was on a fall risk program. Interview with Resident #11's primary care physician on 05/12/2017 at 10:30 a.m. and 11:00 a.m. revealed Resident #11 had never fallen from the wheelchair before and last saw her on 04/27/2017 she was sitting back in the wheelchair and her feet touching the floor. The primary physician also stated If the resident does not sit back in the wheelchair and her feet do not touch the floor and she is scooting forward to the end of her chair for her feet to touch the floor it could be an inappropriate wheelchair. It all depends on the resident and circumstances. The physician made the comment she was never called about the wheelchair not fitting the resident. Review of the last Progress Note by Resident #11's primary physician dated 04/27/2017 revealed in part: the resident was on a different Hospice for CAD (Coronary Artery Disease) Resident #11 was found half asleep when we entered the room sitting on the edge of her bed precariously Musculoskeletal, Decreased Mobility, Painful Movement, poor strength, Proximal Weakness, Distal Muscle Weakness, LE (lower extremity) WEAKNESS, WILL SELF TRANSFER TO THE WC (wheelchair) There were no progress notes indicating the resident was observed sitting in her wheelchair. Observation of Resident #11 on 05/09/2017 at 3:47 p.m. revealed she was moving down the hall in her wheelchair. Resident #11 stopped and talked with the surveyor and began to tell the surveyor her feet would not touch the floor. Further observation revealed Resident #11's feet were dangling approximately 6 inches off the floor. Resident #11 told the surveyor the only way she could walk with her feet in the wheelchair was to scoot up to the edge of the wheelchair to place her feet flat on the floor. The surveyor observed the resident scooting to the front edge of the chair to plant her feet flat on the floor and lean forward to ambulate using her feet. The surveyor went to the nurses desk and talked with ADON C and MDS Coordinator F on 05/09/2017 at 3:55 p.m. and informed them of the concerns of Resident #11's wheelchair not fitting her correctly, indicating the chair was too high for her and her feet dangled approximately 6 inches off the floor when she sat all the way back in the chair. The surveyor also informed ADON C and MDS Coordinator F, when Resident #11 wanted to ambulate with her feet, she would scoot to the front edge of the wheelchair and bend over and could fall out of the chair or the chair could roll out from under her and fall. The surveyor was told by ADON C and MDS Coordinator F, the wheelchair was from Hospice and they would call Hospice to let them know. Again this surveyor restated her concern for Resident #11 and both ADON C and MDS Coordinator F indicated they would take care of it. Observation of Resident #11 on 05/10/17 at 9:30 a.m. and at 12:00 noon in the dining room revealed the resident was sitting in her wheelchair at the table eating. Resident was still in the same wheelchair. Observation on 05/11/2017 at 11:27 a.m. revealed Resident #11 was sitting in the dining room at the dining table. The resident was in the same wheelchair. Interview with the DON on 05/12/2017 at 10:05 a.m. concerning if the facility had a Fall Program revealed there was a Fall Committee consisting of the DON, Nurse Consultant and MDS Coordinator and they met once a week to review falls. The DON indicated in the Lighthouse (secured unit) all the residents were fall risks. The DON stated the ADON identified who was a fall risk and on the Admission form it identifies who is a fall risk. The DON stated the company will not let them use the falling star. The CNA's know who is a fall risk when the charge nurse gives them report. If the resident is a fall risk it is placed on the resident's plan of care. Observation on 05/12/2017 at 2:10 p.m. revealed Resident 11 was lying in bed with a large bruise (approximately 2 inches round) to the right side of her chin and a laceration approximately 1 to 1 1/2 inches across the bridge of her nose with 3 stitches and bruising was starting around her eyes. The surveyor asked the RP (who was in the room) what had happened and the RP informed the surveyor, Resident #11 fell out of her wheelchair the day before (05/11/2017) around 2:00 p.m. and the emergency room doctor told the RP Resident #11 had a fractured nose. On 05/12/2017 at 2:16 p.m. observation revealed the same wheelchair which was a concern was in Resident #11's room. Observation on 05/12/2017 at 2:47 p.m. revealed Resident #11 was being pushed down the hall by her family member in the same wheelchair and Resident #11's feet were dangling. The resident was sitting all the way back in the chair. Interview with ADON C, on 05/12/2017 at 2:50 p.m., confirmed Resident #11 had fallen out of her wheelchair the day before (05/11/2017). Further interview with ADON C reconfirmed she was on duty when this surveyor approached her and MDS Coordinator F and was concerned that Resident #11's feet were too high off the floor and the resident scoots to the front edge of the wheelchair to walk and could fall out. Review of the Facility Resident Incident Report for Resident #11, provided by ADON C on 05/12/2017 at 2:50 p.m. revealed the Incident Report was incomplete and the Post Fall/Trauma Report had not been completed. ADON C stated she was not able to contact the LVN who was on duty at the time of the incident to complete the report. Observation and interview of the RP of Resident #11 on 05/12/2017 at 3:20 p.m. revealed Resident #11 sitting in her wheelchair at the edge and trying to move in the chair. Resident #11 was observed bending forward and moving backwards and forwards (rocking motion), trying to move the chair and move her feet. Interview with ADON C on 05/12/2017 at 3:20 p.m. revealed the wheelchair in Resident #11's room was provided by hospice and got the chair when she went on hospice. Resident #11 was observaed at this same time trying to transfer from her wheelchair to her bed and was stopped by ADON C. ADON C stated Resident #11 had not tried to transfer herself before. Observation on 05/12/2017 at 3:27 p.m. revealed Physical Therapy (PT) came into Resident #11's room to check for a lower chair. Interview with PT BB on 05/12/2017 at 3:27 a.m. revealed everyday they get reports of falls. PT BB continued to reveal Resident #11 was taken off hospice so there was an order for [REDACTED]. PT BB revealed Resident #11's feet did not touch the floor in her old chair. Interview with ADON C, on 05/12/2017 at 3:35 p.m. confirmed she had not called Hospice and there was no documentation in Resident #11's electronic medical record indicating Hospice had been called concerning the wheelchair or the fall of 05/11/2017. Record review of Resident #11's Electronic Departmental Notes dated 05/12/2017 at 3:37 p.m. revealed notes were documented from 05/03/2017 at 10:20 a.m. to 05/12/2017 at 10:10 a.m., there was no documentation indicating Resident #11's wheelchair was assessed for appropriateness by any facility staff member after the surveyor brought the safety concern to ADON C and MDS Coordinator F or after the fall from the wheelchair. Interview with the Clinical Manager of the Hospice Company on 05/12/2017 at 4:10 p.m., revealed from 05/07/2017 to 05/12/2017 the Nurses Notes and the Call Log did not indicate there was a request for a wheelchair change for Resident #11. Further interview with the Clinical Manager revealed if the resident fell they should have called them and reported the fall. Interview with the Hospice Nurse on 05/12/2017 at 4:35 p.m. revealed the Hospice Nurse was not notified until 05/12/2017 at 10:30 a.m. when Resident #11's RP informed him no one had notified him of the wheelchair concern. A copy of Resident #11's revised Plan of Care for a recent fall dated 05/12/2017 presented by the facility Nurse Consultant on 05/12/2017 at 4:44 p.m. revealed she just updated the Plan of Care, revealing a plan of care for recent fall and read in part Resident observed on floor on hallway lighthouse unit. resident sustained [REDACTED]. Goal, Resident will be free of complications related to fall Approach, 1. Notify MD (Resident's Primary Physician was notified) 5. Notify PT/OT of resident's fall (Incident Report opened) 7. Order X rays if indicated (Checked in ER) .10. Complete Post Fall Risk (assessed by Unit Manager/ADON at time of incident .11. Sent to ER (stitches in place to bridge of nose, bruising and swelling noted to chin) .12. PT to screen . Interview with the Director of Nurses (DON) on 05/12/2017 at 5:00 p.m. revealed she was informed of Resident #11's fall right after it had happened and was told Resident #11 flipped out of her wheelchair. The DON stated after she found out the Hospice Company had been bought out by another Hospice Company, she stated she called the new Hospice company and let them know Resident #11 had fallen. The DON further stated she was not aware a surveyor had a concern about the wheelchair until after the resident had fallen and was told the surveyor had talked to ADON C and MDS Coordinator F on 05/11/2017 prior to the fall. The surveyor informed the DON she talked to ADON C and MDS Coordinator F on 05/09/2017 at 3:55 p.m. The DON stated she had questioned ADON C as to why they had not contacted the therapy department for them to check out or get another wheelchair and was informed by ADON C she wanted to let Hospice know about the wheelchair first. The DON revealed she was not aware the wheelchair Resident #11 fell out of was still being used by the resident. Observation on 05/12/2017 at 6:07 p.m. of the video presented by the Administrator of Resident #11 falling out of her wheelchair on 05/11/2017 at 2:45 p.m. revealed the resident going down the long hall in the Lighthouse holding onto the handrails and pulling herself along. CNA W was observed coming out of a room and was standing behind Resident #11's wheelchair and the wheelchair turning, but because of the distance from the camera the images were blurred and could not see if CNA W touched or pushed Resident 11's wheelchair or if Resident 11 was sitting completely back in her wheelchair. Interview with CNA W and review of a statement received from the CNA on 05/12/2017 at 6:15 p.m. revealed in her statement Resident #11 was at the back door yelling so I redirected her to Activity Room. She came back down the hall and I was going to redirect her back again I had my hands on the wheelchair Resident #11 was sitting halfway on the chair feet not touching the ground. With my hands still on the wheelchair I heard the maintenance man yell out to the residents please I'm painting, so I took my eyes off of Resident #11 and was paying attention to the other residents and all I heard was a loud noise and Resident #11 was on the ground. Review of the facility Falls Policy Guidelines dated 04/2017 revealed in part the following : Purpose: To establish a process that identifies risk and establishes interventions to mitigate the occurrence of falls. A fall is an unintentional change in position coming to rest on the ground, floor, or next lower surface either unassisted or assisted. Process: On Admission, newly admitted or readmitted residents are assessed for fall risk. When a risk factor for falls is identified a corresponding intervention addressing that risk factor is developed. When the risk is identified the intervention is documented on the care plan .Post Fall: .A fall huddle is called to help in investigating circumstances around the fall and help determine immediate interventions, the post fall evaluation is completed to assist in developing and implementing interventions to prevent future falls, the fall event and intervention is recorded on the 24 Hour Report, patient's care plan . Tools, Page 2 of 4, If the fall occurred from chair/wheelchair evaluate reason for fall in order to choose appropriate intervention- ex .leaning too far forward, sliding out of chair, etc Seat chair evaluation for positioning devices: Evaluate wheelchair for appropriate size, need for footrests, or need to have wheelchair locked/unlocked for safety, dropseat in wheelchair if necessary, assess for anxiety/behaviors-involve Social Services for interventions, auto lock breaks . Record review of 2 work orders presented to the surveyor on 05/12/2017 at 11:03 p.m. revealed the following information in part: Work Order 1- WORK ORDER DETAILS FOR FACILITY, Work Order #2157 by MDS Coordinator F indicating to drop wheelchair seat on A wing, room 108B, Priority: Medium, Opened Date: 05/09/2017 at 3:53 PM CT, Status: Open Work Order 2- WORK ORDER DETAILS FOR FACILITY, Work Order #2157 by MDS Coordinator F indicating the same information as the first work order except, Opened Date: 05/09/2017 at 3:53 PM CT, Status: Closed. Interview with Maintenance D on 05/12/2017 at 11:05 p.m. revealed he did not know anything about the work order or checking on Resident #11's wheelchair. He stated he had never seen Resident #11's wheelchair before. He stated he had not gotten Resident #11 a new wheelchair. Interview with Maintenance E on 05/12/2017 at 11:08 p.m. revealed he had the two above letters (work orders) on his computer and had looked at Resident #11's wheelchair for the first time earlier today (05/12/2017) and he passed it on to therapy. Maintenance E stated the priority to check out the wheelchair was medium meaning he had 24 to 48 hours to look at it and if it needed to be looked at sooner then, someone should have told him. Interview with Maintenance Z on 05/13/2017 at 12:40 p.m. revealed if a work order came in he would fix the problem. Stated he had not seen a work order for Resident #11's wheelchair to be fixed. He stated he heard the fall and heard the yell. Interviews were conducted with LVNs and CNAs working in the Lighthouse on 05/13/2017 from 12:35 p.m. to 1:45 p.m. and they confirmed Resident 11's feet have always dangled when she sat back in the wheelchair and had to come up to the edge of the wheelchair to place her feet on the floor to propel herself. Interview with LVN U on 05/13/2017 at 12:35 p.m. revealed Resident #11's tip toes were the only thing touching the floor and the resident scooted up to the front of the wheelchair when ambulating, when the family was visiting she would sit to the back of the wheelchair and her feet would dangle. She stated she did not notify Hospice of wheelchair problem. Interview with LVN V on 05/13/2017 at 12:45 p.m. revealed Resident #11 propeled herself with her feet. She never saw the resident with her back up against the wheelchair. She never saw the resident try and get up. LVN V stated she did not notify Hospice of the wheelchair problem. Interview with CNA W on 05/13/2017 at 1:05 p.m. revealed Resident #11's feet never touched the floor and she sat on the edge of the wheelchair to walk with her feet. Interview with CNA X on 05/13/2017 at 1:11 p.m. revealed Resident #11 sometimes sat back in her wheelchair but she stated she had to sit right up on the edge of her wheelchair for her feet to touch the floor. If she sat all the way back her feet dangle. Interview with MA P on 05/13/2017 at 1:45 p.m. revealed Resident #11 sat partly on the edge of her wheelchair to push herself with her feet. Interview with LVN M on 05/13/2017 at 4:20 p.m. revealed Resident #11 propelled herself with her feet, but was not able to say whether resident had her back against the wheelchair or up front in her wheelchair when she propelled herself and she stated she did not notify Hospice about the resident's wheelchair. Record review of the Emergency/Urgent Care Report from the hospital dated 05/11/2017 at 17:55 CDT (5:55 p.m.) revealed on page 25 of 25, Computed Tomography, Report stated in part Report, CT SCAN OF THE BRAIN WITHOUT INTRAVENOUS CONTRAST: Acute head injury in a fall with head pain FINDINGS: There is a laceration over the nasal bones with nasal bone fractures . The administrator was notified on 5/12/17 at 6:25 p.m. of the Immediate Jeopardy for the above failure and a Plan of Removal was requested. The facility's Plan of Removal was provided by the administrator and accepted on 5/13/17 and included the following steps to be taken by the facility: STEP 1 What immediate interventions were initiated or resident identified? Immediate assessment of resident: First aid provided by licensed and registered nurses MD and RP notified on 5/11/17 Orders obtained for in-house treatment Per family request, resident sent to ER for evaluation on 5/11/17 and returned on 5/11/17 PT screened on 5/12/17 DNS notified hospice on 5/12/17 Initiated on 5/11/17 and completed on 5/12/17: DNS/Designee DOR/Designee Audits will be reviewed at QAPI meetings. Once it has been determined that enhanced system interventions and monitoring has been made, the frequency of the auditing process will be determined. STEP 2 What immediate actions were taken to identify all residents potentially affected? What continued and immediate interventions were implemented for identified residents? Director of Rehab and administrative nurses initiated an immediate review of residents that self-propel via wheelchair to ensure proper fit and maximum independence All identified residents were able to safely maneuver and navigate obstacles without difficulty Initiated and completed on 5/12/17: DOR/Designee, DNS/Designee Audits will be reviewed at QAPI meetings. Once it has been determined that enhanced system interventions and monitoring has been made, the frequency of the auditing process will be determined. STEP 3 What system changes were made / modified? All residents, upon admission or a change in physical function and/or mobility, will be referred to therapy for wheelchair positioning and screening if appropriate. Residents noted with difficulty maneuvering and navigating obstacles when in the wheelchair will be referred to therapy for re-evaluation of seating and positioning. All new admissions and residents with change in condition will be discussed at Daily Clinical Start-Up. DOR/Designee will assess residents' mobility status and need for wheelchair evaluation or reevaluation What systemic education was completed to enhance knowledge development of staff? Team members educated on: prevention of resident abuse and neglect, prevention of falls and follow-up, identification of appropriate residents' wheelchair seating identification and follow-up process for any residents experiencing difficulty maneuvering and navigating obstacles when in the wheelchair Team members not currently present will be educated prior to next scheduled shift New team members will receive education during new-hire orientation On-going Administrator/Designee, DNS/Designee, DOR/Designee Audits will be reviewed at QAPI meetings. Once it has been determined that enhanced system interventions and monitoring has been made, the frequency of the auditing process will be determined. STEP 4 Continued Quality Assurance audits implemented to ensure enhanced system compliance? DNS/DOR or their designees will make wheelchair rounds to audit proper positioning and maneuvering 4x/week x 3 months and then weekly thereafter. Wheelchair positioning evaluations and re-evaluations will be discussed and audited for completion at Daily Stand down or by next Daily Start-Up by the DNS/Designee. Results of all audits will be shared at monthly QAPI x3 months. On-going Administrator/Designee, DNS/Designee, DOR/Designee Audits will be reviewed at QAPI meetings. Once it has been determined that enhanced system interventions and monitoring has been made, the frequency of the auditing process will be determined. Observation of Resident #11 on 05/13/2017 at 4:25 revealed the resident was sitting in a different wheelchair. The resident was sitting back in the wheelchair with her feet flat on the floor. Resident #11 stated This chair fits me good. Whatever you do don't let anyone take this chair away from me. On 05/13/2017 the surveyors confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: Interviews with 14 CNAs, 1 Restorative Aide and 2 Medication Aides who said they had been trained on wheelchair safety, and if they saw a resident with their feet dangling or were having a problem with their wheelchair to let the nurse know. These CNAs, Restorative Aide and Medication Aides represented all shifts. Interviews with 8 LVNs and 2 RNs revealed they had been trained to ensure the resident was positioned correctly in their wheelchair and if the wheelchair was appropriate for the resident and if not to notify physical therapy to have the resident and/or wheelchair evaluated. The LVNs and RNs represented all shifts. Review of the In-services dated 05/12/2017 and 05/13/2017, revealed staff were in-serviced concerning falls and inappropriate wheelchairs and safety. 3. Review of Resident #5's electronic face sheet, dated 05/10/2017, revealed an admission date of [DATE] and readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan for Resident #5 revealed a Problem Onset of 10/14/2016 for poor safety awareness and to keep bed in lowest position, keep call light in reach and fall mats at bedside. Review of Resident #5's consolidated Physician order [REDACTED]. Review of the incident/accident reports for January 2017, revealed Resident #5 had a fall from bed on 01/17/ and 01/18/2017. Observations on 05/09/2017 at 9:27 a.m., 9:42 a.m. and 9:55 a.m. revealed Resident #5 was lying in bed with his fall mat folded and stored against his nightside. Interivew with LVN M on 05/09/2017 at 9:55 a.m. confirmed Resident #5's fall mat was stored against the resident's night stand and should have been placed on the floor at the resident's bedside. On 05/13/2017 at 4:38 p.m., the Administrator was informed the Immediate Jeopardy was removed, however, the facility remained out of compliance at a pattern, actual harm, due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The DON indicated on 05/12/2017 there were 10 residents living in the Lighthouse who used a wheelchair and had a history of [REDACTED]. Facility provided information revealed three residents used fall mats on the 200 hall.