Every finding on record at Northeast Rehabilitation and Healthcare Center

Based on interview and record review, the facility failed to ensure residents had the right to privacy of personal mail delivered to the facility for 1 of 3 residents (Resident #1) reviewed for resident rights. The facility failed to ensure staff did not open a letter with a check personally addressed to Resident #1 on 4/19/26.This deficient practice could compromise the residents' right to confidential communication and personal privacy.The findings included:Record review of Resident #1's face sheet dated 7/8/26 reflected a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included respiratory failure, anxiety disorder, and joint pain.Record review of Resident #1's most recent quarterly MDS assessment dated [DATE] reflected the resident was cognitively intact for daily decision-making skills.During an interview on 7/8/26 at 8:40 a.m., Resident #1 stated she had a personal account she used to pay for living expenses at the facility. Resident #1 stated she gave the BOM access to the personal account to make payments to the facility on her behalf. Resident #1 stated she also used her personal account to purchase prizes for a bible study group she put together at the facility but had to stop doing that because I just still kept getting into debt. Resident #1 stated she was worried about not having enough money in the personal account to pay the facility and stated she had a life insurance policy she cashed in to pay the facility. Resident #1 stated she made the BOM aware she had cashed in a life insurance policy to pay the facility. Resident #1 stated the facility opened her personal mail without her knowledge because she never received the life insurance check. Resident #1 stated she reached out to the life insurance company and was told the life insurance check had been cashed and the insurance company representative sent her a copy of the cancelled check by e-mail. Resident #1 stated the BOM opened my mail and cashed my check without me signing it. Resident #1 allowed the surveyor access to her computer tablet and revealed a picture of a cancelled check from the insurance company dated 4/19/26 with Resident #1's name on it in the amount of $625.33 and the back of the insurance check was stamped For Deposit Only and the facility's name. During an interview with Resident #1 at 7:55 a.m. on 7/9/26, she stated she didn't want a check cut out to her because it was being used for her living expenses anyway. It was just the way they did it, cashing the check without showing it to me. I have my rights. It is a federal offense to open somebody's mail when it was not theirs.During an interview with Resident #1's advocate at 10:47 a.m. on 7/7/26, she stated Resident #1 was her own RP and was upset because the check came, and the facility didn't tell her it came, they cashed it and didn't tell her. During an interview on 7/8/26 at 1:33 p.m., the BOM stated, Resident #1 provided her with the resident's personal account information to be used to withdraw funds for the residents stay at the facility. The BOM stated funds were withdrawn from Resident #1's account monthly and during a scheduled transaction, around April 2026, the resident's account showed the account had insufficient funds. The BOM stated she believed Resident #1's bank account had been compromised and she went to Resident #1 and asked about the account and Resident #1 told her she would call the bank to get information. The BOM stated she received monthly bank statements from Resident #1's bank account care of the facility and noticed a charge to an online retail [NAME] in the amount of $600.00. The BOM stated Resident #1 told her she had used the personal account to make an online purchase and was trying to return the items she had bought. The BOM stated, as a result, Resident #1 did not have the funds to pay the facility, but the resident told her she had cashed in on a life insurance policy and told the BOM to use the life insurance check to pay the facility. The BOM stated Resident #1's life insurance check was mailed to the facility and the receptionist at the time, opened the letter with the life insurance check in it, addressed to Resident #1, wrote a receipt for it and then handed the check over to the BOM. The BOM stated when she became aware Resident #1's check was delivered to the facility in the resident's name she knew it was not supposed to be opened by the staff. The BOM stated she told the receptionist she was not supposed to open mail directly addressed to the residents because it was a violation of resident rights. The BOM stated that all incoming mail was supposed to be given to the Activities Director, who was then supposed to sort the mail, and any mail addressed directly to a resident was supposed to be delivered to the residents, unopened. The BOM stated she should have shown Resident #1 the life insurance check when it was delivered so the resident could physically see that the check came. The BOM stated she did not remember the name of the receptionist covering the reception desk in April 2026 and was not sure if that person was still employed by the facility.During an interview on 7/8/26 at 2:31 p.m. the DON stated the process followed when mail was delivered was for the receptionist on duty to sort the mail and any mail addressed directly to a resident was given to the Activities Director who in turn would deliver to the residents. The DON stated that all other mail that was not directly addressed to the resident was given to the business office. The DON stated, a staff cannot open mail directly addressed to the residents unless the residents gave permission, and the mail was opened in front of them. The DON stated, you cannot open a resident's personal mail because it is a violation of their rights.During an interview on 7/8/26 at 3:24 p.m., Receptionist A stated she was currently working as a restorative aide but had worked for the facility for the past 5 years and was employed initially as the receptionist. Receptionist A stated, prior to the current BOM, when the mail was delivered to the facility the receptionist on duty took the mail to the Activities Director who then sorted the mail by department and any mail addressed directly to the resident was given to the resident. Receptionist A stated, after the former BOM left, the current BOM took all the mail delivered to the facility and sorted it. Receptionist A stated, we've never opened mail, none of us (Receptionists), the BOM opens the mail and if it's a check, she brings it to the receptionist so we can write a receipt and then the receipt and the check is returned to the BOM. Receptionist A stated, we are not supposed to open residents personal mail because it is a federal crime first of all, and it is their right to do what they want with their mail, including a personal check. Receptionist A stated the process for sorting and delivering mail had recently changed, maybe within the last month, because Resident #1 had complained about a letter with a check being opened without her knowledge.During an interview on 7/9/26 at 8:57 a.m., the Activities Director stated the BOM handled the mail and gave her mail directly addressed to the resident to give to the residents, in other words junk mail and the BOM would keep the rest. The Activities Director stated the process had recently changed, not sure when exactly, and now she was receiving more mail for the residents than usual and was not sure why. The Activities Director stated that mail addressed directly to the residents should never be opened because it was a rights violation. During an interview on 7/9/26 at 12:31 p.m., Receptionist B stated she had been employed by the facility off and on since 2019 and then full time as of 5/1/2026, and stated the process for mail delivery used to be the mail was taken by the receptionist to the Activities Director who in turn sorted it and any personal mail directly addressed to the residents were delivered to the resident and all other mail was delivered to the BOM by the Activities Director. Receptionist B stated that since she started the receptionist position full time, the current BOM gave a directive that all mail was to go to the BOM. Receptionist B stated, as far as I had seen, the BOM was opening all of the mail and had never given any mail to the Activities Director. Receptionist B stated she recalled an incident with Resident #1 who was apparently waiting for a letter and believed she had seen what Resident #1 was waiting for, but because the BOM had given the directive to give all the mail to her, I didn't say anything. Receptionist B stated she did not know what was in the letter addressed to Resident #1, I just know Resident #1 had been waiting for it. Receptionist B stated that the BOM opens the mail, we (the receptionists) don't open the mail. Receptionist B stated it was not her place to open resident mail; it was not allowed.During an interview on 7/9/26 at 12:49 p.m., the Social Services Assistant stated she had been employed by the facility for over a year and had helped work at the reception desk. The Social Services Assistant stated all mail addressed to the residents was collected by the BOM, it was a habit, I would set it on her desk, and she would go through it. The Social Services Assistant stated initially any mail delivered to the facility was taken by the receptionist on duty and delivered to the Activities Director who would then sort it. The Social Services Assistant stated the process had changed from the mail collected by the BOM to the mail collected by the Activities Director but was not sure when that occurred or why there was a change. The Social Services Assistant stated, you can't open a letter or a package without the resident's consent because that is a federal crime.During an interview on 7/9/26 at 1:25 p.m. the Operations Manager stated her understanding was the BOM opened the mail, except for personal mail directly addressed to the resident. The Operations Manager stated she was not aware the BOM was opening the residents personal mail and stated, we can't be opening personal mail, it's their stuff. It's a violation of their rights.Record review of Resident #1's personal e-mail to the life insurance company dated 6/12/26 reflected in part, Hi Big Brother I am in dire straights! (sic) I canceled my life insurance policy. I never received it. The facility cashed it without my knowledge.Record review of the facility carbon copy document titled RECEIPT dated 4/19/26 reflected payment received from a life insurance company in the amount of $653.33. The carbon copy document was signed by Receptionist A.Record review of the facility document titled Resident Rights and Responsibilities, Notice of, with revision date 4/2025 reflected in part, .It is the policy of this facility to inform the resident both orally and in writing of their rights as a resident, as well as the rules and regulations governing the resident's conduct and responsibilities during their stay in the facility.

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 included measurable objectives and time frames to meet residents' medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and to ensure the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 13 residents (Residents #1, #2, and #3) reviewed for care plans. 1. The facility failed to develop a care plan to address Resident #1 had wandering behaviors.2. The facility failed to develop a care plan to address Resident #2 had a diagnosis of other stimulant abuse.3. The facility failed to develop a care plan to address Resident #3 had a diagnosis of alcohol dependence. These failures could place residents at risk of not having their needs met and not receiving appropriate care.The findings include: 1. Record review of Resident #1's face sheet, dated 06/09/2026, reflected an [AGE] year-old male who was initially admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #1 had diagnoses to include dementia (decline in cognitive functions [memory, reasoning, and thinking]) which interferes with daily life) and cognitive communication deficit. Record review of Resident #1's admission MDS assessment, dated 04/28/2026, reflected Resident #1 had a BIMS score of 12 out of 15, indicating moderate cognitive impairment. It further revealed the resident did not exhibit wandering behavior. Record review of Resident #1's care plan, undated, did not reflect Resident #1's wandering behavior. Record review of Resident #1's electronic medical record reflected Resident #1's Elopement Evaluation, dated 04/21/2026, reflected he was not a risk for wandering. Record review of the facility's self-report Investigative Worksheet, dated 05/24/2026, reflected Resident #1 entered another resident's room without permission. No negative effects occurred. During an interview on 06/09/2026 at 02:55 PM, CNA B revealed Resident #1 would go into other residents' rooms while looking for his friend in the facility. She revealed it should be on his Kardex (system that is populated by a resident's care plan for reference for resident care for CNAs) for staff to know how to care for our residents. It was important to keep him from going into other residents' rooms to protect him and other residents. During an interview on 06/10/2026 at 09:13 AM, RN F revealed Resident #1 wandered into other residents' rooms and had to redirect him many times. She revealed if a resident was not expecting Resident #1, there was no reason for him to wander into other residents' rooms. She further revealed Resident #1's wandering behaviors should be on his care plan. It would be important to be on his care plan because it was a part of his character and he did it all the time and everyone needed to know to redirect him so nothing inappropriate could happen or something upsetting could happen like a male wandering into a female's room. RN F could not recall when he started wandering but at least for the month of May, he wandered a lot. During an interview on 06/10/2026 at 10:38 AM, RN E revealed Resident #1 was not his resident but he knew Resident #1 wandered around the facility looking for his friend and this should be care planned because it was not appropriate for him to wander into residents' rooms. He could not recall when his wandering behavior started. During an interview on 06/10/26 at 01:19 PM, the DON revealed Resident #1 forgot where his room was located sometimes and may be in someone else's room in a different hallway. She revealed she had to investigate if this was Resident #1's behavior. She further revealed if he wandered it should be care planned because it was a safety concern. During an interview on 06/10/2026 at 01:56 PM, Resident #1 revealed he got confused frequently and had poor memory. He revealed he walked around the facility, into different hallways, looking for another resident (his friend) because he sometimes forgot where his friend's room was located and where his room was located. 2. Record review of Resident #2's face sheet, dated 06/09/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had a diagnosis to include other stimulant abuse (the harmful recreational use of substances that speed up the central nervous system). Record review of Resident #2's admission MDS assessment, dated 05/07/2026, reflected Resident #2 had a BIMS score of 08 out of 15, indicating moderate cognitive impairment. Record review of Resident #2's care plan, undated, did not reflect Resident #2's diagnosis of alcohol dependence. 3. Record review of Resident #3's face sheet, dated 06/09/2026, reflected an [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #3 had a diagnosis to include alcohol dependence Record review of Resident #3's quarterly MDS assessment, dated 03/26/2026, reflected Resident #3 had a BIMS score of 13 out of 15, indicating intact cognition. Record review of Resident #3's care plan, undated, did not reflect Resident #3's diagnosis of alcohol dependence. During an interview on 06/09/2026 at 01:30 PM, CNA A revealed she took care of Resident #3 and it would be helpful to know if her residents had a history of substance use so she could be prepared when caring for her residents. During an interview on 06/09/2026 at 03:11 PM, CNA C revealed Resident #3 was one of her residents and it would be important to know if he had a history of substance use to be proactive in his resident care. She revealed Resident #1 wandered into people's rooms and staff knew to be firm with him in redirecting him. She revealed it would be important to put this in his Kardex for new nursing staff to know how to provide resident care for Resident #1. She could not recall how long he had been wandering in the facility. During an interview on 06/10/2026 at 12:40 PM, Restorative Aide D revealed it was important to know Resident #2's and Resident #3's history of substance use like Resident #2's stimulant abuse diagnosis so the nursing staff were all aware to prevent anything negative happening to these residents. She revealed Resident #1's care plan should include that he wandered because this was his behavior and staff knew to redirect him from other residents' rooms and his memory was getting worse. She was not aware of how long he had been wandering. During an interview on 06/10/2026 at 02:03 PM, the Operations Manager revealed on 05/24/2026 Resident #1 was in another resident's room and that resident did not want him in there. She revealed there were no injuries during this incident . She revealed the nursing staff knew to redirect Resident #1 when he was not walking to his room. She further revealed she was not sure if it was in the care plan, but she had not personally seen him go into another resident's room, so she did not know if it needed to be in his care plan. During an interview on 06/10/26 at 02:38 PM, MDS nurse G revealed a history of stimulant abuse for Resident #2 was not care planned because it was historical information and not a current issue and it was not something the facility had to address. She confirmed Resident #3 had a diagnosis of alcohol dependence. She revealed if they were hospitalized for dependency recently, then staff would care plan the diagnosis because the facility would monitor them, however, if they had been clean for years, then the facility would not have to document it. MDS nurse G reviewed Resident #1's electronic medical record and revealed he was not a wander risk per his 04/21/26 elopement assessment. She revealed the standard was to look at the elopement assessment and document the care plan accordingly. She revealed if a resident was wandering then this would be a safety issue and staff would update the care plan. During an interview on 06/10/2026 at 02:53 PM, the DON revealed Resident #3 did not need to have alcohol dependency care planned because it was not active and the facility did not serve alcohol. During an interview on 06/10/2026 at 02:59 PM, MDS nurse H revealed IDT care planned residents' diagnoses upon entry. She revealed when she started working at the facility, Resident #3 was already a resident and had his care plan done. She revealed Resident #3 did not have a current issue with drinking and alcohol dependency did not need to be on his care plan. She revealed the facility documented it if it was an active diagnosis or if there were behaviors related to those certain diagnoses. MDS nurse H revealed the incident in the self-report should have been brought up with the IDT meeting and the care plan would have been updated to reflect Resident #1 was a wanderer. During an interview on 06/10/26 at 04:15 PM, the DON revealed she would not put Resident #2's and Resident #3's history of substance use on their care plans because it was not being treated. She further revealed if it was appropriate to care plan these diagnoses it would be to prevent substance use. Record review of the facility's policy Elopement/Unsafe wandering, revised 4/.2025, reflected Wandering is the random or repetitive locomotion and can be either goal directed or non-goal directed. 2. Residents with high risk factors will be identified as At Risk and will have an individualized care plan developed that includes measurable objectives and timeframes. A. Care plan interventions will consider the elements of the evaluation or behavior observations that identified the resident at risk. Record review of the facility's policy Behavioral Health Services, revised 4/.2025, reflected .Behavioral health encompasses a resident's whole emotional and mental well-being, which includes the prevention and treatment of mental and substance use disorders.Substance use disorder (SUD ) is defined as recurrent use of alcohol and/or drugs that causes clinically and functionally significant impairment.For residents with a history of previous or current SUD, attempts will be made to identify use details. May consider use of behavioral contract as part of the care process. Record review of the facility's policy Comprehensive Person-Centered Care Planning, revised 4/.2025, reflected .12. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on observation, interview, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one (1) of one (1) kitchen (Kitchen 1) reviewed for food safety requirements. 1. Food service staff failed to ensure an unidentified nursing staff member wore hair restraints while in the kitchen during meal preparation on 05/17/2026. 2. Food service staff failed to ensure personal foods and beverages were not kept in the kitchen refrigerator and freezer on 05/19/2026. 3. Food service staff failed to ensure a facility contracted chemical supplier representative wore hair restraints while in the kitchen during meal preparation on 05/20/2026. These failures could place residents at risk for the spread of infections, food contaminations, food-borne illnesses, and diminished quality of life. The findings included: 1. During an observation on 05/17/2026 at 12:23 p.m., an unidentified nursing staff member was observed to walk into the facility kitchen through the dining room to kitchen door and walked through the kitchen to obtain a wrapped silverware set from a dietary staff member. The unidentified nursing staff member was not wearing a hair restraint. The dietary staff were in the middle of lunch service with uncovered cooked foods on the service line. The closest dietary staff member gave the wrapped silverware to the nursing staff member and directed the nursing staff member out of the kitchen. The Dietary Supervisor was then observed to block entry into the kitchen from the dining room door and dietary staff were observed to directly address any requests following the observation from the doorway. 2. During observation and interview on 05/19/2026 at 03:05 p.m., a Styrofoam clamshell container was observed in Refrigerator #2. It had a name and was dated 05/19/2026. It did not have an expiration or use-by date. One (1) single-serving plastic beverage and one (1) Styrofoam beverage cup with lid were observed in the reach-in freezer. Neither beverage was labeled with an open or production date, with a use-by date, or with an owner's identifier. The Dietary Supervisor stated the Styrofoam clamshell container was hers. She identified it as leftovers from lunch. She was then observed to remove the clamshell container and the two beverage containers and told the two other dietary staff present that they could not store their drinks in the reach-in and handed each dietary staff member their beverages. During an interview on 05/19/2026 at 03:22 p.m., the Dietary Supervisor confirmed that she observed the unidentified nursing staff member walk into the kitchen during lunch service on 05/17/2026. She stated she believed the CNAs and nurses received education on the requirement for hairnets but did not provide their education. She stated that when that type of situation occurs, the dietary staff were to re-educate the person that they are not supposed to enter the kitchen. She stated the impact of a person coming into the kitchen without a hair restraint was that with the food, hair could get into the food. 3. During an observation on 05/20/2026 at 11:32 a.m., a facility contracted chemical supplier representative was observed to walk into the facility kitchen through the dining room to kitchen door and walked through the kitchen to ask staff for direction to the three-compartment sink. He was not wearing a hair restraint. The dietary staff were completing meal service preparation with uncovered foods cooking and cooked on the stove tops and on the service line. [NAME] A was observed to redirect him out of the kitchen, to the hall to kitchen door, and observed to educate him on his requirement to put on a hair restraint. During interview on 05/20/2026 at 11:38 a.m., the Dietary Supervisor stated the hair nets were only available on the hall to kitchen door and not on the door from the dining room. She stated dietary staff would usually close the door to the dining room. She stated the chemical supplier was new, from a new contract, and did not know that he was supposed to come into the kitchen from the hall door. She stated staff were not supposed to put their personal food items in either the freezer or refrigerator because the food in the kitchen refrigerators and freezer was only for residents' food. She stated dietary staff were to store their food items in the employee breakroom refrigerator and store their beverages on her desk. She stated the risk of staff storing their food in the kitchen refrigerator or freezer was that it might cause confusion for other dietary staff, thinking the food item was for a resident and serve a food to a resident that did not match their diet order. She stated employee food might also not be dated or labeled appropriately. During an interview on 05/20/2026 at 12:40 p.m., the DON stated her expectation for nursing staff was for them to go to the kitchen door if they needed to ask for something, but not to go grab something on their own. She stated she expected nursing staff to wear a hair net if entering the kitchen. She stated nursing staff attended huddles, received in-services, and reminders from dietary staff to educate and re-educate them on wearing hair restraints in the kitchen. She stated the impact of a staff member entering the kitchen without a hair restraint was that hair could be found in the food. She stated it was an infection control concern. She stated employee food found in the kitchen refrigerator and freezer could result in cross-contamination. During an interview on 05/20/2026 at 02:46 p.m., the Operations Manager stated facility staff received in-service training to educate them on the importance of wearing hair nets. She stated facility contractors were educated when they are coming in to the facility. She stated the storage of employee food items in the kitchen refrigerator or freezer and persons entering the kitchen without hair restraints was an infection control concern. She stated the entry into the kitchen could result in transferring contamination through not hand washing and hair could be unsanitary. She stated it was everyone's responsibility to ensure they follow kitchen sanitation requirements. Record review of the facility's policy, Section: Departmental, Subject: Dietary Services, dated as revised 05/2007, revealed: Policy: It is the policy of this facility to prevent contamination of food products and therefore prevent foodborne illness. Procedures: .4. Personal Hygiene A. Proper attire for food handlers should include a hair covering (hair nets or caps). Record review of the FDA Food Code 2022, https://www.fda.gov/food/retail-food-protection/fda-food-code, accessed 05/21/2026 revealed: 2- 402 Hair restraints 2-402.11 Effectiveness. (A) Except as provided.Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. On-premises preparationPrepare and hold cold3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified., refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.Commercially processed food Open and hold cold (B) Except as specified., refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations. The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1;. The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety.

Based on interview and record review the facility failed to develop, implement, and maintain an effective training program for all new and existing staff for 11 (Medication Aide G, CNA H, CNA I, CNA J, CNA K, Dietary Supervisor, Activity Director, Operations Manager, ADON L, RN D, CNA M) of 28 employees reviewed for training requirements. The facility failed to implement and maintain a training program that ensured Medication Aide G, CNA H, CNA I, Dietary Supervisor, ADON L, and Operations Manager received required training within 21 days of hire, per facility's training policy. The facility failed to implement and maintain a training program that ensured CNA J, CNA K, Activity Director, and RN D received required training annually. This failure could place residents at risk of being cared for by staff who have been insufficiently trained. Findings include: Record review of personnel record for Medication Aide G revealed hire date of 04/08/2026. Review of the training log provided by human resources revealed no evidence that Medication Aide G completed their initial training of HIV, restraint reduction, prevention of falls, or emergency preparedness within 21 days of hire. Record review of personnel record for CNA H revealed hire date of 04/15/2026. Review of the training log provided by human resources revealed no evidence that the CNA H completed their initial training of HIV, restraint reduction, prevention of falls, or emergency preparedness within 21 days of hire. Record review of personnel record for CNA I revealed hire date of 04/08/2026. Review of the training log provided by human resources revealed no evidence that the CNA I completed their initial training of HIV, restraint reduction, prevention of falls, or emergency preparedness within 21 days of hire. Record review of personnel record for Dietary Supervisor revealed hire date of 09/05/2025. Review of the training log for the previous 12 months provided by human resources revealed no evidence that the Dietary Supervisor completed their initial training of behavioral health or restraint reduction within 21 days of hire. Record review of personnel record for Operations Manager revealed hire date of 04/24/2026. Review of the training log provided by human resources revealed no evidence that the Operations Manager completed their initial training of effective communications, resident rights, QAPI program, infection control, behavioral health, HIV, restraint reduction, prevention of falls, or emergency preparedness within 21 days of hire. Record review of personnel record for ADON L revealed hire date of 02/18/2026. Review of the training log for the previous 12 months provided by human resources revealed no evidence that ADON L completed behavioral health or restraint reduction training within 21 days of hire. Record review of personnel record for CNA J revealed hire date of 02/21/2024. Review of the training log for the previous 12 months provided by human resources revealed no evidence that the CNA J completed effective communications, QAPI program, ethics, HIV, restraint reduction, prevention of falls, or emergency preparedness training annually. Record review of personnel record for CNA K revealed hire date of 03/10/2023. Review of the training log for the previous 12 months provided by human resources revealed no evidence that the CNA K completed effective communications or emergency preparedness training annually. Record review of personnel record for Activity Director revealed hire date of 11/04/2024. Review of the training log for the previous 12 months provided by human resources revealed no evidence that the Activity Director completed effective communications, abuse prevention, infection control, behavioral health, prevention of falls, or emergency preparedness training annually. Record review of personnel record for RN D revealed hire date of 07/25/2022. Review of the training log for the previous 12 months provided by human resources revealed no evidence that the RN D completed dementia management or ethics training annually. Record review of personnel record for CNA M revealed hire date of 08/16/2023. Review of the training log for the previous 12 months provided by human resources revealed no evidence that the CNA M completed emergency preparedness training annually. Interview with HR O on 05/20/2026 at 2:15 PM revealed newly hired employees were to complete their new hire training within 21 days of hire. HR O stated new employees signed an agreement at orientation that stated they would complete their training and that it was the employee's responsibility to complete training timely. When asked, HR O did not state how staff not completing their training could affect the residents.A group interview with HR P, DON and Operations Manager on 05/20/2026 at 4:51 PM revealed new employees signed a training agreement in orientation agreeing that they would complete training within 21 days of hire. HR P stated, per facility policy, employees were to complete their training within 21 days of hire or they could be suspended or terminated. DON and Operations Manager stated it was the responsibility of the employees to complete their training on time. DON and Operations Manager stated supervisors were responsible to ensure staff completed training within 21 days and annually. When asked, HR P and Operations Manager stated they were new in their positions and were unaware that staff had not completed their training or how it could affect the residents. DON stated residents could be at risk for poor quality of care by staff not completing their training.Record review of the facility's new employee training acknowledgement, not dated, revealed New Hire LMS Training is due within the first 21 days of your start date. A policy addressing annual employee trainings was requested from the Operations Manager and DON on 05/20/2026 at 2:15 PM and again on 05/20/2026 at 4:51 PM but was not provided prior to exit.

Based on interviews and record reviews, the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for one (1) of two (2) residents (Resident #78) reviewed for clinical records. The facility failed to ensure Resident #78's wound care treatments were accurately documented on her Treatment Administration Records for 14 of 222 scheduled wound care treatments from 12/22/2025 to 05/18/2026. This failure could place residents at risk of not receiving the care and services needed due to inaccurate or incomplete clinical records. The findings included: Record review of Resident #78's Face Sheet, dated 05/18/2026, reflected a [AGE] year-old female. She was initially admitted to the facility on [DATE] and re-admitted on [DATE]. Record review of Resident #78's Medical Diagnosis, undated and accessed 05/18/2026 at 03:16 p.m., revealed a diagnoses of type 2 diabetes mellitus (a condition that develops with the way the body regulates and uses sugar as fuel) with diabetic peripheral angiopathy (narrowing of the peripheral arteries due to diabetes that lowers blood supply), atherosclerosis (the gradual buildup of fat and other substances in the arteries, leading to narrowed arteries and reduced blood flow) of native arteries of extremities (arms and legs) with rest pain, right leg, chronic venous hypertension (a condition where high pressure in the leg veins disrupts normal blood flow) [idiopathic (a condition that arises spontaneously or without an identifiable cause)] with ulcer (a lesion or sore on the skin) of left lower extremity, and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). Record review of Resident #78's Modification of Quarterly MDS, dated [DATE], revealed Resident #78 had a BIMS score of 15, which indicated she was cognitively intact. She had range of motion impairment on both sides of her upper extremities and one side of her lower extremities. She required supervision or touching assistance with rolling left and right in bed, transitioning from sitting to standing, transferring from chair/bed-to chair, and walking 10 feet. She was documented as at risk for developing pressure ulcers/injuries, did not have a pressure ulcer/injury, and had diabetic foot ulcer(s) and surgical wound(s). She received application of dressings to feet (with or without topical medications). Record review of Resident #78's Order Summary Report, dated 05/18/2026, revealed two (2) active wound care orders as of 05/18/2026. Wound care orders noted included:- DFU right 3rd toe-cleanse area with NS/WC, pat dry with gauze, apply lodosorb [a gel used to clean and promote healing of wet ulcers and wounds] and cover with dry dressing MWF every day shift every Mon, Wed, Fri, noted as active, order date 04/25/2026, start date 04/27/2026, and no end date.- Surgical incision left foot-cleanse with NS/WC, pat dry with gauze, apply skin prep to area and LOTA every day shift every Mon, Wed, Fri, noted as active, order date 04/25/2026, start date 04/27/2026, and no end date. Record review of Resident #78's Treatment Administration Records, dates reviewed 12/01/2025- 05/18/2026, revealed the following: - Treatment Administration Record, dated 12/01/2025- 12/31/2025, revealed one (1) wound or skin care order with two (2) blanks out of five (5) scheduled treatments. 1) The order, cleanse wound to right 2nd digit with n/s and pat dry paint with betadine [an ointment that kills bacteria, prevents infection, and aides in healing] and cover with dressing one time a day every Mon, Wed, Friday for wound care, was dated 12/22/2025 at 07:48 a.m. and discontinued on 03/16/2026 at 05:49 p.m. The Treatment Administration Record had blanks for two (2) of the five (5) scheduled treatments, 12/24/2025 and 12/26/2025. - Treatment Administration Record, dated 01/01/2026- 01/31/2026, revealed three (3) wound or skin care orders with two (2) blanks out of twenty-four (24) scheduled treatments. 1) An order, APPLY BETADINE TO right TOE. LOTA every day shift, dated 01/26/2026 at 08:47 a.m. and discontinued on 04/13/2026 at 04:17 p.m. The Treatment Administration Record had a blank for one (1) of five (5) scheduled treatments, 01/29/2026. 2) An order, APPLY BETADINE TO RLE TOE. COVER WITH GAUZE AND KERLIX [a medical grade cotton gauze used to pull moisture from the wound] DAILY. every day shift, dated 01/20/2026 at 01:53 p.m. and discontinued on 01/26/2026 at 08:47 a.m. The Treatment Administration Record had a blank for one (1) of six (6) scheduled treatments, 01/29/2026.- Treatment Administration Record, dated 02/01/2026- 02/28/2026, revealed two (2) wound or skin care orders with six (6) blanks out of forty (40) scheduled treatments. 1) An order, APPLY BETADINE TO right TOE. LOTA every day shift, dated 01/26/2026 at 08:47 a.m. and discontinued on 04/13/2026 at 04:17 p.m. The Treatment Administration Record had blanks for four (4) of twenty-eight (28) scheduled treatments, 02/04/2026, 02/05/2026, 02/20/2026, and 02/26/2026. 2) An order, cleanse wound to right 2nd digit with n/s and pat dry paint with betadine and cover with dressing one time a day every Mon, Wed, Friday for wound care, dated 12/22/2025 at 07:48 a.m. and discontinued 03/16/2026 at 05:49 p.m. The Treatment Administration Record had blanks for two (2) of twelve (12) scheduled treatments, 02/04/2026 and 02/20/2026. - Treatment Administration Record, dated 03/01/2026- 03/31/2026, revealed four (4) wound or skin care orders with four (4) blanks out of fifty-nine (59) scheduled treatments. 1) An order, APPLY BETADINE TO right TOE. LOTA every day shift, dated 01/26/2026 at 08:47 a.m. and discontinued on 04/13/2026 at 04:17 p.m. The Treatment Administration Record had blanks for two (2) of thirty-one (31) scheduled treatments, 03/06/2026 and 03/24/2026. 2) An order, cleanse wound to right 2nd digit with n/s and pat dry paint with betadine and cover with dressing one time a day every Mon, Wed, Friday for wound care, dated 12/22/2025 at 07:48 a.m. and discontinued 03/16/2026 at 05:49 p.m. The Treatment Administration Record had a blank for one (1) of seven (7) scheduled treatments, 03/06/2026. 3) An order, cleanse wound to right 3rd digit DFU with n/s then pat dry paint with betadine. Leave open to air. QD one time a day for wound care, dated 03/16/2026 at 05:49 p.m. and discontinued on 04/13/2026 at 04:19 p.m. The Treatment Administration Record had a blank for one (1) of fifteen (15) scheduled treatments, 03/24/2026. During an interview on 05/17/2026 at 10:33 a.m., Resident #78 stated she had a wound and on one or two occasions staff failed to come to provide the scheduled treatment. She stated the facility has since corrected the issue with a new wound care nurse and she has not experienced any missed treatments in the last month. She stated she expected to be discharged soon but did not want any other residents to have to experience a missed wound care treatment. She stated because she had very sensitive skin and had toes amputated in the past, at the time of the missed treatment she worried about the possibility of having to go through an amputation again. She stated she had no current complaints about her wound care. During an interview on 05/20/2026 at 10:02 a.m., RN D identified herself as the wound care nurse. RN D stated she started in the wound care role in early March 2026 but had been working in the facility since July 2024. She stated Resident #78 had chronic wounds. She stated, when she was first oriented to Resident #78 wound care needs, Resident #78 was noted to have a history of reoccurring pressure ulcers to the foot and had a few amputated toes. She stated the wound care treatments scheduled from December 2025 to early March 2026 would have been completed by ADON C, or another nurse if he was not available. She stated she was told at the time of her change in roles by ADON C that some treatments were not signed off because the nurse had put in the incorrect order. She stated she could not state if the treatments ordered were provided or not during that time. She stated for the blank on 03/24/2026, the order was discontinued on the same day, which was possibly why she did not sign off on the treatment order. She stated she was sure that Resident #78 received wound care on 03/24/2026 while at her doctor's office. She stated she recalled ADON C worked on 03/06/2026, as that was his last day, but could not say if the treatment was missed or not documented as administered. She stated it was expected that staff complete orders on time and the administration of the orders are documented timely. She stated Resident #78 had not reported any missing treatment complaints to her. She stated Resident #78 was diabetic and more susceptible for infections due to having poor circulation which could lead to additional amputations. RN D stated missed treatment documentation could affect staff because staff could not state if a treatment was missed or not documented. During an interview on 05/20/2026 at 12:40 p.m., the DON stated she expected staff to sign off on a treatment right after they provide it. She stated during December 2025- March 2026 she had two (2) separate wound care nurses and she was sure Resident #78 was receiving her scheduled wound care because Resident #78 did not have a decline. She stated Resident #78 did not experience a deterioration in her wound. She stated Resident #78's wounds were recurring and because her skin was frail, the staff were careful with her. She stated the staff ran omissions reports to identify any missed treatments administrations and they had identified issues with both prior wound care nurses. She stated following counseling with both wound care nurses; one nurse voluntarily left and the other was dismissed due to poor documentation. She stated the facility changed wound care staffing due to the identified concern. The DON stated she had not received any complaints from Resident #78 or Resident #78's family regarding her wound care since the change in wound care staffing and the wound care nurse practitioner has since said that there have been improvements in Resident #78's wound and wound documentation. The DON stated she expected treatment documentation to be completed in the Treatment Administration Record and that the Treatment Administration Record was the required documentation to show a treatment was provided. She stated the impact of the Treatment Administration Record having a blank was that it could be questioned whether the order was completed or not. During an interview on 05/20/2026 at 02:56 p.m., the Operations Manager stated a blank in the Treatment Administration Record could indicate the treatment was not administered correctly or not administered. She stated the impact of a blank in the Treatment Administration Record was that if staff were not documenting then how could anyone know if the order was administered. Record review of unnamed and undated document, received from Operations Manager on 05/17/2026, revealed a staff listing of eighty-four (84) Nursing staff. ADON C was not listed. Record review of the facility's policy, Section: Documentation, Subject: Charting and Documentation, dated as revised 05/2007 revealed: Policy: The resident's clinical record is a concise account of treatment, care, response to care, signs, symptoms and progress of the resident's condition. Is also necessary to include data needed for identification and communication with family and friends. Complete history of resident and present illness is required under current law and regulations at the time of admission. Rules for charting. 5. Continuous nurse's notes are required on all residents as the necessary arises.

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 6 medication carts (Medication Aide cart for half of C unit and all of D and E unit) reviewed for storage: The facility failed to ensure Resident #118's Dronabinol capsule (a controlled medication prescribed for protein malnutrition and appetite stimulation) was stored appropriately in the 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 #118's face sheet dated 5/19/26 reflected a [AGE] year old male admitted to the facility on [DATE] with diagnoses that included cerebral infarction (a type of stroke that occurs when blood flow to part of the brain is blocked causing brain tissue to die due to lack of oxygen), sepsis (a life-threatening condition that happens when the body has an extreme and harmful response to an infection), and aphasia (a condition that affects a person's ability to communicate, such as from a stroke). Record review of Resident #118's care plan with revision date 5/15/26 reflected the resident had a nutritional problem or potential nutritional problem related to risk for malnutrition with interventions that included to administer medications as ordered and was prescribed Dronabinol.Record review of Resident #118's Order Summary Report dated 5/19/26 reflected the following:- Dronabinol oral capsule, 5 mg, give 1 capsule by mouth two times a day for protein malnourishment, and to stimulate appetite with order date 5/13/26 and no end date.Record review of Resident #118's Medication Administration Record dated May 2026 reflected the resident was scheduled to receive Dronabinol 5 mg at 7:00 a.m., and 3:00 p.m. Resident #118's Medication Administration Record reflected the resident was administered the 7:00 a.m. morning dose of Dronabinol medication on 5/19/26 by the Medication Aide and the evening dose scheduled for 3:00 p.m. was pending.Record review of the Controlled Substance Administration Record for Resident #118's Dronabinol 5 mg capsules with received date 5/16/26 reflected there were 21 capsules left in the medication package and 7 out of 28 doses had been dispensed.During an interview and inspection of the Medication Aide cart for half of C unit and all of D and E unit on 5/19/26 at 3:06 p.m. with the Medication Aide revealed a loose Dronabinol capsule found in a medication cup on the top left drawer. The Medication Aide stated the Dronabinol capsule was a controlled medication and had to be refrigerated and locked in a box in the refrigerator in the medication room. The Medication Aide stated she did not have access to the key to the lock box. The Medication Aide stated LVN E signed out the Dronabinol in the Controlled Substance Administration Record and then gave her the capsule around 40 minutes ago because LVN E believed he would be busy at the time when the Medication Aide needed the capsule for Resident #118. The Medication Aide stated that since the medication was supposed to be refrigerated, she should not have left it in the medication cart. The Medication Aide stated she had administered the morning dose to Resident #118 and was planning on administering the second dose but the State Surveyor walked up on her. During an interview on 5/19/26 at 3:24 p.m., LVN E stated the Medication Aide did not have access to the lock box in the refrigerator in the medication room and stated he provided the Medication Aide with Resident #118's Dronabinol capsule. LVN E stated the Dronabinol capsule was a controlled medication and required refrigeration. LVN E stated that the Medication Aide should not have loose pills in the medication cart, and when the medications are taken out of the package they should be administered immediately otherwise it could cause a drug diversion.During an interview on 5/19/26 at 3:46 p.m., the DON stated there should not be any loose pills in the medication cart because it puts patients at risk for error or missed dosage. The DON stated, at the time the medication is due and pulled from the package it should be administered to the residents.Record review of the facility document titled Medication Access and Storage, undated reflected in part, .It is the policy of this facility to store all drugs and biologicals in locked compartments under proper temperature controls. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.

Based on interview and record review the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and follow a policy to provide pharmacy services in accordance with State and Federal laws or rules of the Drug Enforcement Administration for 1 of 6 Residents (Resident #118) reviewed for pharmacy services.The facility failed to ensure LVN F documented that she provided the Medication Aide a Dronabinol capsule (a controlled medication prescribed for protein malnutrition and appetite stimulation) on the Controlled Substance Administration Record for May 2026 for Resident #118.This deficient practice could put residents at risk of misappropriation and drug diversion.The findings included:Record review of Resident #118's face sheet dated 5/19/26 reflected a [AGE] year old male admitted to the facility on [DATE] with diagnoses that included cerebral infarction (a type of stroke that occurs when blood flow to part of the brain is blocked causing brain tissue to die due to lack of oxygen), sepsis (a life-threatening condition that happens when the body has an extreme and harmful response to an infection), and aphasia (a condition that affects a person's ability to communicate, such as from a stroke). Record review of Resident #118's care plan with revision date 5/15/26 reflected the resident had a nutritional problem or potential nutritional problem related to risk for malnutrition with interventions that included to administer medications as ordered and was prescribed Dronabinol.Record review of Resident #118's Order Summary Report dated 5/19/26 reflected the following:- Dronabinol oral capsule, 5 mg, give 1 capsule by mouth two times a day for protein malnourishment, and to stimulate appetite with order date 5/13/26 and no end date.Record review of Resident #118's Medication Administration Record dated May 2026 reflected the resident was scheduled to receive Dronabinol 5 mg at 7:00 a.m., and 3:00 p.m. Resident #118's Medication Administration Record reflected the resident was administered the 7:00 a.m. morning dose of Dronabinol medication on 5/19/26 by the Medication Aide and the evening dose scheduled for 3:00 p.m. was pending.Record review of the Controlled Substance Administration Record for Resident #118's Dronabinol 5 mg capsules with received date 5/16/26 reflected there were 21 capsules left in the medication package and 7 out of 28 doses had been dispensed.During an interview and inspection of the Medication Aide cart for half of C unit and all of D and E unit on 5/19/26 at 3:06 p.m. with the Medication Aide revealed a loose Dronabinol capsule found in a medication cup on the top left drawer. The Medication Aide stated the Dronabinol capsule was a controlled medication and had to be refrigerated and locked in a box in the refrigerator in the medication room. The Medication Aide stated she did not have access to the key to the lock box. The Medication Aide stated LVN E signed out the Dronabinol in the Controlled Substance Administration Record and then gave her the capsule around 40 minutes ago because LVN E believed he would be busy at the time when the Medication Aide needed the capsule for Resident #118. The Medication Aide stated that since the medication was supposed to be refrigerated, she should not have left it in the medication cart. The Medication Aide stated she had administered the morning dose to Resident #118 and was planning on administering the second dose but the State Surveyor walked up on her. During record review and interview with LVN E and the Medication Aide on 5/19/26 at 3:24 p.m., LVN E stated the Medication Aide did not have access to the key to the lock box in the refrigerator in the medication room and stated he provided the Medication Aide with Resident #118's Dronabinol capsule. LVN E stated the Dronabinol capsule was a controlled medication and required refrigeration. LVN E stated that the Medication Aide should not have loose pills in the medication cart, and when the medications are taken out of the package they should be administered immediately. LVN E stated he signed out Resident #118's Dronabinol capsule on the Controlled Substance Administration Record. Record review of the Controlled Substance Administration Record for Resident #118's Dronabinol reflected there were 21 capsules on the record, but 20 capsules were observed in the blister pack. LVN E stated the Dronabinol medication count was off. The Medication Aide stated LVN F provided her with the Dronabinol morning dose and LVN E provided her with the afternoon dose. LVN E stated there needed to be a system in place to keep track of controlled medications locked in the refrigerator because the Controlled Substance Administration Record could be overlooked since it was not kept with the medication.During an interview on 5/19/26 at 3:46 p.m., the DON stated the Dronabinol medication was a controlled medication that was supposed to be locked and refrigerated. The DON stated, at the time the medication is due and pulled from the package, the Controlled Substance Administration Record should be filled in and the count should match. The DON stated, the Dronabinol is a narcotic, and has to be accounted for, which in this case the count was off. If the count is off, that is a drug diversion, and I would have to report to the State.During an interview on 5/19/26 at 4:40 p.m., LVN F stated only the nurses had access to the lock box in the refrigerator in the medication room. LVN F stated she provided the Medication Aide with the morning dose of Resident #118's Dronabinol medication, a controlled medication, and admitted she had forgotten to sign out the medication in the Controlled Substance Administration Record. LVN F stated, it got busy and she forgot to go back and sign the record. LVN F stated that after a medication is taken from the package it should be documented in the record otherwise there could be potential for drug diversion. LVN F stated, if a drug diversion should occur it would mean either the medication was given to the wrong resident or the resident never received the medication.Record review of the facility document titled Pharmacy Services; Administration and Documentation of Controlled Medications, undated, reflected in part, .It is the policy of this facility to Administer and document-controlled medications in compliance with State and Pharmacy regulations.When a controlled substance is poured for administration, the administering staff will.Document on the narcotic count down sheet provided for each individual substance, the date, time, and signature of the staff member pouring and administering medication.Staff member will correctly indicate the amount poured.and will enter the correct number of remaining medications.Staff will count all narcotics at the beginning and end of each shift and will sign the master list attesting to accuracy of the count.Any and all discrepancies will be reported immediately to the Director of Nursing or Administrator.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 2 of 6 residents (Resident #116 and #10) reviewed for infection control:The facility failed to ensure RN N wore proper PPE while providing indwelling urinary catheter care to Resident #116 who was on EBP status and failed to use appropriate hand hygiene when moving from a clean area to a dirty area when administering medications to Resident #10.These failures could place residents at risk for cross-contamination and infection and could result in illness due to improper care practices. The findings included:1. Record review of Resident #116's face sheet dated 5/19/26 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included urinary tract infection and sepsis (a serious medical condition that happens when the body's response to infection causes widespread inflammation and organ dysfunction).Record review of Resident #116's Order Summary Report dated 5/18/26 reflected the following:- Enhanced Barrier Precautions: PPE required for high resident contact care activities. Indication: Implanted IV access, Foley (urinary catheter) every shift with order date 5/17/26 and no end date.Record review of Resident #116's care plan with revision date 5/17/26 reflected the resident had an indwelling urinary catheter related to neurogenic bladder (condition in which the bladder does not function normally because of problems with the nerves that control urination) with interventions that included monitoring indwelling catheter output every shift and use Enhanced Barrier Precautions.During an observation on 5/18/26 at 1:59 p.m., RN N completed administering Resident #116's intravenous medication, removed his gown and gloves, and then returned to the resident's bedside to empty the resident's indwelling urinary catheter bag. Resident #116 had signage on the doorway which indicated the resident was on EBP status. RN N did not put on a gown when he emptied the resident's indwelling urinary catheter bag filled with urine. RN N made two trips to the resident's bathroom after he emptied the indwelling urinary catheter bag into a bedside urinal. During an interview on 5/18/26 at 2:03 p.m., RN N stated he was supposed to put on a gown when emptying Resident #116's indwelling urinary catheter bag because it protected the resident and RN N from passing an organism that could cause an infection. RN N stated, disposable gowns were kept in the middle of the unit in a linen cart. RN N stated the CNA staff usually checked and emptied the resident's indwelling urinary catheter bag but decided to empty the bag and forgot to put on a gown.2. Record review of Resident #10's face sheet dated 5/19/26 reflected a 61- year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included pneumonia (an infection of the lungs that causes inflammation and fluid or pus buildup in the air sacs of the lungs), dysphagia/oropharyngeal phase (difficulty swallowing; the stages where food or liquid moves from the mouth through the throat toward the esophagus), severe intellectual disabilities, and gastrostomy status (a medical procedure in which an opening is created through the abdomen directly into the stomach usually to provide nutrition, fluids, or medications; feeding tube).Record review of Resident #10's most recent comprehensive MDS assessment dated [DATE] reflected the resident was severely cognitively impaired for daily decision-making skills, had a swallowing disorder, and had a feeding tube.Record review of Resident #10's Order Summary Report dated 5/19/26 reflected the following:- Enteral Feed Order every shift may crush/combine medications for administration if not contraindicated and mix with 4 ounces of water, may use slow push to facilitate consumption with order date 4/2/26 and no end date.Record review of Resident 10's comprehensive care plan with revision date 1/22/25 reflected the resident required a feeding tube related to dysphagia with interventions that included to use Enhanced Barrier Precautions and mix each medication with water then administer via gastrostomy tube.Observation during the medication pass on 5/19/26 at 8:55 a.m. revealed RN N prepared medications for Resident #10 and placed a pair of gloves on a tray with the resident's medications. RN N put on a disposable gown, put on a disposable glove on his left hand, and with his left hand closed Resident #10's bedroom door to provide privacy. RN N then put on a disposable glove to his right hand. RN N, while he continued to use the same disposable gloves, took the resident's bed remote and placed it on the bed, took an empty cup from the tray and moved to the resident's bathroom and turned on the faucet to fill the empty cup with water. RN N, while in Resident #10's bathroom, pulled on the doorknob to the adjoining room to close the door. RN N then returned to Resident #10's bedside and drew the privacy curtain to provide privacy. RN N then turned off the resident's feeding pump, took a large syringe from the plastic sleeve, and pulled back the resident's hospital gown to expose the gastrostomy tube. RN N checked for residual and then administered Resident #10's medications through the gastrostomy tube. During an interview on 5/19/26 at 9:10 a.m., RN N stated, touching Resident #10's personal items with the disposable gloves was considered cross contamination. RN N stated he was unsure about being able to pull up the sleeves on the disposable gown since there was no sanitizer readily available in the room. RN N stated he should have been able to wash his hands before and after glove changes to prevent cross contamination which could result in the resident getting an infection. During an interview on 5/19/26 at 10:41 a.m., the DON stated, not performing hand hygiene or changing gloves after touching multiple personal items in a resident's room was a potential for cross contamination and considered an infection control issue. The DON stated it was her expectation that the staff should be changing their gloves multiple times during a skill, especially after touching resident items such as curtains, doorknobs and a bed remote. The DON stated, the same applied for residents who were on EBP status, which meant following EBP rules and the use of proper PPE. Record review of the facility document titled Infection Control with revision date 4/2025 reflected in part, .It is the policy of this facility to implement infection control measures to prevent the spread of communicable diseases and conditions.Transmission-Based Precautions are the second tier of basic infection control and used in addition to Standard Precautions for patients who are or may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission.Procedure.Standard Precautions are infection prevention practices that apply to the care of all residents, regardless of suspected or confirmed infection or colonization status. They are based on the principle that all blood, body fluids, secretions, and excretions (except sweat) may contain transmissible infectious agents.Standard Precautions include.Proper selection and use of PPE, such as gowns, gloves, facemasks, respirators, and eye protection.Use and type of PPE is based on the predicted staff interaction with residents and the potential for exposure.Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment.Enhanced Barrier Protection (EBP) used in conjunction with standard precautions and expand the use of PPE through the use of gown and gloves during high-contact resident activities.Indwelling medical devices include, but are not limited to.urinary catheters.Record review of the facility document titled Hand Hygiene, with revision date 4/2025 reflected in part, .It is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene, which is one of the most effective measures to prevent the spread of infection.Wash hands with soap and water for the following situations.Before and after direct contact with residents.Before moving from a contaminated body site to a clean body site during resident care; after contact with a resident's intact skin.After contact with objects.in the immediate vicinity of the resident.

Based on interview and record review the facility failed to develop policies and procedures to ensure the resident's medical record included documentation that indicated, at minimum that the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization and influenza immunizations and that the resident either received the pneumococcal immunization and influenza immunizations or did not receive the pneumococcal immunization and influenza immunization due to medical contraindication or refusal for 1 of 10 residents (Resident #10) reviewed for immunizations. The facility failed to ensure Resident #10 had record of receiving education or being offered the pneumococcal vaccine and influenza (flu) vaccine. This failure could cause residents to be vulnerable to preventable diseases and illness.The findings were: Record review of Resident #10's face sheet dated 5/20/2026 revealed a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] with diagnoses which included: severe intellectual disabilities, anxiety disorder and epilepsy unspecified, not intractable with status epilepticus (seizure disorder). Record review of Resident #10's annual MDS assessment dated [DATE] revealed a BIMS score of 00 which indicated a severe cognitive impairment and/or responses that could not be understood. The assessment indicated inattention and disorganized thinking behaviors that were continuously present without rejection of care behaviors. Resident #10's functional status was documented as total dependance on staff for all care and movement. Record review of Resident #10's Care Plan dated 11/01/2023 revealed the resident was PASRR positive with interventions which included: notify physician and responsible party of any changes. A plan of care for impaired cognitive function/dementia or impaired thought processes dated 10/24/2023 with interventions that included: needs supervision/assistance with all decision making. Record review of Resident #10's Flu Vaccine Consent dated 4/18/2024 revealed Resident #10's RP consented to the vaccination in writing. Record review of Resident #10's Pneumovax Vaccine Consent dated 4/18/2024 revealed Resident #10's RP consented to the pneumovax vaccine in writing. Record review of Resident #10's Flu vaccine Consent dated 8/07/2024 revealed Resident #10's RP consented to the vaccine by phone consent witnessed by two staff members. Record review of Resident #10's Pneumococcal Consent dated 8/07/2024 revealed Resident #10's RP consented to the vaccine by phone consent witnessed by two staff members. Record review of Resident #10's Pneumococcal Vaccine Consent dated 3/02/2026 Resident #10's RP consented to the vaccine by phone consent witnessed by two staff members including RN N. Record review of Resident #10's Influenza Vaccine Consent dated 3/02/2026 revealed Resident #10's RP consented to the vaccine by phone consent witnessed by two staff members including RN N. Record review of Resident #10's Immunization Record in PCC revealed: Influenza vaccine refused by Resident #10 on 12/26/2025. Education provided was marked no. There was no evidence the flu vaccine had been offered in 2024 after consents were signed. No evidence that the pneumococcal vaccination was offered or why it was not administered since consents signed in 2024. Record review of Resident #1's Progress Notes dated 12/25/2025-12/27/2025 when the immunization record was marked as refused by resident, revealed no notes on attempts at vaccination for influenza or communication with the RP and/or Physician for direction. During an interview on 5/20/2026 at 11:25 a.m., RN N stated Resident #10's RP had consented to both flu and pneumococcal vaccines in March 2026. RN N stated he was the charge nurse who obtained the consents. He stated the charge nurses obtain consents but do not administer the vaccinations. He stated nursing management was responsible for ensuring vaccinations were administered. RN N stated Resident #10 had behaviors that were difficult including constantly moving with procedures and refusing cooperation. During an interview on 5/20/2026 at 11:40 am the DON stated the Charge Nurses were responsible for giving vaccinations once the consent was obtained. She stated that applied during flu vaccination season that occurred from October to March of every year. She stated she was not sure of Resident #10's age, but she believed he was under the age threshold of 65 for the pneumococcal vaccine. She stated vaccines were important to protect the residents from illness. During an interview on 5/20/2026 at 11:59 am the Infection Preventionist stated she used to be a facility ADON until February 2026. She stated the Charge Nurses obtain consent but either the Charge Nurses or ADONs administered the vaccinations. She stated the flu vaccine was seasonal during flu season. She stated the pneumococcal vaccine was offered to everyone who enters the facility as a resident regardless of age. She stated residents younger than 65 can also benefit if they are susceptible to respiratory infection. She stated she approached Resident #10 three times on 12/26/2025 when she intended to give the flu vaccine. She stated the resident refused and moved his arms around constantly. She stated she was at greater risk for getting an injection injury by continuing to attempt to administer the vaccine. The Infection Preventionist stated Resident #10 refused most touch. She stated she did not reapproach on any other day; she did not notify the RP or MD of his refusal or for coordination of care and marked the vaccine record as resident refused. She stated she was responsible for tracking vaccinations and doing audits but was new to the position of Infection Preventionist. She stated it was important to vaccinate in order to prevent the spread of diseases and illness. https://www.cdc.gov/pneumococcal/hcp/vaccine-recommendations/index.html as viewed on 5/20/2025 revealed pneumococcal vaccine was appropriate for people aged 50 years and up and those with compromised immunologic conditions. Record review of the facility policy titled Pneumococcal Immunization Monitoring and Management-Guideline Policy dated 11/23/2016 revealed: 1. All residents who have no medical contraindication to the pneumococcal vaccine will be offered the pneumococcal vaccine upon admission. Record review of the facility policy titled Immunizations-Residents last revised 4/2025 revealed: 1. Residents will be screened at the time of admission to determine vaccine status and eligibility, using current CDC/ACIP Guidelines, to receive the influenza, pneumococcal, and/or COVID-19 vaccine(s). During an interview on 5/20/2026 at 1:26 pm the DON stated the facility did not have a policy for resident refusals.

Based on interview and record review, the facility failed to provide mandatory effective communications training for 4 (CNA J, CNA K, Activity Director, Operations Manager) of 28 employees reviewed for training, in that: The facility failed to ensure effective communication training was provided to Operations Manager within within 21 days of hire, per facility's training policy. The facility failed to ensure effective communication training was provided to CNA J, CNA K or Activity Director annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. Findings include: Record review of personnel record for Operations Manager revealed hire date of 04/24/2026. Review of the training log provided by human resources revealed no evidence that the Operations Manager completed their initial training of effective communications within 21 days of hire. Record review of personnel record for CNA J revealed hire date of 02/21/2024. Review of the training log for the previous 12 months provided by human resources revealed no evidence that the CNA J completed effective communications training annually. Record review of personnel record for CNA K revealed hire date of 03/10/2023. Review of the training log for the previous 12 months provided by human resources revealed no evidence that the CNA K completed effective communications training annually. Record review of personnel record for Activity Director revealed hire date of 11/04/2024. Review of the training log for the previous 12 months provided by human resources revealed no evidence that the Activity Director completed effective communications training annually. Interview with HR O on 05/20/2026 at 2:15 PM revealed newly hired employees were to complete their new hire training within 21 days of hire. HR O stated new employees signed an agreement at orientation that stated they would complete their training and that it was the employee's responsibility to complete training timely. When asked, HR O did not state how staff not completing their training could affect the residents.A group interview with HR P, DON and Operations Manager on 05/20/2026 at 4:51 PM revealed new employees signed a training agreement in orientation agreeing that they would complete training within 21 days of hire. HR P stated, per facility policy, employees were to complete their training within 21 days of hire or they could be suspended or terminated. DON and Operations Manager stated it was the responsibility of the employees to complete their training on time. DON and Operations Manager stated supervisors were responsible to ensure staff completed training within 21 days and annually. When asked, HR P and Operations Manager stated they were new in their positions and were unaware that staff had not completed their training or how it could affect the residents. DON stated residents could be at risk for poor quality of care by staff not completing their training. Record review of the facility's new employee training acknowledgement, not dated, revealed New Hire LMS Training is due within the first 21 days of your start date. A policy addressing annual employee training was requested from the Operations Manager and DON on 05/20/2026 at 2:15 PM and again on 05/20/2026 at 4:51 PM but was not provided prior to exit.

Based on interview and record review the facility failed to include as part of its QAPI program mandatory training that outlines and informs staff of the elements and goals of it's QAPI program for 2 (CNA J and Operations Manager) of 28 employees reviewed for training requirements. The facility failed to ensure required QAPI training was provided to Operations Manager within 21 days of hire, per facility's training policy. The facility failed to ensure required QAPI training was provided to CNA annually. This failure could place residents at risk of being cared for by staff who have been insufficiently trained. Findings include: Record review of personnel record for Operations Manager revealed hire date of 04/24/2026. Review of the training log provided by human resources revealed no evidence that the Operations Manager completed their initial training of effective communications, resident rights, QAPI program, infection control, behavioral health, HIV, restraint reduction, prevention of falls, or emergency preparedness within 21 days of hire. Record review of personnel record for CNA J revealed hire date of 02/21/2024. Review of the training log for the previous 12 months provided by human resources revealed no evidence that the CNA J completed effective communications, QAPI program, ethics, HIV, restraint reduction, prevention of falls, or emergency preparedness training annually. Interview with HR O on 05/20/2026 at 2:15 PM revealed newly hired employees were to complete their new hire training within 21 days of hire. HR O stated new employees signed an agreement at orientation that stated they would complete their training and that it was the employee's responsibility to complete training timely. When asked, HR O did not state how staff not completing their training could affect the residents.A group interview with HR P, DON and Operations Manager on 05/20/2026 at 4:51 PM revealed new employees signed a training agreement in orientation agreeing that they would complete training within 21 days of hire. HR P stated, per facility policy, employees were to complete their training within 21 days of hire or they could be suspended or terminated. DON and Operations Manager stated it was the responsibility of the employees to complete their training on time. DON and Operations Manager stated supervisors were responsible to ensure staff completed training within 21 days and annually. When asked, HR P and Operations Manager stated they were new in their positions and were unaware that staff had not completed their training or how it could affect the residents. DON stated residents could be at risk for poor quality of care by staff not completing their training. Record review of the facility's new employee training acknowledgement, not dated, revealed New Hire LMS Training is due within the first 21 days of your start date. A policy addressing annual employee training was requested from the Operations Manager and DON on 05/20/2026 at 2:15 PM and again on 05/20/2026 at 4:51 PM but was not provided prior to exit.

Based on interview and record review, the facility failed to provide resident rights training for 1 (Operations Manager) of 28 employees reviewed for training, in that: The facility failed to ensure resident rights training was provided to Operations Manager within 21 days of hire, per facility's training policy. This failure could affect residents and place them at risk of being uninformed due to lack of staff training.Findings include: Record review of personnel record for Operations Manager revealed hire date of 04/24/2026. Review of the training log provided by human resources revealed no evidence that the Operations Manager completed their initial training of resident rights within 21 days of hire. Interview with HR O on 05/20/2026 at 2:15 PM revealed newly hired employees were to complete their new hire training within 21 days of hire. HR O stated new employees signed an agreement at orientation that stated they would complete their training and that it was the employee's responsibility to complete training timely. When asked, HR O did not state how staff not completing their training could affect the residents. A group interview with HR P, DON and Operations Manager on 05/20/2026 at 4:51 PM revealed new employees signed a training agreement in orientation agreeing that they would complete training within 21 days of hire. HR P stated, per facility policy, employees were to complete their training within 21 days of hire or they could be suspended or terminated. DON and Operations Manager stated it was the responsibility of the employees to complete their training on time. DON and Operations Manager stated supervisors were responsible to ensure staff completed training within 21 days and annually. When asked, HR P and Operations Manager stated they were new in their positions and were unaware that staff had not completed their training or how it could affect the residents. DON stated residents could be at risk for poor quality of care by staff not completing their training. Record review of the facility's new employee training acknowledgement, not dated, revealed New Hire LMS Training is due within the first 21 days of your start date. A policy addressing annual employee training was requested from the Operations Manager and DON on 05/20/2026 at 2:15 PM and again on 05/20/2026 at 4:51 PM but was not provided prior to exit.

Based on interview and record review, the facility failed to provide mandatory behavioral health training for 4 of 28 (Dietary Supervisor, Activity Director, Operations Manager, ADON L) employees reviewed for training requirements was completed. The facility failed to ensure behavioral health training was provided to Dietary Supervisor, Operations Manager, or ADON L within 21 days of hire, per facility's training policy. The facility failed to ensure behavioral health training was provided to Activity Director annually. This failure could place residents at risk of being cared for by staff who have been insufficiently trained.The findings include: Record review of personnel record for Dietary Supervisor revealed hire date of 09/05/2025. Review of the training log for the previous 12 months provided by human resources revealed no evidence that the Dietary Supervisor completed their initial training of behavioral health within 21 days of hire. Record review of personnel record for Operations Manager revealed hire date of 04/24/2026. Review of the training log provided by human resources revealed no evidence that the Operations Manager completed their initial training of behavioral health within 21 days of hire. Record review of personnel record for ADON L revealed hire date of 02/18/2026. Review of the training log for the previous 12 months provided by human resources revealed no evidence that ADON L completed behavioral health training within 21 days of hire. Record review of personnel record for Activity Director revealed hire date of 11/04/2024. Review of the training log for the previous 12 months provided by human resources revealed no evidence that the Activity Director completed behavioral health training annually. Interview with HR O on 05/20/2026 at 2:15 PM revealed newly hired employees were to complete their new hire training within 21 days of hire. HR O stated new employees signed an agreement at orientation that stated they would complete their training and that it was the employee's responsibility to complete training timely. When asked, HR O did not state how staff not completing their training could affect the residents.A group interview with HR P, DON and Operations Manager on 05/20/2026 at 4:51 PM revealed new employees signed a training agreement in orientation agreeing that they would complete training within 21 days of hire. HR P stated, per facility policy, employees were to complete their training within 21 days of hire or they could be suspended or terminated. DON and Operations Manager stated it was the responsibility of the employees to complete their training on time. DON and Operations Manager stated supervisors were responsible to ensure staff completed training within 21 days and annually. When asked, HR P and Operations Manager stated they were new in their positions and were unaware that staff had not completed their training or how it could affect the residents. DON stated residents could be at risk for poor quality of care by staff not completing their training. Record review of the facility's new employee training acknowledgement, not dated, revealed New Hire LMS Training is due within the first 21 days of your start date. A policy addressing annual employee training was requested from the Operations Manager and DON on 05/20/2026 at 2:15 PM and again on 05/20/2026 at 4:51 PM but was not provided prior to exit.

Based on interview and record review, the facility failed to ensure CNAs received the required minimum 12 hours annual in-services for 3 of 8 (CNA J, CNA K, CNA M) CNAs reviewed for trainings requirements. The facility failed to provide the required 12 hours of annual training to CNA J, CNA K, and CNA M. This failure could place residents at risk of being cared for by staff who have been insufficiently trained.The findings were: Record review of personnel record for CNA J revealed hire date of 02/21/2024. Review of the training log for the previous 12 months provided by human resources revealed evidence of less than 12 hours per year of required in-service training being provided annually. Record review of personnel record for CNA K revealed hire date of 03/10/2023. Review of the training log for the previous 12 months provided by human resources revealed evidence of less than 12 hours per year of required in-service training being provided annually. Record review of personnel record for CNA M revealed hire date of 08/16/2023. Review of the training log for the previous 12 months provided by human resources r revealed evidence of less than 12 hours per year of required in-service training being provided annually. Interview with HR O on 05/20/2026 at 2:15 PM revealed newly hired employees were to complete their new hire training within 21 days of hire. HR O stated new employees signed an agreement at orientation that stated they would complete their training and that it was the employee's responsibility to complete training timely. When asked, HR O did not state how staff not completing their training could affect the residents.A group interview with HR P, DON and Operations Manager on 05/20/2026 at 4:51 PM revealed new employees signed a training agreement in orientation agreeing that they would complete training within 21 days of hire. HR P stated, per facility policy, employees were to complete their training within 21 days of hire or they could be suspended or terminated. DON and Operations Manager stated it was the responsibility of the employees to complete their training on time. DON and Operations Manager stated supervisors were responsible to ensure staff completed training within 21 days and annually. When asked, HR P and Operations Manager stated they were new in their positions and were unaware that staff had not completed their training or how it could affect the residents. DON stated residents could be at risk for poor quality of care by staff not completing their training. Record review of the facility's new employee training acknowledgement, not dated, revealed New Hire LMS Training is due within the first 21 days of your start date. A policy addressing annual employee training was requested from the Operations Manager and DON on 05/20/2026 at 2:15 PM and again on 05/20/2026 at 4:51 PM but was not provided prior to exit.

Based on interview and record review, the facility failed to provide mandatory ethics training for 2 (CNA J and RN D) of 28 employees reviewed for training, in that: The facility failed to ensure ethics training was provided to CNA J or RN D annually. This failure could place residents at risk of being cared for by staff who have been insufficiently trained.The findings include: Record review of personnel record for CNA J revealed hire date of 02/21/2024. Review of the training log for the previous 12 months provided by human resources revealed no evidence that the CNA J completed ethics training annually. Record review of personnel record for RN D revealed hire date of 07/25/2022. Review of the training log for the previous 12 months provided by human resources revealed no evidence that the RN D completed ethics training annually. Interview with HR O on 05/20/2026 at 2:15 PM revealed newly hired employees were to complete their new hire training within 21 days of hire. HR O stated new employees signed an agreement at orientation that stated they would complete their training and that it was the employee's responsibility to complete training timely. When asked, HR O did not state how staff not completing their training could affect the residents.A group interview with HR P, DON and Operations Manager on 05/20/2026 at 4:51 PM revealed new employees signed a training agreement in orientation agreeing that they would complete training within 21 days of hire. HR P stated, per facility policy, employees were to complete their training within 21 days of hire or they could be suspended or terminated. DON and Operations Manager stated it was the responsibility of the employees to complete their training on time. DON and Operations Manager stated supervisors were responsible to ensure staff completed training within 21 days and annually. When asked, HR P and Operations Manager stated they were new in their positions and were unaware that staff had not completed their training or how it could affect the residents. DON stated residents could be at risk for poor quality of care by staff not completing their training.Record review of the facility's new employee training acknowledgement, not dated, revealed New Hire LMS Training is due within the first 21 days of your start date. A policy addressing annual employee training was requested from the Operations Manager and DON on 05/20/2026 at 2:15 PM and again on 05/20/2026 at 4:51 PM but was not provided prior to exit.

Based on interview and record review, the facility failed to include as part of its infection prevention and control program mandatory training that includes the written standards, policies, and procedures for the program for 2 (Activity Director and Operations Manager) of 28 employees reviewed for training, in that: The facility failed to ensure standards, policies, and procedures for an infection prevention and control program training was provided to Operations Manager within 21 days of hire, per facility's training policy. The facility failed to ensure standards, policies, and procedures for an infection prevention and control program training was provided to Activity Director annually. This failure could place residents at risk of being cared for by staff who have been insufficiently trained.The findings include: Record review of personnel record for Operations Manager revealed hire date of 04/24/2026. Review of the training log provided by human resources revealed no evidence that the Operations Manager completed their initial training in infection control within 21 days of hire. Record review of personnel record for Activity Director revealed hire date of 11/04/2024. Review of the training log for the previous 12 months provided by human resources revealed no evidence that the Activity Director completed infection control training annually. Interview with HR O on 05/20/2026 at 2:15 PM revealed newly hired employees were to complete their new hire training within 21 days of hire. HR O stated new employees signed an agreement at orientation that stated they would complete their training and that it was the employee's responsibility to complete training timely. When asked, HR O did not state how staff not completing their training could affect the residents.A group interview with HR P, DON and Operations Manager on 05/20/2026 at 4:51 PM revealed new employees signed a training agreement in orientation agreeing that they would complete training within 21 days of hire. HR P stated, per facility policy, employees were to complete their training within 21 days of hire or they could be suspended or terminated. DON and Operations Manager stated it was the responsibility of the employees to complete their training on time. DON and Operations Manager stated supervisors were responsible to ensure staff completed training within 21 days and annually. When asked, HR P and Operations Manager stated they were new in their positions and were unaware that staff had not completed their training or how it could affect the residents. DON stated residents could be at risk for poor quality of care by staff not completing their training. Record review of the facility's new employee training acknowledgement, not dated, revealed New Hire LMS Training is due within the first 21 days of your start date. A policy addressing annual employee training was requested from the Operations Manager and DON on 05/20/2026 at 2:15 PM and again on 05/20/2026 at 4:51 PM but was not provided prior to exit.

Based on interview and record review, the facility failed to provide mandatory training on abuse prevention and dementia management training for 1 (RN D) of 28 employees reviewed for training, in that: The facility failed to ensure abuse prevention training was provided to Activity Director annually. The facility failed to ensure dementia management training was provided to RN D annually. This failure could place residents at risk of being cared for by staff who have been insufficiently trained.The findings include: Record review of personnel record for Activity Director revealed hire date of 11/04/2024. Review of the training log for the previous 12 months provided by human resources revealed no evidence that the Activity Director completed abuse prevention training annually. Record review of personnel record for RN D revealed hire date of 07/25/2022. Review of the training log for the previous 12 months provided by human resources revealed no evidence that the RN D completed dementia management training annually. Interview with HR O on 05/20/2026 at 2:15 PM revealed newly hired employees were to complete their new hire training within 21 days of hire. HR O stated new employees signed an agreement at orientation that stated they would complete their training and that it was the employee's responsibility to complete training timely. When asked, HR O did not state how staff not completing their training could affect the residents.A group interview with HR P, DON and Operations Manager on 05/20/2026 at 4:51 PM revealed new employees signed a training agreement in orientation agreeing that they would complete training within 21 days of hire. HR P stated, per facility policy, employees were to complete their training within 21 days of hire or they could be suspended or terminated. DON and Operations Manager stated it was the responsibility of the employees to complete their training on time. DON and Operations Manager stated supervisors were responsible to ensure staff completed training within 21 days and annually. When asked, HR P and Operations Manager stated they were new in their positions and were unaware that staff had not completed their training or how it could affect the residents. DON stated residents could be at risk for poor quality of care by staff not completing their training. Record review of the facility's new employee training acknowledgement, not dated, revealed New Hire LMS Training is due within the first 21 days of your start date. A policy addressing annual employee training was requested from the Operations Manager and DON on 05/20/2026 at 2:15 PM and again on 05/20/2026 at 4:51 PM but was not provided prior to exit.

Based on observation, interview, and record review, the facility failed to ensure that residents received care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers for 1 of 2 residents (Resident #1) reviewed for monitoring of applied knee immobilizers. The facility failed to develop and implement supports and monitoring systems for Resident #1's need for a right knee immobilizer, and the resident developed skin breakdown underneath the knee immobilizer. This failure could place residents at risk for injuries from unmonitored orthotic devices. The findings include:A record review of Resident #1's admission record dated 3/18/2026, revealed an admission date of 2/2/2026 with a diagnosis of aftercare for orthopedic encounter. A record review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 was an [AGE] year-old female admitted for long term care with ADL supports with a fragile right knee capable of dislocation and supported with an immobilizer. Resident #1 was assessed with a BIMS score of 13 out of a possible of 15 which indicated no cognitive impairment. Resident #1 was assessed with her pressure ulcer located on her right heel and no other skin breakdown. A record review of Resident #1's physician's orders dated 2/18/2026 through 3/19/2026 revealed no orders for Resident #1's right knee immobilizer specifying any care instructions for the knee immobilizer, no orders for monitoring the knee immobilizer for appropriate fit, no orders for monitoring the skin under and around the knee immobilizer. A single order was given on 2/18/2026, 16 days after Resident #1 was admitted with the knee immobilizer, which called for a right knee immobilizer applied to restrict movement for Resident #1's right knee. No orders were revealed for the new skin breakdown assessment on 3/5/2026. A record review of Resident #1's March 2026 medication administration records revealed no evidence for any monitoring of Resident #1's right knee immobilizer; no evidence of wound care to the newly identified wounds on 3/5/3036 until 3/14/2026. A record review of Resident #1's care plan dated 3/18/2026 revealed no focus, no goals, and no interventions for Resident #1's right knee immobilizer. A record review of Resident #1's nursing progress notes revealed LVN A documented on 2/2/2026 at 1:09 PM that Resident #1 had a right knee immobilizer, .Resident has an immobilizer to right knee. No concerns at this time. A record review of Resident #1's weekly skin assessments revealed LVN G had assessed Resident #1 on:- 2/12/2026 as not having a brace when Resident had a right knee brace and no assessment of her skin under the immobilizer and had a right heel pressure ulcer.- 2/19/2026 as not having a brace when Resident had a right knee brace and no assessment of her skin under the immobilizer and had a right heel pressure ulcer.- 2/26/2026 as not having a brace when Resident had a right knee brace and no assessment of her skin under the immobilizer and had a right heel pressure ulcer. A record review of Resident #1's skin assessments revealed on 3/5/2026 LVN G assessed Resident #1 with 2 new skin breakdown areas on her right thigh one measuring 5cm x 2 cm and the other measured 6cm x 2 cm and LVN G described them as Excoriation sic[the act of abrading, scratching, or wearing off the skin, resulting in raw, irritated, or damaged] from neoprene of brace rubbing at edge of brace. During an observation and interview on 3/18/2026 at 10:10 AM revealed Resident #1 was in her room in bed watching television. Resident #1 stated she had a bad right knee which gave out on her and she fell in her home sometime in the fall of 2025. Resident #1 stated she had been admitted to the nursing home to help her regain ability to stand however her right knee began to swell and the physician transferred her to the hospital where an orthopedic surgeon had reset her knee and gave her a knee brace so her knee would not dislocate. Resident #1 stated the staff would sometimes give her a bed bath and other times would wrap her right knee in plastic and move her to a shower bed for bathing. Resident #1 stated no staff had removed her brace to check her skin, no staff had removed her brace, no staff had washed her brace. Resident #1 stated she did not believe the staff knew how to care for her brace and thus was reluctant to allow them to remove or check the brace. Resident #1 stated she had become concerned for the brace and her skin and swelling because the brace began to develop a foul smell. Resident #1 stated on 3/10/2026 her Representative brought a knee brace from her home and replaced the dirty smelly brace with the brace from home which wore currently. Resident #1 stated she had developed some wounds to her right thigh under the brace which she could not see but knew because she was receiving wound care from the nurse and doctor. An observation of any possible wounds under Resident #1's knee immobilizer was not made at the time of the interview. During an interview on 3/18/2026 At 5:14 PM CNA B stated she was the CNA for Resident #1 and recalled Resident #1 had a right knee immobilizer. CNA B stated she had no instructions on her CNA care plan which could guide CNAs on how to provide ADL for Resident #1's brace. CNA B stated she used common sense and did not remove Resident #1's brace and if she would bathe Resident #1 she would wrap the brace so as not to get it wet. During an interview on 3/19/2026 at 10:09 AM with Dr. C and Dr. C's Assistant, Medical Assistant D. Dr. C stated regarding Resident #1's knee immobilizer, he expected for the immobilizer to be removed periodically for monitoring skin breakdown prevention; However, during those times the knee should not have weight on the joint and be kept flat extended during hygiene care. Dr C stated the periodic removal of the brace for hygiene and skin assessments could help prevent skin breakdown. Dr C. stated no one from the facility had called to ask for order clarifications. During an interview on 3/19/2026 at 10:55 AM Physician's Assistant E who works under Dr. F stated that her expectation would be when a resident is admitted with an orthotic device such as a knee immobilizer that there should be a report to the physician to request an order for the knee immobilizer and the daily care on how to apply the knee brace and when and how to remove the knee immobilizer. PA E stated the potential negative outcome for failing to have orders and instructions for daily care could be skin breakdown and possible dislocation of the knee joint. PA E stated Resident #1 was non-weight bearing indefinitely and was to have the knee brace on indefinitely but with opportunities to remove the knee brace and assess her skin for possible breakdown, as well as for staff to provide daily hygiene skin care for areas around the knee brace immobilizer. During an Interview on 3/19/2026 at 1:03 PM NP H stated she assessed Resident #1 on 3/9/2026 by removing the right knee immobilizer and assessed Resident #1 with stable skin breakdown on her right thigh most likely from the edges of the right knee immobilizer. NP H stated she had also seen a 2cm circular area of a potentially resolved deep tissue injury underneath the thigh and would follow for resolution. NP H stated she believed the injury was in the process of healing. NP H stated she was concerned for the brace being ill fitted and possibly being applied too tightly and resident could benefit from a larger brace. NP H stated when she assessed Resident #1 again on 3/16/2026 she had on a clean better fitting brace which she learned was supplied and applied by Resident #1's Representative. During an interview on 3/19/2026 at 1:50 PM treatment nurse LVN G stated he began as a treatment nurse on or about 2/2/2026, and when he first assessed Resident #1 he recognized that she was wearing a right-knee brace. LVN G stated he had reviewed Resident #1 weekly for skin assessments and had not removed Resident #1's knee brace because she would not let him, and on 3/5/2026 he had become concerned for the skin underneath the brace and he gained consent from Resident #1 to gently peel back the brace from the edges and that was when he could see the skin breakdown from the edges of the brace and he described the 2 areas as Excoriation from the brace. LVN G stated the brace had developed a smell and Resident #1 continued to not let him remove the entire brace. LVN G stated he documented the findings and reviewed the findings with the IDT team the next day. LVN G stated the plan was for wound care NP H to assess Resident #1 the following Monday 3/9/2026. LVN G stated NP H rounded weekly on Mondays. During a joint interview on 3/19/2026 at 5:25 PM with the Administrator and the DON, the DON stated LVN A had admitted Resident #1 on 2/2/2026 and had a progress note which stated Resident #1 had right knee immobilizer. The DON stated she reviewed Resident #1's records and recognized Resident #1 had no orders or care plan interventions for the knee immobilizer. The DON stated she expected the ADON to have reviewed the right knee immobilizer order and to have called the physician and requested care instruction orders for the right knee immobilizer. The DON stated she expected the ADON to update Resident #1's care plan. The DON was asked if there was any potential negative outcome for not having an order or a care plan for Resident #1's right knee immobilizer and the DON replied, the brace was being monitored. A policy for caring and or monitoring orthotic devices was requested and not provided. The Administrator stated the facility followed HHSC guidelines.

Based on observation, interview, and record review, the facility failed to maintain medical records on each resident that were complete, accurately documented, readily accessible, and systematically organized for 1 of 2 residents (Resident #1) reviewed for accurate records. Resident #1's medical records contained skin assessments which documented Resident #1 had no knee immobilizer. This failure could place residents at risk for inaccurate medical records. The findings include:A record review of Resident #1's admission record dated 3/18/2026, revealed an admission date of 2/2/2026 with a diagnosis of aftercare for orthopedic encounter. A record review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 was an [AGE] year-old female admitted for long term care with ADL supports with a fragile right knee capable of dislocation and supported with an immobilizer. Resident #1 was assessed with a BIMS score of 13 out of a possible of 15 which indicated no cognitive impairment. A record review of Resident #1's physician's orders dated 2/18/2026 revealed the physician prescribed for Resident #1 to have a right knee immobilizer to restrict movement for Resident #1's right knee. A record review of Resident #1's nursing progress notes revealed LVN A documented on 2/2/2026 at 1:09 PM that Resident #1 had a right knee immobilizer, .Resident has an immobilizer to right knee. No concerns at this time. A record review of Resident #1's weekly skin assessments revealed LVN G had assessed Resident #1 on:2/12/2026 as not having a brace when Resident had a right knee brace.2/19/2026 as not having a brace when Resident had a right knee brace.2/26/2026 as not having a brace when Resident had a right knee brace. During an observation and interview on 3/18/2026 at 10:10 AM revealed Resident #1 was in her room in bed watching television. Resident #1 stated she had a bad right knee which gave out on her and she fell in her home sometime in the fall of 2025. Resident #1 stated she had been admitted to the nursing home to help her regain ability to stand however her right knee began to swell and the physician transferred her to the hospital where an orthopedic surgeon had reset her knee and gave her a knee brace so her knee would not dislocate. During an interview on 3/18/2026 At 5:14 PM CNA B stated she was the CNA for Resident #1 and recalled resident #1 had a right knee immobilizer. During an interview on 3/19/2026 at 1:50 PM treatment nurse LVN G stated as a treatment nurse on or about 2/2/2026, and when he first assessed Resident #1 he recognized that she was wearing a right-knee brace. LVN G stated he had reviewed Resident #1 weekly for skin assessments and was unaware that he had documented on some of those assessments that Resident #1 had no brace. LVN G stated the error was an oversight and could potentially have a negative outcome of an inaccurate record. During an interview with the DON on 3/18/2026 at 5:25 PM the DON stated the expectation was for all staff to have accurate documentation. A record review of the facility's undated Medical Records policy revealed, It is the policy of this facility to ensure every resident has an accurate record.

Based on observations, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment, for 1 of 2 residents (Resident #1) reviewed for a care plan. The facility failed to develop and implement a care plan for Resident #1's physician prescribed right knee immobilizer. This failure could place residents at risk of not having care instructions for orthopedic appliances. The findings include:A record review of Resident #1's admission record dated 3/18/2026, revealed an admission date of 2/2/2026 with a diagnosis of aftercare for orthopedic encounter. A record review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 was an [AGE] year-old female admitted for long term care with ADL supports with a fragile right knee capable of dislocation and supported with an immobilizer. Resident #1 was assessed with a BIMS score of 13 out of a possible of 15 which indicated no cognitive impairment. A record review of Resident #1's physician's orders dated 2/18/2026 revealed the physician prescribed for Resident #1 to have a right knee immobilizer to restrict movement for Resident #1's right knee. A record review of Resident #1's care plan dated 3/18/2026 revealed no focus, no goals, and no interventions for Resident #1's right knee immobilizer. A record review of Resident #1's nursing progress notes revealed LVN A documented on 2/2/2026 at 1:09 PM that Resident #1 had a right knee immobilizer, .Resident has an immobilizer to right knee. No concerns at this time. During an observation and interview on 3/18/2026 at 10:10 AM revealed Resident #1 was in her room in bed watching television. Resident #1 stated she had a bad right knee which gave out on her and she fell in her home sometime in the fall of 2025. Resident #1 stated she had been admitted to the nursing home to help her regain ability to stand however her right knee began to swell and the physician transferred her to the hospital where an orthopedic surgeon had reset her knee and gave her a knee brace so her knee would not dislocate. Resident #1 stated the staff would sometimes give her a bed bath and other times would wrap her right knee in plastic and move her to a shower bed for bathing. Resident #1 stated no staff had removed her brace to check her skin, no staff had removed her brace, no staff had washed her brace. Resident #1 stated she did not believe the staff knew how to care for her brace and thus was reluctant to allow them to remove or check the brace. Resident #1 stated she had become concerned for the brace and her skin and swelling because the brace began to develop a foul smell. Resident #1 stated on 3/10/2026 her Representative brought a knee brace from her home and replaced the dirty smelly brace with the brace from home which she currently wore . During an interview on 3/18/2026 At 5:14 PM CNA B stated she was the CNA for Resident #1 and recalled Resident #1 had a right knee immobilizer. CNA B stated she had no instructions on her CNA care plan which could guide CNAs on how to provide ADL for Resident #1's brace. CNA B stated she used common sense and did not remove Resident #1's brace and if she would bathe Resident #1 she would wrap the brace so as not to get it wet. During an interview on 3/19/2026 at 10:09 AM with Dr. C and Dr. C's Assistant, Medical Assistant D, Dr. C stated regarding Resident #1's knee immobilizer, he expected for the immobilizer to be removed periodically for skin breakdown prevention; However during those times the knee should not have weight on the joint and be kept flat extended during hygiene care. Dr C stated the periodic removal of the brace for hygiene and skin assessments could help prevent skin breakdown. Dr C. stated no one from the facility had called to ask for order clarifications. During an interview on 3/19/2026 at 10:55 AM Physician's Assistant E who works under Dr. F stated that her expectation would be when a resident is admitted with an orthotic device such as a knee immobilizer that there should be a report to the physician to request an order for the knee immobilizer and the daily care on how to apply the knee brace and when and how to remove the knee immobilizer. PA E stated the potential negative outcome for failing to have orders and instructions for daily care could be skin breakdown and possible dislocation of the knee joint. PA E stated Resident #1 was non-weight bearing indefinitely and was to have the knee brace on indefinitely but with opportunities to remove the knee brace and assess her skin for possible breakdown, as well as for staff to provide daily hygiene skin care for areas around the knee brace immobilizer. During an interview on 3/18/2026 at 5:25 PM the DON stated LVN A had admitted Resident #1 on 2/2/2026 and had a progress note which stated Resident #1 had right knee immobilizer. The DON stated she reviewed Resident #1's records and recognized Resident #1 had no orders or care plan interventions for the knee immobilizer. The DON stated she expected the ADON to have reviewed the right knee immobilizer order and to have called the physician and requested care instruction orders for the right knee immobilizer. The DON stated she expected the ADON to update Resident #1's care plan. The DON was asked if there was any potential negative outcome for not having an order or a care plan for Resident #1's right knee immobilizer and the DON replied, the brace was being monitored. A record review of the facility's undated Care Plan policy revealed, It is the policy of this facility that the interdisciplinary team shall develop a comprehensive person centered care plan for each resident that includes measurable objectives and time frames to meet a residents' medical, nursing, mental, and psychosocial, needs that are identified in the comprehensive assessment. The interdisciplinary team will also develop and implement a baseline care plan for each resident within 48 hours of admission that includes minimum health care information necessary to properly care for each resident and instructions needed to provide effective and person-centered care the meat professional standards of quality care.

Based on interview and record review, the facility failed to ensure, based on the comprehensive assessment of a resident, residents received treatment and care and services in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 13 residents (Resident #7) reviewed for quality of care. The facility failed to ensure Resident #7 received care and services according to professional standards when Resident #7, who was on blood thinners, fell before noon on [DATE] and received orders for monitoring and neuro checks. The last neuro check was completed at 2:45 a.m. on [DATE]. Resident #7 was last seen at 4:30 a.m. on [DATE]. Resident #7 was found unresponsive at approximately 7:20 a.m., with EMS services activated at 7:28 a.m. on [DATE] and she expired. This failure resulted in the identification of an Immediate Jeopardy (IJ) on [DATE] at 4:14 p.m. The IJ template was provided to the facility on [DATE] at 4:24 p.m. While the IJ was removed on [DATE] the facility remained out of compliance with a scope identified at isolated and a severity level of potential for more than minimal harm because the facility needed to monitor the implementation of the plan of removal. This failure could place residents at risk of not receiving care and services needed to meet their needs and could result in a decline in health and/or death. The findings included: Record review of Resident #7's face sheet dated [DATE] revealed a [AGE] year-old female admitted on [DATE] with diagnoses which included: hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (stroke affecting the right side), gout (a type of arthritis affecting one or more joints with sudden attacks of severe pain and swelling), and hypertension (high blood pressure). She expired on [DATE] at 7:40 a.m. and was discharged to a funeral home. Record review of Resident #7's quarterly MDS assessment dated [DATE] revealed a BIMSs score of 13 which indicated she was cognitively intact with no symptoms of delirium or behavior symptoms. Her functional status for toileting was listed as substantial/maximal assistance where the helper did more than half of the effort. Her chair/bed-to-chair transfer assistance was listed as partial/moderate assistance where the helper did less than half of the effort. Record review of Resident #7's care plan initiated on [DATE] revealed she was at risk for falls with interventions to be sure her call light was within reach and encourage her to use it to call for assistance as needed. Record review of Resident #7's care plan initiated on [DATE] revealed she had an ADL self-care performance deficit related to generalized weakness with interventions to include: required one-person minimal assistance with transferring. Record review of Resident #7's care plan initiated on [DATE] revealed she had elected Full code Status with interventions to include: initiate full code measures in case of cardiac arrest, to include CPR and AED use. Record review of Resident #7's Order Summary Report for [DATE] revealed the following orders:-aspirin oral tablet chewable 81 mg-give one tablet by mouth one time a day for heart health. (aspirin - an antiplatelet medication which increased bleeding risk).-Clopidogrel Bisulfate (Plavix- antiplatelet medication used to prevent blood clots to reduce risk for heart attack and stroke and increases bleeding risk) oral tablet 75 mg, give one tablet by mouth one time a day for blood thinner with a start date of [DATE]. -Monitor and report to MD immediately any signs and symptoms of unusual bleeding, pale skin, weakness, black/tarry stools, head injury related to fall/trauma with a start date of [DATE]. Record review of Resident #7's progress notes revealed: -[DATE] 12:36 p.m.-Resident on day 1 of 3 fall follow up. Vitals WNL, no visible injuries noted at this time. Resident in wheelchair, call bell in reach. Documented by LVN C. There were no notes on the actual fall or interventions post fall. -[DATE] at 12:42 pm SBAR Summary to Providers: documented below. No orders documented. No interventions documented. The note indicated Resident #7 was an anticoagulant. Documented by LVN C. -[DATE] at 9:21 p.m. Resident #7 was quietly resting in bed during afternoon, she was not trying to get out of bed without assistance, denies pain/discomfort, pain in low position, call light in reach. Will continue to monitor. Documented by LVN D-[DATE] at 7:20 a.m. Change of Condition: Unresponsiveness. Documented by LVN B and ADON I. Record review of a facility fall incident report for Resident #7 dated [DATE]-25 at 12:00 p.m., documented by LVN C revealed the resident was observed on the floor in the restroom in between commode and sink. Resident #7's description of events included: I thought I heard someone say go ahead and stand up, so I was going to get on commode. I bumped my head on toilet and my arms. I don't have no bumps (sic), but my arms were hurting already. Immediate Action Taken: Resident assessed at this time, no visible injuries noted this shift, no bumps to back of head. Call placed to (physician's office) spoke with (RN at physician's office) at this time who stated to follow protocol. (LVN C) advised resident on aspirin 81 mg and had started a new medication buspirone (anti-anxiety medication). RN at physician's office stated if resident had any changes to call back. No injuries observed at time of incident. Predisposition situation factors: recent room change. Record review of Resident #7's SBAR Communication Form dated [DATE] and completed by LVN C indicated Resident #7 was on an anticoagulant medication (not specified) and had a fall. The Resident/Patient Evaluation (assessment) LVN C marked no changes in mental evaluation. LVN C marked not clinically applicable to the change of condition reported to behavior, respiratory, cardiovascular, skin evaluation, pain evaluation and neurological evaluation. Notification to the physician office RN was documented at [DATE] at 12:00 p.m. with check marks in other with note na (not applicable) x 2. No physician orders or feedback was documented. Further review revealed the time of the fall was not documented and there were no interventions documented on this form. Record review of Resident #7's Neurological Assessment Flow Sheet dated 10/02-10/03 (2025) revealed the last neurological assessment was completed on [DATE] at 2:45 a.m. without any documented abnormalities. The next neurological assessment due 4 hours later at 6:45 a.m. was missing from the documentation (in error) and a handwritten note: deceased was written and labeled 6-2 (6 am-2 pm to indicate an assessment due during that time frame). The assessment due at 6:45 am was not marked on the form. Record review of a local police department Incident Detail Report dated [DATE] revealed the first call to 911 was made on [DATE] at 7:28 a.m. for Resident #7 described as a [AGE] year-old female, full code status, CPR in progress. at 7:42 p.m., Resident #7 was pronounced and marked as DOA (dead on arrival). Resident #7 was found by CNA A and RN B estimated at approximately 7:10 a.m. with last wellness check at 4:00 a.m. as reported to EMS personnel. Record review of a police report dated [DATE] revealed local police responded to a DOA at 7:42 am. Police contacted the Medical Examiner's office for an apparent sudden death. The Medical Examiner's office released the body to jurisdiction and staff notified the funeral home. During an interview on [DATE] at 10:12 a.m., CNA A stated on [DATE] at almost lunch time as part of her daily routine, she was going to change Resident #7. She stated she told the resident she was going to get supplies and left her seated in the wheelchair beside the bed. CNA A stated when she returned approximately 5 minutes later, she found Resident #7 on the ground in the bathroom between the toilet and the sink, trying to get up. CNA A stated she asked Resident #7 what happened, and the resident stated she thought she could get up and go (to the toilet). CNA A stated Resident #7 was sometimes continent and sometimes incontinent, and as part of the routine, she would take Resident #7 to the toilet. She stated the resident stood and helped, and could tell her what she needed, but did not walk and used a wheelchair. CNA A stated she called the nurse, LVN C, right away. She stated Resident #7 was still on the floor when the nurse arrived. CNA A stated she thought Resident #7 said she hit the back of her head and it was hurting although she did not see any injuries. CNA A stated she last saw Resident #7 seated in a chair totally fine at the end of the shift. She stated her shift ended at 2:00 p.m. She stated her relief (unknown name) did not show up, so she had no relief. She stated she told the nurse (unknown) she was leaving and left. She stated she did not give report to the oncoming shift or do rounds. CNA A stated on [DATE], her shift started at 6 a.m., but she got to the facility late and did not get a report. She stated she arrived at approximately 6:15-6:20 a.m. She stated she started her rounds and went to Resident #7's room and did not see the resident. CNA A stated because she knew she had the fall the previous day, she thought the resident had probably gone to the hospital, so she continued working. CNA A stated after she got all the other residents up for breakfast, she was just checking rooms as part of her routine. She stated she came to a room that was dark. She later found out Resident #7 had been moved to a new room. She stated the lights were all off, so she turned the light on. She stated she noticed Resident #7 was pale. She stated she did not see any injuries on Resident #7. She stated she tried to wake up Resident #7 and there was no response. She stated she immediately told RN B, who came right away. CNA A stated she watched RN B complete her assessment, she called for help and then they did CPR right away. CNA A stated RN B did chest compressions. She asked for help and for the crash cart and defibrillator. CNA A stated Resident #7 was on the ground. She stated she was running to get help and getting supplies, and someone called 911. She stated she waited outside for the ambulance. CNA A stated after EMS left, they left Resident #7's body in the building after she was pronounced (dead). She stated they waited for the police. CNA A stated she did not know what happened after that because she had other residents to take care of and was no longer with Resident #7. CNA A stated she had received fall prevention training on the computer system after she was hired (unknown time frame). During an interview on [DATE] at 10:47 a.m., RN B stated on [DATE] she worked the 6 a.m.-2 p.m. shift. She stated she was late to work and made arrangements to come in late, approximately 6:35 a.m. She stated when she arrived, the night shift nurse LVN F was still there and had given her a report. She stated LVN F had told her Resident #7 had a fall. She stated she was aware there were neuro checks but could not remember when the next neuro check was due. She stated she just remembered it wasn't due yet. She stated it was reported there had been no changes in her neuro status and she had been sleeping (during the night). RN B stated her assignment was two hallways, D and E. She stated she started working on hallway E, while Resident #7 was located on hallway E. RN B stated while working on hallway E, she was called and told Resident #7 was unresponsive. She stated she asked for the resident's code status and crash cart. She stated she was told she had full code. She stated when she arrived Resident #7 was unresponsive. She appeared to be sleeping with her arms resting on her abdomen. She was not breathing, there was no chest movement, and she was not reacting to stimuli. She stated she completed an assessment, checked for a pulse, looked for chest rise and fall and opened her eye lids. She stated there was no response to her pupils and no signs of life. RN B stated she had a CNA (unknown) to assist getting Resident #7 to the floor where three staff members took turns doing compressions and using the Ambu bag. She stated the AED was placed on the resident, but EMS arrived and took over before it was fully utilized. RN B stated Resident #7 had recently had a room change because she was not getting along with her roommate. She stated there was no physical altercation and no change of condition. She stated she did not have any other details to the room change. RN B stated she had received fall training on an unknown date and had received abuse/neglect training. She stated she was to report immediately to the Administrator. During an interview on [DATE] at 11:08 a.m., LVN C stated a CNA (unknown) told her Resident #7 fell so she went to assess the resident in the bathroom. She stated she did not see any bruises or injury. She stated Resident #7 told her she was in the wheelchair and thought someone told her to get up. She thought she heard someone say stand up but was unable to say whom. LVN C stated Resident #7 was never put on the toilet. LVN C stated CNA A told her she did not put the resident on the toilet and last saw her in the wheelchair. LVN C stated the resident could self-propel in the wheelchair and ambulate with assistance. She described the resident's cognitive status as alert and oriented and able to make her needs known. LVN C stated the resident had not had any recent decline and no increases in pain. She stated the resident requested tramadol approximately one time a day for shoulder pair reported at level 4-5 (moderate pain). LVN C stated she completed the assessment while Resident #7 was on the floor. She stated she felt her head (for bumps) and looked at her arms and legs. She stated once she assessed she was okay; she had the aides get her up. She stated she did not see any knots on the head or any bruising. LVN C stated she notified the physician's office of the fall. She stated she reported to the RN at the physician's office Resident #7 no knots on the head or bruising and that she hit her head, right in the back. She also reported the resident was on aspirin and had a recent change of medications, buspirone. She stated Plavix (blood thinner) was not sticking in her brain, but she had documented it in the SBAR documentation and believed she had notified the RN since she documented it. LVN C stated she marked the SBAR in error as not clinically insignificant. She stated she did assess for injuries and for pain. She stated the resident was not having any significant pain. LVN C stated the RN at the physician office told her to follow the facility protocol which included neuro checks. She stated she was not aware of any other interventions other than monitoring and did not have a copy of the protocol. She stated the facility protocol for unwitnessed falls was to assess vitals and neuros every 15 minutes then every 30 minutes, etc. on a neuro sheet. She stated she did complete the neuros and the vitals, and there was no change of condition. LVN C stated she could not remember if she passed along the fall information in change of shift. She stated she knew it was a male nurse but did not remember who or how report was given. She stated she had received fall protocol in-servicing on [DATE], prior to this incident. She stated it covered change of condition and documentation. She stated she was trained to notify the Administrator for any abuse or neglect. During an interview on [DATE] at 12:37 p.m., LVN D stated she worked evening shift from 2 pm-10 pm on [DATE]. She stated Resident #7 was alert and oriented. LVN D stated at approximately 8:30 p.m. Resident #7 had gotten into an argument with her roommate. She stated Resident #7 was being aggressive verbally with her roommate and would not calm down, so she moved her to a different room across the hall. LVN D stated Resident #7 had a history of arguing with roommates, so it was not a new thing. She stated it was verbal aggression and nothing physical had occurred. She stated both roommates were lying in bed, but Resident #7 just wouldn't stop; she wanted to fight with her roommate. LVN D stated they tried getting her to stop, she tried to close the curtain, but she declined to go to sleep and kept pulling the curtain over. LVN D stated she asked the roommate not to engage, but she was scared, so she decided to make the room change. LVN D stated after the room change Resident #7 was calm. Another staff member gave her a cinnamon roll, and she was fine, and not angry at all. This was approximately 10:00 p.m. She stated she did not complete an assessment or vitals when Resident #7 was verbally aggressive because when she moved her out of the room, she was calm. She did not notify the physician and did not document the behavior, or the room change because it was not a change of condition, it was just two roommates who were arguing. She stated she was aware of the neuro checks. She stated she didn't know when the fall had occurred but believed the last of the neuro checks were completed on her shift. LVN D stated she knew neuro checks lasted 3 days, so if the last of the neuro checks were on her shift, the resident's fall had to not have been that day. LVN D stated neuro checks were every 15 minutes x 4, every 30 minutes x 4, every one-hour x 4, every four hours x 4 and then every shift x 4. LVN D stated Resident #7 had not had a change of condition during her shift, her vitals and neuro checks had been normal all shift, and she had been calm the rest of the shift and after the room change. She stated at end of shift she gave report to RN UU. During an interview on [DATE] at 1:10 pm with RN UU, there was no answer to phone call. At 3:48 RN UU returned the call and stated, when she came in, she had not gotten report from the evening shift. She stated she could not remember the evening nurse's name, but she had written out a report for her. RN UU stated she was assigned to work on Resident #7's hallway, but she decided to switch the assignments and give the hallway to RN F. RN UU stated the evening shift nurse left before RN F arrived to take the assignment and she did not look at the report because it was not her hallway and just gave it to RN F when he got there. RN UU stated she was not aware of Resident #7's fall or any behaviors. She stated she did see Resident #7 in her room at approximately 9:45 p.m. She stated the resident had asked for a cinnamon roll, so she gave her one and sat with her while she ate it. RN UU stated she spoke to Resident #7 who had a lot of complaints about her roommate. RN UU stated she did not think Resident #7 wanted to share a room and she was trying to get a room to herself, like she had done with a previous roommate. RN UU stated Resident #7's cognition was normal, she was talking normal and having normal conversation, and her cognitive status was normal. RN UU stated the resident was not complaining of pain or a headache. RN UU stated she had no further interactions with the resident and was too busy with her own assignment to pay attention to notice what was going on hallway D during the shift. During an interview on [DATE] at 2:00 p.m., the Treatment Nurse stated on [DATE] at approximately 7:20-7:30 a.m., he heard a code blue called. The Treatment Nurse stated he ran over and saw Resident #7 already on the floor with staff doing chest compressions. He stated he put the AED on which showed no shockable rhythm. He stated staff were rotating chest compressions and bagging until EMS arrived. The Treatment Nurse stated once EMS arrived, they continued to work on Resident #7 before pronouncing her death. He stated Resident #7 had not had a recent noticeable decline. He stated he was not aware of the fall event prior to the CPR event and only learned about it later. The Treatment Nurse stated expectations of staff after an unwitnessed fall included: assessment of the resident, neuro checks, ask the resident if they hit their head or had an injury, and call the MD before sending a resident out (to the hospital) to see if it was okay. He stated to his understanding, the doctor in this case did not want her sent out; just to do neuro checks. The Treatment Nurse stated Resident #7 had a past history of verbal aggression, but he was not aware of any recent behavior changes. During an interview on [DATE] at approximately 1:40 p.m., CNA E stated she worked night shift on [DATE]-[DATE]. She stated during her shift; Resident #7 was her normal self. CNA E stated they had moved Resident #7 to a new room earlier in the day. She said in the evening Resident #7 was eating a cinnamon roll. She stated she did not notice anything different and did not see any injuries. CNA E stated the resident then slept through the night. CNA E stated she last checked on Resident #7 at 4 something in the morning and saw she had respirations. CNA E stated she turned on the light but did not provide any care to the resident. She stated her last rounds during night shift typically occur between 4:15-4:30 a.m. and they were supposed to check on the residents every 2 hours. CNA E stated she did not give a report to the oncoming CNA because she was not there when she left. CNA E stated she was trained to just leave. She stated she told the day shift nurse (unknown) she was leaving. She stated she just said Bye. I am leaving. CNA E stated they were not trained to give report or to do walking rounds. She stated since this incident, they had new training and they were supposed to do walking rounds and report, but that just started. She said they were not doing this when Resident #7 died. During an interview on [DATE] at 2:09 p.m., ADON I stated she was not aware of Resident #7's fall on the date of the incident and did not learn about it until the next day. She stated she learned about it when she checked her fall reports. ADON I stated when she arrived at the facility on [DATE], they were already coding her, in the middle of CPR. She stated 911 had already been notified. ADON I stated the paramedics wanted to know who the last person was who saw her alive. ADON I stated she started making calls to find out. ADON I stated she spoke to RN F and he stated 2:30 a.m. was the last time he saw her and CNA E said 4:15-4:30 a.m. ADON I stated she had no concerns about CPR or how the facility responded. ADON I stated the facility policy for an unwitnessed fall was that no one touched the resident until they were assessed for injuries. If there were no injuries, then staff would help the resident up. ADON I stated the nurse should then notify the physician, check to make sure there were no anticoagulants. She stated if the resident was on anticoagulants, then go to the hospital, even if they say they did not hit their head, as a precautionary measure. ADON I stated there was a written policy and the DON had it. She briefly left the interview and returned saying the DON stated they didn't have the policy. ADON I stated staff were trained to send to the hospital for anticoagulants. She stated she was not aware Resident #7 was on them. ADON I stated Resident #7 had a history of making friends and then fighting with them verbally, and she would call her roommates names. ADON I stated she had been moved out of two other shared room situations. ADON I stated any behavior that was enough to cause a room change should be reported and documented. She stated she did not believe this indicated a behavior change for the resident. She stated it was part of the resident's personality. ADON I stated as part of her duties she reviewed neuro checks every morning. She stated Resident #7 only received two of her every four-hour neuro checks. She stated there was a written discrepancy on the neuro check form where someone mis labeled the times and had omitted the 6:45 am neuro check. ADON I stated Resident #7 should have received a neuro check at 6:45 a.m. on [DATE]. During an interview on [DATE] at 2:29 p.m., a staff member for the resident's physician stated on [DATE] at 12:05 p.m. LVN C notified the office of Resident #7's fall. She stated the responding RN (identified as RN for physician's office), documented she told LVN C to transport Resident #7 to the ER. She stated the physician's office did not receive any other notifications about Resident #7 until the death notice. She stated she was unable to answer any questions about what LVN C told the RN for the physician's office, or whether or not she notified about anti-coagulate usage. She stated that information was in the resident's medical record and was available to their staff. This surveyor left a request to speak with the resident's physician. During an interview on [DATE] at 2:46 p.m., ADON VV stated Resident #7 had a fall the day before she passed. She stated LVN C had reported it to the physician, to herself, and to the DON. She stated she was notified that the doctor gave no new orders. ADON VV stated the next day, she was told the resident had passed, that they had coded her, and the resident was pronounced by EMTs. ADON VV stated LVN C had no complaints, no disciplinary action, and was a wonderful nurse. She stated the facility's policy for falls included: Evaluate-assessment by the nurse. ADON VV stated based on the assessment of a resident, they go from there. If there were any complaints of pain, they would look into it more. She stated they go from there to make sure there are no injuries, no alterations in skin. If there are, the wound nurse gets involved. ADON VV stated neuro checks were put in place for 72 hours. She stated any changes were to be documented and any abnormal findings are reported to the physician to get new orders if needed. ADON VV stated for unwitnessed falls, neuro checks and if the resident was receiving any blood thinners, the resident was to be sent out to the hospital for further evaluation. She stated Plavix was a blood thinner. She stated it was best practice to get a physician order to send out, but in an emergency service, no. ADON VV stated nursing staff were aware of this as they had received in-service training. She stated she was not sure it was part of a written policy, but it was something that was taught. She stated she was not sure why Resident #7 was not sent out to the hospital since she was on anticoagulants. ADON VV stated she did not think much of it, and she suspected everything was fine because she saw Resident #7 moving around in her wheelchair. She stated LVN C had told her she did not get any orders. ADON VV reviewed Resident #7's neuro sheet and stated the next neuro check should have been completed on [DATE] at 6:45 a.m. She stated the night nurse, RN UU assigned to Resident #7, was still there and should have done it. ADON VV stated there were three licensed staff on shift that night. She stated the off-going shift should not leave without giving a hand off report. During an interview on [DATE] at 3:02 p.m., RN F stated he arrived at work late on [DATE] for the 10 pm-6 am shift. He stated he could not remember but thought the evening shift nurse (name unknown) was still there. He stated he was informed Resident #7 had a fall during the day. He stated he completed neuro checks on Resident #7 during the shift. RN F stated she was responsive early in the shift while awake and her vitals were within her baseline and there were no changes during the shift. He stated it was after or around 7:00 a.m. before Resident #7 was found unresponsive. He stated he left before that happened. He stated he had already given report to the oncoming nurse RN B when the 6:45 a.m. shift was due and had not done it. He stated he made RN B aware of the fall and the neuro checks. He stated he could not remember if RN B came to work on time as he was busy with another resident. He stated the last time he saw Resident #7 during the shift was as aware around 4:30-ish a.m. where he looked for risk and fall of the resident's chest. He stated he last checked on the residents during his med pass, although he had not given any meds to Resident #7. RN F stated he coordinated with the CNA (unknown) to check on the residents. He stated they do not turn on lights or wake the residents up. RN F stated he used his cell phone light to look. RN F stated Resident #7 did not show any behaviors or change of condition during the night. He stated he thought they changed her room the previous day because of aggression but did not recall exactly. He stated they last time he saw Resident #7 awake, she was her normal self without any signs of injury. Attempted interview with Resident #7's physician on [DATE] at 3:15 p.m., left voicemail requesting a return call. No phone call was received. During an interview on [DATE] at 3:20 p.m., the DON stated Resident #7 had a fall on [DATE]. The DON stated she was in the facility on the date of the fall but not on [DATE], her date of death , as she worked remotely. The DON stated ADON I was the facility fall preventionist and staff would let her know of any falls, and if there was anything out of the ordinary, ADON I would let her know. The DON stated ADON I did not tell her about it on [DATE]. After the death, she went and saw that Resident #7 had fallen the day before. She stated she reached out to ADON I and the Treatment Nurse who said her neuros were stable. The Medical Examiner came to the facility and released the body to the funeral home. She stated the Medical Examiner's office did not do any autopsy and did not find any foul play. She stated Resident #7's vitals had been stable and her neuros had been stable. They coded her and did everything they could for the resident. The DON stated the facility did not correlate her death to the fall. The DON stated her expectation for an unwitnessed fall was always neuro checks and notification of the family and the physician. She stated if they hit their head, neuros. She stated if there was any deviation in neuros, they should notify the physician. The DON stated she was aware Resident #7 hit her head, and they did neuro checks. She stated for a resident on anti-coagulants they tell the physician and let them decide. The DON said the facility did not have a policy to send the resident out to the hospital. She stated she did not know why some staff thought that was their policy. She said that had not been taught. She stated she had not spoken with Resident #7's physician about her fall or her death but knew he was aware because it was a required notification. The DON stated if LVN C had gotten an order to send out (to the hospital) then she should have sent the resident out, but she was not aware of it. The DON stated she was aware Resident #7 was bickering over TV volume with another resident. She stated a staff member (unknown) had asked if she could move the resident and she said yes. The DON stated that was not something the physician would need to be notified of. She stated they had moved Resident #7 a few times because she would [NAME] with roommates and that was not a change of condition. The DON stated staff had been trained on de-escalation and redirection of residents, fall prevention training, and abuse and neglect (dates unknown). The DON stated this surveyor would need to speak with the Medical Director instead of the resident's physician. During an interview on [DATE] at 4:08 p.m., the Medical Director stated Resident #7's physician was not available and her providers were not allowed to be interviewed unless she was present. She stated she looked through the call center log and they had been notified when the fall happened. She stated they (facility) had been given orders to monitor for neuros. The Medical Director stated the representative for the physician's office notified her (on [DATE]) she incorrectly stated (when interviewed) that there was an order to send the resident out to the hospital. The Medical Director stated she listened to the call (original call on the date of fall) and the RN just gave orders to monitor and do neuro checks and no orders to send to the hospital. The Medical Director stated there was no one-set of professional standards of practice for when a resident had an unwitnessed fall, hit their head, and was on anticoagulants. She stated it would depend on the si[TRUNCATED]

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 6 residents (Resident #1) reviewed for wandering, in that: Resident #1 eloped from the facility, traveled approximately 15 miles away from the facility, and obtained and ingested alcoholic beverages. This deficient practice could place residents at risk of harm, serious injury, or death. The noncompliance was identified as PNC. The IJ began on 5/22/2022 and ended on 5/22/2022. The facility had corrected the noncompliance before the survey began. The findings were: Record review of Resident #1's face sheet, dated 06/04/2022, revealed the resident was admitted to the facility on [DATE] with diagnoses including: [CONDITION(S)] (a condition caused by lack of blood that carries oxygen and nutrient to a part of the brain that causes problems with reasoning, planning, judgement, and memory), alcoholic [CONDITION(S)] of liver (an advanced form of alcohol-induced liver disease), other abnormalities of gait and mobility (an inability to walk in the usual way), other lack of coordination (an inability to control the position of the arms and legs or posture), [CONDITION(S)] disorder (includes all disorders in which an area of the brain is temporarily or permanently affected by ischemia [lack of blood] or bleeding in one or more of the cerebral [brain] blood vessels), [CONDITION(S)] (a comprehension and communication [reading, speaking, or writing] disorder resulting from damage or injury to the specific area in the brain), mixed receptive-expressive language disorder (problem speaking and understanding others), cognitive communication deficit (impaired functioning of one or more cognitive processes [thoughts, perception, information storage or information retrieval], and altered mental status (disruption in how the brain works that causes a change in behavior). Record review of Resident #1's admission MDS, dated [DATE], revealed the resident was rarely/never understood and a staff assessment for mental status was performed. The staff assessment for mental status indicated Resident #1 had short-term and long-term memory problems, severely impaired cognitive skills for daily decision making, and continuously presented with inattention, disorganized thinking, and altered level of consciousness. Further review of Resident #1's admission MDS, dated [DATE], revealed the resident requires assistance from staff for bed mobility (how one moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture), transferring (how one moves between surfaces including to or from: bed, chair, wheelchair, standing position), dressing, toilet use, and personal hygiene (how one maintains personal hygiene, including combing hair, brushing teeth, shaving, washing/drying face and hands). Further review of Resident #1's admission MDS, dated [DATE], revealed the resident's balance during transfers and walking was not steady but he was able to stabilize without staff assistance, and he required assistance from others to complete activities such as planning regular tasks (shopping or remembering to take medication). Further review of Resident #1's admission MDS, dated [DATE], revealed the resident wore a wander/elopement alarm on a daily basis. Record review of Resident #1's care plan, dated 05/01/2022, revealed Resident #1 was At risk for impaired cognitive function/dementia or impaired thought processes and at risk for falls. Record review of, LN-Elopement/Wandering Evaluation-V2, in Resident #1's clinical record, revealed an admitted [DATE] and a completion date of the elopement wandering assessment on 5/3/2022. Resident #1 was assessed at a score of 24, or at high risk for elopement. Record review of Resident #1's physician order, dated 05/03/2022, revealed, Monitor placement and functioning of wander guard QS [every shift] ., and Wander guard to left ankle . Record review of Transition of Care Encounter dated 05/09/2022, in Resident #1's clinical record, revealed the resident was seen by Nurse Practitioner F who noted in her report that the resident was cognitively impaired and wandered. Nurse Practitioner F further noted in the treatment plan for Resident #1 diagnosis of alcoholic [CONDITION(S)], continue alcohol abstinence. Record review of Social Services Summary, dated 05/07/2022 in Resident #1's clinical record revealed, [Resident #1's] thought process is incoherent. He is confused and [family member] reported prior admission to other facilities he was known to wander. His behavior upon this admission reflects that report. Resident has multiple chronic medical conditions and a history of alcohol abuse . A wander guard has been placed on his ankle for safety. [Social] worker will refer to psych [psychiatric] team for dementia eval [evaluation] and testing. Record review of the initial facility report to the State Agency, dated 05/22/2022, revealed, The reporter [Administrator] first learned of the incident on 05/22/2022 at 1:00 p.m. [Resident #1] was last seen on the morning of 05/22/2022. The resident was noted to be missing on 05/22/2022 at 1:00 p.m. The resident does not live in a secure unit. It is unknown what time he left the facility since he did not notify anyone .There were no witnesses to the incident. There was no alleged perpetrator. The family was notified of the incident, the [Resident's family] stated he [Resident #1] had eloped in the past and gave staff a list of locations where he has previously been found. The staff is off site looking for the resident . During an interview with CNA B on 5/23/2022 at 1:45 p.m., CNA B stated he was assigned to work on the resident hall where Resident #1 resided. CNA B reported that Resident #1 was known to frequently wander within the facility. CNA B stated he notified the nurse when Resident #1 could not be located at lunch time. CNA B further reported that the nurse immediately instructed staff members to search the facility and the grounds. During an interview with the Facility Administrator and DON on 05/23/2022 at 9:00 a.m., the Administrator stated he was notified by facility staff that they were unable to locate Resident #1 on 05/22/2022. The Administrator stated that it was unknown exactly when Resident #1 left the facility, but it was believed to be between 10:00 a.m. and 12:30 p.m. The Administrator reported the medication aide on the hallway documented a set of vitals at approximately 10:00 a.m. and Resident #1 could not be found during the lunchtime meal service at approximately 12:30 p.m. Resident #1's family member was contacted, and stated they were not surprised given the resident had a history of elopement from previous placements. The Administrator stated Resident #1's family member provided a list of several locations that the resident was known to frequent. The Administrator stated that he and the DON drove to a store approximately 15 miles from the facility and spoke with the store clerk. The Administrator reported that Resident #1 was known to the clerk, who stated, oh, yes if he [Resident #1] is not in jail or in the hospital, he will be around here by 5:00 or 5:30, drunk as a skunk. The Administrator noted a gentleman resembling Resident #1 was sitting near the store, on a bench at the bus stop and drinking a beer. The Administrator reported that he and the DON approached the man, confirmed it was Resident #1, and requested he return to the facility with them. Resident #1 reportedly refused to do so. The Administrator reported he and the DON continued to attempt to persuade the resident to return to the facility while noting that Resident #1 finished one beer and immediately opened another. The Administrator reported that the resident had become increasingly agitated and was stumbling when he attempted to walk, and that he and the DON were concerned that Resident #1 was going to stumble into the road and become injured. The police were called to assist with Resident #1. The Administrator reported that Resident #1 willing went with a police officer who transported him to the hospital. The police officer reported to the Administrator that Resident #1 was acting erratically, had a strong smell of alcohol, and appeared to be intoxicated. The police office further reported to the Administrator that Resident #1 was admitted to a hospital for observation. The DON stated that the facility was aware that Resident #1's had been homeless prior to his admission to the facility, had an addiction to alcohol, and that Resident #1 had voiced his desire to return to the community. The DON stated Resident #1 had frequently wandered within the facility during his admission, but that there had not been any reports of exit seeking behavior. The DON stated Resident #1 was still wearing his wander guard on his ankle when he was located. The DON stated that no other special monitoring had been in place. During an interview with Receptionist C on 06/04/2022 at 11:08 a.m., Receptionist A reported she worked from 8 a.m. to 5 p.m. every Saturday and Sunday, confirmed her workstation was near the television lounge, and reported she frequently saw Resident #1 watching television in the lounge. Further interview revealed Receptionist A was unaware that the sliding glass door leading from the television lounge to the outside was not alarmed at the time Resident #1 eloped from the facility. During an interview with CMT A on 05/23/2022 at 11:00 a.m., CMT A stated she was responsible for checking all wander guards in use daily (Monday-Friday) to ensure that they were working correctly. CMT A stated she had checked Resident #1's wander guard on Friday, 05/20/2022 and it was working correctly. CMT A further stated the wander guard checks were kept on a log at the nurse's station and the log was reviewed with last check documented on 05/20/2022. CMT A stated Resident #1 was independent and wandered around the facility most of the day. During an interview with LVN D on 06/04/2022 at 10:14 a.m., LVN D reported she was assigned to care for Resident #1 on the day of the elopement incident. LVN D reported the facility procedure regarding residents with wander guard devices is for their respective nurse to check the device placement and ensure functionality of the device at each shift. LVN D stated this procedure is documented on the MAR and confirmed she had checked Resident #1's wander guard device on the day of the elopement incident. Record review of Medication Administration Record, dated 05/22/2022 in Resident #1's clinical record revealed placement and functionality of the resident's wander guard had been documented. Further interview with the Administrator and DON on 05/23/2022 at 9:00 a.m., revealed they reported that they were unsure how Resident #1 exited the building and added that the only door without an alarm at the time of the incident was the sliding glass door leading from the television lounge to the outside. The Administrator stated he directed the Maintenance department to install an alarm on the sliding glass door leading from the television lounge to the outside, following the elopement incident. The DON stated Resident #1 was wearing his wander guard device when he was located away from the facility. During an interview with the Maintenance Director on 06/03/2022 at 5:30 p.m., the Maintenance Director confirmed that at the time Resident #1 eloped from the facility, the sliding glass door leading from the television lounge to the outside was not alarmed, confirmed the Administrator directed him to install an alarm on the sliding door following the elopement incident, confirmed he had done so on the day of Resident #1's elopement, and demonstrated for the Surveyor that the alarm was in working order. Observation on 06/03/2022 at 5:30 p.m. revealed the alarm on the sliding glass door leading from the television lounge to the outside emitted a loud sound when engaged, and four staff members immediately responded to the alarm. Observations on 06/03/2022 between 5:30 p.m. and 5:45 pm, of each door leading from the facility to the outside, revealed each door was alarmed and each alarm was in working order. The Maintenance Director accompanied the Surveyor in a tour of the facility and demonstrated that each alarm was in working order. During an interview with the DON on 06/03/2022 at 5:15 p.m., the DON reported that Resident #1 no longer resided at the facility. Record review of Discharge Note, dated 05/23/2022 in Resident #1 clinical record, revealed, worker was notified on Sunday 5/22/22 of resident elopement from the building via text message. worker immediately contact his daughter to inform and to see if she could help identify relative addresses and phone numbers in the city and frequent paces he visited while in the community .staff reported this elopement to the police case number given .resident was found. staff reported he [Resident #1] refused to return to the facility. Police was summoned and escorted resident to the hospital for mental health services and safety. worker informed daughter of this development and the need of a lock unit for his safety going forward. During an interview with the DON on 06/03/2022 at 5:45 p.m., the DON reported that two in-service training for staff were developed and presented to staff as a result of the elopement incident. Record review of facility training documentation revealed an in-service titled Possible Missing Resident given by DON on 05/22/2022 and attended by 27 members of staff. Summary: If staff do not locate a resident while passing out meal trays, notify nurse. If staff cannot locate a resident for any reason, notify a nurse. Further review revealed and in-service titled, Elopement Policy and Procedure given by DON on 05/22/2022 and attended by 48 members of staff. Summary: If a resident elopes, a nurse coordinates search from nursing station, medication aides search staff offices, nurses' aides, and other nurses search resident rooms. During an interview with LVN G on 06/04/2022 at 10:14 a.m., LVN G accurately reported that all facility residents who wear a wander-guard device are listed in the wander-guard book located at the central nurses' station and that part of nurse procedure for each shift is to verify placement of the wander-guard for each resident who wears a device. Further interview with LVN G revealed she was able to accurately summarize the facility elopement policy and procedures as noted in the recent in-service, and to describe her role during an elopement incident. During an interview with CNA B on 06/04/2022 at 10:19 a.m., CNA B accurately reported that all facility residents who wear a wander-guard device are listed in the wander-guard book located at the central nurses' station. Further interview with CNA B revealed he was able to accurately summarize the facility elopement policy and procedures as noted in the recent in-service, and to describe his role during an elopement incident. During an interview with Medication Aide H on 06/04/2022 at 10:27 a.m., Medication Aide H accurately reported that all facility residents who wear a wander-guard device are listed in the wander-guard book located at the central nurses' station. Further interview with Medication Aide H revealed she was able to accurately summarize the facility elopement policy and procedures as noted in the recent in-service, and to describe her role during an elopement incident. During an interview with Medication Aide E on 06/04/2022 at 10:32 a.m., Medication Aide E accurately reported that all facility residents who wear a wander-guard device are listed in the wander-guard book located at the central nurses' station. Further interview with Medication Aide H revealed she was able to accurately summarize the facility elopement policy and procedures as noted in the recent in-service, and to describe her role during an elopement incident. During an interview with CNA I on 06/04/2022 at 10:44 a.m., CNA I accurately reported that all facility residents who wear a wander-guard device are listed in the wander-guard book located at the central nurses' station. Further interview with CNA I revealed she was able to accurately summarize the facility elopement policy and procedures as noted in the recent in-service, and to describe her role during an elopement incident. During an interview with LVN J on 06/04/2022 at 10:57 a.m., LVN J accurately reported that all facility residents who wear a wander-guard device are listed in the wander-guard book located at the central nurses' station and that part of nurse procedure for each shift is to verify placement of the wander-guard for each resident who wears a device. Further interview with LVN J revealed she was a temporary staff member from an employment agency and had been orientated to facility-specific elopement policy and procedures, was able to accurately summarize the recent in-service, and to describe her role during an elopement incident. During an interview with CNA K on 06/04/2022 at 11:02 a.m., CNA K accurately reported that all facility residents who wear a wander-guard device are listed in the wander-guard book located at the central nurses' station. Further interview with CNA K revealed she was a temporary staff member from an employment agency and had been orientated to facility-specific elopement policy and procedures, was able to accurately summarize the recent in-service, and to describe her role during an elopement incident. During an interview with LVN L on 06/04/2022 at 1:59 p.m., LVN L accurately reported that all facility residents who wear a wander-guard device are listed in the wander-guard book located at the central nurses' station and that part of nurse procedure for each shift is to verify placement of the wander-guard for each resident who wears a device. Further interview with LVN L revealed she was a temporary staff member from an employment agency and had been orientated to facility-specific elopement policy and procedures, was able to accurately summarize the recent in-service, and to describe her role during an elopement incident. Record review of the facility policy titled, Section: Quality of Care, Subject: Elopement/Unsafe Wandering, revised June 2018, revealed, Standard: This facility is committed to promoting resident autonomy by providing an environment that remains as free of accident hazards as possible. Each resident is assisted in attaining or maintaining their highest practicable level of function through providing the resident adequate supervision and diversional programs to prevent unsafe wandering while maintaining the least restrictive environment for those at risk for elopement.

Based on interview and record review, the facility failed to immediately consult with the resident's physician when there was 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 2 of 21 residents (Residents #1 and #2) reviewed for change of condition, in that: 1. The facility did not notify the physician when Resident #1 had a change in condition. Resident #1 had increased shortness of breath, and increased anxiety on [DATE]. Resident #1 had increased bilateral upper extremities [MEDICAL CONDITION] starting on [DATE]. Resident #1 was transferred to the hospital on [DATE] where she expired on [DATE]. 2. The facility failed to notify Resident #2's physician of the change of condition. On [DATE], Resident #2 was diagnosed with [REDACTED]. On [DATE], Resident #2 required oxygen to maintain oxygen saturation, had an increased breathing effort, had cyanosis (discoloration of skin which signifies low oxygen delivery to tissue), decreased ability to speak in full sentences, abnormal lung sounds and had severe shortness of breath. On [DATE], the resident expired in the facility. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. These deficient practices placed residents who experienced a change of condition at risk for harm, deteriorating health, and/or death. The findings were: 1. Record review of Resident #1's face sheet, dated [DATE] , revealed an admission date of [DATE] and, a readmission date of [DATE], with [DIAGNOSES REDACTED]. Record review of Resident #1's 5-day Admission MDS, dated [DATE], revealed the resident had a BIMS score of 15, which indicated the resident was cognitively intact. Record review of Resident #1's Physician's Progress Note, dated [DATE] by NP D, revealed, COVID positive resident had close, prolonged exposure totaling more than 15 minutes to a COVID positive staff member. Patient is now COVID positive. Continue to monitor respiratory status as patient is at risk for decline with COVID due to being a diabetic and having CKD. Record review of physician orders [REDACTED]. Record review of Resident #1's Care Plan, initialized on [DATE] and last updated [DATE], revealed the resident had hypertension related to [MEDICAL CONDITION] with interventions which included, Monitor for and document any [MEDICAL CONDITION], notify MD. Further review revealed Resident #1 had end stage heart failure with interventions which included, monitor/document/report to MD any signs and symptoms of [MEDICAL CONDITION]: dependent [MEDICAL CONDITION] of legs and feet, periorbital [MEDICAL CONDITION], SOB upon exertion, dry cough, weakness, crackles and wheezes upon auscultation of the lungs. Further review revealed Resident #1 was a full code status and, Promote resident rights by allowing resident to make decisions about advanced directives. Record review of Resident #1's nurses' progress notes revealed: - [DATE] at 6:39 PM written by LVN A: COVID-19 Evaluation for Confirmed COVID-19 diagnosis, vitals all WNL. Resident is on room air, no cough, no SOB. - [DATE] at 5:58 PM written by LVN A: COVID-19 Evaluation for Confirmed COVID-19 diagnosis, vitals are WNL, non-productive cough, cough efficacy fair, Moderate SOB worst with activity and worst while lying flat. There was no evidence the physician was notified. There was no evidence the physician was notified. - [DATE] at 2:05 PM written by LVN A: COVID-19 Evaluation for confirmed COVID-19 diagnosis, respiratory rate 24 (normal ,[DATE]), nonproductive cough, cough efficacy was poor, severe shortness of breath worst with activity and worse while lying flat. Appetite was low, less than half of baseline, fluid intake adequate. Resident had increased mood/behavior episodes than baseline. - [DATE] at 2:23 AM written the DON: Resident complained of shortness of breath, oxygen at 2 LPM via n/c. sats at 99%, repositioned, HOB already elevated, lung sounds clear to all lobes. There was no evidence documented to indicate the physician was notified. - [DATE] at 6:43 AM: COVID-19 evaluation for confirmed COVID-19 diagnosis, vitals WNL, nonproductive cough, mild SOB noted during evaluation, worse with activity and lying flat. Appetite poor resident is refusing most items, fluid intake is low less than 750 cc/day. - [DATE] at 7:01 AM written by LVN A: Received call from family member stating the resident called him complaining that she is SOB and that nobody is doing anything to help her out. Resident stated she is dying and no one is doing anything. Oxygen sats 97%, BP ,[DATE], pulse 65, respiratory rate 21 (normal ,[DATE]). Resident is stable and not in any respiratory distress. Explain to family that SOB is being treated with [MEDICATION NAME] and oxygen at 2 LPM PRN. Resident has been sating ,[DATE]% on oxygen. Family stated he wanted to call 911 and have the resident picked up and sent to the hospital. Pending arrival of EMS. - [DATE] at 6:43 PM written by LVN A: Resident was never picked up from EMS, resident stated she is scared and feels she is dying because she saw news that people are dying of COVID and she will die. Family member notified of EMS not picking up resident and he stated he understands that resident is short of breath and has very good vital signs but is just worried for his family member. Resident in bed stable with no fever or respiratory distress. There was no indication the physician was notified. - [DATE] at 3:27 PM written by LVN A: Reported [MEDICAL CONDITION] 4 plus to left upper extremity and [MEDICAL CONDITION] 3 plus to right upper extremity. Stat chest x-ray, CBC, BMP, BNP, daily weights x 7 days, VS every 4 hours for 24 hours. - [DATE] at 3:43 PM written by LVN A per NP D: Resident to be sent out (to hospital). - [DATE] at 4:48 PM written by LVN A: Resident was picked up by transportation and sent to hospital. Record review of Resident #1's physician progress notes [REDACTED]. shortness of breath: transfer to hospital, feel her SOB is multilateral . anticipate she will need IV [MEDICATION NAME] . Anticipate she will need IV dieresis. During an interview with NP D on [DATE] at 1:30 p.m., NP D stated on [DATE] she was in the facility to assess residents positive for COVID-19. NP D confirmed she had given her approval for transferring Resident #1 to the hospital because she has been told by LVN A that EMS was on the way to the facility. NP D confirmed she gave a verbal order to LVN A to send Resident #1 to the hospital. NP D stated Resident #1 had received fluids to address her lack of fluid intake and [MEDICAL CONDITION]. NP D stated on her [DATE] visit with Resident #1 the resident had [MEDICAL CONDITION] (swelling) in both arms (bilateral upper extremities), and the [MEDICAL CONDITION] was more pronounced on Resident #1's right arm. NP D further stated she received a text on [DATE] from their on-call services which stated the facility had called them for Resident #1's change in condition. NP D stated Resident #1's condition was getting worse and they asked to send the resident out to the hospital. NP D confirmed she gave the order to send out to the hospital, but could not recall receiving any other calls. NP D confirmed she was not called for Resident #1's change of condition prior to her visit to the facility on [DATE]. NP D confirmed she was not called when Resident #1 was not transported to the hospital on [DATE]. NP D stated she would have given different orders if she had been called about Resident #1's change of condition prior to her visit on [DATE]. NP D confirmed she would have given an order to transfer Resident #1 to the hospital even if the family had not made the request. During an interview with LVN A on [DATE] at 4:20 p.m., LVN A confirmed he had been trained to complete a Change of Condition Assessment for a resident change of condition. LVN A confirmed a Change of Condition Assessment had not been completed for Resident #1 until [DATE] when the resident went out to the hospital. LVN A stated on [DATE] a form was started but was incomplete. LVN A stated the Resident #1's family called 911, and the 911 dispatcher called the facility and spoke with LVN A. LVN A stated he informed the 911 dispatcher that Resident #1's vital signs were stable and the resident was not in any distress. LVN A further stated Resident #1 had a lot of anxiety, was always watching the news, and thought she was dying but her vitals were perfect, and she was not in any distress. LVN A stated on [DATE] the family called 911 and requested the resident go to the hospital. LVN A confirmed by 8:00 PM Resident #1 had not been picked up by EMS so LVN A notified the family the resident had not been picked up. LVN A stated on [DATE] NP D visited Resident #1 and noted [MEDICAL CONDITION] to upper extremities and wanted to start medications to help. LVN A stated he told NP D the family had called 911 and NP D stated that was fine and the hospital could work on the resident's issues with [MEDICAL CONDITION]. LVN A further stated when he came to work on [DATE] at 2:00 PM he noted Resident #1 had 4 plus [MEDICAL CONDITION] to upper extremities and called the physician group. LVN A stated NP D was upset EMS had not picked the resident up on [DATE], and further stated NP D, I could have done something about it yesterday. LVN A confirmed Resident #1 expired on [DATE] at the hospital. LVN A stated he notified NP D for each change of condition, but confirmed he had forgotten to document. LVN A stated, honestly, I can't remember if I notified the physician except on [DATE]. LVN A stated he notified the DON on [DATE] that Resident #1's family had requested the resident be sent out to the hospital, and further stated he notified the DON on [DATE] the ambulance had not picked the resident up on [DATE]. LVN A confirmed the DON had asked if NP D knew, and further confirmed he notified NP D after notifying the DON. During an interview with LVN A on [DATE] at 4:30 p.m., LVN A confirmed on [DATE] he had received a verbal order from NP D to send out Resident #1 to the hospital. LVN A confirmed he had not called NP D or the DON when EMS failed to pick Resident #1 up. LVN A stated he gave a report to the incoming nurse (unknown). LVN A stated when he came back to the facility on [DATE] for his shift he found Resident #1 was still in the facility and the resident's [MEDICAL CONDITION] had worsened. LVN A confirmed he called NP D to notify her and received a new order to send Resident #1 to the hospital. During an interview with the DON on [DATE] at 9:28 a.m., the DON confirmed there was not a facility policy or rule for when a staff member should call EMS if EMS failed to show at the facility. The DON stated her expectation for staff was that they called EMS back after 20 minutes. During an interview with LVN R on [DATE] at 10:00 a.m., LVN R confirmed she worked day shift on [DATE] with Resident #1. LVN R stated the night shift nurse (unknown) did not tell her Resident #1 needed to go to the ER, but during the shift change a CAN (unknown) told her the family had called 911. LVN R stated she looked through Resident #1's medical record and noticed a slow decline in blood pressure, and also noted Resident #1 was not eating. LVN R further stated Resident #1 was, very alert, and stated she wanted to go home. LVN R confirmed she did not perform an assessment of Resident #1 and did not notice any swelling. LVN R further stated she did a COVID-19 assessment but it did not include looking for swelling. When asked if she was trained to perform daily assessments on residents, LVN R stated, We just take vitals and the CAN's perform assessments while proving peri-care. LVN R confirmed she did not notify Resident #1's physician about the resident's change of condition, and further confirmed she did not notify the physician the resident had not been sent to the hospital. During an interview with the local fire department on [DATE] at 11:08 a.m., the local fire department stated on [DATE] at approximately 7:00 a.m. they provided a medical consult with LVN A regarding Resident #1. The local fire department stated they did not dispatch an EMS unit to the facility after speaking with LVN A. The details of the conversation with LVN A and the dispatcher were not available. During an interview with Resident #1 family member on [DATE] at 12:18 p.m., Resident #1's family member stated, Resident #1 kept calling family and stating could not breathe and the facility wasn't doing anything to help her. We called an ambulance and the facility refused transport. During an interview with the DON on [DATE] at 2:15 p.m., the DON confirmed NP D was not notified of Resident #1's change of condition prior to NP D's visit on [DATE]. The DON further confirmed NP D was not notified when Resident #1 was not transferred to the hospital on [DATE]. The DON confirmed she was not notified herself of Resident #1's change of condition or that EMS had not picked up Resident #1 on [DATE]. The DON stated when she came at the facility on [DATE] LVN A was on the phone with NP D to notifying NP D that Resident #1 was still at the facility and the resident's condition had worsened. The DON confirmed NP D gave an order to transfer Resident #1 to the hospital. The DON confirmed nurses were supposed notify the physician of any residents' changes of condition immediately. 2. Record review of Resident #2's face sheet, dated [DATE], revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #2's Admission MDS, dated [DATE], revealed the resident had a BIMS score of 6, which indicated the resident was severely cognitively impaired. Further review revealed the resident required extensive assistance of ,[DATE] staff to assist with ADLs. Record review of Resident #2's Care Plan, initiated on [DATE] and last revised on [DATE], revealed Resident #2 was Full Code with interventions which included, initiate CPR upon [MEDICAL CONDITION]. Further review revealed Resident #2 was at risk for signs and symptoms of COVID-19 with interventions which included: observe for signs and symptoms of COVID-19, document and promptly report fever, cough, shortness of breath or difficulty breathing, chills repeated shaking with chills, muscle pain, headache, sore throat, new loss of taste or smell, runny nose, congestion, diarrhea, nausea, vomiting and notify NP/MD if present. On [DATE], Resident #2's Care Plan was updated to include the resident had confirmed COVID-19 and was at risk for severe illness and other complications secondary to cardiovascular disease, diabetes and the residents age, and interventions included: observe for psychosocial and mental status changes, document and report as indicated. Perform clinical evaluation and escalate the monitoring of signs and symptoms. Record review of Resident #2's vital signs revealed: Oxygen saturation (normal ,[DATE]) - [DATE] 4:40 p.m. oxygen saturation 89% on room air with no follow up oxygen reading documented by LVN A. - [DATE] 10:46 a.m. oxygen saturation 88% on room air with no follow up oxygen reading documented by ADON C. - [DATE] 8:02 p.m. oxygen saturation 93% on oxygen (of unknown quantity) via nasal cannula documented by LVN A. - [DATE] 5:03 a.m. (which was after the resident's time of death) oxygen saturation 98% on room air documented by RN B. Respiratory Rate (normal ,[DATE]) - [DATE] 4:39 p.m. respiratory rate (RR) 26 documented by LVN A. - [DATE] 12:39 a.m. RR 24 documented by RN B. - [DATE] 4:04 a.m. RR 24 documented by RN B. - [DATE] 8:57 a.m. RR 22 documented by LVN R. - [DATE] 8:02 p.m. RR 23 documented by LVN A. - [DATE] 4:57 p.m. RR 30 documented after the residents time of death by RN B. Record review of Resident #2's physician progress notes [REDACTED].#2 had new onset of COVID-19 virus with a note that stated the visit took place via telepathy with limited response from patient during assessment; normal baseline. Further review revealed, Patient (Resident #2) is seen and examined via telemedicine with LVN charge nurse assisting. No shortness of breath or chest pain. COVID-19: onset of virus; maintain oxygen saturation . monitor closely for symptom onset . notify NP/MD for changes or concerns. Further review revealed the note was signed by the NP. Record review of Resident #2's chest x-ray, dated [DATE], revealed the x-ray showed a, retrocede infiltrate (pneumonia), and, cardiomegaly (enlarged heart). Record review of Resident #2's Infection Surveillance Form, dated [DATE] at 1:01 p.m., revealed: Resident #2 had an onset of symptoms beginning [DATE] with an acute change in mental status from baseline which included disorganized thinking (thinking incoherent, rambling conversation, unpredictable switches in subject or altered level of consciousness). Surveillance of body systems included: a respiratory tract infection listed as pneumonia from an interpretation of a chest x-ray demonstrating pneumonia or the presence of new infiltrate with a new or increased cough. Further review revealed the resident was listed as COVID-19 positive, and the evaluation was signed by ADON C. Record review of Resident #2's COVID-19 Daily Evaluation (COVID-19 symptom tracker and resident assessment tool), dated [DATE] at 10:43 p.m., revealed: Resident #2 had a confirmed [DIAGNOSES REDACTED]. Resident #2 had a nonproductive cough, fair cough efficacy (ability to cough up secretions), and no increase in breathing effort with abnormal lung sounds which included wheezing on expiration (exhale or breathing out). No shortness of breath was noted during the evaluation. The resident had a poor appetite and was refusing most items and an adequate fluid intake. Resident #2's cognitive status was at baseline. Further review revealed the evaluation marked the current medications and treatments effective in managing resident presentation, and the evaluation was signed by LVN A. Further review revealed there was no evidence the physician was notified. Record review of Resident #2's COVID-19 Daily Evaluation, dated [DATE], revealed: Resident #2 had a confirmed [DIAGNOSES REDACTED]. Resident #2 was observed to have a nonproductive cough, with a poor cough efficacy. The resident was observed to have a increase in breathing effort (abnormal) which included pursed lip breathing (abnormal), discolored lips/nail beds (also referred to as cyanosis and is abnormal), decreased ability to speak in full sentences, decreased volume of speech, increased respiratory effort during drinking/eating and cough during drinking and eating. The resident also had abnormal lung sounds with identified wheezing upon inspiration (breathing in) and expiration (breathing out). On both sides of the lung fields in both the upper and lower portion of the lungs the resident had diminished lung sounds. Also noted were shortness of breath which was noted as severe. The resident was noted to have pain of muscle/body aches during the evaluation and had a poor appetite of refusing most items. Resident #2 was also noted to have a low fluid intake of less than 750 ml/day. The resident was noted to have poor or lower than normal activity tolerance, have a poorer cognitive status than typical for the resident, and had low urine output. Further review revealed the evaluator marked the current medications and treatments were effective in managing resident presentation, and the evaluation was signed by ADON C. Further review revealed there was no evidence the physician was notified. Record review of Resident #2's COVID-19 Daily Evaluation, dated [DATE] at 2:00 a.m., revealed: the resident had a low pulse of 51 (normal ,[DATE]), increased respiratory rate of 30 (normal ,[DATE]) and had oxygen saturations of 98% on room air. Resident #2 had a nonproductive cough with poor cough efficacy, an increased breathing effort, pursed lip breathing, eye redness, decreased ability to speak in full sentences, decreased volume of speech, increased respiratory effort during eating/drinking. Resident #2 also had abnormal lung sounds with strider (high pitched sound made with breathing through a narrow or partially blocked airway) and severe shortness of breath which was marked worst at risk, with activity and while lying flat. The evaluation also noted that Resident #2 had a poor appetite and was refusing most items, had a low fluid intake of less than 750 ml day. Her cognitive status was marked as, 'poorer than baseline.' Further review revealed the evaluator marked the current medications and treatments were effective in managing resident presentation, and the evaluation was signed by RN B. Further review revealed there was no evidence the physician was notified. Record review of a local EMS dispatch record for Resident #2, dated [DATE], revealed EMS services received a call at 2:35 a.m. on [DATE] for a [MEDICAL CONDITION], and when EMS personnel arrived on scene at the nursing facility at 2:47 a.m. CPR was in progress. Further review revealed the resident was listed as, DOA (dead on arrival). Record review of a facility document titled, Determination and Pronouncement of Death by a Registered Nurse (Texas Only), revealed Resident #2 expired (died ) and was pronounced dead on [DATE] at 3:18 a.m. while in the nursing facility and was signed by RN B. During an interview with RN B on [DATE] at 10:02 a.m., RN B stated he arrived late for work on [DATE] at 11:00 p.m. and checked on Resident #2 between 11:30 p.m. to 11:45 p.m. RN B stated when he checked on Resident #2 he noticed the resident's breathing was a little different, but the resident was asleep, so he left the room. RN B stated, Her (Resident #2's) breathing was more audible. I didn't think it was . yeah. RN B stated he performed an assessment of the resident and listened to her lungs. RN B stated the resident's lungs sounded, wet, and had, crackles (abnormal breath sound with fluid). RN B stated he did not take Resident #2's vitals at the time because he did not have the equipment with him but did eventually did get a set of vitals. RN B stated he could not remember what Resident #2's vitals were, but he remembered the resident's pulse was low and he documented his findings. RN B stated he set the resident up high in bed (to facilitate ease in breathing and oxygenation) and noted the resident was already on oxygen. RN B stated he could not remember what time this occurred. RN B stated a CNA (unknown) at an unknown time informed him Resident #2 was not breathing. RN B stated at this time, approximately 2:30 a.m., he initiated CPR. RN B could not provided an answer for how he was trained to respond when a resident had a change of condition, and stated, I deal with the change of condition, follow facility protocols, document, stabilize the patient. RN B confirmed he did not notify the NP or MD that Resident #2 had a change of condition prior to CPR being initiated. During an interview with NA E on [DATE] at 11:06 a.m., NA E stated she worked the evening shift on [DATE] from 2:00 p.m. to 10:00 p.m. NA E stated Resident #2 was normally, up and alert, and after Resident #2 developed COVID-19, NA E noticed Resident #2 started sleeping a lot and then she stopped eating completely. NA E stated the resident had a noticeable decline, and further stated on [DATE], Resident #2 was just sleeping, and her breathing was slow. NA E stated she was not able to obtain an oxygen saturation reading while performing vital signs, so she told LVN A who put oxygen on Resident #2. NA E stated, Resident #2's heart rate was low. I could tell something was going to happen. When asked what Resident #2's heart rate was, NA E stated slow. When asked again about the slow heart rate NA E stated, I don't know . because she was already asleep. I don't remember what her HR was. NA E confirmed she did not tell anyone about the resident's noticeable decline except for LVN A on the night of [DATE]. During an interview with CNA G on [DATE] at 12:11 p.m., CNA G stated she worked a double shift from 1:45 p.m. to 6:00 a.m. on [DATE] thru [DATE]. CNA G stated Resident #2 had been awake, alert, and talkative until approximately one week prior to her death. CNA G stated when she came to work at 1:45 p.m. on [DATE] Resident #2 was, in a total decline. She was dying. She was just lying on her bed with her eyes open and not responding. CNA G stated she told LVN A she did not think Resident #2 was breathing. CNA G further stated LVN A said, Yes, the resident was breathing. This is the COVID Hall. She has polyps. This is the way the residents are going to look. CNA G stated she kept telling LVN A that something was wrong with Resident #2, and further stated she had repeated it to LVN A at least 3 times. CNA G stated when RN B came to work she was performing vitals on Resident #2's roommate and noticed the resident really was not breathing. CNA G stated she told RN B that, Resident #2 was making weird motions and it sounded funny. Like a woman in labor with really fast shallow breathing but no breathe was actually coming out of her mouth. Gulping motions with her mouth. CNA G stated she repeated to RN B, Sir, she (Resident #2) is not breathing at all. CNA G stated at that time RN B started CPR and called 911. During an interview with ADON H on [DATE] at 12:56 p.m., ADON H stated she provided wound care for Resident #2 on [DATE] and noticed the resident was lethargic. ADON H stated she notified the charge nurse (unknown) about the resident's change of condition but did not remember which nurse she notified. ADON H stated the nurse acknowledged the conversation but she did not remember the response and did not know if anyone followed up with Resident #2. ADON H stated RN B was about to call the doctor because he did not like the way Resident #2 looked. ADON H stated she told RN B to do an assessment of Resident #2 and that was when he came to the door and asked for help and stated the resident's breathing was not normal. ADON H further stated Resident #2 did not have a pulse when she entered the room but was still warm. ADON H confirmed she did not notify MD that Resident #2 was lethargic or had a change of condition. ADON H stated it was the charge nurse's responsibility but any licensed nurse could have called the MD. During an interview with NP I on [DATE] at 1:24 p.m., NP I stated Resident #2 came to the facility for therapy and rehab, but tested positive for COVID-19 after her admission during an outbreak somewhere around [DATE]. NP I stated he started the resident on COVID-19 protocol: [MEDICATION NAME], steroids, and Vitamin C. NP I stated the facility needed to monitor the resident and maintain oxygen saturations greater than ,[DATE]% and monitor hydration. NP I stated staff could administer oxygen at ,[DATE] liters for SOB and the nurses needed to use their own judgement. NP I stated if a resident had respiratory distress the facility staff should call 911 not him. NP I stated he should be notified later. NP I stated it was the facility's protocol to call 911. NP I stated staff should notify the MD for any change of condition, and confirmed he did not receive any calls from the facility about Resident #2's change of condition. NP I stated if he had known Resident #2 had lower than normal oxygen saturations he probably would have taken further action. During an interview with LVN A on [DATE] at 3:09 p.m., LVN A stated on day shift on [DATE] he noted Resident #2 had pneumonia and he heard, crackles (abnormal breath sounds indicating fluid), that could be heard without using a stethoscope (mild crackles can only be heard by listening with a stethoscope). LVN A stated Resident #2 was already on antibiotics to treat the pneumonia so he was just monitoring her. LVN A stated during the shift the resident was responsive and was, perfectly fine. LVN A stated he checked on Resident #2 ,[DATE] times during his shift from 6:00 a.m. to 10:00 p.m. and did not notice any change of condition. LVN A stated no one had expressed concern about Resident #1's condition. LVN A he stated, one CNA (unknown) was worried about the water sound that could be heard with her breathing and stated the resident didn't look good. We both went into Resident #2's room together. I did not perform vitals or listen to her lungs but I could hear the crackling. LVN A stated he told the CNA Resident #2 had pneumonia and was on antibiotics. LVN A further stated during change of shift on [DATE] he gave a report to RN B and informed him there were several residents who, looked concerning because of the COVID pneumonia. LVN A stated a CNA (unknown) had told him she could not get a pulse oximeter reading but stated Resident #2 had long finger nails. LVN A stated he performed the pulse oximeter reading and Resident #2 had sats of ,[DATE]% (normal ,[DATE]). LVN A confirmed he did not notify Resident #2's physician of the resident's change of condition because she had COVID-19 and it was expected. During an interview with ADON C/Infection Preventionist on [DATE] at approximately 5:35 p.m., ADON C/Infection Preventionist stated she would notify a resident's physician when the resident had a change of condition. ADON C/Infection Preventionist stated, I will call and I will get orders. I will document in the progress notes. ADON C/Infection Preventionist stated an example of a change of condition in which she would notify the physician was, Fever or something I don't have an order for [REDACTED].#2's change of condition ADON C/Infection Preventionist stated, I don't remember, I think I gave her oxygen but I am not sure. I am not sure if a low oxygen saturation is considered a change of condition. With COVID-19 it is expected. When asked if she notified the DON of the resident's change of condition ADON C/Infection Preventionist stated, I don't remember. When asked if she notified the resident's physician of the change of condition ADON C/Infection Preventioni (TRUNCATED)

Based on interview and record review, the facility failed to ensure residents were free from neglect for 2 of 21 residents (Residents #1 and #2) whose care was reviewed for neglect, in that: 1 a. Resident #1 had increased shortness of breath and, increased anxiety on [DATE] staff failed to notify the resident's physician of the change of condition. On [DATE], staff prevented Resident #1 from being transported to the hospital by EMS after the resident's family called 911 when the resident complained she was SOB, was dying, nobody would help her and had visible swelling in both her arms. Staff failed to follow the physician's orders [REDACTED].#1 to the hospital after she experienced a change of condition. Resident #1 was not transferred to the hospital until [DATE] where she expired on [DATE]. b. Staff failed to notify Resident #2's physician of the resident's the change of condition when the resident was diagnosed with [REDACTED]. On [DATE], Resident #2 required oxygen to maintain oxygen saturation, had an increased breathing effort, had cyanosis (discoloration of skin which signifies low oxygen delivery to tissue), decreased ability to speak in full sentences, abnormal lung sounds and had severe shortness of breath. On [DATE], the resident expired in the facility. 2 a. Resident #1 did not have receive laboratory work which included a CBC and CMP on [DATE] as ordered by a physician. b. Resident #2 did not receive medication including [MEDICATION NAME] ordered [DATE] and steroids ordered [DATE] as ordered by a physician to treat symptoms of pneumonia and COVID-19. These deficient practice could place residents who experience a change of condition at risk for harm, deteriorating health and/or death. The findings were: 1 a. Record review of Resident #1's face sheet, dated [DATE] , revealed an admission date of [DATE] and, a readmission date of [DATE], with [DIAGNOSES REDACTED]. Record review of Resident #1's 5-day Admission MDS, dated [DATE], revealed the resident had a BIMS score of 15, which indicated the resident was cognitively intact. Record review of Resident #1's Physician's Progress Note, dated [DATE] by NP D, revealed, COVID positive resident had close, prolonged exposure totaling more than 15 minutes to a COVID positive staff member. Patient is now COVID positive. Continue to monitor respiratory status as patient is at risk for decline with COVID due to being a diabetic and having CKD. Record review of physician orders [REDACTED]. Record review of Resident #1's Care Plan, initialized on [DATE] and last updated [DATE], revealed the resident had hypertension related to [MEDICAL CONDITION] with interventions which included, Monitor for and document any [MEDICAL CONDITION], notify MD. Further review revealed Resident #1 had end stage heart failure with interventions which included, monitor/document/report to MD any signs and symptoms of [MEDICAL CONDITION]: dependent [MEDICAL CONDITION] of legs and feet, periorbital [MEDICAL CONDITION], SOB upon exertion, dry cough, weakness, crackles and wheezes upon auscultation of the lungs. Further review revealed Resident #1 was a full code status and, Promote resident rights by allowing resident to make decisions about advanced directives. Record review of Resident #1's nurses' progress notes revealed: - [DATE] at 6:39 PM written by LVN A: COVID-19 Evaluation for Confirmed COVID-19 diagnosis, vitals all WNL. Resident is on room air, no cough, no SOB. - [DATE] at 5:58 PM written by LVN A: COVID-19 Evaluation for Confirmed COVID-19 diagnosis, vitals are WNL, non-productive cough, cough efficacy fair, Moderate SOB worst with activity and worst while lying flat. There was no evidence the physician was notified. There was no evidence the physician was notified. - [DATE] at 2:05 PM written by LVN A: COVID-19 Evaluation for confirmed COVID-19 diagnosis, respiratory rate 24 (normal ,[DATE]), nonproductive cough, cough efficacy was poor, severe shortness of breath worst with activity and worse while lying flat. Appetite was low, less than half of baseline, fluid intake adequate. Resident had increased mood/behavior episodes than baseline. - [DATE] at 2:23 AM written the DON: Resident complained of shortness of breath, oxygen at 2 LPM via n/c. sats at 99%, repositioned, HOB already elevated, lung sounds clear to all lobes. There was no evidence documented to indicate the physician was notified. - [DATE] at 6:43 AM: COVID-19 evaluation for confirmed COVID-19 diagnosis, vitals WNL, nonproductive cough, mild SOB noted during evaluation, worse with activity and lying flat. Appetite poor resident is refusing most items, fluid intake is low less than 750 cc/day. - [DATE] at 7:01 AM written by LVN A: Received call from family member stating the resident called him complaining that she is SOB and that nobody is doing anything to help her out. Resident stated she is dying and no one is doing anything. Oxygen sats 97%, BP ,[DATE], pulse 65, respiratory rate 21 (normal ,[DATE]). Resident is stable and not in any respiratory distress. Explain to family that SOB is being treated with [MEDICATION NAME] and oxygen at 2 LPM PRN. Resident has been sating ,[DATE]% on oxygen. Family stated he wanted to call 911 and have the resident picked up and sent to the hospital. Pending arrival of EMS. - [DATE] at 6:43 PM written by LVN A: Resident was never picked up from EMS, resident stated she is scared and feels she is dying because she saw news that people are dying of COVID and she will die. Family member notified of EMS not picking up resident and he stated he understands that resident is short of breath and has very good vital signs but is just worried for his family member. Resident in bed stable with no fever or respiratory distress. There was no indication the physician was notified. - [DATE] at 3:27 PM written by LVN A: Reported [MEDICAL CONDITION] 4 plus to left upper extremity and [MEDICAL CONDITION] 3 plus to right upper extremity. Stat chest x-ray, CBC, BMP, BNP, daily weights x 7 days, VS every 4 hours for 24 hours. - [DATE] at 3:43 PM written by LVN A per NP D: Resident to be sent out (to hospital). - [DATE] at 4:48 PM written by LVN A: Resident was picked up by transportation and sent to hospital. Record review of Resident #1's physician progress notes [REDACTED]. shortness of breath: transfer to hospital, feel her SOB is multilateral . anticipate she will need IV [MEDICATION NAME] . Anticipate she will need IV dieresis. During an interview with NP D on [DATE] at 1:30 p.m., NP D stated on [DATE] she was in the facility to assess residents positive for COVID-19. NP D confirmed she had given her approval for transferring Resident #1 to the hospital because she has been told by LVN A that EMS was on the way to the facility. NP D confirmed she gave a verbal order to LVN A to send Resident #1 to the hospital. NP D stated Resident #1 had received fluids to address her lack of fluid intake and [MEDICAL CONDITION]. NP D stated on her [DATE] visit with Resident #1 the resident had [MEDICAL CONDITION] (swelling) in both arms (bilateral upper extremities), and the [MEDICAL CONDITION] was more pronounced on Resident #1's right arm. NP D further stated she received a text on [DATE] from their on-call services which stated the facility had called them for Resident #1's change in condition. NP D stated Resident #1's condition was getting worse and they asked to send the resident out to the hospital. NP D confirmed she gave the order to send out to the hospital, but could not recall receiving any other calls. NP D confirmed she was not called for Resident #1's change of condition prior to her visit to the facility on [DATE]. NP D confirmed she was not called when Resident #1 was not transported to the hospital on [DATE]. NP D stated she would have given different orders if she had been called about Resident #1's change of condition prior to her visit on [DATE]. NP D confirmed she would have given an order to transfer Resident #1 to the hospital even if the family had not made the request. During an interview with LVN A on [DATE] at 4:20 p.m., LVN A confirmed he had been trained to complete a Change of Condition Assessment for a resident change of condition. LVN A confirmed a Change of Condition Assessment had not been completed for Resident #1 until [DATE] when the resident went out to the hospital. LVN A stated on [DATE] a form was started but was incomplete. LVN A stated the Resident #1's family called 911, and the 911 dispatcher called the facility and spoke with LVN A. LVN A stated he informed the 911 dispatcher that Resident #1's vital signs were stable and the resident was not in any distress. LVN A further stated Resident #1 had a lot of anxiety, was always watching the news, and thought she was dying but her vitals were perfect, and she was not in any distress. LVN A stated on [DATE] the family called 911 and requested the resident go to the hospital. LVN A confirmed by 8:00 PM Resident #1 had not been picked up by EMS so LVN A notified the family the resident had not been picked up. LVN A stated on [DATE] NP D visited Resident #1 and noted [MEDICAL CONDITION] to upper extremities and wanted to start medications to help. LVN A stated he told NP D the family had called 911 and NP D stated that was fine and the hospital could work on the resident's issues with [MEDICAL CONDITION]. LVN A further stated when he came to work on [DATE] at 2:00 PM he noted Resident #1 had 4 plus [MEDICAL CONDITION] to upper extremities and called the physician group. LVN A stated NP D was upset EMS had not picked the resident up on [DATE], and further stated NP D, I could have done something about it yesterday. LVN A confirmed Resident #1 expired on [DATE] at the hospital. LVN A stated he notified NP D for each change of condition, but confirmed he had forgotten to document. LVN A stated, honestly, I can't remember if I notified the physician except on [DATE]. LVN A stated he notified the DON on [DATE] that Resident #1's family had requested the resident be sent out to the hospital, and further stated he notified the DON on [DATE] the ambulance had not picked the resident up on [DATE]. LVN A confirmed the DON had asked if NP D knew, and further confirmed he notified NP D after notifying the DON. During an interview with LVN A on [DATE] at 4:30 p.m., LVN A confirmed on [DATE] he had received a verbal order from NP D to send out Resident #1 to the hospital. LVN A confirmed he had not called NP D or the DON when EMS failed to pick Resident #1 up. LVN A stated he gave a report to the incoming nurse (unknown). LVN A stated when he came back to the facility on [DATE] for his shift he found Resident #1 was still in the facility and the resident's [MEDICAL CONDITION] had worsened. LVN A confirmed he called NP D to notify her and received a new order to send Resident #1 to the hospital. During an interview with the DON on [DATE] at 9:28 a.m., the DON confirmed there was not a facility policy or rule for when a staff member should call EMS if EMS failed to show at the facility. The DON stated her expectation for staff was that they called EMS back after 20 minutes. During an interview with LVN R on [DATE] at 10:00 a.m., LVN R confirmed she worked day shift on [DATE] with Resident #1. LVN R stated the night shift nurse (unknown) did not tell her Resident #1 needed to go to the ER, but during the shift change a CAN (unknown) told her the family had called 911. LVN R stated she looked through Resident #1's medical record and noticed a slow decline in blood pressure, and also noted Resident #1 was not eating. LVN R further stated Resident #1 was, very alert, and stated she wanted to go home. LVN R confirmed she did not perform an assessment of Resident #1 and did not notice any swelling. LVN R further stated she did a COVID-19 assessment but it did not include looking for swelling. When asked if she was trained to perform daily assessments on residents, LVN R stated, We just take vitals and the CAN's perform assessments while proving peri-care. LVN R confirmed she did not notify Resident #1's physician about the resident's change of condition, and further confirmed she did not notify the physician the resident had not been sent to the hospital. During an interview with the local fire department on [DATE] at 11:08 a.m., the local fire department stated on [DATE] at approximately 7:00 a.m. they provided a medical consult with LVN A regarding Resident #1. The local fire department stated they did not dispatch an EMS unit to the facility after speaking with LVN A. The details of the conversation with LVN A and the dispatcher were not available. During an interview with the local fire department on [DATE] at 11:08 a.m., the local fire department stated on [DATE] at approximately 7:00 a.m. they provided a medical consult with LVN A regarding Resident #1. The local fire department stated they did not dispatch an EMS unit to the facility after speaking with LVN A. The details of the conversation with LVN A and the dispatcher were not available. During an interview with Resident #1 family member on [DATE] at 12:18 p.m., Resident #1's family member stated, Resident #1 kept calling family and stating could not breathe and the facility wasn't doing anything to help her. We called an ambulance and the facility refused transport. During an interview with the DON on [DATE] at 2:15 p.m., the DON confirmed NP D was not notified of Resident #1's change of condition prior to NP D's visit on [DATE]. The DON further confirmed NP D was not notified when Resident #1 was not transferred to the hospital on [DATE]. The DON confirmed she was not notified herself of Resident #1's change of condition or that EMS had not picked up Resident #1 on [DATE]. The DON stated when she came at the facility on [DATE] LVN A was on the phone with NP D to notifying NP D that Resident #1 was still at the facility and the resident's condition had worsened. The DON confirmed NP D gave an order to transfer Resident #1 to the hospital. The DON confirmed nurses were supposed notify the physician of any residents' changes of condition immediately. 1 b. Record review of Resident #2's face sheet, dated [DATE], revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #2's Admission MDS, dated [DATE], revealed the resident had a BIMS score of 6, which indicated the resident was severely cognitively impaired. Further review revealed the resident required extensive assistance of ,[DATE] staff to assist with ADLs. Record review of Resident #2's Care Plan, initiated on [DATE] and last revised on [DATE], revealed Resident #2 was Full Code with interventions which included, initiate CPR upon [MEDICAL CONDITION]. Further review revealed Resident #2 was at risk for signs and symptoms of COVID-19 with interventions which included: observe for signs and symptoms of COVID-19, document and promptly report fever, cough, shortness of breath or difficulty breathing, chills repeated shaking with chills, muscle pain, headache, sore throat, new loss of taste or smell, runny nose, congestion, diarrhea, nausea, vomiting and notify NP/MD if present. On [DATE], Resident #2's Care Plan was updated to include the resident had confirmed COVID-19 and was at risk for severe illness and other complications secondary to cardiovascular disease, diabetes and the residents age, and interventions included: observe for psychosocial and mental status changes, document and report as indicated. Perform clinical evaluation and escalate the monitoring of signs and symptoms. Record review of Resident #2's vital signs revealed: Oxygen saturation (normal ,[DATE]) - [DATE] 4:40 p.m. oxygen saturation 89% on room air with no follow up oxygen reading documented by LVN A. - [DATE] 10:46 a.m. oxygen saturation 88% on room air with no follow up oxygen reading documented by ADON C. - [DATE] 8:02 p.m. oxygen saturation 93% on oxygen (of unknown quantity) via nasal cannula documented by LVN A. - [DATE] 5:03 a.m. (which was after the resident's time of death) oxygen saturation 98% on room air documented by RN B. Respiratory Rate (normal ,[DATE]) - [DATE] 4:39 p.m. respiratory rate (RR) 26 documented by LVN A. - [DATE] 12:39 a.m. RR 24 documented by RN B. - [DATE] 4:04 a.m. RR 24 documented by RN B. - [DATE] 8:57 a.m. RR 22 documented by LVN R. - [DATE] 8:02 p.m. RR 23 documented by LVN A. - [DATE] 4:57 p.m. RR 30 documented after the residents time of death by RN B. Record review of Resident #2's physician progress notes [REDACTED].#2 had new onset of COVID-19 virus with a note that stated the visit took place via telepathy with limited response from patient during assessment; normal baseline. Further review revealed, Patient (Resident #2) is seen and examined via telemedicine with LVN charge nurse assisting. No shortness of breath or chest pain. COVID-19: onset of virus; maintain oxygen saturation . monitor closely for symptom onset . notify NP/MD for changes or concerns. Further review revealed the note was signed by the NP. Record review of Resident #2's chest x-ray, dated [DATE], revealed the x-ray showed a, retrocede infiltrate (pneumonia), and, cardiomegaly (enlarged heart). Record review of Resident #2's Infection Surveillance Form, dated [DATE] at 1:01 p.m., revealed: Resident #2 had an onset of symptoms beginning [DATE] with an acute change in mental status from baseline which included disorganized thinking (thinking incoherent, rambling conversation, unpredictable switches in subject or altered level of consciousness). Surveillance of body systems included: a respiratory tract infection listed as pneumonia from an interpretation of a chest x-ray demonstrating pneumonia or the presence of new infiltrate with a new or increased cough. Further review revealed the resident was listed as COVID-19 positive, and the evaluation was signed by ADON C. Record review of Resident #2's COVID-19 Daily Evaluation (COVID-19 symptom tracker and resident assessment tool), dated [DATE] at 10:43 p.m., revealed: Resident #2 had a confirmed [DIAGNOSES REDACTED]. Resident #2 had a nonproductive cough, fair cough efficacy (ability to cough up secretions), and no increase in breathing effort with abnormal lung sounds which included wheezing on expiration (exhale or breathing out). No shortness of breath was noted during the evaluation. The resident had a poor appetite and was refusing most items and an adequate fluid intake. Resident #2's cognitive status was at baseline. Further review revealed the evaluation marked the current medications and treatments effective in managing resident presentation, and the evaluation was signed by LVN A. Further review revealed there was no evidence the physician was notified. Record review of Resident #2's COVID-19 Daily Evaluation, dated [DATE], revealed: Resident #2 had a confirmed [DIAGNOSES REDACTED]. Resident #2 was observed to have a nonproductive cough, with a poor cough efficacy. The resident was observed to have a increase in breathing effort (abnormal) which included pursed lip breathing (abnormal), discolored lips/nail beds (also referred to as cyanosis and is abnormal), decreased ability to speak in full sentences, decreased volume of speech, increased respiratory effort during drinking/eating and cough during drinking and eating. The resident also had abnormal lung sounds with identified wheezing upon inspiration (breathing in) and expiration (breathing out). On both sides of the lung fields in both the upper and lower portion of the lungs the resident had diminished lung sounds. Also noted were shortness of breath which was noted as severe. The resident was noted to have pain of muscle/body aches during the evaluation and had a poor appetite of refusing most items. Resident #2 was also noted to have a low fluid intake of less than 750 ml/day. The resident was noted to have poor or lower than normal activity tolerance, have a poorer cognitive status than typical for the resident, and had low urine output. Further review revealed the evaluator marked the current medications and treatments were effective in managing resident presentation, and the evaluation was signed by ADON C. Further review revealed there was no evidence the physician was notified. Record review of Resident #2's COVID-19 Daily Evaluation, dated [DATE] at 2:00 a.m., revealed: the resident had a low pulse of 51 (normal ,[DATE]), increased respiratory rate of 30 (normal ,[DATE]) and had oxygen saturations of 98% on room air. Resident #2 had a nonproductive cough with poor cough efficacy, an increased breathing effort, pursed lip breathing, eye redness, decreased ability to speak in full sentences, decreased volume of speech, increased respiratory effort during eating/drinking. Resident #2 also had abnormal lung sounds with strider (high pitched sound made with breathing through a narrow or partially blocked airway) and severe shortness of breath which was marked worst at risk, with activity and while lying flat. The evaluation also noted that Resident #2 had a poor appetite and was refusing most items, had a low fluid intake of less than 750 ml day. Her cognitive status was marked as, 'poorer than baseline.' Further review revealed the evaluator marked the current medications and treatments were effective in managing resident presentation, and the evaluation was signed by RN B. Further review revealed there was no evidence the physician was notified. Record review of a local EMS dispatch record for Resident #2, dated [DATE], revealed EMS services received a call at 2:35 a.m. on [DATE] for a [MEDICAL CONDITION], and when EMS personnel arrived on scene at the nursing facility at 2:47 a.m. CPR was in progress. Further review revealed the resident was listed as, DOA (dead on arrival). Record review of a facility document titled, Determination and Pronouncement of Death by a Registered Nurse (Texas Only), revealed Resident #2 expired (died ) and was pronounced dead on [DATE] at 3:18 a.m. while in the nursing facility and was signed by RN B. During an interview with RN B on [DATE] at 10:02 a.m., RN B stated he arrived late for work on [DATE] at 11:00 p.m. and checked on Resident #2 between 11:30 p.m. to 11:45 p.m. RN B stated when he checked on Resident #2 he noticed the resident's breathing was a little different, but the resident was asleep, so he left the room. RN B stated, Her (Resident #2's) breathing was more audible. I didn't think it was . yeah. RN B stated he performed an assessment of the resident and listened to her lungs. RN B stated the resident's lungs sounded, wet, and had, crackles (abnormal breath sound with fluid). RN B stated he did not take Resident #2's vitals at the time because he did not have the equipment with him but did eventually did get a set of vitals. RN B stated he could not remember what Resident #2's vitals were, but he remembered the resident's pulse was low and he documented his findings. RN B stated he set the resident up high in bed (to facilitate ease in breathing and oxygenation) and noted the resident was already on oxygen. RN B stated he could not remember what time this occurred. RN B stated a CNA (unknown) at an unknown time informed him Resident #2 was not breathing. RN B stated at this time, approximately 2:30 a.m., he initiated CPR. RN B could not provided an answer for how he was trained to respond when a resident had a change of condition, and stated, I deal with the change of condition, follow facility protocols, document, stabilize the patient. RN B confirmed he did not notify the NP or MD that Resident #2 had a change of condition prior to CPR being initiated. During an interview with NA E on [DATE] at 11:06 a.m., NA E stated she worked the evening shift on [DATE] from 2:00 p.m. to 10:00 p.m. NA E stated Resident #2 was normally, up and alert, and after Resident #2 developed COVID-19, NA E noticed Resident #2 started sleeping a lot and then she stopped eating completely. NA E stated the resident had a noticeable decline, and further stated on [DATE], Resident #2 was just sleeping, and her breathing was slow. NA E stated she was not able to obtain an oxygen saturation reading while performing vital signs, so she told LVN A who put oxygen on Resident #2. NA E stated, Resident #2's heart rate was low. I could tell something was going to happen. When asked what Resident #2's heart rate was, NA E stated slow. When asked again about the slow heart rate NA E stated, I don't know . because she was already asleep. I don't remember what her HR was. NA E confirmed she did not tell anyone about the resident's noticeable decline except for LVN A on the night of [DATE]. During an interview with CNA G on [DATE] at 12:11 p.m., CNA G stated she worked a double shift from 1:45 p.m. to 6:00 a.m. on [DATE] thru [DATE]. CNA G stated Resident #2 had been awake, alert, and talkative until approximately one week prior to her death. CNA G stated when she came to work at 1:45 p.m. on [DATE] Resident #2 was, in a total decline. She was dying. She was just lying on her bed with her eyes open and not responding. CNA G stated she told LVN A she did not think Resident #2 was breathing. CNA G further stated LVN A said, Yes, the resident was breathing. This is the COVID Hall. She has polyps. This is the way the residents are going to look. CNA G stated she kept telling LVN A that something was wrong with Resident #2, and further stated she had repeated it to LVN A at least 3 times. CNA G stated when RN B came to work she was performing vitals on Resident #2's roommate and noticed the resident really was not breathing. CNA G stated she told RN B that, Resident #2 was making weird motions and it sounded funny. Like a woman in labor with really fast shallow breathing but no breathe was actually coming out of her mouth. Gulping motions with her mouth. CNA G stated she repeated to RN B, Sir, she (Resident #2) is not breathing at all. CNA G stated at that time RN B started CPR and called 911. During an interview with ADON H on [DATE] at 12:56 p.m., ADON H stated she provided wound care for Resident #2 on [DATE] and noticed the resident was lethargic. ADON H stated she notified the charge nurse (unknown) about the resident's change of condition but did not remember which nurse she notified. ADON H stated the nurse acknowledged the conversation but she did not remember the response and did not know if anyone followed up with Resident #2. ADON H stated RN B was about to call the doctor because he did not like the way Resident #2 looked. ADON H stated she told RN B to do an assessment of Resident #2 and that was when he came to the door and asked for help and stated the resident's breathing was not normal. ADON H further stated Resident #2 did not have a pulse when she entered the room but was still warm. ADON H confirmed she did not notify MD that Resident #2 was lethargic or had a change of condition. ADON H stated it was the charge nurse's responsibility but any licensed nurse could have called the MD. During an interview with NP I on [DATE] at 1:24 p.m., NP I stated Resident #2 came to the facility for therapy and rehab, but tested positive for COVID-19 after her admission during an outbreak somewhere around [DATE]. NP I stated he started the resident on COVID-19 protocol: [MEDICATION NAME], steroids, and Vitamin C. NP I stated the facility needed to monitor the resident and maintain oxygen saturations greater than ,[DATE]% and monitor hydration. NP I stated staff could administer oxygen at ,[DATE] liters for SOB and the nurses needed to use their own judgement. NP I stated if a resident had respiratory distress the facility staff should call 911 not him. NP I stated he should be notified later. NP I stated it was the facility's protocol to call 911. NP I stated staff should notify the MD for any change of condition, and confirmed he did not receive any calls from the facility about Resident #2's change of condition. NP I stated if he had known Resident #2 had lower than normal oxygen saturations he probably would have taken further action. During an interview with LVN A on [DATE] at 3:09 p.m., LVN A stated on day shift on [DATE] he noted Resident #2 had pneumonia and he heard, crackles (abnormal breath sounds indicating fluid), that could be heard without using a stethoscope (mild crackles can only be heard by listening with a stethoscope). LVN A stated Resident #2 was already on antibiotics to treat the pneumonia so he was just monitoring her. LVN A stated during the shift the resident was responsive and was, perfectly fine. LVN A stated he checked on Resident #2 ,[DATE] times during his shift from 6:00 a.m. to 10:00 p.m. and did not notice any change of condition. LVN A stated no one had expressed concern about Resident #1's condition. LVN A he stated, one CNA (unknown) was worried about the water sound that could be heard with her breathing and stated the resident didn't look good. We both went into Resident #2's room together. I did not perform vitals or listen to her lungs but I could hear the crackling. LVN A stated he told the CNA Resident #2 had pneumonia and was on antibiotics. LVN A further stated during change of shift on [DATE] he gave a report to RN B and informed him there were several residents who, looked concerning because of the COVID pneumonia. LVN A stated a CNA (unknown) had told him she could not get a pulse oximeter reading but stated Resident #2 had long finger nails. LVN A stated he performed the pulse oximeter reading and Resident #2 had sats of ,[DATE]% (normal ,[DATE]). LVN A confirmed he did not notify Resident #2's physician of the resident's change of condition because she had COVID-19 and it was expected. During an interview with ADON C/Infection Preventionist on [DATE] at approximately 5:35 p.m., ADON C/Infection Preventionist stated she would notify a resident's physician when the resident had a change of condition. ADON C/Infection Preventionist stated, I will call and I will get orders. I will document in the progress notes. ADON C/Infection Preventionist stated an example of a change of condition in which she would notify the physician was, Fever or something I don't have an order for [REDACTED].#2's change (TRUNCATED)

Based on interview and record review, the facility failed to implement written policies and procedures to ensure residents were free from neglect for 2 of 21 residents (Residents #1 and, #2) whose care was reviewed for neglect, in that: 1. The facility failed to implement written policies to include: a. The failure to identify a change of condition for Resident #1 who had a [DIAGNOSES REDACTED].#1 sent to the hospital. Resident #1 had increased shortness of breath and, increased anxiety which started on [DATE]. Resident #1 had increased bilateral upper extremities [MEDICAL CONDITION] starting on [DATE] at which time the NP gave an order to transfer Resident #1 to the hospital which did not occur. Resident #1 was transferred to the hospital on [DATE] where she expired on [DATE]. b. The failure to identify a change of condition for Resident #2 who had a [DIAGNOSES REDACTED]. Resident #2 was diagnosed with [REDACTED]. On [DATE] Resident #2 required oxygen to maintain oxygen saturation, had an increased breathing effort, had cyanosis (discoloration of skin which signifies low oxygen delivery to tissue), decreased ability to speak in full sentences, abnormal lung sounds and had severe shortness of breath. On [DATE] the resident expired in the facility. These deficient practices could place residents who experience a change of condition at risk for harm, deteriorating health and/or death. The findings were: Record review of the facility's policy titled, Abuse Prevention, dated [DATE], revealed: It is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Prevention: All personnel, residents, visitors etc. are encouraged to report incidents and grievances without the fear of retribution. Feedback regarding concerns will be given. The employees of our facility will take action to protect and prevent abuse and neglect from occurring within the facility by: Staff has knowledge if the individual resident's care needs. Supervision of staff to identify inappropriate behaviors . Definitions: To assist the facility's staff members in recognizing incidents of abuse, the following definitions are provided . Neglect - is the failure of the facility, its employees or service providers to provide goods and services to resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. 1 a. Record review of Resident #1's face sheet, dated [DATE] , revealed an admission date of [DATE] and, a readmission date of [DATE], with [DIAGNOSES REDACTED]. Record review of Resident #1's 5-day Admission MDS, dated [DATE], revealed the resident had a BIMS score of 15, which indicated the resident was cognitively intact. Record review of Resident #1's Physician's Progress Note, dated [DATE] by NP D, revealed, COVID positive resident had close, prolonged exposure totaling more than 15 minutes to a COVID positive staff member. Patient is now COVID positive. Continue to monitor respiratory status as patient is at risk for decline with COVID due to being a diabetic and having CKD. Record review of physician orders [REDACTED]. Record review of Resident #1's Care Plan, initialized on [DATE] and last updated [DATE], revealed the resident had hypertension related to [MEDICAL CONDITION] with interventions which included, Monitor for and document any [MEDICAL CONDITION], notify MD. Further review revealed Resident #1 had end stage heart failure with interventions which included, monitor/document/report to MD any signs and symptoms of [MEDICAL CONDITION]: dependent [MEDICAL CONDITION] of legs and feet, periorbital [MEDICAL CONDITION], SOB upon exertion, dry cough, weakness, crackles and wheezes upon auscultation of the lungs. Further review revealed Resident #1 was a full code status and, Promote resident rights by allowing resident to make decisions about advanced directives. Record review of Resident #1's nurses' progress notes revealed: - [DATE] at 6:39 PM written by LVN A: COVID-19 Evaluation for Confirmed COVID-19 diagnosis, vitals all WNL. Resident is on room air, no cough, no SOB. - [DATE] at 5:58 PM written by LVN A: COVID-19 Evaluation for Confirmed COVID-19 diagnosis, vitals are WNL, non-productive cough, cough efficacy fair, Moderate SOB worst with activity and worst while lying flat. There was no evidence the physician was notified. There was no evidence the physician was notified. - [DATE] at 2:05 PM written by LVN A: COVID-19 Evaluation for confirmed COVID-19 diagnosis, respiratory rate 24 (normal ,[DATE]), nonproductive cough, cough efficacy was poor, severe shortness of breath worst with activity and worse while lying flat. Appetite was low, less than half of baseline, fluid intake adequate. Resident had increased mood/behavior episodes than baseline. - [DATE] at 2:23 AM written the DON: Resident complained of shortness of breath, oxygen at 2 LPM via n/c. sats at 99%, repositioned, HOB already elevated, lung sounds clear to all lobes. There was no evidence documented to indicate the physician was notified. - [DATE] at 6:43 AM: COVID-19 evaluation for confirmed COVID-19 diagnosis, vitals WNL, nonproductive cough, mild SOB noted during evaluation, worse with activity and lying flat. Appetite poor resident is refusing most items, fluid intake is low less than 750 cc/day. - [DATE] at 7:01 AM written by LVN A: Received call from family member stating the resident called him complaining that she is SOB and that nobody is doing anything to help her out. Resident stated she is dying and no one is doing anything. Oxygen sats 97%, BP ,[DATE], pulse 65, respiratory rate 21 (normal ,[DATE]). Resident is stable and not in any respiratory distress. Explain to family that SOB is being treated with [MEDICATION NAME] and oxygen at 2 LPM PRN. Resident has been sating ,[DATE]% on oxygen. Family stated he wanted to call 911 and have the resident picked up and sent to the hospital. Pending arrival of EMS. - [DATE] at 6:43 PM written by LVN A: Resident was never picked up from EMS, resident stated she is scared and feels she is dying because she saw news that people are dying of COVID and she will die. Family member notified of EMS not picking up resident and he stated he understands that resident is short of breath and has very good vital signs but is just worried for his family member. Resident in bed stable with no fever or respiratory distress. There was no indication the physician was notified. - [DATE] at 3:27 PM written by LVN A: Reported [MEDICAL CONDITION] 4 plus to left upper extremity and [MEDICAL CONDITION] 3 plus to right upper extremity. Stat chest x-ray, CBC, BMP, BNP, daily weights x 7 days, VS every 4 hours for 24 hours. - [DATE] at 3:43 PM written by LVN A per NP D: Resident to be sent out (to hospital). - [DATE] at 4:48 PM written by LVN A: Resident was picked up by transportation and sent to hospital. Record review of Resident #1's physician progress notes [REDACTED]. shortness of breath: transfer to hospital, feel her SOB is multilateral . anticipate she will need IV [MEDICATION NAME] . Anticipate she will need IV dieresis. During an interview with NP D on [DATE] at 1:30 p.m., NP D stated on [DATE] she was in the facility to assess residents positive for COVID-19. NP D confirmed she had given her approval for transferring Resident #1 to the hospital because she has been told by LVN A that EMS was on the way to the facility. NP D confirmed she gave a verbal order to LVN A to send Resident #1 to the hospital. NP D stated Resident #1 had received fluids to address her lack of fluid intake and [MEDICAL CONDITION]. NP D stated on her [DATE] visit with Resident #1 the resident had [MEDICAL CONDITION] (swelling) in both arms (bilateral upper extremities), and the [MEDICAL CONDITION] was more pronounced on Resident #1's right arm. NP D further stated she received a text on [DATE] from their on-call services which stated the facility had called them for Resident #1's change in condition. NP D stated Resident #1's condition was getting worse and they asked to send the resident out to the hospital. NP D confirmed she gave the order to send out to the hospital, but could not recall receiving any other calls. NP D confirmed she was not called for Resident #1's change of condition prior to her visit to the facility on [DATE]. NP D confirmed she was not called when Resident #1 was not transported to the hospital on [DATE]. NP D stated she would have given different orders if she had been called about Resident #1's change of condition prior to her visit on [DATE]. NP D confirmed she would have given an order to transfer Resident #1 to the hospital even if the family had not made the request. During an interview with LVN A on [DATE] at 4:20 p.m., LVN A confirmed he had been trained to complete a Change of Condition Assessment for a resident change of condition. LVN A confirmed a Change of Condition Assessment had not been completed for Resident #1 until [DATE] when the resident went out to the hospital. LVN A stated on [DATE] a form was started but was incomplete. LVN A stated the Resident #1's family called 911, and the 911 dispatcher called the facility and spoke with LVN A. LVN A stated he informed the 911 dispatcher that Resident #1's vital signs were stable and the resident was not in any distress. LVN A further stated Resident #1 had a lot of anxiety, was always watching the news, and thought she was dying but her vitals were perfect, and she was not in any distress. LVN A stated on [DATE] the family called 911 and requested the resident go to the hospital. LVN A confirmed by 8:00 PM Resident #1 had not been picked up by EMS so LVN A notified the family the resident had not been picked up. LVN A stated on [DATE] NP D visited Resident #1 and noted [MEDICAL CONDITION] to upper extremities and wanted to start medications to help. LVN A stated he told NP D the family had called 911 and NP D stated that was fine and the hospital could work on the resident's issues with [MEDICAL CONDITION]. LVN A further stated when he came to work on [DATE] at 2:00 PM he noted Resident #1 had 4 plus [MEDICAL CONDITION] to upper extremities and called the physician group. LVN A stated NP D was upset EMS had not picked the resident up on [DATE], and further stated NP D, I could have done something about it yesterday. LVN A confirmed Resident #1 expired on [DATE] at the hospital. LVN A stated he notified NP D for each change of condition, but confirmed he had forgotten to document. LVN A stated, honestly, I can't remember if I notified the physician except on [DATE]. LVN A stated he notified the DON on [DATE] that Resident #1's family had requested the resident be sent out to the hospital, and further stated he notified the DON on [DATE] the ambulance had not picked the resident up on [DATE]. LVN A confirmed the DON had asked if NP D knew, and further confirmed he notified NP D after notifying the DON. During an interview with LVN A on [DATE] at 4:30 p.m., LVN A confirmed on [DATE] he had received a verbal order from NP D to send out Resident #1 to the hospital. LVN A confirmed he had not called NP D or the DON when EMS failed to pick Resident #1 up. LVN A stated he gave a report to the incoming nurse (unknown). LVN A stated when he came back to the facility on [DATE] for his shift he found Resident #1 was still in the facility and the resident's [MEDICAL CONDITION] had worsened. LVN A confirmed he called NP D to notify her and received a new order to send Resident #1 to the hospital. During an interview with the DON on [DATE] at 9:28 a.m., the DON confirmed there was not a facility policy or rule for when a staff member should call EMS if EMS failed to show at the facility. The DON stated her expectation for staff was that they called EMS back after 20 minutes. During an interview with LVN R on [DATE] at 10:00 a.m., LVN R confirmed she worked day shift on [DATE] with Resident #1. LVN R stated the night shift nurse (unknown) did not tell her Resident #1 needed to go to the ER, but during the shift change a CAN (unknown) told her the family had called 911. LVN R stated she looked through Resident #1's medical record and noticed a slow decline in blood pressure, and also noted Resident #1 was not eating. LVN R further stated Resident #1 was, very alert, and stated she wanted to go home. LVN R confirmed she did not perform an assessment of Resident #1 and did not notice any swelling. LVN R further stated she did a COVID-19 assessment but it did not include looking for swelling. When asked if she was trained to perform daily assessments on residents, LVN R stated, We just take vitals and the CAN's perform assessments while proving peri-care. LVN R confirmed she did not notify Resident #1's physician about the resident's change of condition, and further confirmed she did not notify the physician the resident had not been sent to the hospital. During an interview with the local fire department on [DATE] at 11:08 a.m., the local fire department stated on [DATE] at approximately 7:00 a.m. they provided a medical consult with LVN A regarding Resident #1. The local fire department stated they did not dispatch an EMS unit to the facility after speaking with LVN A. The details of the conversation with LVN A and the dispatcher were not available. During an interview with the local fire department on [DATE] at 11:08 a.m., the local fire department stated on [DATE] at approximately 7:00 a.m. they provided a medical consult with LVN A regarding Resident #1. The local fire department stated they did not dispatch an EMS unit to the facility after speaking with LVN A. The details of the conversation with LVN A and the dispatcher were not available. During an interview with Resident #1 family member on [DATE] at 12:18 p.m., Resident #1's family member stated, Resident #1 kept calling family and stating could not breathe and the facility wasn't doing anything to help her. We called an ambulance and the facility refused transport. During an interview with the DON on [DATE] at 2:15 p.m., the DON confirmed NP D was not notified of Resident #1's change of condition prior to NP D's visit on [DATE]. The DON further confirmed NP D was not notified when Resident #1 was not transferred to the hospital on [DATE]. The DON confirmed she was not notified herself of Resident #1's change of condition or that EMS had not picked up Resident #1 on [DATE]. The DON stated when she came at the facility on [DATE] LVN A was on the phone with NP D to notifying NP D that Resident #1 was still at the facility and the resident's condition had worsened. The DON confirmed NP D gave an order to transfer Resident #1 to the hospital. The DON confirmed nurses were supposed notify the physician of any residents' changes of condition immediately. 1 b. Record review of Resident #2's face sheet, dated [DATE], revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #2's Admission MDS, dated [DATE], revealed the resident had a BIMS score of 6, which indicated the resident was severely cognitively impaired. Further review revealed the resident required extensive assistance of ,[DATE] staff to assist with ADLs. Record review of Resident #2's Care Plan, initiated on [DATE] and last revised on [DATE], revealed Resident #2 was Full Code with interventions which included, initiate CPR upon [MEDICAL CONDITION]. Further review revealed Resident #2 was at risk for signs and symptoms of COVID-19 with interventions which included: observe for signs and symptoms of COVID-19, document and promptly report fever, cough, shortness of breath or difficulty breathing, chills repeated shaking with chills, muscle pain, headache, sore throat, new loss of taste or smell, runny nose, congestion, diarrhea, nausea, vomiting and notify NP/MD if present. On [DATE], Resident #2's Care Plan was updated to include the resident had confirmed COVID-19 and was at risk for severe illness and other complications secondary to cardiovascular disease, diabetes and the residents age, and interventions included: observe for psychosocial and mental status changes, document and report as indicated. Perform clinical evaluation and escalate the monitoring of signs and symptoms. Record review of Resident #2's vital signs revealed: Oxygen saturation (normal ,[DATE]) - [DATE] 4:40 p.m. oxygen saturation 89% on room air with no follow up oxygen reading documented by LVN A. - [DATE] 10:46 a.m. oxygen saturation 88% on room air with no follow up oxygen reading documented by ADON C. - [DATE] 8:02 p.m. oxygen saturation 93% on oxygen (of unknown quantity) via nasal cannula documented by LVN A. - [DATE] 5:03 a.m. (which was after the resident's time of death) oxygen saturation 98% on room air documented by RN B. Respiratory Rate (normal ,[DATE]) - [DATE] 4:39 p.m. respiratory rate (RR) 26 documented by LVN A. - [DATE] 12:39 a.m. RR 24 documented by RN B. - [DATE] 4:04 a.m. RR 24 documented by RN B. - [DATE] 8:57 a.m. RR 22 documented by LVN R. - [DATE] 8:02 p.m. RR 23 documented by LVN A. - [DATE] 4:57 p.m. RR 30 documented after the residents time of death by RN B. Record review of Resident #2's physician progress notes [REDACTED].#2 had new onset of COVID-19 virus with a note that stated the visit took place via telepathy with limited response from patient during assessment; normal baseline. Further review revealed, Patient (Resident #2) is seen and examined via telemedicine with LVN charge nurse assisting. No shortness of breath or chest pain. COVID-19: onset of virus; maintain oxygen saturation . monitor closely for symptom onset . notify NP/MD for changes or concerns. Further review revealed the note was signed by the NP. Record review of Resident #2's chest x-ray, dated [DATE], revealed the x-ray showed a, retrocede infiltrate (pneumonia), and, cardiomegaly (enlarged heart). Record review of Resident #2's Infection Surveillance Form, dated [DATE] at 1:01 p.m., revealed: Resident #2 had an onset of symptoms beginning [DATE] with an acute change in mental status from baseline which included disorganized thinking (thinking incoherent, rambling conversation, unpredictable switches in subject or altered level of consciousness). Surveillance of body systems included: a respiratory tract infection listed as pneumonia from an interpretation of a chest x-ray demonstrating pneumonia or the presence of new infiltrate with a new or increased cough. Further review revealed the resident was listed as COVID-19 positive, and the evaluation was signed by ADON C. Record review of Resident #2's COVID-19 Daily Evaluation (COVID-19 symptom tracker and resident assessment tool), dated [DATE] at 10:43 p.m., revealed: Resident #2 had a confirmed [DIAGNOSES REDACTED]. Resident #2 had a nonproductive cough, fair cough efficacy (ability to cough up secretions), and no increase in breathing effort with abnormal lung sounds which included wheezing on expiration (exhale or breathing out). No shortness of breath was noted during the evaluation. The resident had a poor appetite and was refusing most items and an adequate fluid intake. Resident #2's cognitive status was at baseline. Further review revealed the evaluation marked the current medications and treatments effective in managing resident presentation, and the evaluation was signed by LVN A. Further review revealed there was no evidence the physician was notified. Record review of Resident #2's COVID-19 Daily Evaluation, dated [DATE], revealed: Resident #2 had a confirmed [DIAGNOSES REDACTED]. Resident #2 was observed to have a nonproductive cough, with a poor cough efficacy. The resident was observed to have an increase in breathing effort (abnormal) which included pursed lip breathing (abnormal), discolored lips/nail beds (also referred to as cyanosis and is abnormal), decreased ability to speak in full sentences, decreased volume of speech, increased respiratory effort during drinking/eating and cough during drinking and eating. The resident also had abnormal lung sounds with identified wheezing upon inspiration (breathing in) and expiration (breathing out). On both sides of the lung fields in both the upper and lower portion of the lungs the resident had diminished lung sounds. Also noted were shortness of breath which was noted as severe. The resident was noted to have pain of muscle/body aches during the evaluation and had a poor appetite of refusing most items. Resident #2 was also noted to have a low fluid intake of less than 750 ml/day. The resident was noted to have poor or lower than normal activity tolerance, have a poorer cognitive status than typical for the resident, and had low urine output. Further review revealed the evaluator marked the current medications and treatments were effective in managing resident presentation, and the evaluation was signed by ADON C. Further review revealed there was no evidence the physician was notified. Record review of Resident #2's COVID-19 Daily Evaluation, dated [DATE] at 2:00 a.m., revealed: the resident had a low pulse of 51 (normal ,[DATE]), increased respiratory rate of 30 (normal ,[DATE]) and had oxygen saturations of 98% on room air. Resident #2 had a nonproductive cough with poor cough efficacy, an increased breathing effort, pursed lip breathing, eye redness, decreased ability to speak in full sentences, decreased volume of speech, increased respiratory effort during eating/drinking. Resident #2 also had abnormal lung sounds with strider (high pitched sound made with breathing through a narrow or partially blocked airway) and severe shortness of breath which was marked worst at risk, with activity and while lying flat. The evaluation also noted that Resident #2 had a poor appetite and was refusing most items, had a low fluid intake of less than 750 ml day. Her cognitive status was marked as, 'poorer than baseline.' Further review revealed the evaluator marked the current medications and treatments were effective in managing resident presentation, and the evaluation was signed by RN B. Further review revealed there was no evidence the physician was notified. Record review of a local EMS dispatch record for Resident #2, dated [DATE], revealed EMS services received a call at 2:35 a.m. on [DATE] for a [MEDICAL CONDITION], and when EMS personnel arrived on scene at the nursing facility at 2:47 a.m. CPR was in progress. Further review revealed the resident was listed as, DOA (dead on arrival). Record review of a facility document titled, Determination and Pronouncement of Death by a Registered Nurse (Texas Only), revealed Resident #2 expired (died ) and was pronounced dead on [DATE] at 3:18 a.m. while in the nursing facility and was signed by RN B. During an interview with RN B on [DATE] at 10:02 a.m., RN B stated he arrived late for work on [DATE] at 11:00 p.m. and checked on Resident #2 between 11:30 p.m. to 11:45 p.m. RN B stated when he checked on Resident #2 he noticed the resident's breathing was a little different, but the resident was asleep, so he left the room. RN B stated, Her (Resident #2's) breathing was more audible. I didn't think it was . yeah. RN B stated he performed an assessment of the resident and listened to her lungs. RN B stated the resident's lungs sounded, wet, and had, crackles (abnormal breath sound with fluid). RN B stated he did not take Resident #2's vitals at the time because he did not have the equipment with him but did eventually get a set of vitals. RN B stated he could not remember what Resident #2's vitals were, but he remembered the resident's pulse was low and he documented his findings. RN B stated he set the resident up high in bed (to facilitate ease in breathing and oxygenation) and noted the resident was already on oxygen. RN B stated he could not remember what time this occurred. RN B stated a CNA (unknown) at an unknown time informed him Resident #2 was not breathing. RN B stated at this time, approximately 2:30 a.m., he initiated CPR. RN B could not provide an answer for how he was trained to respond when a resident had a change of condition, and stated, I deal with the change of condition, follow facility protocols, document, stabilize the patient. RN B confirmed he did not notify the NP or MD that Resident #2 had a change of condition prior to CPR being initiated. During an interview with NA E on [DATE] at 11:06 a.m., NA E stated she worked the evening shift on [DATE] from 2:00 p.m. to 10:00 p.m. NA E stated Resident #2 was normally, up and alert, and after Resident #2 developed COVID-19, NA E noticed Resident #2 started sleeping a lot and then she stopped eating completely. NA E stated the resident had a noticeable decline, and further stated on [DATE], Resident #2 was just sleeping, and her breathing was slow. NA E stated she was not able to obtain an oxygen saturation reading while performing vital signs, so she told LVN A who put oxygen on Resident #2. NA E stated, Resident #2's heart rate was low. I could tell something was going to happen. When asked what Resident #2's heart rate was, NA E stated slow. When asked again about the slow heart rate NA E stated, I don't know . because she was already asleep. I don't remember what her HR was. NA E confirmed she did not tell anyone about the resident's noticeable decline except for LVN A on the night of [DATE]. During an interview with CNA G on [DATE] at 12:11 p.m., CNA G stated she worked a double shift from 1:45 p.m. to 6:00 a.m. on [DATE] thru [DATE]. CNA G stated Resident #2 had been awake, alert, and talkative until approximately one week prior to her death. CNA G stated when she came to work at 1:45 p.m. on [DATE] Resident #2 was, in a total decline. She was dying. She was just lying on her bed with her eyes open and not responding. CNA G stated she told LVN A she did not think Resident #2 was breathing. CNA G further stated LVN A said, Yes, the resident was breathing. This is the COVID Hall. She has polyps. This is the way the residents are going to look. CNA G stated she kept telling LVN A that something was wrong with Resident #2, and further stated she had repeated it to LVN A at least 3 times. CNA G stated when RN B came to work she was performing vitals on Resident #2's roommate and noticed the resident really was not breathing. CNA G stated she told RN B that, Resident #2 was making weird motions and it sounded funny. Like a woman in labor with really fast shallow breathing but no breathe was actually coming out of her mouth. Gulping motions with her mouth. CNA G stated she repeated to RN B, Sir, she (Resident #2) is not breathing at all. CNA G stated at that time RN B started CPR and called 911. During an interview with ADON H on [DATE] at 12:56 p.m., ADON H stated she provided wound care for Resident #2 on [DATE] and noticed the resident was lethargic. ADON H stated she notified the charge nurse (unknown) about the resident's change of condition but did not remember which nurse she notified. ADON H stated the nurse acknowledged the conversation but she did not remember the response and did not know if anyone followed up with Resident #2. ADON H stated RN B was about to call the doctor because he did not like the way Resident #2 looked. ADON H stated she told RN B to do an assessment of Resident #2 and that was when he came to the door and asked for help and stated the resident's breathing was not normal. ADON H further stated Resident #2 did not have a pulse when she entered the room but was still warm. ADON H confirmed she did not notify MD that Resident #2 was lethargic or had a change of condition. ADON H stated it was the charge nurse's responsibility but any licensed nurse could have called the MD. During an interview with NP I on [DATE] at 1:24 p.m., NP I stated Resident #2 came to the facility for therapy and rehab, but tested positive for COVID-19 after her admission during an outbreak somewhere around [DATE]. NP I stated he started the resident on COVID-19 protocol: [MEDICATION NAME], steroids, and Vitamin C. NP I stated the facility needed to monitor the resident and maintain oxygen saturations greater than ,[DATE]% and monitor hydration. NP I stated staff could administer oxygen at ,[DATE] liters for SOB and the nurses needed to use their own judgement. NP I stated if a resident had respiratory distress the facility staff should call 911 not him. NP I stated he should be notified later. NP I stated it was the facility's protocol to call 911. NP I stated staff should notify the MD for any change of condition, and confirmed he did not receive any calls from the facility about Resident #2's change of condition. NP I stated if he had known Resident #2 had lower than normal oxygen saturations he probably would have taken further action. During an interview with LVN A on [DATE] at 3:09 p.m., LVN A stated on day shift on [DATE] he noted Resident #2 had pneumonia and he heard, crackles (abnormal breath sounds indicating fluid), that could be heard without using a stethoscope (mild crackles can only be heard by listening with a stethoscope). LVN A stated Resident #2 was already on antibiotics to treat the pneumonia so he was just monitoring her. LVN A stated during the shift the resident was responsive and was, perfectly fine. LVN A stated he checked on Resident #2 ,[DATE] times during his shift from 6:00 a.m. to 10:00 p.m. and did not notice any change of condition. LVN A stated no one had expressed concern about Resident #1's condition. LVN A he stated, one CNA (unknown) was worried about the water sound that could be heard with her breathing and stated the resident didn't look good. We both went into Resident #2's room together. I did not perform vitals or listen to her lungs but I could hear the crackling. LVN A stated he told the CNA Resident #2 had pneumonia and was on antibiotics. LVN A further stated during change of shift on [DATE] he gave a report to RN B and informed him there were several residents who, looked concerning because of the COVID pneumonia. LVN A stated a CNA (unknown) had told him she could not get a pulse oximeter reading but stated Resident #2 had long finger nails. LVN A stated he perfor (TRUNCATED)