Every finding on record at Onion Creek Nursing and Rehabilitation Center

Based on observation, record reviews, and interviews, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one of three residents reviewed for accidents (Resident #1).This resulted in Resident #1 having a fall from her bed during peri-care which resulted in an acute fracture to the right tibial metaphysis on 07/08/2026.The noncompliance was identified as PNC. The noncompliance began on 07/08/2026 and ended on 07/16/2026. The facility had corrected the noncompliance before the survey began.This failure could place residents at risk of accidents and serious injuries. Findings Included: Record review of Resident #1's MDS assessment dated [DATE], reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included hemiplegia, hemiparesis, aphasia and osteoporosis. The MDS reflected a BIMS of 10 which indicates moderate cognitive impairment, and section GG, functional Abilities reflects that the Resident is Dependent for rolling left and right, sitting to lying, lying to sitting, Chair/bed to chair transfer, and tub/shower transfer. Record review of Resident #1's care plan, revision date of 02/06/2025, reflected Resident #1 had an ADL self-care performance deficit and requires mechanical aide/ mechanical lift for transfers x 2 staff. The care plan reflected the resident required total assistance times two with personal hygiene and peri care. Resident#1 was totally dependent on staff times two for repositioning and turning in the bed. Record review of Resident #1's progress notes, dated 07/08/2026 at 10:45 AM, completed by LVN A revealed the following: This writer was alerted by CNA resident had sustained a fall during care, CNA stated, while changing brief, the resident began to roll to the left side of bed and staff was unable to maintain position in bed. Additionally, CNA described an unexpected change in elevation with the resident landing in a sitting position on to floor with left leg extended and right leg flexed. The resident was able to verbalize pain top her right leg and illustrated the fall exactly how CNA stated. Immediately asked for assistance from the therapy team for assistance to reposition to bed after a physical assessment was performed without remarkable findings. Vitals WNL, except for pain. Notified ADON, Provider, and family. Record review of Resident #1's Care plan dated 7/13/2026, reflected Resident #1 had a fall on 7/8/2026, from bed during brief change. Record review of Resident #1's Care plan dated 7/13/2026, reflected Resident # 1, Mechanical Aide/ mechanical lift for transfers x 2 staff. Record review of Resident #1's Care plan dated 7/13/2026, reflected Resident #1 be sure call light is within reach and respond promptly to all requests for assistance. Record review of the facility's Provider Investigation Report, signed 7/16/2026, revealed the following: Resident #1 Level of Supervision: No special Supervision. Independently ambulatory: No Description of assessment: Skin pain and fall assessments completed. Mobile xrays ordered and obtained. Xray revealed positive for a distal tibial fracture combined with a proximal fibular fracture. Safe Surveys completed. Provider Response: Resident interview attained. Staff interviews were completed. Safe surveys were initiated. In-services initiated. Mobile xray ordered. Notification of ED, DON, NP, ombudsman, medical director and family. Suspension of CNA (CNA E).Investigation Summary: Xray revealed positive a distal tibial fracture combined with a proximal fibular fracture. Safe surveys completed. Record review of Facility incident case file, dated 7/9/2026, revealed CNA E, suspended-unpaid, from Wed. [DATE]-Sun, [DATE]. Record review revealed that the Facility held a Quality Assurance and Performance Improvement Meeting, dated 07/09/2026, time 13:44 (01:44 p.m.) Record review of Facility training checklist-Transfers (Mechanical Lift), dated 07/09/2026 to 07/16/2026, for all staff. Additional review revealed CNA E included. Additional review revealed post-test, Fall Quiz questions: Where do you look for transfers and ADL care status in Point Click Care before you provide care? When providing care in bed, what should staff do to help prevent a resident from falling? What should you do when a resident falls on the floor and is in pain? When performing a mechanical lift transfer, even placing a sling you should? Record review of Facility in-service, topic: Post Fall Assessment and Transfer, dated 07/09/2026, for all staff. Additional review revealed CNA E included. Record review of Facility in-service, topic: Patient Care, dated 07/09/2026, for all staff. Additional review revealed CNA E included. Record review of Facility in-service, topic: Steps on How to place a sling under a Resident, dated 07/09/2026, for all staff. Additional review revealed CNA E included. Record review of Facility in-service, topic: Bed Positioning, dated 07/09/2026, for all staff. Additional review revealed CNA E included. Record review of Facility Resident Safe Surveys, completed 07/09/2026 to 07/10/2026, 19 sample Residents. No significant findings. Record review of Facility Audit of Incidents, dated 07/15/2026, No significant findings. Record review of Care Plan Item/Task Listing Report completed on Residents, dated 07/10/2026, No significant findings. Record review of Resident #1's Neurological Nurses Notes and Observation Sheets, dated 07/08/2026, No significant findings. Record review of Resident #1's care plan, Revised 07/09/2026. Record review of Facility in-service, topic: Abuse and Neglect Policy and Procedure Review and Training, dated 07/09/2026, for all staff. Additional review revealed CNA E included. Record review of Resident #1's orders, no significant findings. Record review of in-services dated 07/09/2026, with all staff conducted by the RN regarding the topics of post fall assessment and transfers revealed the following: When a resident has fallen, do not move the resident from the floor before the nurse assesses ROM. The nurse should also assess the situation. Record review of Facility email to SA for self-report, dated 07/09/2026. In an interview on 07/21/2026, at 10:06 AM, Resident #1 stated the aide performed care on her alone, and when she attempted to turn her on the side of the bed, she slid down to the ground. In an interview on 07/21/2026, at 11:01 AM, with a concerned family member at the facility during the time of the investigation he stated he has noticed the facility is often short-staffed with staff when he arrives to visit his spouse. In an interview on 07/21/2026, at 3:10 PM, CNA A stated to identify two-person assist on his hall, he uses Kardex as a quick reference guide when he has a resident on his hall that required a two person assist. In an interview on 07/21/2026, at 3:50PM, CNA B, stated to identify residents on her hall that are a two person assist she looks in Kardex. She stated she was called to the room to assist Resident # 1 off the ground. When she arrived Resident # 1 was found on the side of the bed with other staff members present. She stated she believed the staff member in question was assisting her alone. In an interview on 07/21/2026, at 3:50 PM, CNA C, stated she has worked with Resident #1 and knows she is a two-person transfer. She stated she heard of the recent incident but was not present, but if she is ever shorthanded and is the only CNA available, she would call for help from the therapy department or another nurse before assisting the resident. In an interview on 07/22/2026, at 8:59 AM, CNA D stated that to find out if a resident is a two-person assist, he checks the Kardex to find this information. He stated he has not worked with Resident #1, and if he is working alone with a two-person assist, he knows to always call another aide. He stated he was trained to prevent a resident from falling. He said you should turn the resident towards himself, make sure the resident is centered in the bed, and always have two people to ensure a resident does not fall. He stated he was recently trained on resident care plans, transfers, and accident prevention. In an interview on 07/22/2026, at 10:05 AM, Resident #1 stated she has always been a two-person assist, and the aide was working alone and did not request any help when assisting her. Resident #1 did not voice any other recent incident. In an interview on 07/22/2026, at 9:19 AM, CNA E stated the required level of assistance for residents who require two-person assist is identified on the residents' Kardex and Care Plan. CNA E stated that Resident# 1 requires a two-person assist for transfers and peri-care. She stated that if a resident requires two-person assistance and only one staff member is available, the appropriate action is to obtain another staff member before providing care. CNA E stated she has been inserviced on all topics related to the incident that occurred. In an interview on 07/22/2026, at 2:22 PM, NP A stated she is familiar with Resident # 1, and the Resident should have had orders for a two-person assist before and after the incident. The NP stated the Resident is at a higher risk due to her condition of Osteoporosis. NP A stated Resident #1 could not walk before the injury and would not be able to walk after the injury due to her medical condition. She said the incident is expected to cause the Resident pain and/or discomfort. In an interview on 07/22/2026, at 3:17 PM, ADM, stated that the facility has in-serviced all staff on Abuse and neglect, Patient care, Post Fall assessment & transfers, how to place a sling, Fall response, Bed Positioning, and Pain Assessment. She stated that all new staff are being trained before being released to the floor. In addition, audits are being carried out to ensure staff are performing their jobs correctly. She stated that an injury could occur if care was not provided with two staff members when required. During an observation, on 08/11/2026 at 10:00 a.m., of Peri care and Mechanical lift transfer for Resident #2, CNA A performed peri care thoroughly, communicating with resident ensuring he was comfortable. RN A was on the resident's left side assisting and providing help to resident as he turned to his left side. Resident #2 was able to turn himself from side to side independently using his upper extremities. During mechanical lift transfer observation, CNA A and RNA placed sling carefully and gently behind Resident #2 back. CNA A and RNA then secured sling onto the mechanical lift properly. Communication between the staff was done making sure placement of the wheelchair and the mechanical lift facilitated transfer efficiently. Resident # 2 transferred carefully, no issue noted during transfer. During an observation, on 08/11/2026 at 10:50 a.m., with Resident# 3 for peri care and mechanical lift transfer, CNA C was on the left side for assistance and provided additional support for the resident during turning. CNA B thoroughly cleaned the resident's perineal area. CNA C provided safety for Resident# 3 by holding her during turning. Resident# 2 was transferred with no issues and concerns. In an interview on 8/11/2026, at 10:45 AM, with Resident #2, he stated he lived in the facility for 6 years. He gets out of bed in the morning and goes back to bed between 5-6pm. He stated he is transferred from bed to wheelchair using mechanical lift. He stated there are 2 staff every time they provide him peri care. He stated that there are always 2 staff transferring him using the mechanical lift. He feels safe when being transferred. The noncompliance was identified as PNC. The noncompliance began on 07/08/2026 and ended on 07/16/2026. The facility had corrected the noncompliance before the survey began, and interventions were made. Fall Prevention in-service Post fall assessment and transfers in-service Fall prevention and Proper Bed positioning in service Patient Care Training How to put a Sling under a Resident Fall response Training Fall quiz Pain assessment and management post Inservice Quiz Transfers & Mechanical Lift Time off Entries – Suspension Unpaid for CNA E Safe Survey Training Care plan Item Task Listing Report

Based on observation, record review and interviews, the facility failed to ensure residents remained free of any significant errors for 1 of 3 residents (Resident # 1) reviewed for medication error. The facility failed to ensure resident #1 received physician ordered medication Apixaban 2.5 mg and Insulin Glargine 16 units on May 31,2026 as prescribed. This failure could place residents at risk of complications such as blood clots or high blood sugars levels. Observation of pyxis system (automated medication cabinet that stores frequently used medications) on 6/5/2026 at 09:00 AM reflected the medication Apixaban 2.5 mg (medication used to decrease the risk of blood clot formation) was available for administration to the resident with 9 tablets available, there was no insulin glargine (medication used to lower blood sugar) available in the pyxis. Record review of Resident #1's face sheet reflected an admission date of 1/17/2026, an [AGE] year-old female with diagnoses that included type 2 diabetes mellitus with diabetic chronic kidney disease, long term (current) use of insulin, andParoxysmal atrial fibrillation (occasional irregular heartbeat). Record review of Resident #1's care plan dated 1/19/2026 reflected anticoagulant therapy related to atrial fibrillation with interventions to administer medication per physician orders, also reflected resident had diabetes mellitus with a goal of not having complications related to diabetes and interventions of diabetes medication as ordered by doctor. Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected Resident #1's BIMS score was 11 which indicates moderate cognitive impairment. Record review of Resident #1's medication administration record dated for May 2026 reflected that Resident #1 did not receive her bedtime scheduled doses of Apixaban 2.5mg and Insulin Glargine 16 units on 5/31/2026. On the medication administration record the box indicates a #2 which in the key states hold/see nurse note. Record review of Resident #1's progress notes dated 5/31/2026 at 19:41 reflected insulin Glargine Solostar subcutaneous solution pen injector 100 unit/mL inject 16 unit subcutaneously at bedtime for DM2 hold if BS < 110, supply not on hand, reordered. Signed by RN C. Record review of Resident #1's progress notes dated 5/31/2026 at 20:49 reflected Apixaban oral tablet 2.5 mg give 1 tablet by mouth two times a day for anticoagulant, supply not on hand, reordered. Signed by RN C. Record review of the StatSafe pyxis access log for Apixaban (Eliquis) 2.5 mg tablet reflected the only time the medication had been removed from the pyxis was dated 1/17/2026 at 7:47 PM for Resident #1, leaving 9 tablets in the pyxis. Record review of the StatSafe pyxis access log dated for 5/30/2026 - 6/3/2026 reflected no access to the pyxis was attempted on 5/31/2026, the date the medication was not administered. During an interview on 6/5/2026 at 08:43 AM, Registered Nurse C stated Resident # 1 missed her bedtime dose of Insulin Glargine and Apixaban due to medications not being available in the facility. She stated she did look in the pyxis for the medications, but they were not there. Registered Nurse C stated Resident #1 could possibly get a blood clot from not getting her Apixaban and she could have an high blood sugar from not getting her insulin Glargine, which could possibly result in Resident # 1 needing to go to the hospital. During an interview on 6/5/2026 at 09:00 AM, Licensed Vocational Nurse A stated if a resident is out of a medication on the medication cart, they had an overflow system to check first if the medication is not there then we check in the pyxis. She stated the pyxis is connected to the pharmacy and they monitor the counts on the medications and replenished the stock when the pyxis was running low on a certain medication. LVN A stated that if a resident had to go without insulin or anticoagulant medication, they could get sick with blood clots or high blood sugar that could result in hospital trip. During an interview on 6/5/2026 at 10:33 AM, Registered Nurse D stated that if a resident were to run out of a medication she would check to see if it was in the overflow, if not she would try to pull it from the pyxis and if it is not in the pyxis she would call the pharmacy and notify the doctor. She stated if a resident had to go without insulin, they could become hyperglycemic (high blood sugar) or an anticoagulant they could get blood clots, which both could result in going to the hospital. During an interview on 6/5/2026 at 3:39 PM, Medication Aide B stated if a resident was missing a medication, he would let the nurse know and they could pull it from the pyxis. He stated a possible negative effect of not getting their anticoagulant or insulin could result in the resident getting sick. During an interview on 6/5/2026 at 4:05 PM, the Director of Nursing stated her expectation for a missing medication is for the nurses to look in the overflow, pull missing medications from the pyxis, call the pharmacy and notify the doctor if medication cannot be administered for possible alternate medication and notify the family. The Director of Nursing stated a possible negative outcome for a resident not receiving the prescribed insulin Glargine could result in variation in blood sugar and not received the prescribed anticoagulant Apixaban could result in a change in the clotting factors that could result in hospitalization.

Based on interviews, and record review, the facility failed to immediately inform the resident and the resident representative(s) when there is a a need to alter treatment significantly for one (Resident #1) of five residents reviewed for change in condition. The facility failed to ensure that Resident #1's RP was notified when Resident #1's MD discontinued his Amoxicillin-Potassium Clavulanate, Alprazolam, Divalproex Sodium, Mirtazapine, Furosemide, Eplerenone, Glipizide and Potassium Chloride, on 01/13/2026. This failure could result in decreased continuity of care, and a delay in the treatment and services needed.Findings included: Review of Resident #1's face sheet reflected an [AGE] year-old male admitted on [DATE] with diagnoses of metabolic encephalopathy (broad term for brain dysfunction caused by illness, chemical imbalances or toxins), type 2 diabetes mellitus (chronic condition that the body cannot effectively use insulin to maintain blood sugar levels), altered mental status (change in a person's thinking, awareness or consciousness), unspecified dementia (significant decline in memory loss, thinking/judgement problem), acute and chronic respiratory failure with hypoxia (sudden severe worsening of low blood oxygen). Review of Resident #1's admission MDS dated [DATE] reflected a BIMS of 03 which indicated severe cognitive impairment. Review of Resident #1's care plan dated 01/14/2026 reflected Resident #1 has altered cardiovascular status with hypertension with interventions to administered medications as ordered. Review of care plan dated 01/12/2026 reflected Resident #1 has increased risk for altered renal status related to acute kidney injury with interventions to given medication as ordered by physician. Review of Resident #1 care plan dated 01/13/2026 reflected Resident #1 had infection of pneumonia with intervention to administer antibiotics as ordered. Review reflected Resident #1 had diabetes mellitus with intervention to give diabetes medication as ordered by doctor. Review reflected Resident #1 had potential fluid deficit related to diuretic use with intervention to administer medications as ordered. Review of Resident #1 care plan dated 01/12/2026 reflected antidepressant medication use with intervention to give antidepressant medications ordered by physician. Review of Resident #1's MPOA dated 08/23/2021 reflected the FM listed as the agent/RP. Review of the MD's initial H&P for Resident #1 dated 01/13/2026 reflected Resident #1 is a poor historian discussed with nursing since he has been here his cognitive status been stable. He does not have any abnormal or concern behaviors although he is not eating for drinking and was refusing meds today. Exam is limited due to [Resident #1's] compliance he is alert and orient x 0 (unable to name, person, time place or situation). Under the plan it was reflected presumed chronic diagnosis with acute delirium of unknown etiology. The latter could be from medications decreased oral intake with food or dehydration, do not suspect additional or secondary infection. Minimize medications and reassess, palliative care, while he is not eating and with this issue, we will discontinue his Xanax (alprazolam), Depakote (Divalproex Sodium), mirtazapine, Lasix (furosemide) and KCI (Potassium chloride). Review of Resident #1's January 2026 MAR reflected an order for Eplerenone Tablet 50 MG, give one tablet by mouth one time a day for hypertension with a start date of 01/11/2026 and discontinue date of 01/13/2026. Review reflected an order for Furosemide tablet 40 MG for edema, give by mouth one time a day for edema (swelling caused by fluid buildup) with a start date of 01/10/2026, discontinue date of 01/11/2026 and a start date of 01/12/2026 and discontinue date of 01/13/2026. Review reflected Resident #1 had an order for Glipizide for diabetes tablet 5 MG one time a day for diabetes with a start date of 01/10/2026 and discontinue date of 01/13/2026. Review reflected an order for Mirtazapine tablet 15 MG to give 1 tablet by mouth at bedtime for depression, with start date of 01/10/2026 and end date of 01/11/2026 and a separate order with a start date of 01/12/2026 and discontinue date of 01/13/2026. Review reflected an order for potassium chloride tablet 20 MEQ give 1 tablet by mouth one time a day for supplement with a start date and discontinue date of 01/13/2026, additional order with a start date of 01/10/2026 and discontinue date of 01/11/2026. Review reflected an order for Amoxicillin-Potassium Clavulanate 875-125 MG give 1 tablet by mouth every 12 hours for pneumonia for 10 days until finished with a start date of 01/10/2026 and discontinue date of 01/13/2026. Review of Resident #1's MAR reflected an order for Divalproex Sodium delayed release sprinkle 125 MG, give 2 capsule by mouth three times a day for psychosis with a start date of 01/10/2026 and discontinue date of 01/13/2026 and a separate order with a start and end date of 01/13/2026. Review of Resident #1's MAR reflected an order for Alprazolam tablet .5 MG give 1 tablet by mouth every 12 hours as needed for anxiety / agitation with a start date of 01/09/2026 and discontinue date of 01/13/2026 and separate order to start on 01/20/2026. Review of Resident #1's progress note by RN C dated 01/17/2026 reflected the FM asked about alprazolam and was notified that medication had been discontinued. During an interview on 01/28/2026 at 10:32 AM, Resident #1's FM stated that she was not notified of changes to Resident #1's medications. The FM stated that several of Resident #1's medications were removed and she felt it was not beneficial. The FM stated it was only when she specifically asked about the medications on 01/17/2026 that it was mentioned that Resident #1 was no longer taking anti-depression or mood stabilizer medication. The FM stated the MD never spoke with her regarding discontinuing medications. The FM stated that she had provided the facility a MPOA for Resident #1 upon admission. During an interview on 01/28/2026 at 3:11 PM, LVN A stated that she recalled working with Resident #1. LVN A stated the MD usually visited the facility on Monday or Tuesday and she recalled the MD asking about Resident #1. LVN A stated she reported that Resident #1 looked okay and had no behaviors. LVN A stated the MD stated he was going to review mediations and make changes. LVN A stated she did not understand why or what happened for the MD to make changes to the medications. LVN A stated she did not ask the MD what changes he was going to make. LVN A stated that when medications were discontinued, if the resident was their own RP then the resident was notified, and if not then the resident's RP would be notified. LVN A stated that the NP or MD would normally call and follow up and speak with the resident's family. During an interview on 01/28/2026 at 3:36 PM, LVN B stated that the resident and POA were notified of medications changes to see if they agreed. LVN B stated it was the nurse's responsibility to notify the family of medication changes. LVN B stated that the discontinued medication would pop up on the MAR and would say who discontinued the medication. LVN B stated it was important to notify the family to keep them updated on the residents' care and they had a right to know what was going on and to answer any questions or concerns. During an interview on 01/28/2026 at 4:19 PM, the DON stated that if a nurse discontinued medication they should call and let either the POA or resident know depending on if the resident was their own responsible party or not. The DON stated if the MD discontinued medication it was the nurse's responsibility to notify the resident if self-responsible or the RP if not. The DON stated that the discontinued medication would show on the queue in PCC (electronic health record) for the nurses. The DON stated if the doctor mentioned medications changes, the nurse should ask the doctor if they talked with the family. During an interview on 01/28/2026 at 5:02 PM, the ADM stated if the resident was their own responsible party then she would expect staff to let the resident know and if they had an RP then staff would need to let that person know of any medication changes as well. The ADM stated it was important because it was a resident's right and family also had a right to know about their care and be involved in treatment. During an interview on 01/28/2026 at 5:08 PM, the MD stated that he saw Resident #1 on 01/13/2026 and discontinued a bunch of meditations because the resident was acutely altered based on reviewed records. The MD stated he felt other conditions may have been exacerbated, so to get an understanding of Resident #1's baseline to try to help Resident #1 improve, medications were discontinued. The MD stated he did not reach out to the POA or family unless the specifically requested and the process was that the nurses usually made the notification for changes he was going to make. The MD stated that once he notified the nurse of the changes, then they would notify the family. Review of facility in-service dated 12/17/2026 reflected the topic family should be notified of any medications changes, change in condition, appointments, refusal of medications/showers completed with nursing. Review of facility policy titled Change in Condition with revision date of 04/2025 reflected the resident / resident representative will be notified of the change of condition and any changes in the resident's medical or nursing care.

Based on interviews and records review the facility failed to ensure Residents were free of any significant medication error for one (Resident #1) of three Residents review for medication.The facility failed to follow physician's orders for Resident #1 when she was discharged from the hospital on [DATE]. Resident #1's order for Divalproex Sodium (Depakote) [A type of drug that is used to prevent or treat seizures or convulsions by controlling abnormal electrical. It can also be used as mood stabilizer) for this with intervention to give medications as ordered.] Oral Tablet Delayed Release 250 MG (Divalproex Sodium) Give 1 tablet BID was never carried out and Resident #1 did not receive six doses of the medication. This deficient practice placed residents at risk of not receiving therapeutic dose of medication and hospitalization.Findings included: Review of Resident #1's face sheet printed 11/05/2025 reflected a [AGE] year-old female who was admitted on [DATE] and readmitted on [DATE] with the following dx: Urinary Tract Infection (UTI- an infection of the urinary tract, which includes the kidneys, ureters, bladder, and urethra.), Unspecified Dementia, moderate with mood disturbances (Dementia is a general term for a group of conditions that cause a decline in cognitive functions, such as memory, thinking, reasoning, and problem-solving, severe enough to interfere with daily life.), Unspecified Dementia with anxiety, (a normal reaction to stress that can become an overwhelming and persistent disorder, characterized by excessive worry, fear, or dread)Review of Resident#1's quarterly MDS assessment dated [DATE] reflected a BIMS score of 99, indicating the resident was unable to complete the interview. It also reflected Resident #1 had both short-term and long-term memory problems. Section C also reflected Resident #1 had an Acute Onset Mental Status Changes that is an Is evidence of an acute change in mental status from the resident's baseline. Review of Resident 1's care plan revised 09/01/2025 reflected Resident #1 had a mood disorder and received Antiepileptic medication (A type of drug that is used to prevent or treat seizures or convulsions by controlling abnormal electrical. It can also be used as mood stabilizer) for this with intervention to give medications as ordered. Monitor/document for effectiveness and side effects. The care plan also reflected Resident #1's potential for injury due to a behavior problem related to purposely sliding/scooting from the bed and/or w/c to get onto the floor and then scooting around in room. Review of Resident #1's progress notes dated 10/25/2025 at 08:37 am written by RN B reflected: Resident [#1] observed with frequent episodes of loud vocalizations/yelling throughout the day. Resident [#1] wandering behavior noted to be continuous and non-aggressive. Multiple attempts by staff throughout the day to redirect Resident [1] by verbal reassurance, offering a quite environment, distraction, and reorientation. Resident [#1] unable to be calmed or redirected despite intervention attempts. Resident displays clinical signs of agitation, inconsolable verbal outbursts and yelling. Review of Resident #1's progress notes dated 10/25/2025 at 10: am written by RN B reflected: Charge nurse reported to NP on call [XXXX], that Resident [#1] was screaming inconsolably despite interventions by charge nurse, medication aid, and CNA. Charge nurse tried to assist Resident [#1] with taking her scheduled medications. Resident [#1] remains unable to be consoled Resident [#1] spit it out and continued yelling. Resident [#1] denied her coke zero, offered to assist Resident [#1] to the restroom. Resident [#1] refused assistance. Resident [#1] started screaming again. notified NP of her lab results as well. NP stated that since resident is non-verbal and can't really tell you what's wrong or pinpoint any specifics to send her out to ER to be evaluated and treated. ADON, DON notified, family notified. DNR, Medication list, labs, and face sheet sent with resident with EMS. Review of Resident #1's hospital records dated 10/26/2025 reflected: Problem list - Vascular Dementia with behavioral/agitation. Continue home Depakote. Depakote level noted to be low. If noted to have worsening behavioral disturbance, can consider titrating the dose. Review of Resident #1's hospital records dated 10/27/2025 reflected: Continue home Depakote. Depakote level noted to be low- increasing Depakote to BID. Review of Resident #1's hospital discharged orders dated 10/28/2025 reflected an order for Divalproex Sodium (Depakote) Oral Tablet Delayed Release 250 MG (Divalproex Sodium) Give 1 tablet BID. It also reflected blue checks on the right side of the medication and black checks on the left side of the medication listed on the scanned document. Review of Resident #1's NP's note dated 10/28/2025 reflected Divalproex Sodium Oral Tablet Delayed Release 250 MG (Divalproex Sodium) Give 1 tablet by mouth one time a day for mood stabilizer DO NOT CRUSH active 10/09/2025. Review of Resident #1's current physician's order dated 11/05/2025 reflected an order for Divalproex Sodium Oral Tablet Delayed Release 250 MG (Divalproex Sodium) Give 1 tablet by mouth one time a day for mood stabilizer DO NOT CRUSH dated 10/08/2025. Review of Resident #1's current MAR for 11/2024 reflected an order for Divalproex Sodium Oral Tablet Delayed Release 250 MG (Divalproex Sodium) Give 1 tablet by mouth one time a day for mood stabilizer DO NOT CRUSH dated 10/08/2025. It was noted there was no documented evidence that Resident #1 was started on Divalproex Sodium Oral Tablet Delayed Release 250 MG (Divalproex Sodium) Give 1 tablet BID as was ordered in the hospital. Review of Resident #1's clinical records reflected no documentation of the hospital order for Divalproex Sodium (Depakote) Oral Tablet Delayed Release 250 MG (Divalproex Sodium) Give 1 tablet BID being discontinue and why. During an interview on 11/04/2025 at 12:33 pm RN B stated she worked with Resident #1 on 10/25/2025 and she was the one who sent Resident #1 to the ER. RN B stated Resident #1 had behavior problems like screaming but on 10/25/2025 they were unable to calm Resident #1 down. RN B stated Resident #1 refused all attempts to be redirected. RN B stated she noticed Resident #1 was in her wheelchair all day, usually she would attempt to walk but not that day and was on one-on-one monitoring. RN B stated Resident #1 spit out her pain medication and no intervention was effective. RN B stated she called the on-call NP and notified her and told her [NP] that she [RN B] could not figure out what was wrong with Resident #1. RN B stated the NP ordered Resident #1 to be sent to the ER since she was non-verbal, not at baseline and was not able to say what was happening. During a phone interview on 11/04/2025 at 1:04 pm the NP stated she had no idea Resident #1's Depakote 250 mg was increased to BID while in the hospital. The NP then stated maybe Resident #1 was seen by the Psych NP after her hospital stay that was why her Depakote BID from the hospital was decreased to once a day. The NP stated she [NP] was looking at Resident #1's progress notes and it was noted Resident #1 was still on Depakote 250 mg PO daily and was dated 10/09/2025. The NP stated sometimes she and the MD made changes to psych medications as needed. The NP stated due to the clinical effect of sedation, she would want to keep Resident #1 on Depakote once a day, but she could not find where she made changes to Resident #1's hospital order from BID to once a day. The NP stated she understood if there were no orders to discontinue the Depakote 250mg BID order and order to resume Depakote 250 mg once a day, that was a medication errorDuring an interview on 11/04/2025 at 1:27 pm the DON stated on 10/25/2025 she received a call from RN B that Resident #1's yelling had increased and was not able to walk, the on-call was notified, and Resident #1 was sent to the ER. The DON stated that when a resident was admitted or re-admitted , the admitting nurse was responsible for verifying the medications with the NP and transcribe to the resident's clinical records. The DON stated typically, there would be a check mark by the medication that the NP wanted the resident to continue taking and no check mark to the medication they wanted to discontinue. The DON stated she did not know Resident #1's Depakote 250 mg was increased to BID while in the hospital. The DON stated the ADON was responsible for auditing new admission and readmission medications after the medications had been transcribed to ensure the resident was taking the right medications as were ordered in the hospital. The DON stated if Resident #1's medication list indicated the medications were approved, checked, and not carried over, then that was medication error, except there was something else written beside the medication. The DON stated if the MD/NP decided to change Resident #1's Depakote 250 mg BID to once a day on a later date, it should have been documented. The DON reviewed Resident #1's hospital discharge orders and the check marks next to the medications and stated it should have been Depakote 250 mg BID.During an interview on 11/04/2025 at 1:55 pm the ADON stated the nurses were supposed to verify medication with the NP before transcribing to the resident's clinical records. The ADON stated she couldn't remember if she was in the facility when Resident #1 was re-admitted to the facility, but she was made aware by LVN A that the NP was present and reviewed Resident #1's hospital discharge orders. The ADON stated she remembered Resident #1's Depakote was changed to 250 mg BID. The ADON stated she verified /audited Resident #1's orders and she remembered seeing Resident #1's Depakote 250 mg BID. The ADON looked at the resident's orders in the computer and stated the BID orders were not there, only the once-a-day order and it showed the order from 10/09/2025 and not the order from readmission on [DATE]. The ADON stated it was a medication error, but there was no medication error report because she did not realize until being asked. During a phone interview on 11/04/2025 at 2:16 pm LVN A stated she was the nurse working when Resident #1 was re-admitted to the facility on [DATE]. LVN A stated they usually verified the medications for admission and re-admission with the NP before transcribing the orders in the resident's clinical records. LVN A stated she verified Resident #1's hospital discharge orders with the NP while the NP was in the facility on the day of re-admission. LVN A stated she could not remember Resident #1's exact discharge order for Depakote but if there was a check mark on the order sheet, that was what the NP verified and approved. LVN A stated every medication with the check mark meant to go ahead and give to the residents. LVN A stated sometimes the NP would make changes to medications upon admission and there would be a note indicating that. During another phone interview on 11/04/2025 at 2:45 pm the NP called back and stated the blue check mark on Resident #1's discharge orders from the hospital was done by her [NP]. The NP stated she approved Resident #1's order from the hospital for Depakote 250 mg BID and later intended to decrease to Depakote 250 mg daily but did not write the order. The NP stated she and the MD were discussing Resident #1 coming back to the facility on palliative care with hospice and was thinking about discontinuing some medications. The NP later sent a text message exchange between she and the MD dated 10/28/2025 at 6:05 pm indicating discontinuing some of Resident #1's medications once Resident #1 got on hospice services on 10/29/2025. It was also noted in the text message exchange that the MD stated to change Resident #1's medication to crushed to enable Resident #1 to be compliant with medication administration. Review of Resident #1's clinical records reflected no order to discontinue medications or to change Depakote 250 mg bid to once a day. Review of the facility's policy titled Medication Orders, undated reflected: POLICY: It is the policy of this facility that medications are administered only upon the clear, complete. and signed order of a person lawfully authorized to prescribe. Verbal orders are received only by licensed nurses or pharmacists and confirmed in writing by the prescriber within forty eight (48) hours.2. Documentation of the Medication Order.A. Each medication order is documented in the resident's medical record with the date, time, and signature of the person receiving the order. The order is recorded on the physician order sheet, or the telephone order sheet if it is a verbal order and the medication Administration Record (MAR). Call (or fax) the medication order to the provider pharmacy. Transcribe newly prescribed medications on the MAR or treatment record. When a new order changes the dosage of a previously prescribed medication, discontinue previous entry by writing DC'd and the date and yellowing through the entry. Enter the new order on the MAR. After completion, document each medication order noted on the physician's order form with the date, time, and signature. Review of the facility's policy titled Medication Errors and Adverse Reactions revised 12/2019 reflected: POLICY:It is the policy of this facility that medication errors and adverse drug reactions must be reportedto the resident's attending physician.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs for one (Resident #1) of five residents reviewed for care plans, in that: The facility failed to care plan Resident #1's history of refusal of care and medication from 01/02/2025 to present. This failure placed residents at risk of not receiving goals and interventions for the residents' individual needs for person-centered care. Findings included: Review of Resident #1's face sheet dated 06/30/25 reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure (a patient has a pre-existing chronic heart failure condition that suddenly worsens due to both systolic (the pressure in your arteries when your heart contracts and pumps blood out to the body) and diastolic (the pressure in the arteries when the heart is at rest between beats) dysfunction, vascular dementia (damage to the brain's blood vessels impairs cognitive functions, leading to memory, thinking, and behavioral changes) and cognitive communication deficit (communication difficulties stemming from impairments in cognitive processes like attention, memory, and reasoning, rather than primary language or speech problems). Review of Resident #1's quarterly MDS assessment, dated 04/27/25, reflected a BIMS score of 3, indicating severe cognitive impairment. [BR1] [TN2] Review of Resident #1’s Nurse Progress Note (identity of nurse unknown) dated 1/2/2025 reflected nurse attempted to assess resident's weight; resident refused. Nurse attempted three times with no success. Review of Resident #1’s Nurse Progress Note by LVN A dated 03/30/25 eMAR Medication Administration Note reflected Resident #1 refused her medication. Review of Resident #1’s Nurse Progress Note by LVN A dated 04/03/25 eMAR Medication Administration Note reflected Resident #1 refused her medication. Review of Resident #1’s Nurse Progress Note by LVN A dated 04/05/25 eMAR Medication Administration Note reflected Resident #1 refused her medication. Review of Resident #1’s Nurse Progress Note by LVN A dated 04/09/25 eMAR Medication Administration Note reflected Resident #1 refused her medication. Review of Resident #1’s Nurse Progress Note by LVN A dated 04/10/25 eMAR Medication Administration Note reflected Resident #1 refused her medication. Review of Resident #1’s Nurse Progress Note by LVN A dated 04/11/25 eMAR Medication Administration Note reflected Resident #1 refused her medication. Review of Resident #1’s Nurse Progress Note by LVN A dated 04/15/25 eMAR Medication Administration Note reflected Resident #1 refused her medication. Review of Resident #1’s Nurse Progress Note by LVN A dated 04/16/25 eMAR Medication Administration Note reflected Resident #1 refused her medication. Review of Resident #1’s Nurse Progress Note by LVN A dated 04/16/25 eMAR Medication Administration Note reflected Resident #1 refused her medication. Review of Resident #1’s Nurse Progress Note by LVN A dated 05/03/25 eMAR Medication Administration Note reflected Resident #1 refused her medication. Review of Resident #1’s Nurse Progress Note by LVN A dated 05/04/25 eMAR Medication Administration Note reflected Resident #1 refused her medication. Review of Resident #1’s Nurse Progress Note by LVN A dated 05/05/25 eMAR Medication Administration Note reflected Resident #1 refused her medication. Review of Resident #1’s Nurse Progress Note by LVN A dated 05/09/25 eMAR Medication Administration Note reflected Resident #1 refused her medication. Review of Resident #1’s Nurse Progress Note by LVN A dated 05/10/25 eMAR Medication Administration Note reflected Resident #1 refused her medication. Review of Resident #1’s Nurse Progress Note by LVN A dated 05/15/25 eMAR Medication Administration Note reflected Resident #1 refused her medication. Review of Resident #1’s Nurse Progress Note by LVN A dated 05/21/25 eMAR Medication Administration Note reflected Resident #1 refused her medication. Review of Resident #1’s Nurse Progress Note (identity of nurse unknown) dated 05/26/25 reflected Resident #1 refused shower and bed bath this evening. Review of Resident #1’s Nurse Progress Note (identity of nurse unknown) dated 06/09/25 reflected Resident #1 refused shower when asked by CNA and nurse and refused bed bath. Review of Resident #1's care plan reflected no identified focus, goals, or interventions/tasks for her history of refusal of care and medication. Interview on 06/30/25 at 3:42 pm with the Wound Care Nurse revealed he had witnessed Resident #1 being resistant to resident care, but she had not refused care when he had offered wound care. He said a combination of people were responsible for care plans. He said the MDS Coordinator was not the only person responsible for care plans. He said the care plan was a structured plan geared to a specific outcome with intentional interventions. He said it was important to know if a resident had care refusal because it would change the approach that needed to be taken for resident care. Interview on 06/30/25 at 3:58 pm with the MDS Coordinator reflected, after she reviewed Resident #1’s care plan, that Resident #1’s care plan did not include medication or shower refusals and said the refusals should be included in the care plan. She said the MDS coordinator was ultimately responsible for the care plan, but it was a group effort because she was not a floor nurse, and she had to rely on the information that had been discussed in morning clinical meetings to update the care plan. She said she did not recall that the staff had discussed Resident #1’s history of medication or shower refusals in morning clinical meetings. She said every nurse in the building had access to the care plans and the ability to update the care plan. She said a care plan was in place for everybody to know the status of where residents were and what care they needed. She said if something was not care planned, staff would not know all aspects of a residents care. She said resident refusals for showers and medication were important because if the resident was developing sores or a rash the facility would know why and would be able to notify the MD about what was going on. She said that care plans included interventions that assisted with resident care. Interview on 06/30/25 at 5:19 pm with LVN A revealed he regularly administered Resident #1 her medications and she had a history of refusing medication at least 50% of the time and additionally, she refused showers. He said the care plan was needed for any resident issues, concerns, and solutions. The care plan was in place to prevent resident issues or have a plan to, overtime, solve resident issues. He said the DON was responsible for care plans and he thought care plans were definitely important because they were a reminder to the staff of the care that they give to the residents. He said he thought including resident refusal of medications and care were important to add to the care plan so the nurse was up to date and could keep track of if the resident improved or did not improve. He said the negative affect of not included medication and care refusals in the resident care plan was if the resident was refusing medication, health issues the resident was having were not being addressed. He said because he worked in the evenings and did not attend staff morning meetings, but he believed that the DON had been told about Resident #1 refusing medication and showers. Interview on 06/30/25 at 4:30 pm with LVN B revealed she worked with Resident #1 and Resident #1 refused showers. She said the purpose of a care plan was to know how to care for a resident step by step. She said it was a plan for care. She said that resident refusals should be care planned because it was important to know what to do when a resident refused care. She said the interventions in a care plan could help to solve a problem with a resident. She said nurses were responsible for care plans and Resident #1’s refusals of showers had been discussed in the morning clinical meetings. Interview on 07/03/25 at 4:02 pm with the Administrator revealed a care plan was an assessment that painted a picture of the resident and the MDS Coordinator was responsible for the care plans. It was the responsibility of the floor nurses to inform the MDS Coordinator about Resident #1’s shower and medication refusals at the morning clinical meeting. She said she did not know until recently that Resident #1 refused care and said refusal of care should be care planned. She said you would want refusals of shower and medications to be care planned because you would want everyone to be aware of the refusals. She said there could be possible interventions for refusals that could help. Care plans are needed because they were important to patient centered care. She said ultimately the DON was responsible for making sure the care plans were person centered and completed. Interview on 07/03/25 at 5:56 pm with the DON reflected she was not previously aware that Resident #1 had a history of refusals of showers and medications. She said a care plan was in place because it let the facility know the things that you needed to do for the resident. She said the DON and the MDS Coordinator were responsible for the care plans. She said the Resident #1’s refusals of medication and shower should have been discussed at morning clinical meeting. She said a possible negative affect of not care planning Resident #1’s refusals of medications and showers was that other staff did not know she had a history of refusing her medication and her showers. Review of facility policy Comprehensive Person-Centered Care Planning dated December 2023 reflected it was 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. Resident goal refers to the resident’s desired outcomes and preferences for admission, which guide decision making during care planning. Interventions are actions, treatments, procedures, or activities designed to meet an objective. Measurable is the ability to be evaluated or quantified. Objective is a statement describing the results to be achieved to meet the resident’s goals. Person centered care means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives.

Based on interview and record review the facility failed to ensure that residents received proper treatment to maintain vision abilities by not assisting the resident in making appointments for 1 of 20 residents (Resident #1) reviewed for vision. The facility failed to address Resident #1's glasses and vision issues, first requested by Resident #1's family via email in March of 2025. Resident #1 did not corrective lenses to assist her vision. This deficient practice could affect residents who need vision and hearing services and could result in avoidable vision loss and a decreased quality of life. Findings included: Review of Resident #1's face sheet dated 06/30/25 reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure (a patient has a pre-existing chronic heart failure condition that suddenly worsens due to both systolic (the pressure in your arteries when your heart contracts and pumps blood out to the body) and diastolic (the pressure in the arteries when the heart is at rest between beats) dysfunction, vascular dementia (damage to the brain's blood vessels impairs cognitive functions, leading to memory, thinking, and behavioral changes) and cognitive communication deficit (communication difficulties stemming from impairments in cognitive processes like attention, memory, and reasoning, rather than primary language or speech problems). Review of Resident #1's quarterly MDS assessment, dated 04/27/25, reflected a BIMS score of 3, indicating severe cognitive impairment. Review of Hearing, Speech, and Vision Section B 1000 reflected vision adequate in light (with glasses or other visual appliances) and Section B1200 Hearing, Speech, and Vision reflected corrective lenses (contacts, glasses, or magnifying glass) used, No. Review of Resident #1's care plan reflected focus dated 01/26/24 revealed the resident was at risk for impaired visual function, goal dated 01/26/24 and revised on 12/18/24. The goal reflected Resident #1 will use appropriate visual devices to promote participation in ADL’s and other activities. Interventions dated 01/26/24 reflected arrange consultation with eye care practitioner as required, remind resident to wear glasses when up. Review of an email sent to a facility staff, 1st FFE, from Resident #1’s family member dated 03/05/25 reflected, “Do you know how we would go about getting my [Resident #1’s] glasses fixed? They are very loose and need some adjusting because they keep falling off. Is there someone that comes to do this?” Review of an email sent from a facility staff member, 1st FFE, to Resident #1’s family member dated 03/06/25 reflected, “There is an optometrist that visits. I’ll call and see if they make adjustments in house or send out the glasses to a lab and get back with you.” Review of a email sent to a facility staff, 1st FFE, from Resident #1’s family member dated 03/17/25 reflected, “I was just writing to follow up regarding the glasses and when we might be able to have someone take a look at them.” Review of an email sent from Resident #1’s family member to AA dated 03/18/25 reflected, “Hi [AA] I had been in correspondence with [1st FFE] at the beginning of the month to try and get [Resident #1’s] glasses fixed and an eye exam. I sent an email to follow up yesterday and got the reply that [1st FFE] was no longer with [facility name]. I just wanted to touch base with someone to see if she was able to contact the visiting optometrist, or what the next steps would be. Unfortunately, her glasses are falling off and are in need of adjustment. “ Review of an email sent from AA to Resident #1’s family member dated 03/18/25 reflected, “I will let you know when her appointment is made.” Review of an email sent from Resident #1’s family member to AA dated 03/25/25 reflected, “I was just following up on the eye appointment for my [Resident #1] to fix her glasses and to get an exam. Has her appointment been made yet?” Review of an email sent from Resident #1’s family member to 2nd FFE and cc’d AA dated 04/07/25 reflected, “I wanted to let someone know that one of the lenses in my [Resident #1’s] glasses fell out due to one of the screws coming out. We found them on her rolling tray today, and I tried looking for the screw but had no luck finding it. Were there any updates regarding her appointment with the optometrist? We left her glasses and the lense on top of her tall dresser.” Review of an email sent from Resident #1’s family member to AA and cc’d to the facility Administrator dated 04/30/25 reflected, “I was writing again to follow up on my [Resident #1’s] optometrist/dental appointments. Her glasses have been missing since Saturday, and no one knows where they are. We searched her room and couldn’t find them.” Review of an email sent from Resident #1’s family member to SW dated 06/09/25 reflected, “I was just following up to see if the optometrist was able to see my [Resident #1] last week or if there’s a pending visit.” Review of an email sent from SW to Resident #1’s family member dated 06/09/25 reflected, “I have recently reached out to the optometrist asking if there would be a visit soon. What I have just found out is they need 20 people minimum to be seen otherwise they can’t see folks. I’ve asked them to see if they can make an exception and I’m waiting on their response. This was definitely news to me to say the least.” Review of an email sent from Resident #1’s family member to SW dated 06/17/25 reflected, “I just wanted to follow up about the optometrist appointment and if they ever got back to you.” Review of an email sent from Resident #1’s family member to SW dated 06/18/25 reflected, “I wanted to see if I could get the name of the optometrist who visits the facility. If we cannot get her seen at [facility name], then our family will need to figure out another way to get her an eye exam and a new set of glasses. We’ve been trying since the beginning of March to get her glasses fixed, and now they’re lost and need to be replaced. She has not had an eye exam or dental exam since she was admitted in November of 2023.” Review of an email sent from SW to Resident #1’s family member dated 06/19/25 reflected, “I’ve tried to escalate request to [provider name], our optometry provider as they keep saying they need 20 patients on the roster before they can come out. They came the week I started so I’m not sure what changed. I included [the Administrator] to see what options we may have as I know [Resident #1] has vision needs.” Attempted interview on 06/30/25 at 6:00 pm with Resident #1 revealed the resident was not interviewable. Interview on 07/03/25 at 4:14 pm with the SW revealed she had been working as the facility social worker for 2 months and prior to her, they did not have a social worker. The SW said Resident #1’s family had kept asking for Resident #1’s glasses issue to be addressed and it was rather urgent. The SW wore glasses and said she understood it was miserable if people did not have their glasses. She said the last time the optometry provider was at the facility was when she was hired, and the provider will not come to the facility unless there are 20 residents who need optometry assistance. She said Resident #1 was on the list to be seen when the optometry provider comes to the facility. Interview on 07/03/25 at 4:02 pm with the Administrator revealed Resident #1’s family had discussed Resident #1’s glasses situation since April of 2025. Resident #1 was currently on the list with other residents to be seen when the optometrist comes to the facility. The Administrator said the facility had not had a social worker for a while and that was who would normally handle optometry and glasses issues. Resident #1’s family member sent an email to the former AA about the glasses then the AA quit. The ADON was asked to take care of Resident #1’s glasses needs and the ADON stopped working at the facility. Sometime in the middle of May 2025 Resident #1’s glasses needs were discussed during the morning clinical meeting. The Administrator said she understood that Resident #1’s family took her glasses to be repaired because they were broken but she was not aware if the glasses were returned. She said with the staff turnover, Resident #1’s glasses issues were not addressed. She said it was the responsibility of the Administrator and the DON to make sure residents have their glasses. She said if you were already confused, Resident #1 had dementia, you would be more confused and frustrated if you did not have your glasses.

Based on interview, and record review, the facility failed to ensure residents had the right to send and receive mail for 7 of 7 confidential residents reviewed for right to communication. The facility failed to ensure residents received their mail on the weekend. This failure could put residents in the facility who receive mail at risk for not receiving mail in a timely manner that could result in a decline in resident's psychosocial well-being and quality of life. Findings included: During a confidential group interview on 5/14/2025 at 11:00 am., 7 of 7 residents said mail was not being distributed on the weekend. They indicated they were unsure why mail was not delivered by the weekend staff. They indicated they had never received mail on the weekend, nor had they ever been asked at their regular monthly meetings about receiving mail on the weekend. They stated they thought that was not a service offered by the facility. In an interview on 05/14/25 at 1:05 PM BOM stated the Receptionist is responsible for going and getting the mail from the mailbox. BOM stated after receipt of mail the Receptionist then separates the mail for the facility and for the residents. BOM stated the mail is locked in a drawer at the Receptionist desk until Monday and then given to the AD to distribute to the residents. BOM stated the residents have never received mail on the weekends since they have worked at the facility. In an interview on 05/15/25 at 10:05 AM Receptionist stated they had worked at the facility for 2 1/2 years. Receptionist stated they are the only person in the facility that has a key for the mailbox. Receptionist stated they go pick the mail up from the mailbox and then they take the mail to the BOM who sorts thru the mail and removes anything that is for the facility. Receptionist stated since they can't leave the front desk they wait until they see residents going out of the building for physical therapy and they will let them know at that time to stop by on their way back in to pick up their mail. Receptionist stated if they do not see a resident come thru then they give the mail to the AD to distribute to the residents. Receptionist stated they check the mail daily Monday thru Friday. Receptionist stated the mail is not checked on the weekend as they do not work on the weekends. Receptionist stated any mail delivered on the weekend is picked up on Monday when they go retrieve the mail and it is then distributed to the residents. Receptionist stated they did not feel the residents having to wait until Monday to receive mail could negatively affect them or that it would be a violation of Resident Rights. Receptionist stated this has been the process since they started working at the facility. In an interview on 05/15/25 at 10:25 AM AD stated they were not aware the residents did not receive mail on the weekend. AD stated they were under the impression that the weekend Receptionist got the mailbox key from the weekday Receptionist and went and retrieved the mail. AD stated they knew Amazon packages were delivered to the residents on the weekends. AD stated it was the responsibility of the Receptionist and the AD for ensuring the residents have access to their mail. AD stated it could negatively affect a resident by not receiving mail on the weekends if it is something that is time sensitive and that it is also a violation of Resident Rights. In an interview on 05/16/25 at 11:30 AM DON stated they did not know the exact process for resident mail delivery. DON stated they were unaware that the residents did not receive mail on the weekends. DON stated it could negatively affect a resident by not receiving mail on the weekends and that it was a violation of Resident Rights as well. DON stated it was the responsibility of the facility staff for ensuring the residents have access to and receive their mail in a timely fashion. In an interview on 05/16/25 at 12:15 PM ADM stated the Receptionist receives the mail and the AD is responsible for distributing the resident mail. ADM stated the facility had recently hired a new AD assistant and they will also be responsible for helping to distribute resident mail. ADM stated the Receptionist is the one who has access to the mailbox key. ADM stated they were unaware that the weekday receptionist did not pass off the mailbox key to the weekend Receptionist. ADM stated they were unaware that the residents did not receive mail on the weekends. ADM stated it could potentially negatively affect a resident emotionally by not receiving mail on the weekends. ADM stated not having access to receiving mail on the weekends could potentially be a violation of Resident Rights. ADM stated it was the responsibility of the AD and the Receptionist to ensure the residents have access to and receive their mail. Record review of Federal Resident Rights dated 02.24.2022 found in the Resident admission packet reflected in the section Privacy and Confidentiality that a resident had the right to send and receive unopened mail and other letters, packages, and other materials delivered to the facility for you, including those delivered through a means other than the postal service. Record review of the HUMAN RESOURCES CODE CHAPTER 102. RIGHTS OF THE ELDERLY (texas.gov) accessed on 5/22/2025 revealed: An elderly individual has all the rights, benefits, responsibilities, and privileges granted by the constitution and laws of this state and the United States, except where lawfully restricted. The elderly individual has the right to be free of interference, coercion, discrimination, and reprisal in exercising these civil rights. (b) An elderly individual has the right to be treated with dignity and respect for the personal integrity of the individual, without regard to race, religion, national origin, sex, age, disability, marital status, or source of payment. This means that the elderly individual: . (g) An elderly individual is entitled to privacy while attending to personal needs and a private place for receiving visitors or associating with other individuals unless providing privacy would infringe on the rights of other individuals. This right applies to medical treatment, written communications, telephone conversations, meeting with family, and access to resident councils. An elderly person may send and receive unopened mail, and the person providing services shall ensure that the individual's mail is sent and delivered promptly. If an elderly individual is married and the spouse is receiving similar services, the couple may share a room.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 (Resident # 24, #42, # 43, # 78, and # 79) of 8 residents reviewed for infection control and 10 (MA, LVN L, DA, LVN M, HK, CNA F, CNA O, CNA P, PT, and Maintenance Manager) of 17 staff reviewed for infection control in that: 1. The facility failed to ensure LVN L conducted hand hygiene when passing resident lunch trays to Resident #24, Resident #42, Resident #43, Resident #78, and Resident #79. 2. The facility failed to ensure TB screenings were completed annually for MA, LVN L, DA, HK, CNA F, CNA O, CNA P, PT, and Maintenance Manager. 3. The facility failed to ensure TB screening was completed within 2 weeks of hire for LVN M. These failures could place residents at risk of transmission of disease and infection. Findings include: 1. Record review of Resident #42's admission record, dated 05/16/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #42 had diagnoses which included: Anemia (a condition of low red blood cells that can cause fatigue, shortness of breath, and pale skin), unspecified dementia (a disease that causes a general decline in cognitive abilities that can affect the ability to perform everyday activities, memory loss, and poor judgement), other chronic pancreatitis (a long-term inflammation of the pancreas that can lead to persistent abdominal pain and digestive issues), and cognitive communication deficit (difficulty with communicating). Record review of Resident #42's Quarterly MDS, dated [DATE], reflected a BIMS score 0, which indicated severe cognitive impairment. Record review of Resident #42's care plan, dated 12/06/2023 and last revised on 12/18/2024, reflected: Focus: [Resident #42] has an ADL self-care performance deficit r/t dementia. Interventions/Tasks included: Eating- [Resident #42] needs limited assistance with eating. Observation on 05/13/2025 at 01:04 PM revealed LVN L took a tray off the meal tray carts and delivered it to Resident #42. LVN L assisted Resident #42 with setting up the tray then returned to the meal tray cart and set the empty tray in a stack. LVN L did not perform hand hygiene prior to or after delivering the tray to Resident #42. 2. Record review of Resident #78's admission record, dated 05/16/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #78 had diagnoses which included: Type II Diabetes Mellitus (a condition that affects the way the body processes blood sugar), chronic kidney disease (a disease in which kidneys are damaged and can't filter blood properly), unspecified dementia (a disease that causes a general decline in cognitive abilities that can affect the ability to perform everyday activities, memory loss, and poor judgement), hypertension (high blood pressure), and cognitive communication deficit (difficulty with communicating). Record review of Resident #78's Quarterly MDS, dated [DATE] reflected a BIMS score 03, which indicated severe cognitive impairment. Record review of Resident #78's care plan, dated 09/25/2023 and last revised on 09/24/2024, reflected: Focus: [Resident #78] ADL self-care performance deficit r/t impaired mobility, incontinence, dementia. Interventions/Tasks included: Eating: resident requires x 1 staff participation to eat. Observation on 05/13/2025 at 01:05 PM revealed LVN L took a tray off the meal tray carts and delivered it to Resident #78. LVN L assisted Resident #78 with setting up the tray then returned to the meal tray cart and set the empty tray in a stack. LVN L did not perform hand hygiene prior to or after delivering the tray to Resident #78. 3. Record review of Resident #43's admission record, dated 05/16/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #43 had diagnoses which included: unspecified dementia (a disease that causes a general decline in cognitive abilities that can affect the ability to perform everyday activities, memory loss, and poor judgement), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), dysphagia (difficulty with swallowing), and cognitive communication deficit (difficulty with communicating). Record review of Resident #43's Quarterly MDS, dated [DATE], reflected a BIMS score 00, which indicated severe cognitive impairment. Record review of Resident #43's care plan, dated 10/04/2022 and last revised on 09/11/2024, reflected: Focus: [Resident #43] has potential nutritional problem r/t dysphagia current diet order Regular Mechanical soft with thin liquids. Interventions/Tasks included: Provide and serve diet as ordered. Observation on 05/13/2025 at 01:07 PM revealed LVN L took a tray off the meal tray carts and delivered it to Resident #43. LVN L assisted Resident #43 with setting up the tray then returned to the meal tray cart and set the empty tray in a stack. LVN L did not perform hand hygiene prior to or after delivering the tray to Resident #43. 4. Record review of Resident #24's admission record, dated 05/16/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #24 had diagnoses which included: unspecified dementia (a disease that causes a general decline in cognitive abilities that can affect the ability to perform everyday activities, memory loss, and poor judgement), hyperlipidemia (high cholesterol), Bipolar II (a mental disorder that can cause mood swings and severe depression), Essential Hypertension (high blood pressure), Type II Diabetes Mellitus (a condition that affects the way the body processes blood sugar), and dysphagia (difficulty with swallowing). Record review of Resident #24's Comprehensive MDS, dated [DATE], reflected a BIMS was not conducted. Section C - Cognitive Patterns reflected Resident #24 had memory problems with short-term and long-term memory. Record review of Resident #24's care plan, dated 10/26/2022 and last revised on 06/10/2024, reflected: Focus: [Resident #24] has an ADL Self Care Performance Deficit/ Muscle wasting and atrophy. Interventions/Tasks included: Eating- supervision and set up, assist as needed. Observation on 05/13/2025 at 01:08 PM revealed LVN L took a tray off the meal tray carts and delivered it to Resident #24. LVN L assisted Resident #24 with setting up the tray then returned to the meal tray cart and set the empty tray in a stack. LVN L did not perform hand hygiene prior to or after delivering the tray to Resident #24. 5. Record review of Resident #79's admission record, dated 05/16/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #79 had diagnoses which included: chronic kidney disease (a disease in which kidneys are damaged and can't filter blood properly), Alzheimer's Disease with early onset (a progressive brain disorder that slowly destroys memory and thinking skills and ultimately interfering with daily life/activities that starts before the age of 65), hypertension (high blood pressure), hyperlipidemia (high cholesterol), and cognitive communication deficit (difficulty with communicating). Record review of Resident #79's Quarterly MDS, dated [DATE], reflected a BIMS score 99, which indicated the resident was unable to complete the interview. Section C- Cognitive Patterns reflected Resident #79 had short-term and long-term memory problems. Record review of Resident #79's care plan, dated 09/25/2023 and last revised on 01/14/2024, reflected: Focus: [Resident #79] has an ADL self-care performance deficit r/t age-related physical debility. Goal included: Will maintain current level of function in bed mobility, transfers, eating, dressing, grooming, toilet use and personal hygiene through the review date. Observation on 05/13/2025 at 01:10 PM revealed LVN L took a tray off the meal tray carts and delivered it to Resident #79. LVN L assisted Resident #79 with setting up the tray then returned to the meal tray cart and set the empty tray in a stack. LVN L did not perform hand hygiene prior to or after delivering the tray to Resident #79. Interview on 05/13/2025 at 01:14 PM with LVN L revealed she had worked at the facility almost a year. She stated she had been trained on infection control. LVN L stated it was policy to perform hand hygiene, either wash hands or sanitize hands, before picking up a new tray for a resident. LVN L stated she didn't sanitize her hands between each resident while passing trays. She stated she knew she was supposed to but didn't do it. LVN L stated if hands were not sanitized between touching residents, then an infection could be passed from one resident to another. Interview on 05/15/2025 at 10:43 AM with CNA F revealed she had been trained on infection control. She stated it was policy to perform hand hygiene every time between residents when passing out meal trays. She stated not doing so could spread infection between the residents. Interview on 05/15/2025 at 10:53 AM with LVN H revealed she had been trained on infection control. She stated when passing meals trays it was important to wash hands every 3 residents and use hand sanitizer between every resident. She stated bacteria can grow and cause infection. LVN H stated not performing hand hygiene is the #1 cause of spreading infections. Interview on 05/15/2025 at 11:13 AM with MA revealed she had received training on infection control. MA stated they were supposed to perform hand hygiene or sanitize their hands between every tray. She stated not performing hand hygiene between each tray could spread germs between residents. Interview on 05/15/2025 at 11:56 AM with the ADM revealed she had been in her current position at the facility since October 2022. She stated she had received training on infection control. She stated she expected all staff to perform some sort of hand hygiene before handling each resident's tray. The ADM stated if hand hygiene was not performed, it could cause an infection between the residents. Interview on 05/15/2025 at 12:37 PM with the DON revealed she received training on infection control. She stated she expected staff to sanitize their hands when entering the dining room and between each resident's tray. The DON stated there was a member of the nursing administration team in each dining room for each meal and they were required to monitor for hand hygiene with tray pass. She stated if hand hygiene wasn't performed between contact with each resident, then germs could be spread between residents. Interview on 05/16/2025 at 10:17 AM with LVN I revealed she had received training on infection control. She stated staff were expected to wash hands before serving meal trays and sanitize between each resident's tray. LVN I stated residents could get an infection if hand hygiene was not performed appropriately. Interview on 05/16/2025 at 11:13 AM with CNA E revealed she had received training on infection control. She stated staff were trained to sanitize hands between each resident and wash their hands every 3 residents. CNA E stated if hand hygiene wasn't performed correctly then germs could spread from one resident to another. Interview on 05/16/2025 at 11:21 PM with LVN K revealed she received training on infection control. LVN K stated she was expected to wash or sanitize hands after each meal tray. She stated not doing so could cause an infection in one of the residents. Interview on 05/16/2025 at 12:20 PM with the IP revealed she was responsible for the infection prevention and control program. She stated the expectation for staff when serving meal trays was to sanitize before and in between each resident's tray. The IP stated not doing so could spread germs from one resident to another. She stated she monitored hand hygiene but was not sure how frequently. 6. Record review of facility personnel file for MA reflected the following: MA with a DOH of 7/14/24 and a TB screening form dated 4/6/22. 7. Record review of facility personnel file for LVN L reflected the following: LVN L with a DOH of 7/15/24 and a TB screening form undated. 8. Record review of facility personnel file for DA reflected the following: DA with a DOH of 3/20/23 and a TB screening form undated. 9. Record review of facility personnel file for CNA F reflected the following: CNA F with a DOH of 11/11/22 and a TB screening form undated. 10. Record review of facility personnel file for CNA O reflected the following: CNA O with a DOH of 1/13/25 an no documented TB screening completed. 11. Record review of facility personnel file for CNA P reflected the following: CNA P with a DOH of 1/6/25 and no documented TB screening completed. 12. Record review of facility personnel file for HK reflected the following: HK with a DOH of 4/28/25 and no documented TB screening completed. 13. Record review of facility personnel file for Maintenance Manager reflected the following: Maintenance Manager with a DOH of 12/5/24 and a TB screening form undated. 14. Record review of facility personnel file for PT reflected the following: PT with a DOH of 6/19/23 and a TB screening form dated 7/14/21. 15. Record review of facility personnel file for LVN M reflected the following: LVN M with a DOH of 1/15/24 and a TB screening form dated 9/5/24. In an interview on 05/16/25 at 11:00 AM HR stated they had worked at the facility for 2 years and they are responsible for ensuring the personnel files are complete and accurate. HR stated they were aware that TB screenings had not been completed annually, dated, or upon hire for some staff members. HR stated the facility had discussed the problem at their QAPI meetings and put a new program in place after it was discovered that nursing was not attending the employee orientation and completing the TB screening and testing or dating the screens that had been completed. HR stated it could possibly negatively affect a resident if the staff TB screenings were not completed upon hire and annually because there could be potential of infection of TB. In an interview on 05/16/25 at 11:30 AM DON stated HR is responsible for completing personnel files and checking for accuracy. DON stated they were not aware that TB screenings had not been conducted for some of the staff members. DON stated it could possibly negatively affect a resident if a TB screening was not conducted for a staff member and if they had TB they could infect the residents. In an interview on 05/16/25 at 12:15 PM ADM stated HR is responsible for completing personnel files and checking for accuracy. ADM stated they had been made aware in the last couple of weeks that TB screenings had not been being completed for staff and that a new process had been implemented to address the issue. ADM stated it could negatively affect a resident by TB screenings not being completed by infection exposure. In an interview on 05/16/25 at 12:30 PM IP stated they were not aware that TB screenings were not being completed until the survey team brought it to the attention of the facility. IP stated the facility is currently putting together a corrective action plan to address the issue. IP stated it is the responsibility of the IP and HR to ensure TB screenings are being conducted upon hire and annually thereafter. IP stated it could negatively affect a resident if a staff member has active TB and could potentially pass it on to the residents. Requested policy related to hand hygiene and dining service on 05/14/2025 at 12:33 PM. Received response to refer to the Texas Food Establishment Rules for policy. Record review of Texas Food Establishment Rules reflected no mention of hand hygiene specifically during dining service meal pass. Record review of facility policy titled, Personnel Files and Record Maintenance with a revision date of 07/2014 reflected the following: Policy . It is the policy of the company that personnel records will be maintained for all employees in compliance with this policy and state and federal requirements. Procedure 6. The employee's confidential file includes, but is not limited to the following documents: H. TB test results Record review of facility policy titled, Infection Prevention and Control Program dated 06/2021 and last revised in 10/2022 reflected the following: Policy . The elements of the infection prevention and control program consist of coordination/oversight, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. The program will be carried out by the facility infection preventionist. It is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene based on acceptable standards . Scope of the Infection Control and Prevention Program: The infection prevention and control program is comprehensive in that it addresses detection, prevention, and control of infections among residents and personnel. 1.Surveillance of infections and reporting There is on-going monitoring for infection among residents and personnel and subsequent documentation of infections that occur. Surveillance tools are used to recognize the occurrence of infections, record their number and frequency, detect outbreaks and epidemics, monitor personnel infections, and detect unusual pathogens with infection control implications. This also includes reporting of communicable disease per Centers for Disease Control (CDC) guidelines. a. Under the infection control program, the facility will: Investigate, control, and prevent infections in the facility. 3. The facility personnel will conduct themselves and provide care in a way that minimizes the spread of infection. b. Facility personnel will wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice .

Based on interview and record review, the facility failed to operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility for 6 (ADM, HK, CNA F, PT, IP, and Maintenance Manager) of 17 employees personnel files reviewed. The facility failed to conduct reference checks for ADM, HK, CNA F, PT, IP, and Maintenance Manager prior to employment. These failures placed the residents at risk of abuse, neglect, and exploitation. Findings included: 1. Record review of facility personnel file for ADM reflected the following: ADM with a DOH of 10/1/22 and no documentation of reference checks on file. 2. Record review of facility personnel file for HK reflected the following: HK with DOH of 4/28/25 and no documentation of reference checks on file. 3. Record review of facility personnel file for CNA F reflected the following: CNA F with DOH of 11/11/22 and no documentation of reference checks on file. 4. Record review of facility personnel file for PT reflected the following: PT with a DOH of 6/19/23 and no documentation of reference checks on file. 5. Record review of facility personnel file for IP reflected the following: IP with a DOH of 5/10/24 and no documentation of reference checks on file. 6. Record review of facility personnel file for Maintenance Manager reflected the following: Maintenance Manager with DOH of 12/5/24 and no documentation of reference checks on file. In an interview on 05/16/25 at 11:00 AM HR stated they had worked at the facility for 2 years. HR stated they were responsible for completing personnel files and checking for accuracy. HR stated they were aware reference checks had not been completed for some of the staff. HR stated some of the staff in question were hired prior to her starting work at the facility and for the ADM she does not complete their personnel file. She said that is completed by the service center corporate staff, and she was unable to provide an answer as to why the ADM references were not checked prior to employment. HR did not provide an answer as to why the reference checks were not completed for the staff in question that had been hired in the past 2 years that they had worked for the facility. HR stated it could possibly negatively affect a resident if reference checks were not completed upon hire by putting residents at risk of abuse or neglect. In an interview on 05/16/25 at 11:30 AM DON stated HR is responsible for completing personnel files and checking for accuracy. DON stated they were not aware that reference checks had not been completed for staff. DON stated it could potentially negatively affect a resident by potentially putting them at risk of abuse or neglect if reference checks are not completed and it would just depend on the results of the reference checks. In an interview on 05/16/25 at 12:15 PM ADM stated it is the responsibility of HR for completing personnel files and checking for accuracy. ADM stated they were not aware reference checks were not being completed on staff. ADM stated it could negatively affect a resident if a staff member is hired that is not safe to be around residents with the potential for abuse or neglect. Record review of facility policy titled, Pre-Employment Investigation Texas with a revision date of 01/2022 reflected the following: Policy . Reasonable and prudent pre-employment investigations, including reference checks, applicable licensing, and certification verifications, criminal background checks and other necessary or desirable pre-employment checks are conducted on applicants for employment. Pre-employment offer Procedures . 4. Required reference checks. The hiring manager or designee must perform a minimum of two reference checks with prior employers on all applicants successfully completing a personal interview. All references must be documented, using the Confidential reference check form. Completed reference checks are kept in the applicant's confidential application file. Record review of Abuse: Prevention of and Prohibition Against policy undated reflected Policy: 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. The facility will provide oversight and monitoring to ensure that its staff, who are agents of the facility, deliver care and services in a way that promotes and respects the rights of the residents to be free from abuse, neglect, misappropriation of resident property, and exploitation. Procedures: A. Screening (Prospective Employees) 1. Prior to hire, the facility will screen potential employees for a history of abuse, neglect, exploitation, or misappropriation of resident property. This screening will include but not limited to: -Attempting to obtain information from previous employers and/or current employers, whether favorable or unfavorable. -Reviewing the prospective employee's employment history, especially when there is or may be a pattern of inconsistency.

Based on observation, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for sanitation. 1. The facility failed to dispose of perishable food products that are opened and not sealed properly. 2. The facility failed to properly label and date food products in the dry food storage, refrigerator, and freezer. 3. The facility failed to ensure Maintenance Manager wore a facial and hair restraint properly while performing duties throughout the kitchen. These failures could place residents who were served from the kitchen at risk for consuming contaminated food and developing foodborne illnesses. Findings include: Observation on 05/13/2025 at 9:09 AM revealed undated or labeled deli-ham slices in a Ziplock baggy not sealed properly in the kitchen refrigerator. Observation revealed an undated open gallon of milk in the kitchen refrigerator. Observation revealed there was an undated or labeled open bag of frozen tortillas in the kitchen freezer. Observation revealed there was a rice bin lid open and not sealed appropriately in the kitchen dry food storage. Observation revealed there was a sugar bin lid not sealed shut securely in the kitchen dry food storage. Observation revealed the Maintenance Manager walked through the main kitchen preparation area not wearing a hair or facial hair restraint as he had a full-grown beard. In an interview on 05/14/2025 at 10:15 AM [NAME] stated she has been trained in hair restraints and it's to prevent hair getting in food for the residents they serve and for infection control. [NAME] has been trained in labeling and dating. [NAME] stated all food products that were opened had to be labeled and dated, and if not, it needs to be thrown away since the food can cause harm to residents if they are served undated food products. In an interview on 05/14/2025 at 10:20 AM Dietary Manager B stated she has been trained in facial and hair restraints. Dietary Manager B stated it's important to wear facial and hair restraints to prevent contaminating food and avoid hair getting in the food the facility serves to the residents. Dietary Manager B stated if facility staff are not wearing proper facial and hair restraints, a resident can choke on a hair in the food, or it can contaminate the food and cause illness to a resident. Dietary Manager B stated all staff in the facility have been trained to wear facial and hair restraints, and it's her expectation for all staff to follow wearing hair restraints and it's posted on signs at each entrance and throughout the kitchen area. Dietary Manager B stated staff not wearing hair or facial hair restraints can cause a quality-of-life issue with residents. Dietary Manager B stated she has been trained in labeling and dating food products. Dietary Manager B stated the training went over labeling and dating food products or anything that's been opened needs to be labeled and dated. Dietary Manager B stated all food products need to be closed and secured properly. Dietary Manager B stated if there is any food not labeled or dated in the dry food storage, refrigerator, and freezer, it needs to be thrown away since staff won't know how long it's been stored. Dietary Manager B stated it's important to label and date food products to make sure they are safe to consume for the residents. Dietary Manager B stated it will be an issue giving residents exposed open food or undated and labeled food, as it can get a resident ill or hospitalize the resident, and potentially lead to a resident dying. Dietary Manager B stated not labeling and dating food products poses a concern to the resident's quality of life. In an interview on 05/14/2025 at 10:35 AM Dietary Resource Consultant stated she has been trained in labeling and dating. Dietary Resource Consultant stated all staff in the kitchen are trained to do labeling and dating. Dietary Resource Consultant stated her expectation on labeling and dating is for anything that arrives to be dated, anything opened is to be dated, and any leftovers are to be dated along with consumption within 72 hours. Dietary Resource Consultant stated it's important to label and date so it can prevent illness to residents and serve residents good food products. Dietary Resource Consultant stated if food is not properly closed, or labeled and dated, it can pose a quality-of-life concern to the residents as the food should be thrown away and not given to the residents. Dietary Resource Consultant stated she has been trained in wearing facial and hair restraints. Dietary Resource Consultant stated all staff are trained to wear facial and hair restraints and even if staff wear a hat they are to wear a hair restraint as well. Dietary Resource Consultant stated even maintenance has been trained on wearing hair restraints, and there are postings of facial and hair restraints at each entrance along with extra hair restraints. Dietary Resource Consultant stated it's important to wear facial and hair restraints due to working with vulnerable residents. It's to prevent hair getting in the food and it isn't pleasant for residents to see hair in the food and a resident can gag if eating food with hair. Dietary Resource Consultant stated if any of the policies or rules in the kitchen aren't followed it can pose concerns for the residents and potentially can cause death. In an interview on 05/14/2025 at 10:50 AM Dietary Aide stated she has been trained in facial and hair restraints, and it's important to prevent hair getting in the food for the residents. Dietary Aide stated everyone is trained in facial and hair restraints, not just the kitchen staff. Dietary Aide stated facial and hair restraints are posted at the entrances and exits for all staff. Dietary Aide stated residents shouldn't eat food that has hair in it from a staff member not wearing hair restraints. Dietary Aide stated she has been trained in labeling and dating as all food products need to be dated and labeled especially food that is opened otherwise kitchen staff will have to throw the food product away. Dietary Aide stated the kitchen staff shouldn't provide residents food that isn't labeled and dated as it can get residents sick. In an interview on 05/14/2025 at 11:05 AM Dietary Manager A stated he's been trained in labeling and dating such as, dating anything that's open and sealing food properly. Dietary Manager A stated food products not labeled and dated should be discarded if they are in the refrigerator, freezer, or dry food storage. Dietary Manager A stated it's important for food to be labeled and dated to make sure food is in regulatory compliance and up to date with not serving bad food quality. Dietary Manager A stated if food products in the dry food storage, refrigerator, or freezer were not labeled and dated or sealed properly as well as not thrown away, it can pose a quality health issue for the residents such as, by getting a resident sick or spreading of diseases. Dietary Manager A stated he's been trained on wearing facial and hair restraints and all staff have been trained in that as well as an in-service was conducted yesterday on it including there are postings at the entrance to the kitchen. Dietary Manager A stated it would be a concern for him if staff aren't wearing proper facial and hair restraints as it helps to prevent hair getting in food keeping the food products, they serve safe for the residents they provide food to. In an interview on 05/14/2025 at 11:58 AM Maintenance Manager stated he's been trained in wearing facial and hair restraints, and all staff are trained to wear hair and facial hair restraints before entrance to the kitchen. Maintenance Manager stated there is posted signs to tell facility staff to wear facial and hair restraints. Maintenance Manager stated to wear facial and hair restraints along with extra facial and hair restraints stored at the entrance before entering the kitchen area . Maintenance Manager stated it's important to wear facial and hair restraints as it's a sanitation issue for the residents. Maintenance Manager didn't divulge as to why he didn't remember to wear a facial and hair restraint when entering the kitchen area, but he stated knowing all the expectations to follow. In an interview on 05/15/2025 at 9:30 AM Director of Nursing stated she has been trained in facial and hair restraints and staff aren't supposed to enter the kitchen without putting on facial and hair restraints. Director of Nursing stated she is newer and not 100 percent sure if there are postings listed for facial and hair restraints. Director of Nursing stated there were extra facial and hair restraints outside of the kitchen area for staff to utilize. Director of Nursing stated it's important for staff to utilize facial and hair restraints so staff in the kitchen area don't contaminate the food products or get hair in the food. Director of Nursing stated if there was hair in the resident's food, it can pose a health issue to them such as, a resident who has difficulty swallowing can choke. Director of Nursing stated she has been trained on labeling and dating food products that come into the kitchen area. Director of Nursing stated everything foodwise should be dated or have the use by date listed on it. Director of Nursing stated it's important to label and date foods to prevent providing residents expired food or drinks as it can get a resident sick. Director of Nursing stated her expectations for labeling and dating by the kitchen staff as well as utilizing facial and hair restraints is for the policy to be followed at all times by facility staff for the resident's quality of life . Director of Nursing stated resident's quality of life can be affected if kitchen staff aren't properly wearing facial and hair restraints nor appropriately labeling and dating since it's supposed to be a homelike environment for the residents. In an interview on 05/15/2025 at 9:49 AM Administrator stated she has been trained on facial and hair restraints including the proper covering of hair before entering the kitchen., She said it's for all staff if she remembers correctly and not just the kitchen staff as it's for infection control. Administrator stated she believes if a staff member isn't wearing a facial or hair restraint in the kitchen area, it can possibly be a health issue to residents. Administrator stated her expectation is for all staff to wear facial and hair restraints in the kitchen area. Administrator stated she has been trained in labeling and dating such as, kitchen staff are to properly label and date if it's for a certain resident and expiration dates. Administrator stated if not dated or labeled food products from the kitchen area such as, dry food storage, refrigerator, and freezer, are served to the residents, it won't be adequate for the residents and would need to be thrown away. Administrator stated it could be a concern if a resident was served undated or not labeled food from the kitchen as it can be a contamination issue or health issue to residents. Administrator stated her expectations for labeling and dating were for the kitchen staff to make sure everything is labeled and dated immediately. Administrator stated the resident's quality of life can be affected if staff aren't wearing proper facial and hair restraints if hair is in the food and if residents are being given expired food that's not at the quality level it should be. In an interview attempt on 05/15/2025 at 1:32 PM with Dietician, two back-to-back call out attempts via phone were made with no answer and the calls went straight to voicemail. A voicemail message was left, and no call was returned. Review of provided policy documents reflected that the facility didn't have a direct policy on file for facial and hair restraints to provide. Review of provided policy documents reflected that the facility didn't have a direct policy on file for labeling and dating to provide. Review of the provided policy documents reflected the facility follows the Texas Food Establishment Rules for facial and hair restraints, and for labeling and dating. Review of Texas Food Establishment Rules reflected: Chapter 3 of the Texas Food Establishment Regulations outlines essential food preparation requirements to ensure safety and compliance in food service operation. Food Safety Practices: Food must be sourced from approved suppliers, and prepared food must be stored properly, labeled with expiration dates, and kept at appropriate temperatures. This includes practices for cooling hot foods down safely and preventing cross-contamination. Review of Texas Food Establishment Rules reflected: Food employees must wear effective hair restraints to prevent contamination while handling food, especially those in direct contact with food, are required to wear hair restraints designed to keep hair away from food and food contact surfaces. Types of Hair Restraints; Employees must wear hair nets, caps, or other types of hair coverings to ensure no hair falls into food. This rule applies to all food handlers in cooking, food preparation, or serving roles. Facial Hair Guidelines: Food handlers with beards or mustaches may be required to wear beard nets or similar restraints to avoid food contamination. The specific requirements can vary based on the establishment's policies. Adhering to hair restraint guidelines is critical in preventing foodborne illnesses and maintaining customer satisfaction. Failure to comply can result in health code violations for establishments.

Based on observation, interview and record review, the facility failed to ensure residents were free from involuntary seclusion and any physical restraint not required to treat the resident's medical symptoms for 1 of 8 (Resident #73) residents reviewed for involuntary seclusion. The facility failed to ensure Resident #73 met criteria to remain on the secure unit per secure unit criteria. This failure could place residents who resided on the secure unit at risk for feelings of isolation and anxiety. Findings included: Record review of Resident #73's admission record, dated 05/16/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #73 had diagnoses which included: unspecified dementia (a disease that causes a general decline in cognitive abilities that can affect the ability to perform everyday activities, memory loss, and poor judgement), Alzheimer's Disease (a progressive brain disorder that slowly destroys memory and thinking skills and ultimately interfering with daily life/activities), depression (a mood disorder characterized by a persistent feeling of sadness and loss of interest), age-related physical debility (general decline in strength and vitality associated with aging), and generalized anxiety disorder ( a condition characterized by persistent and excessive worry about everyday issues). Record review of Resident #73's IDT-BIMS assessment dated [DATE], reflected a BIMS score 03, which indicated severe cognitive impairment. Record review of Resident #73's Elopement/Wandering Evaluation dated 01/30/2025 reflected a low-risk score. Ambulation status was answered with Immobile in bed or chair. Section: History of elopement in last 6 months reflected A. no history B. Resident makes statement about a desire to leave the facility 0. No C. Does the wandering place the resident at significant risk of getting to a potentially dangerous place 1. No, resident has not exhibited wandering behavior but has a history of wandering D. Does the wandering significantly intrude on the privacy or activities of others? 1. No, resident has not exhibited wandering behavior but has a history of wandering and E. How does the resident's wandering behavior compare to prior evaluation or 90 days if a new admission? 2. Same. Record review of Resident #73's Elopement/Wandering Evaluation dated 04/30/2025 reflected a low-risk score. Ambulation status was answered with Immobile in bed or chair. Section: History of elopement in last 6 months reflected A. no history B. Resident makes statement about a desire to leave the facility 0. No C. Does the wandering place the resident at significant risk of getting to a potentially dangerous place 0. Not applicable, resident has no history or current behaviors of wandering D. Does the wandering significantly intrude on the privacy or activities of others? 0. Not applicable, resident has no history or current behaviors of wandering and E. How does the resident's wandering behavior compare to prior evaluation or 90 days if a new admission? 0. Not applicable, resident has no history or current behaviors of wandering. Record review of Resident #73's IDT-Care Plan Review dated 04/02/2025 reflected Section VII. Care Plan Elements 7b. Additional comments: remains on secure unit. Record review of Resident #73's order summary, dated 05/16/2025, reflected no orders for secure unit placement. Record review of Resident #73's nurses notes, dated 03/16/2025-05/16/2025, reflected no wandering or elopement attempts documented. Record review of Resident #73's care plan, dated 10/11/2022 and last revised on 02/06/2025, reflected: Focus: [Resident #73] has an ADL self-care performance deficit. Interventions/Tasks included: Bed mobility- assist of one, transfer- extensive assist of 2. Record review of Resident #73's care plan, dated 01/30/2024 and last revised on 09/11/2024, reflected: Focus: [Resident #73] is an elopement risk/wanderer r/t history of attempts to leave facility unattended. Interventions/Tasks included: Document wandering behavior and attempted diversional interventions. Observation on 05/13/2025 at 10:47 AM revealed Resident #73 sitting at a dining room table in the secure unit in her specialty wheelchair sleeping. Observation on 05/13/2025 at 02:13 PM revealed Resident #73 transferred with assist from bed to wheelchair. Resident appeared tired and unable to speak with surveyor. In an interview on 05/15/2025 at 11:56 AM the ADM revealed residents were admitted to the secure unit based off their elopement assessment and behaviors. She stated that in order to admit a resident to the secure unit it would require a discussion with the family or responsible party, a discussion with the resident, and a discussion with the doctor. The ADM stated no consent form or order was required. If a resident were identified as not appropriate for the secure unit anymore then they would be transferred to the next available bed that was appropriate for the resident. She stated that the psychologist and therapy would assess the resident prior to transfer from the secure unit. She stated she was aware of one resident that was in the process of receiving the necessary evaluations, but she didn't think Resident #73 was being evaluated. Interview on 05/15/2025 at 12:37 PM with the DON revealed the admission process to the secure unit is the same everywhere. She stated if the elopement risk was high then they look at the paperwork and verify it with the nurse. The DON stated she thought an order should be received first. She stated that no consent was received prior to placement on the secure unit. She stated if the resident had not had exit seeking or wandering behaviors for a [unknown] period of time, then there was a discussion with the practitioner to evaluate the resident for placement off the secure unit. The DON stated the DON and practitioner should work together to decide who should be transferred off the secure unit. She stated she had not seen a policy on what the criteria for admission to the secure unit included. She stated if a resident was on the secure unit that didn't meet criteria, then it could make the resident feel isolated. Interview on 05/16/2025 at 10:17 AM with LVN I revealed she had not witnessed Resident #73 move her wheelchair independently and had never witnessed any exit seeking behaviors either. She stated she had worked at the facility 10 months but had been working in the secure unit full time for about 3 months. LVN I stated Resident #73 only really wakes up to eat or perform ADLs with assistance. She stated Resident #73 liked to remain in one spot. LVN I stated if a resident was on the secure unit and didn't have the need to be there then the resident may get depressed and miss out on social activities. Interview on 05/16/2025 at 11:08 AM with LVN H revealed she worked PRN in the facility. She stated she had not seen Resident #73 move herself around in the wheelchair. She stated that Resident #73 had not displayed any exit seeking or wandering behaviors around her. LVN H stated Resident #73 would be a good candidate to be moved off the secure unit. Interview on 05/16/2025 at 12:06 PM with the DON revealed she was not familiar with Resident #73, but that any resident who was not able to move around the facility independently should be assessed for transfer off the secure unit. She stated Resident #73 was not on the list for assessment for transfer off the secure unit. The DON stated that Resident #73 should be assessed for transfer off the secure unit so Resident #73 doesn't feel so isolated. Phone interview on 05/16/2025 at 12:13 PM with the MD revealed he was the provider for Resident #73. He stated he felt Resident #73 was safe in the secure unit since they have CNAs and activities on the secure unit. The MD stated the process to have a resident moved off the secure unit was for the facility to monitor the resident then make a recommendation to him. He stated he would then assess the resident for transfer off the secure unit. He stated he doesn't think having a resident who does not meet criteria back in the secure unit would affect the resident in any way. The MD stated, in the deeply demented (residents who had dementia that had progressed) patient, they don't realize they are on a locked unit anyway. Interview on 05/16/2025 at 12:20 PM with the IP revealed she was familiar with Resident #73. She stated she had never witnessed Resident #73 move her wheelchair independently or exhibit any wandering/exit seeking behaviors. The IP stated if the resident is not mobile then they don't require placement in the secure unit. She stated she was unaware if Resident #73 was on the list for assessment for transfer off the secure unit. The IP stated having a resident on the secure unit that didn't require it could leave the resident out of some social activities. Interview on 05/16/2025 at 12:30 PM with the ADM revealed she had not witnessed Resident #73 move her wheelchair independently or the resident exhibit any exit seeking behaviors. She stated she didn't make the decisions on what residents remained in the secure unit. She stated the decision was made by the Interdisciplinary Team and therapy or the charge nurse needed to make the recommendation for determination. The ADM stated that residents that were on the secure unit and didn't meet criteria could be left out of some of the social activities with the rest of the facility. Record review of undated facility policy titled Secured Unit admission Criteria reflected: Procedure: 1. The admission Coordinator or designee obtains information about possible placement on new referrals to the unit. Residents transferring from facility to unit will be assessed by IDT to ensure that the clinical criteria for placement is met. admission Criteria: a. The individual must have a dementia diagnosis and/or cognitive impairment with wandering or exit seeking behavior. b. Resident should be ambulatory or able to wheel self when in wheelchair as a criteria for admission to the unit. 2. There will be documentation of resident/ representative's involvement in the decision for placement in the secured/locked area. 3. Documentation that reflects whether placement in the secured/locked area is the least restrictive approach that is reasonable to protect the resident and assure his/her health and safety. Transition from secure unit guidelines: Psychological evaluation Contact Medical Director Contact Treating Provider New Elopement Assessment Nursing documentation x 3 days Family notification Roommate compatibility and room availability

Based on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs for 2 of 14 residents (Residents #36 and #14) reviewed for call lights button device in reach. The facility failed to ensure that Resident #36 had the call light button device in reach while resident was sitting in her wheelchair in her room, next to her bed. The facility failed to accommodate Resident #36 with a call light device that would meet their individual needs. The call light was hanging on the wall out of reach. The facility failed to ensure that Resident #14 had the call light button device in reach while Resident was lying in bed. The facility failed to accommodate Resident #14 with a call light device that would meet their individual needs. the call light device was in the room and located on the floor (right side of bed) out of reach of resident. This deficient practice could affect and diminish the resident's quality of life by potentially placing the resident at risk of injury, not receiving timely care or receiving nursing interventions to meet the resident's needs, and or it can make the resident feel neglected affecting their mental health. The findings included: Review of Resident #36's Face Sheet dated 05/15/2025 reflected Resident # 36 was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #36 had diagnoses which included Huntington's Disease (condition that affects a person's movements, thinking ability and mental health) , Severe Dementia ( Condition which involves memory loss, affecting thinking, and social abilities which interfere with their daily lives), Behavioral Disturbance ( Refers to a range of disruptive behaviors), Psychotic Disturbance (A severe mental health condition characterized by a disconnection from reality, often manifesting as hallucinations and delusions). Mood Disturbance ( mental health condition that primarily affects a person's emotional state) and Anxiety Disorder, Unspecified ( Characterized by feelings of fear or apprehension about what's to come and persistent and excessive worry), Unspecified Severe Protein-Calorie Malnutrition (A serious condition characterized by inadequate intake of protein and calories), and Other Seasonal Allergic Rhinitis (known as Hay Fever is an allergic reaction that causes sneezing, congestion, itchy nose and watery eyes) . Review of Resident #36's Quarterly MDS (assessment used to determine functional capabilities and health needs) Assessment, dated 04/12/2025 reflected in Section GG Functional Abilities, indicated the resident was Dependent for ADLs meaning, Staff does all of the effort and Resident #36 does none of the effort to complete the activity. Review of Resident # 36's Assessment by IDT and BIMS dated 03/23/2025 reflected resident interview cannot be conducted due to resident is rarely / never understood. Therefore, a BIMS score of 0 (indicates severe cognitive impairment)is was reported for Resident # 36. Review of Resident #36's Comprehensive Care Plan dated 04/12/2025 reflected Resident # 36 required assistance with bed mobility, bathing, hygiene, toileting, dressing, grooming, eating, and all assisted daily living care needs. The goals were for Resident #36 to maintain current level of cognitive function, tolerate ordered diet, maintain weight and nutritional balance. Observation on 05/13/25 @10:45 AM revealed Resident #36 was sitting in a wheelchair and her body was performing making involuntary repetitive movements of hands, arms, and legs. During the observation, it was found that the call light button device (specialized for this resident, ultra-sensitive) was seen to be out of reach located on the bed table behind the resident's wheelchair. Resident #36 was observed to have contracted hands. There was no observation of an additional call light or pad button device attached to the wheelchair for the resident's use. Surveyor attempted an interview with Resident # 36 on 05/13/2025 at 10:45 AM. Resident # 36 was unable to communicate verbally with Surveyor. Resident # 36 made brief eye contact with Surveyor. Observation of Resident # 36 on 05/15/25 @ 08:31 AM revealed Resident # 36 was sitting in her wheelchair, resting with her eyes closed. Observed a specialized, flat call button hanging on the upper right of residents. wheelchair upper right of Resident # 36's shoulder on the wheelchair. The call button was not within reach of Resident # 36. In an interview on 05/13/25 @ 10:55 AM CNA D stated regarding call light button devices, that CNAs are responsible for the call button and that CNA D usually moves the call button closer to Resident #36, but Resident # 36 doesn't use the call button. CNA D explained the specialized, round, flat call button is very sensitive, and it comes on with the slightest movement. CNA D advised she will check on Resident # 36's call button location now. In an interview on 05/14/25 at 02:39 PM LVN G stated she did not know what has been done about the call light for Resident # 36. LVN G was asked if she believes that Resident # 36 could reach the call button in its current location on the upper right-hand side of the wheelchair? LVN G stated that maybe the call button should be located on the handrail of the wheelchair for easier access by Resident # 36. In an interview on 05/15/25 @ 11:17 AM RN stated that everyone is responsible for making sure the call light is within reach of Resident # 36, and she stated, we are a team. RN was asked did you notice that the call button was not within reach of Resident #36? RN stated no, she didn't notice that the call button was not within reach of Resident #36. The RN stated that Resident # 36 is checked on when we they do their rounds and adjustments should be made when and if the call button appears to be in the wrong place. In an interview on 05/15/25 @ 1:20 PM DON stated, each Resident should be able to reach his/her call light button. DON stated the entire team is responsible for making sure the call buttons are accessible to each Resident. DON stated, Staff includes CNAs 's, Nurses, and Therapy. Staff should be checking for call light location and accessibility to the resident when entering any Resident's room. DON stated training is required regarding the call button location and the importance of accessibility to the residents. DON stated training and reminders to the staff should be done on a regular basis. Surveyor inquired of the DON, does DON know that Resident # 36 has a specialized, flat call button and does DON know if there are any trainings for the use of this type of call button? the DON said she did not know Resident #36 had a specialized, flat call button and was not aware of any trainings for the use of this type of call button. The DON said if Resident #36 is unable to reach the call button, the resident's needs may not be met. The DON stated, did not know and not that I am aware of. DON understands that if Resident # 36 is unable to reach the call button, the resident's needs may not be met. Resident #14 The facility failed to ensure that Resident #14 had the call light button device in reach while Resident was lying in bed. The facility failed to accommodate Resident #14 with a call light device that would meet their individual needs. This deficient practice could affect and diminish the resident's quality of life by potentially placing the resident at risk of injury, not receive timely care or receive nursing interventions to meet the resident's needs, and or it can make the resident feel neglected affecting their mental health. Findings include: Review of Resident #14's Face Sheet dated 05/15/2025 reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #14 had diagnoses which included: Other Sequelae of Cerebral Infarction ( refers to the long-term, late effects or conditions that can occur after a cerebral infarction (ischemic stroke) , Vascular Dementia (a type of cognitive decline caused by damage to the blood vessels in the brain) , Moderate, with Mood Disturbance (a significant change in a person's emotional state that can affect their thoughts, feelings, and behaviors) , Aphasia (neurological condition that impairs a person's ability to communicate effectively), Mood Disorder Due to known Physiological Condition with Depressive Features ( a type of mental health condition characterized by persistent sadness, low energy, loss of interest in activities, and other symptoms that can significantly impact daily life)., Unspecified Dementia (a condition where a person exhibits dementia symptoms but the specific type of dementia cannot be determined) , Unspecified Severity, with other behavioral disturbance ( a dementia diagnosis where the severity level is not specified, but behavioral disturbances are present). Mixed Receptive- Expressive Language Disorder (is a neurodevelopmental condition where individuals struggle with both understanding (receptive language) and expressing (expressive language) through communication) Adjustment Disorder with Mixed Anxiety and Depressed Mood, Insomnia (a mental health condition where an individual experiences both anxiety and depressed symptoms alongside sleep difficulties in response to a specific stressful life event) , Moderate Protein-Calorie Malnutrition (a state where an individual's weight is 2 or more, but less than 3 standard deviations below the mean for their age and sex) Hyperlipidemia (a medical condition characterized by abnormally high levels of lipids (fats) in the blood), Unspecified Depression (a person is experiencing depressive symptoms but doesn't meet the criteria for a more specific diagnosis within the depressive disorder category.) Unspecified, Essential (Primary) Hypertension (high blood pressure where there's no known identifiable cause.), Aphasia following Cerebral Infarction (an acquired language disorder that affects a person's ability to understand and/or express language. Other Hyperlipidemia (conditions where there's an abnormally high level of lipids (fats) in the blood, specifically excluding high levels of LDL cholesterol (often referred to as bad cholesterol) and triglycerides) Other Specified Glaucoma (Glaucoma is a group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of your eye called the optic nerve), Other Speech and Language Deficits following Cerebral Infarction (the death of brain tissue caused by a sudden interruption of blood flow, leading to a lack of oxygen and vital nutrients) , Disorientation (the condition of having lost one's sense of direction) Unspecified, need for assistance with Personal Care. Review of Resident #14's Quarterly MDS Assessment, dated 04/12/2025, revealed the MDS for functional abilities with activities of daily living was not completed. indicated in Section C- Cognitive Patterns (Cognition also describes how the brain perceives and expresses experiences) the resident's BIMS score was 00 (indicates severe cognitive impairment) and Behavior present, fluctuates (Comes and goes, changes in severity). Section GG indicated the resident's range of motion ROM listed has no impairment, and resident used a walker. Review of Resident # 14's Care Plan dated 04/30/2025 reflected Resident # 14 required assistance with bed mobility, hygiene, toileting (transfer to chair when toileting), dressing and eating. Staff was to encourage Resident # 14 to discuss feelings about self -care deficit and to fully participate if possible with each interaction. Observation on 05/13/25 at 08:50 AM revealed Resident #14 was lying in bed with eyes closed and revealed the call light device was in the room and located on the floor (right side of bed) out of reach of resident. Interview attempted on 05/13/25 at 08:50 AM. Surveyor spoke softly to Resident # 14, but Resident#14 was asleep and did not awaken. In an Observation: on 05/14/2025 at 12:27 PM., Surveyor Observed Resident # 14 was in bed and sleeping soundly., The call button/ device was located between the headboard and the wall not in reach of the resident. In an Interview on 05/15/25 at 10:35 AM CNA C was asked 'Who is responsible for making sure the call light is within reach of this resident? CNA C stated, CNA C stated they were responsible for making sure the call light was within reach of the residents they were assigned to. We are responsible for that person in which we are assigned to CNA C said she did not notice the call button was not within reach of Resident #14. Surveyor inquired; did you notice that the call button was not within reach of Resident # 14? CNA C stated Missed that. I Didn't see that. CNA C stated Resident # 14 often throws things and Resident # 14 has repeatedly thrown her call button as she gets frustrated that it is in her way on her bed. CNA C stated she understands that they are required to reposition the call button if it is not in the right place. CNA C stated if a residents can't use a call button, it is horrible, horrible and they could get hurt. CNA C stated she understands if residents don't get assistance when needed, they would not be happy, and CNAs are the eyes mouth and ears for these people. In an interview on 05/15/25 at 10:44 AM LVN H stated everyone on staff is responsible for making sure the call light is within reach of the resident. LVN H stated Resident # 14 often throws the call button off the bed and onto the floor, even if staff put the call button on the bed, next to Resident # 14 she will throw it off the bed. LVN H stated if a resident is not able to use the call button to call for help, the residents could hurt themselves. LVN H stated, if a resident is not able to get help, they may feel unsafe. LVN H stated she does not know why Resident # 14's call button would have been located on the back of the bed frame against the wall and out of reach of the resident. In an interview on 05/15/25 @ 1:10 PM DON stated the entire team to include CNAs, Nurses and Therapy team should be checking to make sure the call buttons are within reach of all Residents when entering a Resident's room. DON stated Staff are trained to observe the location of the call buttons for each resident when the Staff enter a resident's room. DON also stated the Team should be reminded on a regular basis to observe all residents' call button locations. DON stated she believes Resident # 14 may have thrown her call button where is it landed on the back of the bed frame against the wall. DON stated Residents could attempt to ambulate without proper assistance and could injure themselves if the resident is not able to call for assistance when needed. DON stated that Staff Management do room rounds often and the staff should be educated on this matter. In an interview on 05/15/2025 @ 3:51 PM ADM was asked 'Is there in-service training for staff regarding requirements to observe and address residents call buttons? ADM stated, yes, there was one on one training and an online training course for staff regarding requirements to observe and address residents' call buttons. ADM stated, residents may feel Anxious if they are not able to call for help. ADM stated that training regarding call lights is being conducted today. Record Review of Surveyor located an in- service log dated 05/15/2025 subject titled Ensuring Call lights are within reach. Revealed that staff had been trained on call light placement. Record Review Call Light/ Bell: Undated revealed there is no policy saying a call light has to be within reach. The policy stated that Staff is responsible for answering a call light.

Based on observations, interviews, and record review the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for 1 of 4 residents (Resident #52) reviewed for medication errors. The facility failed to ensure LVN M administered medications according to physician's order and policy for Resident #52 when LVN M left 2 medications on the over the bed table and left the room. This failure could place residents at risk for missed dosages resulting in reduced healing or unnecessary hospitalizations. Findings include: 1. Record review of Resident #52's admission record, dated 05/16/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #52 had diagnoses which included: cognitive communication deficit (difficulty with communicating), moderate protein-calorie malnutrition (the body does not receive enough protein and calories to maintain proper health and functioning), unspecified dementia (a disease that causes a general decline in cognitive abilities that can affect the ability to perform everyday activities, memory loss, and poor judgement), irritable bowel syndrome with constipation (a condition characterized by abdominal pain and disordered bowel habits), hypothyroidism (a condition where the thyroid gland doesn't produce enough thyroid hormone leading to a slowdown in metabolism), and chronic idiopathic constipation (a long-term condition characterized by infrequent bowel movements with no identifiable cause). Record review of Resident #52's Comprehensive MDS, dated [DATE], reflected a BIMS score 08, which indicated moderate cognitive impairment. Record review of Resident #52's care plan, dated 04/10/2025, reflected: Focus: [Resident #52] has unplanned/unexpected weight loss r/t poor food intake. Interventions/Tasks included: Give supplements as ordered. Alert nurse/dietitian if not consuming on a routine basis. Record review of Resident #52's care plan, dated 04/13/2025, reflected: Focus: [Resident #52] has hypothyroidism and receives medication daily. Interventions/Tasks included: Monitor of s&sx of hypothyroidism: chronic fatigue (tiredness), difficulty concentrating, sensitivity to cold, headache, muscle and joint aches, weight gain, constipation, and dry skin. Record review of Resident #52's order summary, dated 05/16/2025, reflected: 2 cal three times a day 120 ml TID or equivalent supplement and polyethylene glycol 3350 oral powder 17 gm/scoop Give 1 scoop by mouth two times a day for bowel support mix with 6-8 oz fluid of choice. Record review of Resident #52's medication administration record for the month of May 2025 on 05/16/2025 reflected both polyethylene glycol 3340 oral powder and 2 cal were administered on 05/14/2025 in the AM by LVN M. Observation on 05/14/2025 at 07:48 AM of Medication Administration with LVN M revealed LVN M failed to ensure Resident #52 consumed 2 cups of liquid with medication. One 8 oz cup contained approximately 5 oz water mixed with polyethylene glycol 3350 oral powder 17gm (a medication used for constipation). The other cup contained approximately 4 oz of Ready care 2.0 (the equivalent to 2cal). LVN M then told Resident #52, Thank you. I will return later to make sure you drank these. LVN M then left the cups with medication on the over the bed table across Resident #52's lap, walked to the bathroom, washed his hands, and left the room. Attempted interview on 05/14/2025 at 07:53 AM with Resident #52. Resident not able to answer questions appropriately at this time. Interview on 05/15/2025 at 10:53 AM with LVN H revealed the policy was to ensure residents take all of their medications prior to leaving the resident. She stated this included polyethylene glycol and 2 cal. LVN H stated if those medications were left at the bedside unattended by staff, then it could spill and cause a fall hazard or someone else that it wasn't prescribed to, could take it and it could cause unintended reactions. Interview on 05/15/2025 at 11:13 AM with MA revealed when administering medications, they were expected to watch the resident take all their medications prior to leaving the resident. She stated if medication was left at the bedside, then another resident could take the medication and have unintended side effects or an allergy to the medication. Interview on 05/15/2025 at 11:56 AM with the ADM revealed it was her expectation that during medication administration, the staff ensure the resident swallowed all their medication. The ADM stated if staff doesn't watch the resident take their medication, then the resident may not be getting the medication that was prescribed by the doctor or another resident could possibly take the medication. Interview on 05/15/2025 at 12:37 PM with the DON revealed it was her expectation that during medication administration, the staff ensure the resident swallowed their medication before leaving the resident. She stated it was not within her expectation to tell the resident I will come back to make sure you drank all that. She stated that all staff went through skills check offs prior to their start, but if she were to see that happen, she would council the staff member. The DON stated if medications were left on the over the bed table for the resident to take unsupervised then, another resident could come along and take the medication, or the resident may not get the medication that was ordered for them. Interview on 05/16/2025 at 10:17 AM with LVN I revealed when administering medication, it was the person giving the medication responsibility to ensure the resident took their medication. She stated it was never appropriate to leave medication at the bedside and follow up later to ensure they swallowed all their medication. LVN I stated leaving medication at the bedside unsupervised could allow another resident to take the medication and they could be allergic to the medication. Interview on 05/16/2025 at 11:21 AM with LVN K revealed staff are responsible for ensuring the resident completely took their medication before leaving the room. She stated if medication were left for the resident to take on their own then the resident could miss the dose by not taking it or another resident could take the medication that wasn't prescribed for them. Attempted phone interview with LVN M on 05/16/2025 at 09:50 AM with no return call prior to exit. Record review of undated facility policy with subject title Medication & Treatment Administration reflected the following: Policy: It is the policy of this facility that medications and treatments are administered only upon the clear, complete, and prescribed by lawfully authorized provider. No mention of ensuring the resident completely took the medication was mentioned in this policy.

Based on observation, interview, and record review the facility failed to ensure drugs were labeled in accordance with currently accepted professional principles in 1 of 5 medication carts (the 400-hall nurse's cart) reviewed for drug storage and labeling. The facility failed to ensure all medications that required a prescription were labeled with a resident name for the 400-hall nurses' cart. These failures could place residents at risk of not receiving the appropriate medications or missed dosages. Findings included: Observation on 05/15/2025 at 08:51 AM of the 400-hall nurses' cart with LVN N revealed a 1-gallon sized zipper sealed baggie with 4 opened tubes labeled as Santyl and 1 opened tube of Betamethasone Dipropionate Cream. Each tube of medication had the words Rx Only printed on them. No resident labels or indicators as to whom the medication belonged to were found on any of the tubes or baggie containing the medication. Interview on 05/15/2025 at 09:00 AM with LVN N revealed she had been employed with the facility for 2 years. LVN N stated she was responsible for the 400-hall nurses' cart and its contents. She stated that any medication, including the ones located on her cart, that had Rx only should have a resident's name on it. LVN N stated nurses responsible for the cart should be checking the carts once a week to ensure all prescribed medications were properly labeled. She stated that the consultant pharmacist also checked the carts about once a month. LVN N stated if a medication was not labeled correctly then it could cause cross contamination from use on other residents. Interview on 05/15/2025 at 09:19 AM with the DON revealed she expected all medications labeled as Rx only to have a resident's name on them. She stated a medication that didn't have a resident's name on it could be used on the wrong resident and depending on the medication, like Santyl, it could potentially take their skin off. Interview on 05/15/2025 at 10:53 AM with LVN H revealed she was responsible for ensuring medications in her nurses' cart were labeled correctly. She stated any medication with the words Rx only needed to have a label on it with the resident's name. She stated not having a label on it could cause cross contamination and possible infections. Interview on 05/15/2025 at 11:56 AM with the ADM revealed it was her expectation that all medications that required a prescription have a label with the resident's name on it. She stated if a medication didn't have a resident's name on it then the medication could be used on the wrong resident or the medication could possibly be contaminated from use on another resident. Interview on 05/16/2025 at 10:17 AM with LVN I revealed that medications with Rx only should be labeled with the resident's name that the medication was prescribed to. She stated not having a resident's name on a medication that required a prescription could lead to the medication being used on the wrong resident. Interview on 05/16/2025 at 11:21 AM with LVN K revealed medications that had Rx only should be labeled with an associated resident's name. She stated that a prescription medication that was not labeled could be used on another resident and that resident could potentially have an allergy to the medication. Record review of undated facility policy titled Medication Access and Storage reflected: Policy: It is the policy of this facility to store all drugs and biological 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: Procedures: 1. The provider pharmacy dispenses medications in containers that meet legal requirements, including requirements of good manufacturing practices where applicable. Medications are kept and stored in these containers. Transfer of medications from one container to another is done only by a pharmacist . 12. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction and reordered from the pharmacy, if a current order exists .

Based on observation, interview, and record review the facility failed to ensure residents received care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable for 1 of 14 residents at risk of pressure ulcers. The facility failed to ensure Resident #1 had interventions in place to prevent an Unstageable Pressure ulcer in the thoracic spine (thoracic spine is the middle section of your spine. It starts at the base of your neck and ends at the bottom of your ribs). From 02/28/2025 to 03/04/2025 Resident #1 did not receive wound care treatment or interventions to prevent the abrasion found at admission from developing into an Unstageable Pressure ulcer in the thoracic spine. An IJ was identified on 04/03/2025. The IJ Template was provided to the facility on [DATE] at 05:22 p.m. While the IJ was removed on 04/05/2025, the facility remained out of compliance at a scope of pattern and severity of no actual harm with potential for more than minimal harm that was not Immediate Jeopardy. This failure placed residents at risk to develop an unstageable pressure ulcer. Findings included: Review of Resident #1's face sheet reflected an 89 -year-old female admitted to the facility on [DATE] with the following diagnoses Pulmonary Hypertension (blood pressure increases in the arteries of the lungs), ADL Needs (activities of daily living), Chronic Kidney Disease (involves a gradual loss of kidney function), Venous Insufficiency (condition in which the flow of blood through the veins is blocked), Diabetes (body doesn't make enough - or any - insulin), and Myocardial Infarction (happens when a part of the heart muscle doesn't get enough blood). Review of Resident #1's Initial MDS dated [DATE] reflected no BIMS score for Resident #1. No indication of skin conditions was listed. Review of Resident #1's MDS dated [DATE] reflected BIMS score for Resident #1 at 14 indicating better cognitive function. Further review of section M revealed risk of pressure ulcer injuries. Review of Resident #1's Admission/Shift Assessment from hospital, dated and timed 02/28/2025 at 08:30 (am), revealed skin alteration as present/exits, other erythema (redness of skin), posterior back. Additional review revealed PT (patient) has kyphosis and has blanchable erythema on her (Resident #1) spine, wound surrounding tissue appearance is blanched/dull. Further review revealed wound cleansing: analgesic/crm (cream)/oint (ointment)/spray, dressing type foam. Review of Resident #1's Admission assessment dated [DATE] reflected results opening/abrasion to mid back on spine. Review of Resident #1's Braden assessment dated [DATE] reflected results of 15 indicating high risk for predicting pressure sore. Review of Resident #1's Initial Care Plan dated 02/28/2025 reflected potential for pressure ulcer development, goal will have intact skin, educate resident on skin breakdown, encourage fluid intake, monitor skin changes, out of bed unless contraindicated, weekly head to toe skin at risk assessment. Review of Resident #1's EMR revealed a Skin/Pressure/Ulcer Weekly Assessment, dated 03/04/2025 revealed 12cmx2cm open area, unable to determine depth, location right side of thoracic spine. Further review revealed no Skin/Pressure/Ulcer Weekly Assessment prior to 03/04/2025. Review of Resident #1's Wound Care Physician Surgical Note dated 03/04/2025 reflected: Reason for Visit: Consultation for a wound located at the thoracic spine. Wound from sitting against wheelchair. Wound: Thoracic Spine Etiology: Pressure injury/ulcer - Wound Stage: Unstageable Pressure Injury Preoperative indications: Slough Procedure Performed: Subcutaneous tissue debridement performed by surgical excision of devitalized subcutaneous tissue. A total area of 5.04 sq cm of devitalized tissue was debrided with <5 cc estimated blood loss. The pre-op wound area was 12 cm x 2 cm x UTD cm (24 sq cm). The post-op wound area was evaluated to be 12 cm x 2.1 cm x 0.2 cm (25.2 sq cm). Wound Description: Odor: None Exudate: Scant, Serous Periwound: Stable Wound Edge: Normal Wound progress: Undetermined: first visit. Operative note: A curettage debridement technique was conducted using a 5 mm surgical steel curette. Hemostasis was managed by dry gauze. Blood loss: less than 5 cc. Honey-based Gel and Dry Dressing were applied to the wound. Review of Resident #1's Physician Orders written and initiated on 03/05/2025 revealed Thoracic Spine: cleanse with NS or wound cleanser, pat dry, apply Medi honey, cover with dry dressing. as needed for Unstageable PI. Review of Resident #1's Wound Care Physician Surgical Note dated 03/11/2025, reflected: Reason for Visit: Evaluation of a wound at the thoracic spine. Wound: Thoracic Spine Etiology: Pressure injury/ulcer - Wound Stage: Unstageable Pressure Injury Preoperative indications: Slough Procedure Performed: Subcutaneous tissue debridement performed by surgical excision of devitalized subcutaneous tissue. A total area of 4.34 sq cm of devitalized tissue was debrided with <5 cc estimated blood loss. The pre-op wound area was 3 cm x 2 cm x UTD cm (6 sq cm). The post-op wound area was 3.1 cm x 2.0 cm x 0.2 cm (6.2 sq cm). Wound Description: Odor: None Exudate: Scant, Serous Periwound: Stable Wound Edge: Normal Operative note: A curettage debridement technique was employed using a 5 mm surgical steel curette. Hemostasis was achieved using dry gauze. Blood loss was approximately less than 5 cc. Honey-based Gel and Dry Dressing were applied to the wound. Review of Resident #1's Wound Care Physician Surgical Note dated 03/18/2025, reflected: Reason for Visit: To evaluate this patient for a wound located on the thoracic spine. Wound: Thoracic Spine Etiology: Pressure injury/ulcer - Wound Stage: Unstageable Pressure Injury Preoperative indications: Slough and Devitalized tissue Procedure Performed: Subcutaneous tissue debridement performed by surgical excision of devitalized subcutaneous tissue. A total area of 2.5 sq cm of devitalized tissue was debrided with <5 cc estimated blood loss. The pre-op wound area was evaluated to be 1.8 cm x 1.3 cm x 0.1 cm (2.3 sq cm). The post-op wound area was 1.8 cm x 1.4 cm x 0.2 cm (2.5 sq cm). Wound Description: Odor: None Exudate: Mild, Serous Periwound: Stable Wound Edge: Normal Unhealthy granulated tissue identified within the wound! Operative note: A curettage debridement technique was employed using a 5 mm surgical steel curette. Hemostasis was achieved using dry gauze. Blood loss was approximately less than 5 cc. Calcium Alginate with Honey, Dry Dressing, and Skin prep peri wound were applied to the wound. Observation on 04/03/2025 at 9:00 a.m. revealed Resident #1's open wound to thoracic area, surrounding redness, slough to the wound base. Observation on 4/3/2025 at 10:36 am revealed Resident #1 sitting up in her wheelchair with a pillowed positioned between her and the back of her chair. Resident #1 was groomed well and dressed appropriately for the weather with no odors. LVN TN removed the pillow from Resident #1's back area and revealed a covered wound. LVN TN provided wound treatment while Resident #1 was sitting in her wheelchair. Interview on 04/03/2025 at 08:40 a.m. Wound Care Nurse stated he the expectations of the floor nurses are to notify him by phone during after-hours or on the weekends to initiate treatment orders. He initiated a wound care consult the day he was notified of the wound, 03/04/2025. Interview on 04/03/2025 at 12:21 p.m., Wound Care Doctor stated he visits the facility once a week, on Tuesday. He further stated he was doing his rounds on 03/04/2025, and the Wound Care Nurse notified him of Resident #'1s wounds and he confirmed Resident #1 was treated. The Wound Care Doctor stated it was misdiagnosed as it should not have been listed as an abrasion, he further stated based on history it should have been diagnosed as a wound upon admission. Interview on 04/03/2025 at 12:32 p.m., LVN Charge Nurse stated he was tasked with the admission of resident on 02/28/2025 and it was an oversight that he did not put in orders or monitoring of resident's wound and stated he was not properly educated on admission expectations with skin concerns (04/03/2025). Interview on 04/03/2025 at 11:59 a.m. DON stated that the LVN at admission described the wound inappropriately and believes it was a pressure ulcer at admission. She stated, she understands he missed all the steps in place and believes it was a good system in place if everyone follows the process it will work. DON reached out to the hospital and received clinical records on 04/03/2025 at 2:00 p.m. and confirmed in the records that Resident #1 had a wound on the thoracic region. Review of the facility's document titled, Policy/Procedure - Nursing Administration, Admission, undated revealed the following: Provide the resident with information and resources for his care and comfort, as well as federal and state requirements. Initiate any required treatments (oxygen, intravenous) necessary at time of admission per transfer orders. Do a complete assessment of body systems and complete admission assessment form and nursing notes. Include a through skin check. Review of the facility's document titled, Policy/Procedure -Nursing Administration, Wound Management dated 05/2007 revealed the following: A wound flow sheet will be started as soon as a wound is identified. The ADM was notified on 04/03/2025 at 5:22 p.m., that an IJ situation was identified due to the above failures and the IJ template was provided. The POR (Plan of Removal) was accepted on 04/04/2025 at 5:40 p.m., and included the following: On 04/02/2025 an abbreviated survey was initiated. On 04/03/2025 the surveyor provided a Template notification that the Regulatory Services has determined that the condition at the facility constitutes an Immediate Jeopardy to resident health and safety. Action: One on one in service with LVN Charge Nurse to review admission Skin Assessment/ Documentation Treatments and Notification. Overview of Resident #1 and education on expectations of interventions, notification, and documentation. LVNs knowledge and effectiveness of training by conducting quiz, chart audit and feedback given with results of audit, will continue training x4 week. LVN received counseling for insufficient assessment and documentation. Start Date: 04/04/2025 Completion Date: 04/04/2025 Responsible: Executive Director, Director of Nursing and/or designee Action: Resident #1's head-to-toe skin assessment completed. Initiated medication review by Medical Provider, Wound Care Provider review of treatment orders for appropriateness. Social Service Assessment conducted to ensure psychosocial well-being. No mental anguish or psychological distress related to delay in treatment, notification of findings communicated to medical provider and Resident #1. Start Date: 04/04/2025 Completion Date: 04/04/2025 Responsible: Executive Director, Director of Nursing and/or designee Action: In service provided to Administrator and DON by Clinical Resource on New Admission Skin Assessment/ Documentation Treatments and Notification and expectation to notify Medical Provider, Responsible Party and Treatment Nurse and Treatment nurse or designee to see all new admissions. In serviced on following up on new admission with chart audits and continue education and counseling as needed by Clinical Resource. Start Date: 04/03/2025 Completion Date: 04/03/2025 Responsible: Clinical Resource Action: 100% Charge Nurse In-Service for New Admission Skin Assessment/ Documentation Treatments and Notification. PRN nurses in serviced. We do not utilize agency staff. New staff will be in serviced upon hire. Nurses will not work floor until in serviced. 1. Current Protocol: Upon admission the head-to toe skin assessment was to be completed (including staples, bandages, scars, bruising, missing digits/limbs). 2. DO NOT STAGE or measure areas. Only document location, characteristic and odor. 3. Obtain a physician's order for wound care. If you are not sure ask the treatment nurse or call the on-call manager if after hours. 4. DO NOT DOCUMENT TREATMENT NURSE TO EVAL AND TREAT - as admitting nurse you must intervene and ensure orders and treatments are in place. 5. Place appropriate interventions based on Braden score and current wounds. Possible interventions: Low Air Loss Mattress, turning and repositioning program, wedges for positioning, boots for heel protection, float heels, etc. 6. Document all skin tears/skin alterations x 3 days and notify family. Please pass on the need to follow up documentation during the nurse-to-nurse shift change/24-hour report. 7. Notify treatment nurse of all new admission with wounds and any new wounds. Action: 100% Nurse Management in service for New Admission Skin Assessment/ Documentation Treatments and Notification and expectation to notify Medical Provider, Responsible Party and Treatment Nurse and Treatment nurse or designee to see all new admissions. Start Date: 04/04/2025 Completion Date: 04/04/2025 Responsible: Director of Nursing and/or designee Action: Admissions, MDS, DOR, ADOR, Treatment Nurse, ADON informed of IJ, and template reviewed. Start Date: 04/04/2025 Completion Date: 04/04/2025 Responsible: Executive Director, Director of Nursing and/or designee Action: Medical Director notified of IJ. Medical Director involved in development of plan and in agreement. Start Date: 04/03/2025 Completion Date: 04/03/2025 Responsible: Executive Director, Director of Nursing and/or designee Action: An Ad hoc QA meeting will be completed. Attendees will include ED, DON, ADON, Clinical Resource, and Medical Director. Meeting will include the Plan of Removal and interventions. Start Date: 04/03/2025 Completion Date: 04/03/2025 Responsible: Executive Director, Director of Nursing and/or designee Action: Audit on current residents with pressure ulcers. In process pending completion date. Start Date: 04/03/2025 Completion Date: 04/04/2025 Responsible: Director of Nursing Services or designee. Action: Audit on new admissions without Treatment Nurse Assessment. New admission from 04/02/2025 Treatment Nurse Assessments are in place, Treatment in place when appropriate. Start Date: 04/03/2025 Completion Date: 04/04/2025 Responsible: Director of Nursing Services or designee. Action: Skin sweep on with residents with wounds and new admissions. Resulted in no new finding. Start Date: 04/03/2025 Completion Date: 04/04/2025 Responsible: Director of Nursing Services or designee. Action: RCA/QIT with IDT and Medical Director. IDT meet to discuss initial admission skin assessments that identify skin issues without treatment orders being placed initially by charge nurse and then a delay in treatment. This was often found on Friday admissions, where the treatment nurse did not see patients until the following week. All nurses being in-serviced prior to working their next shift on Admission skin assessment process, implementing orders and interventions and documentation. Treatment nurse was only assessing patient's that it was communicated had wounds. Treatment nurse or designee is to complete a skin assessment on all admissions on next working day to ensure accurate assessment and treatments are appropriate. Start Date: 04/03/2025 Completion Date: 04/03/2025 Responsible: IDT Action: Treatment Nurse, Admissions Nurse and MDS Resource to conduct in service to nurses trained on New Admission Skin Assessment/ Documentation Treatments and Notification and expectation. Start Date: 04/03/2025 Completion Date: 04/03/2025 Responsible: Director of Nursing Services or designee. Action: DON or designee to verify nurse knowledge on New Admission Skin Assessment/ Documentation Treatments and Notification by quizzing 5 nurses weekly x3m and ongoing for nurse new hires Start Date: 04/03/2025 Completion Date: 07/03/2025 Responsible: Director of Nursing Services or designee. Action: Summary of IJ and corrective action to be reviewed by QAPI Committee monthly x3 months or until substantial compliance established. Start Date: 04/03/2025 Completion Date: 07/03/2025 Responsible: Executive Director, Director of Nursing Services, or designee. Action: Care Plan audit for all residents with pressure/skin alterations. Care Plans update for appropriate interventions. Start Date: 04/03/2025 Completion Date: 04/03/2025 Responsible: Director of Nursing Services or designee. Action: Audit new Admissions within 72 hours of admission for initial skin assessment and treatment nurse assessment, ensuring interventions and orders in place x3 months. Start Date: 04/04/2025 Completion Date: 07/04/2025 Responsible: Director of Nursing Services or designee. The Survey Team monitored the Plan of Removal from 04/04/2025, 4:00 p.m. to 9:15 p.m. and 04/05/2025, 11:00 a.m. to 1:00 p.m. revealed the following: Record review on 04/04/2025 revealed LVN A Charge Nurse received one-on-one in-service on 04/03/2025 with ADM and DON on topics of admission Skin Assessment/ Documentation Treatments and Notification. Further record review revealed LVN A completed quiz to check knowledge and effectiveness of chart audits and feedback given with successful results of audit and received counseling for insufficient assessment and documentation. Record review on 04/04/2025 revealed Resident #1's head-to-toe skin assessment completed, medication reviewed by Medical Provider, Wound Care Provider reviewed treatment orders for appropriateness. Further record review on 04/04/2025 revealed Social Service Assessment was conducted on Resident #1 to ensure psychosocial well-being status., which resulted in no mental anguish or psychological distress related to delay in treatment, notification of findings communicated to medical provider and Resident #1. Record review on 04/04/2025 revealed ADM and DON completed in-services on 4/3/2025 conducted by Clinical Resource on topics of New Admission Skin Assessment, Documentation, Treatments and Notifications, Follow-up on new admissions with chart audits to ensure compliance and continued education and counseling with staff as needed. Record review on 04/04/2025 revealed 100% of Charge Nurses and PRN Nurses completed in-services 04/03/2025 and 04/04/2025 conducted by DON, CN, and Clinical Resource on topics of New Admission Skin Assessment/Documentation Treatments and Notification. Record review on 04/04/2025 revealed in-services completed on 04/03/2025 and 04/04/2025 for 60 staff on topics of New Admission Skin Assessment, Documentation, Treatments and Notification. Further record review revealed 38 Post-test signed and dated 4/3/2025 and 4/4/2025 confirmed completion and knowledge of new admissions. Record review on 04/04/2025 revealed Nursing Management staff received in-service training on 04/03/2025 and 04/04/2025 conducted by DON on topics of New Admission Skin Assessment/ Documentation Treatments and Notification and expectation to notify Medical Provider, Responsible Party and Treatment Nurse and Treatment nurse or designee to see all new admissions. Record review on 04/04/2025 revealed ED and DON informed Admissions, MDS, DOR, ADOR, Treatment Nurse and ADON of IJ on 04/03/2025 and template was reviewed. Record review on 04/04/2025 revealed ED notified Medical Director on 4/3/2025 of IJ and he was involved in the development of plan and in agreement. Record review on 04/04/2025 revealed ADHOC QAPI meeting held on 04/03/2025 with the Physician, Administrator, Director of Nursing, Assistant Director of Nursing, Administrator 2, Administrator 3, Director of Nursing 2, Director of Nursing 3, Clinical Market Leader, and Clinical Resource. Meeting included the Plan of Removal and interventions. Record review on 04/04/0205 revealed DON completed audit on current residents with pressure ulcers on 04/04/2025. Record review on 04/04/2025 revealed DON completed audit on new admissions without Treatment Nurse Assessment and new admissions from 04/02/2025 Treatment Nurse Assessments are in place on 04/04/2025. Record review on 04/04/2025 revealed DON completed skin sweep on residents with wounds and new admissions on 04/04/2025. This skin sweep resulted in no new finding. Record review on 04/04/2025 revealed RCA/QIT with IDT and Medical Director was completed on 04/03/2025. IDT met to discuss initial admission skin assessments that identify skin issues without treatment orders, the delay in treatment, all nurses being in-serviced prior to working their next shift, and Treatment Nurse is to complete a skin assessment on all admissions on next working day to ensure accurate assessment and treatments are appropriate. Record review on 04/04/2025 revealed Corporate Nurse, RN conducted in-services on 04/03/2025 and 04/04/2025 to nurses trained on New Admission Skin Assessment/ Documentation Treatments and Notification and expectation. Record Review on 04/04/2025 and 04/05/2025 revealed DON completed Care Plan audit for all residents with pressure/skin alterations and Care Plan updates for appropriate interventions for 14 residents. Phone call interview on 04/04/2025 at 4:43 p.m., CWSP stated that with the additional hospital discharge information provided for Resident #1 he believes, the hospital could have staged P1 incorrectly at the hospital. He stated that sometimes there could be slough on the wound and he doesn't know how deep it goes, and if on the wound belly he would categorize it as unstageable. He stated that a P1 can progress within a day or even in a few hours due to many different factors of the individual. He stated that a healthy-looking wound could be categorized from P1 to unstageable. He stated that based on how much slough he saw on the wound on 3/4/2025 he believes it was going to progress due to her poor health and being very skinny, and he stated he doesn't believe it could have been unavoidable. He stated that, in his opinion as the P1 was incorrectly staged progression could not have been avoided those couple of days treatment was delayed, it was going to progress either way. Interview on 04/04/2025 at 4:55 p.m., LVN W stated that with the additional factors provided to him regarding Resident #1's hospital discharge status and the discussion with the CWSP, he stated for the wound to be an unstageable, P1 was not uncommon, and where the wound was, the fat tissues, more tissue based on body size, doesn't believe it could have been avoided because she was compliant with sideline, aware of the wound, her family was also aware helping reposition her. He stated that she would have had to be completely immobile, moist, friction, other factors to have progressed to a worsening condition. LVN W stated that he has taken in-services conducted by CN and Clinical Resource on 04/03/2025 and 04/04/2025 on AM shift, on topics of new admission skin assessment, documentation, treatments, and notifications. He stated the expectation moving forward is for him to review all new admissions regardless of receiving wound referral. Interview on 04/04/2025 at 5:32 p.m., DON stated she has taken in-services conducted by Clinical Resource on 04/03/2025 at AM shift, on topics of new admission skin assessment, documentation, treatments, and notifications. DON stated she attended an ADHOC QAPI meeting addressing Plan of Removal and interventions. She stated she held a one-on-one in-service with LVN A on topics of new admission skin assessment, documentation, treatments, and notifications. She stated that LVN received counseling for insufficient assessment and documentation. DON stated that she is responsible for following up on LVNs, Charge Nurses knowledge and effectiveness of training by conducting quizzes, completing chart audits, and providing nurses with ongoing training. Interview on 04/04/2025 at 5:42 p.m., ADM stated she has taken in-services conducted by Clinical Resource on 04/03/2025 at AM shift, on topics of new admission skin assessment, documentation, treatments, and notifications. ADM stated she notified the MD of IJ and he was involved in the development of Plan of Removal and interventions and agreed. ADM stated she attended an ADHOC QAPI meeting addressing Plan of Removal and interventions. She stated she held a one-on-one in-service with LVN A on topics of new admission skin assessment, documentation, treatments, and notifications. She stated that LVN received counseling for insufficient assessment and documentation. ADM stated she was responsible for following up on new admissions with chart audits and continue education and counseling as needed by Clinical Resource. Record review and interview on 04/04/2025 at 5:53 p.m., LVN A stated that he has taken in-services on 04/03/2025 and 04/04/2025 over phone with CN and Clinical Resource on topics of new admission skin assessment, documentation, treatments, and notifications. He stated he taken one-on-one in-services on 04/03/2025 at AM shift with ADM and DON on topics of insufficient assessment and documentation. He stated that now he recalled the expectations of a charge nurse and LVN job description he received as a new hire. He stated that he now remembers why it is so important to follow the processes that are in place with new admissions and skin assessments. Post-test signed and dated 4/3/2025 and 4/4/2025 confirmed completion and knowledge of new admissions. Counseling/Disciplinary Notice signed and dated 4/3/2025 acknowledging insufficient assessment and documentation. Record review and phone call interview on 04/04/2025 at 6:53 p.m., LVN B stated that she has taken in-services on 04/03/2025 and 04/04/2025 on AM shift, on topics of new admission skin assessment, documentation, treatments, and notifications. Post-test signed and dated 4/3/2025 and 4/4/2025 confirmed completion and knowledge of new admissions. Record review and Interview on 04/04/2025 at 7:03 p.m. LVN C stated that he has taken in-services on 04/03/2025 and 04/04/2025 over phone with CN and Clinical Resource on topics of new admission skin assessment, documentation, treatments, and notifications. Post-test signed and dated 4/4/2025 confirmed completion and knowledge of new admissions. Phone call interview on 04/04/2025 at 7:06 p.m. RN A stated that she stated that he has taken in-services on 04/03/2025 over phone with CN and Clinical Resource on topics of new admission skin assessment, documentation, treatments, and notifications. Post-test signed and dated 4/3/2025 confirmed completion and knowledge of new admissions. Record review and phone call interview on 04/04/2025 at 7:15 p.m. LVN D stated that she has taken in-services on 04/03/2025 and 04/04/2025 over phone with CN and Clinical Resource on topics of new admission skin assessment, documentation, treatments, and notifications. Post-test signed and dated 4/3/2025 and 4/4/2025 confirmed completion and knowledge of new admissions. Record review and phone call interview on 04/04/2025 at 7:22 p.m. Interview with LVN E stated that he has taken in-services on 04/03/2025 and 04/04/2025 on AM shift, on topics of new admission skin assessment, documentation, treatments, and notifications. Post-test signed and dated 4/3/2025 and 4/4/2025 confirmed completion and knowledge of new admissions. Record review and phone call interview on 04/04/2025 at 7:32 p.m. LVN F stated that she has taken in-services on 04/03/2025 over phone with CN and Clinical Resource on topics of new admission skin assessment, documentation, treatments, and notifications. Post-test signed and dated 4/3/2025 confirmed completion and knowledge of new admissions. Record review and interview on 04/04/2025 at 7:46 p.m. LVN M stated that she has taken in-services on 04/03/2025 and 04/04/2025 over phone and on AM shift with CN and Clinical Resource on topics of new admission skin assessment, documentation, treatments, and notifications. Post-test signed and dated 4/4/2025 confirmed completion and knowledge of new admissions. Record review and phone call interview on 04/04/2025 at 8:15 p.m. LVN G stated that she has taken in-services on 04/03/2025 over phone with CN and Clinical Resource on topics of new admission skin assessment, documentation, treatments, and notifications. Post-test signed and dated 4/3/2025 confirmed completion and knowledge of new admissions. Phone call interview on 04/04/2025 at 8:20 p.m. ADON stated that she has taken in-services on 04/03/2025 and 04/04/2025 over phone and on AM shift with CN and Clinical Resource on topics of new admission skin assessment, documentation, treatments, and notifications. She stated that she was notified of IJ Template via phone on 4/3/2025. The ADM was notified on 04/05/2025 at 01:20 PM that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of pattern that is not Immediate Jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to ensure the residents environment remained as free of accident hazards as is possible and ensure each resident received adequate supervision for one (Resident #1) of three residents reviewed for accidents and hazards. The facility failed to ensure Resident #1 did not leave the facility with nursing staff being aware as she was found approximately 2.5 hours later and approximately 4.2 miles away (at a store off a major highway - 65 MPH) after being contacted by an outside party 02/16/25. The temperature was approximately 58 degrees. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 02/18/25 at 2:16 PM and an IJ template was given. While the IJ was removed on 02/19/25 at 4:42 PM, the facility remained out of compliance at a level of no actual harm at a scope of isolated that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk for unsafe elopements, falls, injuries, dehydration, and hospitalization . Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including psychotic disorder with delusions, generalized anxiety disorder, dementia, unsteadiness on feet, and difficulty in walking. She was not her own RP. Review of Resident #1's quarterly MDS assessment, dated 11/08/24, reflected a BIMS score of 10, indicating a moderate cognitive impairment. Section E (Behavior) reflected she had not exhibited behaviors of wandering. Section GG (Functional Abilities) reflected she utilized a walker for ambulation. Review of Resident #1's quarterly care plan, dated 01/15/25, reflected she was at risk for impaired cognitive function/dementia or impaired thought process with an intervention of needing supervision/assistance with all decision making. There was no focus area related to wandering or elopement. Review of Resident #1's quarterly Elopement/Wandering Evaluation, dated 01/10/23, reflected a score of 15, indicating she was a high-risk for elopement. Review of Resident #1's progress note, dated 01/14/25 at 1:08 AM and documented by LVN F, reflected the following: [Resident #1] found rummaging through front desk drawers. CN was advised that [Resident#1] has attempted to exit the facility prior to today's date . Review of Resident #1's MD progress note, dated 01/21/25, reflected the following: Discussed with [Resident #1] again upon request from her to talk about her taking the bus, discussed with director of nursing and administrator, that and we all agree that [Resident #1] is safe to go, as long as there is a chaperone with her . Review of Resident #1's progress note, dated 01/30/25 at 5:28 PM and documented by LVN A, reflected the following: [Resident #1] is asking all during shift if can go and take the bus to pick up income taxes. Writer redirected [Resident #1] to speak with social worker or administrator for the ok to leave facility. [Resident #1] is not allowed to leave facility without supervision from stass [sic] or family. Review of Resident #1's progress notes, dated 02/03/25 at 1:50 PM and documented by LVN B, reflected the following: Will continue to monitor for elopement, plan of care ongoing. Review of Resident #1's NP progress note, dated 02/03/25, reflected the following: Otherwise, nursing reporting [Resident #1] has been trying to leave facility . Upon discussion with nursing staff, [Resident #1] often with these behaviors intermittently . Although, [Resident #1] tells me she talked to (name) recently and is discharging tomorrow to a different facility. No discharge plans have been made. Is a wander risk. Alerted staff and DON regarding [Resident #1]'s above statement. (Psychiatric team) is following. Will have (Psychiatric team) follow up. . Mood stable today, thought with intermittent agitation and wandering behaviors . Review of Resident #1's progress notes, dated 02/16/25 at 5:24 PM and documented by LVN C, reflected the following: [Resident #1] signed herself out 2-16-25 at 11:40 am went to the (store) in (town), [Resident #1] returned around 14:00 (2:00 PM) DON aware. After returning back to facility [Resident #1] went to her room. Review of Resident #1's progress note, dated 02/16/25 at 5:49 PM and documented by the DON, reflected the following: [Resident #1] is cognitively intact (BIMS 15) and able to make decisions, although she has had a change in condition and is not making safe decisions and voicing desire to leave and attempting without a safe plan in place . Review of the Out on Pass binder at the desk in the front lobby, on 02/18/25, reflected Resident #1 signed out on 02/16/25 at 11:40 AM but there was no returned time documented. Observations made on 02/18/25 at 9:02 AM revealed an elopement binder with residents that were a high risk located at the Receptionist's desk and each nurses' station. The binders contained Resident #1's information. During a telephone interview on 02/17/25 at 3:48 PM, CNA D stated Resident #1 eloped from the facility on 02/16/25. She stated she was working that day but on another hall. She stated she (Resident #1) left sometime in the morning and was brought back to the facility around 2:00 PM. She stated no one knew how long she had been missing. She stated she did not see her in the dining room at lunch, but that was not unusual because she often ate her meals in her room. She stated the facility received a call from someone at another facility notifying them of where she was located. She stated the ADM went and picked her up and brought her back. She stated the ADM and DON talked to Resident #1's nurse, LVN C, and told her it was not an elopement since she signed herself out. She stated Resident #1 was in their high-elopement binder at the nurses' station and Resident #1 did not have the cognitive ability to sign herself out. She stated she was currently on a 1:1 due to the elopement. During an observation and interview on 02/18/25 at 8:59 AM revealed CNA E sitting in a chair next to Resident #1's bed. She stated Resident #1 was on 1:1 and she was to ensure she stayed with her. She stated she was not sure why she was on a 1:1 but thought it had to do something with an elopement. Resident #1 stated it was because of her shopping trip. She then started crying and talking about the social worker, not getting her money, and missing her family member. She was hard to redirect. During a telephone interview on 02/18/25 at 10:07 AM, LVN C stated she was working Resident #1's hall on 02/16/25. She stated no one knew Resident #1 had left the facility until LVN G received a phone call from the van driver from a facility close by and informed him she was seen at the grocery store in a town approximately five miles way. She stated everyone knew she was not allowed to sign out or leave the facility without someone knowing and going with her. She stated she attempted to leave the facility daily and constantly had to be re-directed. She stated everyone was aware she was not supposed to leave the facility. She stated she immediately called the DON to notify her of Resident #1's location and she and the ADM brought her back to the facility. She stated the DON told her it was not considered an elopement because she signed herself out, she was aware what she was doing, and her mental status was fine. She stated she did sign out at the front desk but as a nurse, she considered it an elopement because no one knew she was gone or where she was. She stated she could have gotten seriously hurt. During an interview on 02/18/25 at 10:38 AM, CNA H stated he worked Resident #1's hall on 02/16/25. He stated it was not his normal hall, so he was not that familiar with her but did know she was ambulatory and liked to sit in the lobby by the Receptionist's desk. He stated he did remember seeing her that day but did not remember what time. He stated he heard a rumor she was missing but he did not see anything. During a telephone interview on 02/18/25 at 11:25 AM, Resident #1's FM I stated she should not have been able to leave the facility on her own. He stated he was very upset she was able to walk out the front door. He stated when he took her out on pass, he had to sign out at two different locations and then get the Receptionist to put the code in to unlock the door, How did she get past all that? He stated he understood she could physically sign herself out, but she had dementia, and it was not safe at all. He stated if she walked out the door and forgot where she was at, then what? He stated she could have gotten ran over or gotten left for dead. He stated he believed the weekend Receptionist (REC J) was a new hire and probably had not been thoroughly trained. He stated the Administrator and DON were aware she had a history of eloping when she was admitted . During a telephone interview on 02/18/25 at 1:13 PM, Resident #1's NP stated it was not safe for her to leave the facility on her own. She stated her psychiatric competency was more complex than most. She stated something would happen, she would get confused, or get lost. She stated if she had signed out, it would still be considered an elopement because the staff did not know she left or her whereabouts. During a telephone interview on 02/18/25 at 1:57 PM, Resident #1's MD stated she had been asking to leave the facility for a long time. He stated they had been trying to do the right thing for her and her safety but also be respectful of her wishes and rights. He stated she was over-all pretty with it in terms of her alertness and orientation. He stated she historically needed to be redirected from the front door. He stated ideally, she would need a chaperone to go out on pass. He stated there was no real reason why she could not go out and it would be against her rights and will. He stated he did expect for there to be a process in place when a resident signed out to leave the facility, but he could not remember what theirs was. He stated generally, staff should be aware when a resident was leaving the facility. During an interview on 02/18/25 at 2:32 PM, the DON stated it was preferred that when a resident wanted to leave, they would sign out and notify their nurse. She stated sometimes residents would forget to notify their nurse. The ADM stated there was a sign out book at the nurses' station and the Receptionist's desk where the residents were supposed to sign out. She stated for a resident to go out on pass alone, it would depend on their cognitive level and their BIMS score. The ADM stated the BIMS score would need to be high - 13, 14, or 15. She stated if a resident had a BIMS score of 10, it would depend and they would need to talk to their provider about it. The ADM stated staff knew which residents were a high-elopement risk by their elopement binders located at the nurses' station and Receptionist's desk. The ADM stated on 02/16/25, REC J told her Resident #1 came to the desk and told her she was going out and signed out in the binder. She stated REC J told her she did not leave, but just sat in the lobby. She stated REC J went to lunch and when she came back Resident #1 was gone. She stated Resident #1 left at some point and was not sure how she left without the code to the door. She stated at that time she was able to be out independently at that time because of her cognitive status and high BIMS score. She stated she was able to answer all of their questions, such as where she had gone and what she had been doing. The ADM stated they did not consider it an elopement because when they found out she was not in the building, they went to the book and saw that she had signed out and, in that moment, they knew where she was. She stated when they got to her location, she was safe and knew everything she was doing. On 02/18/25 at 10:20 AM and 1:14 PM, attempts were made to interview LVN G. A returned call was not received prior to exiting. On 02/18/25 at 10:24 AM and 12:35 PM, attempts were made to interview REC J. A returned call was not received prior to exiting. Review of the facility's Elopement/Unsafe Wandering Policy, revised 12/2023, reflected the following: It is the policy of this facility to provide a safe environment, as free of accidents as possible, for all residents through appropriate assessment, interventions, and adequate supervision to prevent accidents related to unsafe wandering or elopement while maintaining the least restrictive manner for those at risk for elopement. Definition: Elopement occurs when a resident leaves the facility premises or a safe area without the facility's knowledge, authorization (i.e. an order for discharge, appointment, or leave of absence) and/or any necessary supervision to do so. The ADM and DON were notified on 02/18/25 at 2:16 PM that an IJ had been identified and an IJ template was provided. The following POR was approved on 02/19/25 at 2:39 PM: Action: 100% all staff in service on communication regarding out on pass with nursing approval and elopement process. PRN staff in serviced, we do not utilize agency staff and new staff will be in serviced upon hire. Resident was put on 1:1, psychological evaluation completed by Psychology Services (pending report), neurocognitive testing initiated due to change of condition conducted by Psychological Services (pending report), 100% audit for high-risk elopement residents completed. There were no other residents identified that may display this behavior. Previous protocol: Charge nurse is informed, resident signs out on at reception or nurse's station. Current protocol: Charge nurse to be notified of request and confirms with IDT that resident is appropriate for out on pass independently, Charge nurse completes sign out sheet with resident, informs receptionist if resident is appropriate for out on pass. RP, Resident and Provider to be notified by DON or designee with IDT determination. DON or designee responsible for ongoing compliance. Sign out book has been reviewed as of 2/19/25 and will be audited ongoing in QAPI x90 days to ensure ongoing compliance. Audit on high-risk elopement resident completed by DON and Clinical Resource on 2/18/25. Conducting 100% all staff in service on Elopements. Start Date: 02/18/2025 Completion Date: 02/19/2025 Responsible: Executive Director, Director of Nursing Services or designee. Action: Medical director notified of IJ Start Date: 02/18/2025 Completion Date: 02/18/2025 Responsible: Director of Nursing Services Action: An Ad hoc QA meeting will be completed. Attendees will include ED, DON, ADON, Clinical Resource, and Medical Director. Meeting will include the Plan of Removal and interventions. Start Date: 02/18/2025 Completion Date: 02/18/2025 Responsible: ED/DON Action: Train the trainer in-service given to ED and DON on communication for out on pass Start Date: 02/18/2025 Completion Date: 02/18/2025 Responsible: Clinical Resource Action: ED or Designee will verify staff knowledge on communication for out on pass with 10 staff weekly using the abuse and neglect knowledge checks. This will be completed weekly following the initial training and knowledge checks Knowledge check will be completed by quizzes and in services. This will continue for 90 days then ongoing for all new hires. Start Date: 02/18/2025 Completion Date: 05/18/2025 Responsible: ED/Designee Action: Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks beginning 02/18/25 or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. Start Date: 02/18/2025 Completion Date: 05/18/2025 Responsible: ED/DON The Surveyor monitored the POR on 02/19/25 as followed: During an interview on 02/19/25 at 2:45 PM, the ADM stated more than 90% of their staff had been in-serviced on elopement and residents leaving out on pass. She stated no one will work until they get in-serviced. She stated Resident #1 had psychiatric and neurocognitive evaluations conducted the day prior, 02/18/25, and the reports were still pending. During interviews on 02/19/25 from 2:58 PM - 4:21 PM, four LVNs, two CNAs, one MA , and REC K (weekday receptionist) from different shifts all stated they were in-serviced before their shifts on elopement and the process for residents signing out on pass. All were able to describe what the elopement binders were and where they were located. All staff knew to redirect residents to their nurse if voicing a desire to go out on pass. Each staff member was able to define elopement as a resident leaving the facility premises without the staff being aware. The nurses stated they would assess their cognitive status and orientation and would contact the DON for further approval. The nurses stated the log had to be filled out completely whether the resident was leaving with staff and/or family or if leaving independently - name, date, time, location, phone number, and estimated time of return. The nurses stated any time a resident signed out, they would then accompany them to the receptionist area, have them sign out again, and then give the Receptionist the okay to unlock the door. All staff were able to give possible signs and symptoms of residents seeking elopement - pacing to exit doors, voicing wanting to leave, agitation, or actively exit-seeking. All staff stated residents should be rounded on at least every two hours and if they were unable to locate them, the nurse should be notified immediately. Observation on 02/19/25 at 2:42 PM revealed Resident #1 ambulating in the lobby with a CNA closely behind her providing 1:1 supervision. Review of the facility's Ad Hoc QAPI agenda, dated 02/18/25, reflected the ADM, DON, AIT, DOR, ADON, MD, SW, MDSC, and other corporate officials were in attendance. Review of in-services entitled Communication Regarding Out on Pass, dated from 02/18/25 - 02/19/25, reflected nursing staff from all shifts were in-serviced. Review of Out on Pass quizzes, dated from 02/18/25 - 02/19/25, reflected nursing staff from all shifts completed the following quiz: 1. If a resident wants to go out on pass, where do they need to be directed for clearance? 2. Who can give the ok for a resident to go out on pass independently? 3. Where is the sign out binder located? 4. How does the receptionist know if a resident can go out on pass? Review of in-services entitled Elopement, dated from 02/18/25 - 02/19/25, reflected nursing staff from all shifts were in-serviced on their elopement policy. Review of Elopement Inservice quizzes, dated from 02/18/25 - 02/19/25, reflected nursing staff from all shifts completed the following quiz: Location of elopement binder What to do if possible elopement 3 patients that are located in elopement binder Review of the facility's elopement binder, on 02/19/25, reflected fifteen residents that were deemed a high risk. Three residents' EMR's were reviewed to reflect they were a high-risk of elopement. Review of Resident #1's progress note, dated 02/19/25 at 1:22 PM and documented by the SW, reflected the following: Called [FM I] for quarterly care plan meeting. Review of Psychological Evaluation, dated 02/18/25, reflected Resident #1 had a psychological evaluation conducted. The ADM and DON were notified the IJ was removed on 02/19/25 at 4:42 PM. However, the facility remained out of compliance at a level of no actual harm at a scope of isolated that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure all alleged violations involving abuse or neglect were reported immediately or no later than 24 hours for one (Resident #1) of three residents reviewed for abuse and neglect. The facility failed to report to the State Agency an incident when Resident #1 left the facility without nursing staff being aware on 02/16/25. This failure could place residents at risk of abuse or and neglect. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including psychotic disorder with delusions, generalized anxiety disorder, dementia, unsteadiness on feet, and difficulty in walking. She was not her own RP. Review of Resident #1's quarterly MDS assessment, dated 11/08/24, reflected a BIMS score of 10, indicating a moderate cognitive impairment. Section E (Behavior) reflected she had not exhibited behaviors of wandering. Section GG (Functional Abilities) reflected she utilized a walker for ambulation. Review of Resident #1's quarterly care plan, dated 01/15/24, reflected she was at risk for impaired cognitive function/dementia or impaired thought process with an intervention of needing supervision/assistance with all decision making. There was no focus area related to wandering or elopement. Review of Resident #1's quarterly Elopement/Wandering Evaluation, dated 01/10/23, reflected a score of 15, indicating she was a high-risk for elopement. Review of Resident #1's progress note, dated 02/16/25 at 5:24 PM and documented by LVN C, reflected the following: [Resident #1] signed herself out 2-16-25 at 11:40 am went to the (store) in (town), [Resident #1] returned around 14:00 (2:00 PM) DON aware. After returning back to facility [Resident #1] went to her room. Review of Resident #1's progress note, dated 02/16/25 at 5:49 PM and documented by the DON, reflected the following: [Resident #1] is cognitively intact (BIMS 15) and able to make decisions, although she has had a change in condition and is not making safe decisions and voicing desire to leave and attempting without a safe plan in place . Review of the Out on Pass binder at the desk in the front lobby, on 02/18/25, reflected Resident #1 signed out on 02/16/25 at 11:40 AM but there was no returned time documented. During a telephone interview on 02/17/25 at 3:48 PM, CNA D stated Resident #1 eloped from the facility on 02/16/25. She stated she was working that day but on another hall. She stated she (Resident #1) left sometime in the morning and was brought back to the facility around 2:00 PM. She stated no one knew how long she had been missing. She stated she did not see her in the dining room at lunch, but that was not unusual because she often ate her meals in her room. She stated the facility received a call from someone at another facility notifying them of where she was located. She stated the ADM went and picked her up and brought her back. She stated the ADM and DON talked to Resident #1's nurse, LVN C, and told her it was not an elopement since she signed herself out. She stated Resident #1 was in their high-elopement binder at the nurses' station and Resident #1 did not have the cognitive ability to sign herself out. She stated she was currently on a 1:1 due to the elopement. She stated she believed the ADM should have reported this incident to the State. During a telephone interview on 02/18/25 at 10:07 AM, LVN C stated she was working Resident #1's hall on 02/16/25. She stated no one knew Resident #1 had left the facility until LVN G received a phone call from the van driver from a facility close by and informed him she was seen at the grocery store in a town approximately five miles way. She stated everyone knew she was not allowed to sign out or leave the facility without someone knowing and going with her. She stated she attempted to leave the facility daily and constantly had to be re-directed. She stated everyone was aware she was not supposed to leave the facility. She stated she immediately called the DON to notify her of Resident #1's location and she and the ADM brought her back to the facility. She stated the DON told her it was not considered an elopement because she signed herself out, she was aware what she was doing, and her mental status was fine. She stated she did sign out at the front desk but as a nurse, she considered it an elopement because no one knew she was gone or where she was. She stated she could have gotten seriously hurt. During an interview on 02/18/25 at 10:38 AM, CNA H stated he worked Resident #1's hall on 02/16/25. He stated it was not his normal hall, so he was not that familiar with her but did know she was ambulatory and liked to sit in the lobby by the Receptionist's desk. He stated he did remember seeing her that day but did not remember what time. He stated he heard a rumor she was missing but he did not see anything. During a telephone interview on 02/18/25 at 11:25 AM, Resident #1's FM I stated she should not have been able to leave the facility on her own. He stated he was very upset she was able to walk out the front door. He stated when he took her out on pass, he had to sign out at two different locations and then get the Receptionist to put the code in to unlock the door, How did she get past all that? He stated he understood she could physically sign herself out, but she had dementia, and it was not safe at all. He stated if she walked out the door and forgot where she was at, then what? He stated she could have gotten ran over or gotten left for dead. He stated he believed the weekend Receptionist (REC J) was a new hire and probably had not been thoroughly trained. He stated the Administrator and DON were aware she had a history of eloping when she was admitted . During an interview on 02/18/25 at 2:32 PM, the DON stated it was preferred that when a resident wanted to leave, they would sign out and notify their nurse. She stated sometimes residents would forget to notify their nurse. The ADM stated there was a sign out book at the nurses' station and the Receptionist's desk where the residents were supposed to sign out. She stated for a resident to go out on pass alone, it would depend on their cognitive level and their BIMS score. The ADM stated the BIMS score would need to be high - 13, 14, or 15. She stated if a resident had a BIMS score of 10, it would depend and they would need to talk to their provider about it. The ADM stated staff knew which residents were a high-elopement risk by their elopement binders located at the nurses' station and Receptionist's desk. The ADM stated on 02/16/25, REC J told her Resident #1 came to the desk and told her she was going out and signed out in the binder. She stated REC J told her she did not leave, but just sat in the lobby. She stated REC J went to lunch and when she came back Resident #1 was gone. She stated Resident #1 left at some point and was not sure how she left without the code to the door. She stated at that time she was able to be out independently at that time because of her cognitive status and high BIMS score. She stated she was able to answer all of their questions, such as where she had gone and what she had been doing. The ADM stated they did not consider it an elopement because when they found out she was not in the building, they went to the book and saw that she had signed out and, in that moment, they knew where she was. She stated when they got to her location, she was safe and knew everything she was doing. The ADM stated she did not report the incident to the State because they did not consider it an elopement because she had signed out. On 02/18/25 at 10:20 AM and 1:14 PM, attempts were made to interview LVN G. A returned call was not received prior to exiting. On 02/18/25 at 10:24 AM and 12:35 PM, attempts were made to interview REC J. A returned call was not received prior to exiting. Review of the facility's undated Abuse and Neglect Policy reflected nothing related to reporting to the State after a resident elopement. Review of HHSC's PL 2024-14, dated August 29,204, reflected emergency situations that pose a threat to resident health and safety should be reported to HHSC immediately, but not later than 24 hours after the incident occurs or is suspected.

Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of three residents reviewed for quality of care. The facility failed to implement orders from the hospital for blood glucose monitoring four times a day and administering of a sliding scale insulin four times a day upon Resident #1's admission on 09/16/24. Orders were not implemented until 10/01/24 and during that timeframe Resident #1 was worried about his diabetes, felt sick to his stomach, funny, different, and really off. This failure could place residents at risk of not receiving necessary medical care, harm, and hospitalization . Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the hospital on 09/16/24 with diagnoses including respiratory failure, type II diabetes, urinary tract infection, and muscle weakness. Review of Resident #1's admission MDS assessment, dated 09/16/24, reflected a BIMS score of 7, indicating severe cognitive impairment. Section N (Medications) reflected he did not have an order for insulin. Review of Resident #1's admission care plan, dated 09/17/24, reflected he had diabetes mellitus with an intervention of administering medications as ordered by the doctor. Review of Resident #1's hospital discharge summary, dated 09/16/24, reflected the following: Diabetes with hyperglycemia (elevated blood sugar) - glucose 275 - HbA1c of 7.3 (reference 4 - 5.6) - changed to medium dose sliding scale. Home/Current Medications: Insulin lispro - 0 - 6 units subcutaneous qidACbedtime Discharge Medications (to continue with no changes): Insulin lispro - Sliding Scale Subcutaneous, 4 times a day (before meals and at bedtime) Sliding Scale Correctional Scale based on POC blood glucose level: 71 - 149 = no insulin lispro; 150 - 199 = 2 units; 200 - 249 = 4 units; 250 - 299 = 6 units; 300 - 349 = 8 units; 350 - 399 = 10 units; greater than 399 = 12 units and notify provider. Last dose given: 09/16/24 at 5:17 PM Discharge Information: Treatments/Special Instructions: Blood Glucose Monitoring: 4 times a day Review of Resident #1's CBC results, dated 09/27/24, reflected a high glucose level of 234 (reference 74 - 100 mg/dL). Review of Resident #1's physician order, dated 09/18/24, reflected blood sugar checks two times a day for DM 2. Review of Resident #1's blood sugar readings in his EMR, from 09/18/24 - 10/02/24, reflected the following: 09/18/24 at 4:14 PM - 291.0 mg/dL 09/19/24 at 11:01 AM - 229.0 mg/dL 09/19/24 at 6:43 PM - 220.0 mg/dL 09/20/24 at 7:25 AM - 179.0 mg/dL 09/20/24 at 4:34 PM - 249.0 mg/dL 09/23/24 at 9:43 PM - 264.0 mg/dL 09/24/24 at 6:35 AM - 110.0 mg/dL 09/24/24 at 8:11 PM - 243.0 mg/dL 09/25/24 at 6:52 AM - 278.0 mg/dL 09/25/24 at 8:13 PM - 192.0 mg/dL 09/26/24 at 6:46 AM - 165.0 mg/dL 09/26/24 at 9:04 PM - 196.0 mg/dL 09/27/24 at 7:24 AM - 212.0 mg/dL 09/27/24 at 9:08 PM - 201.0 mg/dL 09/28/24 at 6:51 AM - 169.0 mg/dL 09/28/24 at 9:41 PM - 201.0 mg/dL 09/29/24 at 7:30 AM - 162.0 mg/dL 09/29/24 at 10:23 PM - 184.0 mg/dL 09/30/24 at 7:24 AM - 206.0 mg/dL 09/30/24 at 9:06 PM - 273.0 mg/dL 10/01/24 at 6:50 AM - 395.0 mg/dL 10/01/24 at 10:01 PM - 235.0 mg/dL 10/02/24 at 8:32 AM - 124.0 mg/dL Review of Resident #1's physician order, dated 10/01/24, reflected Novolog Solution 100 unit/ML - Inject subcutaneously three times a day for diabetes. Inject as per sliding scale: If 0 - 149 = 0 units; 150 - 299 = 2 units; 300 - 349 = 4 units; 350 - 399 = 6 units; 400 - 449 = 8 units; 450 - 999 = 10 units Review of Resident #1's TAR, October 2024, reflected insulin was not administered on 10/01/24 although his BS readings were 395 and 235. Insulin was not administered in the morning on 10/02/24 due to his BS reading falling under the parameters (124). During an interview on 10/02/24 at 10:40 AM, LVN A stated she was not sure why Resident #1 had not been on insulin prior to yesterday. She stated she did notice that his blood sugars were elevated some days. She stated she had not notified the NP because she thought she had been monitoring the levels. She stated since he was a diabetic and his blood sugars had been elevated, he should have been on insulin or Metformin (medication used to lower blood sugar) sooner. During an interview on 10/02/24 at 12:12 PM, Resident #1 stated he did not know why he had not been getting his insulin. He stated he was supposed to take it, that was just the way it was supposed to be. He stated he had been asking the nurses for it because he was worried about his diabetes, but he never got any answers. He stated since he was admitted to the facility and had not been getting insulin, he had felt funny, different, really off, and sick to his stomach. He stated he had a hard time eating because he had been so nauseous. During a telephone interview on 10/02/24 at 12:32 PM, Resident #1's NP stated she had not put Resident #1 on insulin when he was admitted to the facility because she believed he had some recent hypoglycemic episodes and was not clear what he was on at home before hospitalization . She stated she put an order for accu checks twice a day so his blood sugar could be monitored before she ordered something long-lasting. She stated a nurse contacted her the day prior (10/01/24) and told her FM B was asking why he was not getting insulin so she put in an order for a sliding scale. She stated she had not been notified by anyone that his blood sugars had been elevated (over 150) and would have been preferred to have been notified sooner. During an interview on 10/02/24 at 1:27 PM, the DON stated orders from the hospital should be implemented and followed after the NP reviewed the orders. She stated as far as she could remember, the NP wanted to monitor Resident #1's blood sugars before putting anything into place and was trying to get history prior to his hospitalization . She stated her expectations were for the nurses to have been notifying the NP that his blood sugar had been elevated because she was supposed to be reviewing and watching his blood sugar. She stated a negative outcome of not notifying the NP could result in hyperglycemia. A request was made for policies on physician notifications and new admissions/orders from the hospital but neither were provided prior to exiting.

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for two (Resident #1 and Resident #2) of four residents reviewed for pharmacy services. The facility failed to administer scheduled time-sensitive medications to Residents #1 and #2 until 2.5 - 6 hours after the ordered scheduled time from 06/24/24 - 06/27/24. This deficient practice could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements, worsening or exacerbation of chronic medical conditions, and hospitalization . Findings included : Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including type II diabetes, depression , asthma (A lung disorder characterized by narrowing of the airways) with exacerbation, and fracture of left femur (thigh bone). Review of Resident #1's admission MDS assessment, dated 05/25/24 , reflected a BIMS of 14, indicating she was cognitively intact. Section N (Medications) reflected she was taking an antidepressant, a diuretic, an opioid, and hypoglycemic. Review of Resident #1's admission care plan, dated 05/22/24, reflected she was on diuretic therapy related to edema (swelling) with an intervention of administering medication as ordered. Review of Resident #1's Medication Administration Audit Report, from 06/24/24 - 06/30/24, reflected the following late medication administrations: 06/24/24 Ordered for 7:00 AM and not administered until 9:51 AM: Ranolazine (for Angina [shortness of breath]), Amlodipine (for high blood pressure), Zoloft (for depression), Gabapentin (for pain), Keppra (for seizures) Ordered for 12:00 PM and not administered until 2:26 PM: Gabapentin, Hydroxyzine (for anxiety) 06/25/24 Ordered for 12:00 PM and not administered until 2:47 PM: Gabapentin, Hydroxyzine Ordered for 4:00 PM and not administered until 8:47 PM: Gabapentin, Hydroxyzine 06/26/24 Ordered for 7:00 AM and not administered until 12:22 PM: Gabapentin, Keppra, Hydroxyzine, Zoloft, Ranolazine, Amlodipine, Abilify (for bipolar disorder) 06/27/24 Ordered for 12:00 PM and not administered until 6:19 PM: Gabapentin, Hydroxyzine During an interview on 07/01/24 at 12:17 PM, Resident #1 stated her medications were given to her late all the time, and she often went hours waiting. She stated getting her pain and anxiety medications late was what affected her the most. She stated she could feel her pain and anxiety symptoms heighten as she waited for her medications. Review of Resident #2's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including hypertension (high blood pressure), scoliosis (a sideways curvature of the spine), and rheumatoid arthritis (a chronic inflammatory disease that affects the joints). Review of Resident #2's admission MDS assessment, dated 05/25/24, reflected a BIMS of 14, indicating she was cognitively intact. Section N (Medications) reflected she was taking an antidepressant and an opioid. Review of Resident #2's admission care plan, dated 04/23/24, reflected she was on an antidepressant medication related to depression and had acute/chronic pain with an intervention of giving antidepressant and analgesia (arthritic pain) medications as ordered by the physician. Review of Resident #2's Medication Administration Audit Report, from 06/24/24 - 06/30/24, reflected the following late medication administrations: 06/24/24 Ordered for 7:00 AM and not administered until 10:24 AM: Oxycodone (for pain), Meloxicam (for pain), Gabapentin (for pain) Ordered for 7:00 AM and not administered until 11:04 AM: Brovana Inhalation Nebulization Solution (for respiratory support), Budesonide Inhalation Suspension (for respiratory support) 06/26/24: Ordered for 7:00 AM and not administered until 12:18 PM: Brovana Inhalation Nebulization Solution, Budesonide Inhalation Suspension During an interview on 07/01/24 at 12:24 PM, Resident #2 stated her medications were not always given to her late. She stated sometimes her nebulizer and inhaler treatments were late but it did not affect her. During an interview on 07/01/24 at 1:15 PM, MA A stated medications should be administered within one hour before or one hour after the scheduled time. She stated she sometimes had a hard time administering all medications within that timeframe. She stated it was important for medications to be administered within the timeframe to ensure residents do not go too long without a medication or were administered the same medication too close together. During an interview on 07/01/24 at 1:54 PM, the ADM stated they utilized a liberal medication pass to make it a more homelike environment for their residents. She stated they did not follow the one-hour before or one-hour after the scheduled time for medication administration. She stated pain medications, anxiety medications, or breathing treatments going 3-6 hours past the scheduled time would not meet her expectations. She stated this could cause the residents to be in pain or experience heightened anxiety. Review of an in-service entitled Medication Administration, dated 06/21/24 and conducted by the DON, reflected staff were in-serviced on their Medication Administration policy and notifying leadership when medications were administered late. Review of the facility's Administration of Medications Policy, dated 07 of 2017, reflected the following: Policy: It is the policy of this facility, medication shall be administered as prescribed by the resident's physician, nurse practitioner, or physician's assistant. .7. Unless otherwise specified by the resident's attending physician, routine medications will be administered per the facility time ranges. This is to promote the continuance of a home like environment for our residents.

Based on interview and record review, the facility failed to ensure residents were free of any significant medication errors for two (Resident #1 and Resident #2) of four residents reviewed for pharmacy services. The facility failed to administer scheduled time-sensitive medications to Residents #1 and #2 until 2.5 - 6 hours after the ordered scheduled time from 06/24/24 - 06/27/24. This deficient practice could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements, worsening or exacerbation of chronic medical conditions, and hospitalization . Findings included : Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including type II diabetes, depression , asthma (A lung disorder characterized by narrowing of the airways) with exacerbation, and fracture of left femur (thigh bone). Review of Resident #1's admission MDS assessment, dated 05/25/24 , reflected a BIMS of 14, indicating she was cognitively intact. Section N (Medications) reflected she was taking an antidepressant, a diuretic, an opioid, and hypoglycemic. Review of Resident #1's admission care plan, dated 05/22/24, reflected she was on diuretic therapy related to edema (swelling) with an intervention of administering medication as ordered. Review of Resident #1's Medication Administration Audit Report, from 06/24/24 - 06/30/24, reflected the following late medication administrations: 06/24/24 Ordered for 7:00 AM and not administered until 9:51 AM: Ranolazine (for Angina [shortness of breath]), Amlodipine (for high blood pressure), Zoloft (for depression), Gabapentin (for pain), Keppra (for seizures) Ordered for 12:00 PM and not administered until 2:26 PM: Gabapentin, Hydroxyzine (for anxiety) 06/25/24 Ordered for 12:00 PM and not administered until 2:47 PM: Gabapentin, Hydroxyzine Ordered for 4:00 PM and not administered until 8:47 PM: Gabapentin, Hydroxyzine 06/26/24 Ordered for 7:00 AM and not administered until 12:22 PM: Gabapentin, Keppra, Hydroxyzine, Zoloft, Ranolazine, Amlodipine, Abilify (for bipolar disorder) 06/27/24 Ordered for 12:00 PM and not administered until 6:19 PM: Gabapentin, Hydroxyzine During an interview on 07/01/24 at 12:17 PM, Resident #1 stated her medications were given to her late all the time, and she often went hours waiting. She stated getting her pain and anxiety medications late was what affected her the most. She stated she could feel her pain and anxiety symptoms heighten as she waited for her medications. Review of Resident #2's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including hypertension (high blood pressure), scoliosis (a sideways curvature of the spine), and rheumatoid arthritis (a chronic inflammatory disease that affects the joints). Review of Resident #2's admission MDS assessment, dated 05/25/24, reflected a BIMS of 14, indicating she was cognitively intact. Section N (Medications) reflected she was taking an antidepressant and an opioid. Review of Resident #2's admission care plan, dated 04/23/24, reflected she was on an antidepressant medication related to depression and had acute/chronic pain with an intervention of giving antidepressant and analgesia (arthritic pain) medications as ordered by the physician. Review of Resident #2's Medication Administration Audit Report, from 06/24/24 - 06/30/24, reflected the following late medication administrations: 06/24/24 Ordered for 7:00 AM and not administered until 10:24 AM: Oxycodone (for pain), Meloxicam (for pain), Gabapentin (for pain) Ordered for 7:00 AM and not administered until 11:04 AM: Brovana Inhalation Nebulization Solution (for respiratory support), Budesonide Inhalation Suspension (for respiratory support) 06/26/24: Ordered for 7:00 AM and not administered until 12:18 PM: Brovana Inhalation Nebulization Solution, Budesonide Inhalation Suspension During an interview on 07/01/24 at 12:24 PM, Resident #2 stated her medications were not always given to her late. She stated sometimes her nebulizer and inhaler treatments were late but it did not affect her. During an interview on 07/01/24 at 1:15 PM, MA A stated medications should be administered within one hour before or one hour after the scheduled time. She stated she sometimes had a hard time administering all medications within that timeframe. She stated it was important for medications to be administered within the timeframe to ensure residents do not go too long without a medication or were administered the same medication too close together. During an interview on 07/01/24 at 1:54 PM, the ADM stated they utilized a liberal medication pass to make it a more homelike environment for their residents. She stated they did not follow the one-hour before or one-hour after the scheduled time for medication administration. She stated pain medications, anxiety medications, or breathing treatments going 3-6 hours past the scheduled time would not meet her expectations. She stated this could cause the residents to be in pain or experience heightened anxiety. review of an in-service entitled Medication Administration, dated 06/21/24 and conducted by the DON, reflected staff were in-serviced on their Medication Administration policy and notifying leadership when medications were administered late. review of the facility's Administration of Medications Policy, dated 07 of 2017, reflected the following: Policy: It is the policy of this facility, medication shall be administered as prescribed by the resident's physician, nurse practitioner, or physician's assistant. .3. MEdications must be administered in accordance with the written orders of the attending physician. .7. Unless otherwise specified by the resident's attending physician, routine medications will be administered per the facility time ranges. This is to promote the continuance of a home like environment for our residents.

Based on observation, interview, and record review, the facility failed to ensure services provided by the facility meet professional standards of quality for one of two residents reviewed for being at risk for respiratory distress/failure with a [MEDICAL CONDITION] (Resident #1). Resident #1 had a [MEDICAL CONDITION] (a tube surgically placed through the neck into the trachea-windpipe to provide an airway), a history of respiratory distress, and was morbidly obese (415 lbs.). On [DATE] Resident #1 called out for help stating he was having difficulty breathing and then went into respiratory arrest followed by [MEDICAL CONDITION]. Four licensed nursing staff (LVN Z, LVN X, ADON T, and RN Y) failed to check his airway for a blockage, provide oxygenation (rescue breathing) via an ambu bag, and use a backboard for CPR for a bariatric resident with a trachesotomy. Resident #1 was diagnosed with [REDACTED]. 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 a severity of actual harm with a scope of isolated. This deficient practice could place 1 resident with a [MEDICAL CONDITION], and 44 residents with Full Code (all possible measures are taken to revive a person and sustain life) Advance Directives at risk for delayed and/or ineffective emergency nursing interventions which could result in [MEDICAL CONDITIONS] and/or death if respiratory distress and/or [MEDICAL CONDITION] should occur. The Findings Include: Review of a face sheet for Resident #1 reflected he was [AGE] years old and was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of a MDS for Resident #1 dated [DATE] reflected he was dependent on two staff for bed mobility and transfers and dependent on 1 or 2 staff for hygiene and dressing. Resident #1 had a BIMS score of 13 on admission from the hospital and was alert and oriented to person, place and time. Resident #1 had an admission weight of 401 lbs. Review of a Care Plan for Resident #1dated [DATE] reflected the following: Monitor Vital signs per physician orders, Monitor for Shortness of breath; Resident has a [MEDICAL CONDITION] and is at risk for increased secretions/congestion and infections- Monitor resident for needed suctioning, Provide resident with oxygen, [MEDICAL CONDITION] care and tubing change per physician orders; Monitor resident for shortness of breath, notify physician of shortness of breath not relieved by medications; Impaired cardiac function and gas exchange related to [MEDICAL CONDITION], Chronic Obstructive Airway Disease-oxygen and suction as ordered- Monitor for signs and symptoms of shortness of breath to include panting, sweating, changes in skin color, very low blood pressure, check oxygen saturation as ordered and if less than 89 % contact the physician. Review of physician orders [REDACTED]. suction every ,[DATE] hours, continuous aresol mist via [MEDICAL CONDITION] with oxygen at 3 liters per minute, Keep oxygen saturates greater than or equal to 92%. nebulizer treatments 4 times a day and as needed. Review of a local EMS Patient Care Report dated [DATE] reflected the following: - Dispatch received call from the facility at 4:13 pm. - EMS at the scene at 4:24 and at patient ' s bedside at 4:25 pm. Local fire department performing compressions and oxygen level at 96 %. At 4:38 pm a blood pressure and pulse were obtained- -Transported from facility at 4:48 pm. -5:04 pm arrived at destination- local hospital. - Narrative- Patient reportedly called out for help at nursing home and staff found patient unresponsive with agonal (intense suffering) gasping respirations. 911 contacted and CPR initiated. Local fire department arrived and took over compressions. EMS finds patient in the above condition. Bag valve mask (ambu bag) adjusted from face mask to patient ' s [MEDICAL CONDITION]. Review of hospital admission records for Resident #1 dated [DATE] reflected- [AGE] year old male with [MEDICAL CONDITION] and morbidly obesity (415 lbs) admitted after having shortness of breath episode followed by [MEDICAL CONDITION]. This patient is critically ill and unresponsive with no purposeful movements. Review of a hospital Computerized Tomography-CT of the Head without Contrast report dated [DATE] reflect- global [MEDICAL CONDITION] (total lack of oxygen) injury. In a telephone interview on [DATE] at 1:01 pm Resident #1's family member stated he was removed from life support due to his [DIAGNOSES REDACTED]. An observation on [DATE] at 5:00 pm revealed Resident #1 ' s bed and suctioning equipment were still in his room since his discharge on [DATE]. Resident #1's bed was an older style bariatric bed that did not have a mattress that would deflate in the event CPR is needed and did not have a removable head/foot board. There was a deflated overlay mattress (a removable inflatable mattress to aid with comfort) on top of the permanent mattress. In an interview on [DATE] at 3:43 pm MA B stated on [DATE] at approximately sometime between 3:00 and 4:00 pm he was passing medications and heard Resident #1 calling for help and he was saying he was having trouble breathing. MA B stated he took Resident #1 ' s oxygen saturation level and got a reading of, he thinks 62 %, and then immediately went to get LVN Z who was in another resident ' s room doing a dressing change. MA B stated he told LVN Z he needed her " stat " (defined as immediately-without delay). MA B stated when LVN Z came to the room in a minute or so and she instructed him to call 911 (emergency services) and instructed CNA A to get the mobile vital signs equipment and inform the other nurses to get the emergency cart and backboard. MA B stated he stayed in the room while he was on his cell phone with emergency services to continue to give them information. MA B stated staff could not locate the facility ' s backboard for emergencies. In a telephone interview on [DATE] at 2:10 pm LVN Z stated on [DATE] she was in a resident ' s room wrapping his legs with dressings when MA B came to the room and informed her she was needed immediately in Resident #1 ' s room because his oxygen saturation level was very low, she thought he stated it was 46 % but couldn't remember. LVN Z stated she finished the leg wrapping, which reportedly took approximately one minute, and then went to Resident #1's room and found him sitting in bed at approximately a 45 degree angle. LVN Z stated he "didn't look like he was breathing and he was turning blue." LVN Z stated she had a wrist blood pressure monitor device with her and she took his vital signs and they were ,[DATE] with a pulse of 111 and an oxygen saturation rate of 45%, and he was cyanotic. LVN Z stated she did not attempt any other oxygen saturation levels because the device in his room had fallen to the floor when she attempted to use it afterwards and it had "no reading." LVN Z added she had just given Resident #1 a breathing treatment an hour or so before and he was " fine " LVN Z stated when she initially found Resident #1 cyanotic she checked the oxygen tubing connections, but did not attempt to suction him or check for a mucus plug that could be blocking his airway. LVN Z stated she told MA B to call 911 and CNA A to get the emergency cart and the backboard. LVN Z stated she attempted to do chest compressions but she could not maintain positioning while trying to kneel in his bed and do deep compressions because of Resident #1's size. When asked how Resident #1 was [MEDICATION NAME] when he went into respiratory and [MEDICAL CONDITION] she responded " I wasn't worried about his breathing I wanted to get his heart rate back. " LVN Z stated RN Y came into the room and applied the AED monitor (a portable electronic device that automatically [DIAGNOSES REDACTED]. LVN Z denied using an ambu bag (a medical device used to provide assisted ventilation to people who are either not breathing or having trouble breathing) or a backboard at any time during the resuscitative efforts for Resident #1. LVN Z stated her CPR certification had expired and she wasn't sure when, but she had received training on the care of a residents with a [MEDICAL CONDITION] a few months ago. LVN Z was not able to explain the discrepancy in her nusrse's notes that Resident #1 was not breathing, but had respirations of 24 (see notes below). Review of nurse's notes for Resident #1 dated [DATE] (no time was noted) reflected the following: "Aide came and got me out of the room because patient was having a hard time breathing. I left my patient and went to his room. When I arrived he was blue and unresponsive. Told aid to call 911. Started chest compressions. Oxygen saturation level was 45% vital signs ,[DATE] (blood pressure) pulse 121, respirations 24. Also, other nurse started AED machine. Machine kept prompting to do chest compressions-other nurses did chest compressions until EMS arrived. EMS stated they got his pulse to a regular beat and his oxygen saturation to 100 %. Patient continued to be unresponsive. ' EMS took him to a local hospital. In an interview on [DATE] at 2:20 pm RN Y stated on [DATE] she was walking to the nurses' station and heard CNA A yelling LVN Z "needs help" RN Y stated when she went into the room LVN Z was putting the side rails down and deflating the overlay mattress and no one was doing chest compressions. RN Y stated ADON T handed her the AED and she applied it and made sure everyone stood back away from the machine in case an electrical shock was needed. RN Y stated when the AED indicated chest compressions were needed she started doing them and had to stand on the side rails of the bed to have the best position possible (RN Y reported being 68 inches tall). RN Y stated she became fatigued and CNA A took over the chest compressions. RN Y stated the AED device instructed her to do deeper compressions when she became fatigued and that no one was able to locate the facility backboard prior to the fire department's arrival. When asked how Resident #1's oxygenation was maintained during the resuscitative efforts for Resident #1 RN Y stated that " first of all current guidelines for CPR does not require rescue breathing and secondly he had oxygen attached to his [MEDICAL CONDITION]. " RN Y ended by saying her CPR certification was not current and she did not know when it expired. In an interview on [DATE] at 1:05 pm LVN X stated she was working on [DATE] when Resident #1 went into respiratory distress. LVN X stated she was called into the room and she saw that Resident #1's mattress did not deflate so she ran out of the room to find the backboard, but could not find it. She stated she then went to call the family and when she returned to the room she relieved CNA A from compressions because the AED device was saying " go deeper/harder compressions. " LVN X added no backboard was used during the resuscitation and she did not think to get one from a resident ' s bed. She also stated she could not recall an ambu bag being used. In an interview on [DATE] at 2:40 pm ADON T stated on [DATE] MA B came to get her at LVN Z ' s instruction because the emergency cart and backboard were needed for Resident #1. ADON T stated she grabbed the AED but could not find the facility ' s backboard that is supposed to be kept next to the crash cart. ADON T stated she took the AED to the room and by that time 2 other nurses were heading to the Resident #1's room. ADON T stated she saw LVN Z doing chest compressions when she went into the room to deliver the AED. ADON T stated she remained outside of Resident #1 's room at the door until she saw the fire department ' s arrival and she went outside to direct them to the room. ADON T stated while standing outside the room she heard the AED recording several times saying the chest compressions needed to be "deeper." ADON T also stated shortly after their arrival a member of the fire department ' s rescue staff went back to their truck and brought a backboard to place under Resident #1. ADON T stated when Resident #1 left the facility with EMS she thought he was being ventilated with an ambu bag and she did not see an ambu bag being used at any time when facility staff were doing chest compressions. The ADON admitted in a follow up interview on [DATE] at 10:00 am that part of her role as an ADON is she is responsible for supervising care provided, but did not intervene with Resident #1's care during his respiratory and [MEDICAL CONDITION]. She also confirmed she had received [MEDICAL CONDITION] care training in ,[DATE]. In an interview on [DATE] at 3:00 RN W stated he is the owner and one of the instructors for a local company in Austin, Texas that provides CPR training to medical personnel and first responders; including the local city/county fire and ambulance services. RN W stated when a patient is in respiratory distress it is imperative first of all to assess for possible causes for the respiratory distress and intervene immediately to try and maintain oxygenation to the brain. RN W stated if a patient is in respiratory and [MEDICAL CONDITION], assisted ventilation with an ambu bag is required because the positive pressure is needed to move the oxygen and applying oxygen to an established [MEDICAL CONDITION] does not replace rescue breathing. In an interview on [DATE] at 1:50 pm with the DON and DCS, the DON stated the facility did not have a policy and procedure for CPR and licensed staff are not required to provide proof of current CPR certification when the are hired even though the facility offers CPR for residents with Advance Directives for Full Code. The DCS stated this is from direction at the corporate level. The DCS confirmed the facility had no procedure in place to ensure at least one licensed staff is CPR certified per shift. In an interview on [DATE] at 2:00 pm the DCS went on to say some licensed staff had been trained on [MEDICAL CONDITION] care to include suctioning, [MEDICAL CONDITION] change and cleaning the [MEDICAL CONDITION] in ,[DATE] and she would provide documentation of the certificates. The DCS added she was a CPR instructor for medical professionals and would train all licensed staff that did not have current CPR certification to include management of advanced airways. Review of the Certificates of the [MEDICAL CONDITION] Care Training provided by a licensed Respiratory Therapist revealed LVN Z and ADON T had received the training on [DATE] and RN Y received it on [DATE]. Further review of the Certificates of [MEDICAL CONDITION] Care Training reflected two licensed nurses on the ,[DATE] pm shift had not received the training RN U and LVN V. Resources: American Heart Association, Brainandspinalcord.org/[MEDICAL CONDITION] Review of the most recent American Heart Association Guidelines for CPR refelcted the following: -The 2010 AHA Guidelines for CPR and ECC once again emphasize the need for high-quality CPR, including ? A compression rate of at least 100/min -? A compression depth of at least 2 inches (5 cm) in adultsComponent Adults .- Whether 1 or more rescuers are present, initiation of CPR with chest compressions ensures that the victim receives this critical intervention early, and any delay in rescue breaths should be brief. -Ventilations with advanced airway 1 breath every ,[DATE] seconds (,[DATE] breaths/min) Asynchronous with chest compressions About 1 second per breath Visible chest rise -Education, Implementation and Teams The current 2-year certification period for basic and advanced life support courses should include periodic assessment of rescuer knowledge and skills, with reinforcement or refresher information provided as needed Debriefing is a learner-focused, nonthreatening technique to help individual rescuers and teams reflect on and improve performance The facility did not have a policy and procedure for CPR or required licensed staff to have current CPR certifications. The facility Administrator-, the DON, and the corporate DCS were notified on [DATE] at 4:35 that an IJ situation had been identified due to the above failures. In an interview with the Medical Director on [DATE] at 4:21 pm he stated due to Resident #1's history of [MEDICAL CONDITIONS] and [MEDICAL CONDITION] he had questioned the administrator prior to his admission to the facility and he assured him that staff would be trained on [MEDICAL CONDITION] care and [MEDICAL CONDITION]. The Medical Director was informed there were staff that had not been trained. Two of three licensed nurses that worked the night shift and in some incidences worked the same shifts had not received [MEDICAL CONDITION] care training and/or were CPR certified. The Medical Director was also informed that the facility did not require staff to be current with CPR certifications. The Medical Director expressed his disappointment in Resident #1's care during the respiratory and [MEDICAL CONDITION] on [DATE] and stated he would ensure the matter would be corrected. The final Plan of Removal was accepted by the investigator on [DATE] at 8:25 pm. The facility provided the following plan of removal: 1. Will ensure at least 1 CPR certified nurse available every shift. [DATE]. Monday we will initiate CPR certification for current full time nurses to be completed by [DATE]. Part time nurses will be CPR certified by if not in attendance on [DATE] or [DATE] will not be scheduled to work. CPR certified according to American Heart Association Guidelines to include advanced airways. CPR certifications will be audited and maintained by the PSR and audited weekly and documentation will be reviewed by the administrator to include knowledge on advanced airway perfusion during CPR. If CPR not current will be immediately removed from the schedule. New hires will be required to provide proof of CPR certification prior to completing orientation. Nurses assigned a tracheotomy resident has received tracheotomy training at the are as follows with verbalization of knowledge of advanced airway and assessment and knowledge of resident with respiratory distress. Specialized Medical Services Respiratory Therapist will conduct an in-serve to be completed at 8am on [DATE]. Upon a new nurse hired they will be educated with return demonstration and checked off on competency prior to assignment to a tracheotomy patient. RT on call 24 hours, all nurse staff has phone number posted at nurse ' s station. (The facility provided a list of names of staff for each shift that were either CPR certified or had received [MEDICAL CONDITION] training from [DATE] 2:00 pm-6:00 pm through [DATE] 10:00 pm - 6:00 am) 2. [DATE] in serviced direct care staff on deflating bed for a bariatric resident before commencing CPR to serve as a back board hard surface. Bariatric resident in room [ROOM NUMBER] has a STAT 5000C bed that has a CPR mode that will deflate the bed and serve as a back board/hard surface in the event CPR needs to be performed. Continue to be in serviced direct care staff prior to starting their shift, on the STAT 5000C capability of the CPR mode. DON will audit for compliance. 3. Crash cart supplied with back board [DATE]. [DATE] 5:30pm initiated each shift will be audited ever day by ,[DATE] shift. If not available DON will be notified immediately. Head board will be used if back board is not available. [DATE] in serviced on current ,[DATE] staff to remove the headboard to serve as a back board and continuing to in service all direct care staff prior to receiving their assignment. DON will conduct audit weekly. To ensure continued compliance current full time nurses and new nurses will be required to maintain CPR certification. During Morning Clinical Meeting/IDT the facility will discuss bariatric/tracheotomy residents prior to admission to ensure residents safety needs are met in the event of emergency. Ensure everyone assigned to a tracheotomy patient to have demonstrated competency and have been checked off by facility prior to accepting assignment. In an interview on [DATE] at 11:00 am the corporate DCS stated it was the expectation that licensed staff would use a backboard during CPR when a resident is morbidly obese without a deflating mattress and/or unable to be moved to the floor. It was also the expectation the licensed staff should have used an ambu bag for rescue breathing and cue each other during an emergency situation to ensure everything possible is being done for a resident in a respiratory and/or [MEDICAL CONDITION]. The investigator monitored the current plan of removal as follows: On [DATE] and [DATE] staff listed on the schedule for current CPR certification and [MEDICAL CONDITION] care training (to include the use of an ambu bag if rescue breathing is needed in a patient with a [MEDICAL CONDITION]) were observed to be on duty and they were interviewed as to the expectations (assessments) and their responsibilities in the event a resident experienced respiratory distress or arrest and/or [MEDICAL CONDITION]. Licensed staff was interviewed on the location of the facility backboard and what to do in the event it cannot be located i.e. resident bed head/foot boards. Staff was interviewed on the operation of a bariatric bed with a mattress that can be deflated in the event of an emergency and CPR is needed. Staff was able to answer questions according to the training they received from [DATE] to [DATE]. In a follow up interview on [DATE] at 11:00 am LVN Z stated had just completed training at the facility on assessing a resident in respiratory distress provided by a licensed respiratory therapist. LVN Z stated Resident #1 did not receive any assisted ventilation when he went into respiratory distress and he should have. LVN Z added she would " have done things differently " and made sure Resident #1 was thoroughly assessed and received ventilation with an ambu bag and she would have taken a head or foot board from another resident ' s bed to use when the facility backboard could not be found. In a follow up interview on [DATE] RN Y at 1:20 pm stated she completed her CPR certification online on [DATE] and it included training of advanced airways ([MEDICAL CONDITION]). She stated the training for assessment of respiratory distress included checking for the rise and fall of the chest, oxygen saturation levels and using an ambu bag to assist with ventilation in a patient with respiratory distress. RN Y stated she was there to assist LVN Z with the code because Resident #1 was her patient; therefore she did not question if the ambu bag should be used and did not direct staff to get a foot or head board from another resident ' s bed to use for a backboard. RN Y also stated none of the licensed staff thought of getting a head or foot board from another resident ' s bed to use for Resident #1 during CPR. RN Y stated it had been months since she had seen the facility ' s backboard that was normally kept next to the emergency cart. Review of in-services for licensed staff conducted from [DATE] to [DATE] reflected the following: -Assessment of a resident in respiratory distress- suction resident as needed to clear airway. If unsuccessful notify MD or call 911. If resident is unresponsive and no pulse or respirations Start CPR with chest compressions and rescue breathing with an ambu bag. An ambu bag is necessary for positive pressure and adequate air perfusion. Ensure chest is rising. -If backboard is unavailable from the crash cart- utilize head/foot board of bed as a backboard. -How to deflate the bed mattress on a STAT 5000 C bariatric bed in the event CPR is indicated. -Use of Manual Resuscitators for rescue breathing in non-[MEDICAL CONDITION] and [MEDICAL CONDITION] patients; assessing a resident in respiratory distress, tracheal [MEDICATION NAME] suctioning and [MEDICAL CONDITION] care. (Conducted by a licensed respiratory therapist). On [DATE] at 4:33 pm, the Administrator and DCS were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm with a scope as isolated due to the facility requiring time to train all staff and monitor their Plan of Removal. The facility DON provided a list of one resident with a [MEDICAL CONDITION] and 44 residents with Full Code Advance Directives.

Based on interview and record review the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical well being of each resident when: A. The Administrator failed to supervise, train and evaluate licensed staff on how to manage a bariatric resident with a [MEDICAL CONDITION] in need of CPR; and failed to identify staff were not prepared prior to an admission of a bariatric resident with a [MEDICAL CONDITION] with an Advance Directive of Full Code (all possible measures are taken to revive a person and sustain life). B. The DON failed to ensure the facility backboard was available to staff for emergency use in CPR. C. ADON T did not supervise or intervene when Resident #1 was in respiratory and [MEDICAL CONDITION]. D. The DON and Administrator failed to develop policies and procedures to ensure residents with Advance Directives for Full Codes would have CPR provided by licensed staff certified in CPR. These 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 a severity of harm and a scope identified as isolated. These deficient practices could place one resident with a [MEDICAL CONDITION], and 44 residents with Advance Directives for Full Codes at risk for ineffective or delayed nursing interventions which could result in [MEDICAL CONDITIONS] or death. The findings include: A. An observation on [DATE] at 1:45 pm revealed Resident #1's bed and suctioning equipment were still in his room since his discharge on [DATE]. Resident #1's bed was an older style bariatric bed that did not have a mattress that would deflate in the event CPR is needed and did not have a removable head/foot board to be used as a backboard. There was a deflated overlay mattress on top of the permanent mattress. In an interview on [DATE] at 1:30 pm the Administrator stated the facility owned two bariatric beds. One of the beds is a newer model with a mattress that deflates if CPR is needed and the base of the bed serves as a backboard; and it is currently in use. The Administrator stated Resident #1 had an older model bed that did not have a mattress that deflated or a removable head or foot board to use as a backboard for CPR. Resident #1 had used the older model bed when he was admitted in ,[DATE] and the decision was made for him to use it again when he returned to the facility in ,[DATE]. The Administrator stated he had made the assumption that licensed staff knew how to provide effective CPR and to use a backboard. The Administrator stated in the event the facility accepts another bariatric resident they will be provided with a bed with a mattress that deflates for CPR. In an interview on [DATE] at 2:00 pm the DCS stated some licensed staff had been trained on [MEDICAL CONDITION] care to include suctioning, [MEDICAL CONDITION] change and cleaning the [MEDICAL CONDITION] in ,[DATE] and she would provide documentation of the certificates. Review of facility provided Certificates of Completion for [MEDICAL CONDITION] Care as of [DATE] reflected 8 out of a total of 22 licensed staff had completed the training. Further review of the facility provided Certificates of Completion for [MEDICAL CONDITION] Care reflected reflected RN U and LVN V had not received the training and they worked the 10:00 pm to 6:00 am shifts together and would be the only licensed care staff on duty. In an interview with the DON on [DATE] she stated she would ensure at least one person for each shift would have received [MEDICAL CONDITION] training until [DATE] when all staff will be in-serviced as part of the plan of removal for the IJ. The DON stated she thought all staff had been trained that needed to be. In an interview with the Medical Director on [DATE] at 4:21 pm he stated due to Resident #1's history of [MEDICAL CONDITIONS] and [MEDICAL CONDITION] he had questioned the administrator prior to his admission to the facility and he assured him that staff would be trained on [MEDICAL CONDITION] care and [MEDICAL CONDITION]. The Medical Director was informed there were staff that had not been trained. Two of three licensed nurses that worked the night shift, and in some incidences worked the same shifts, had not received [MEDICAL CONDITION] care training and/or were not CPR certified. The Medical Director was also informed that the facility did not require staff to be current with CPR certifications. The Medical Director expressed his disappointment in Resident #1's care during the respiratory and [MEDICAL CONDITION] on [DATE] and stated he would ensure the matter would be corrected. B. In an interview on [DATE] at 1:45 pm the corporate DCS stated she had searched for the facility backboard and it was not located. The DCS added one was being ordered and should arrive on [DATE]. In an interview on [DATE] at 1:45 pm RN U stated he works the 10:00 pm-6:00 am shift and the nurses on the night shift are responsible for completing the Emergency Cart Daily Check log. The [DATE] and [DATE] Emergency Cart Logs were reviewed with RN U to confirm his signatures on the log to indicate the facility backboard was in place and he confirmed them. RN U stated he routinely documented the backboard was in place, but did not check to make sure it was. In an interview on [DATE] at 2:20 pm RN Y stated when she was doing chest compressions on Resident #1 and the AED device instructed her to do deeper compressions when she became fatigued and that no one was able to locate the facility backboard prior to the fire department's arrival and they provided one. In an interview on [DATE] at 1:05 pm LVN X stated she was working on [DATE] when Resident #1 went into respiratory distress. LVN X stated she was called into the room and she saw that Resident #1's mattress did not deflate so she ran out of the room to find the facility backboard, but could not find it. In an interview on [DATE] at 2:40 pm ADON T stated on [DATE] MA B came to get her at LVN Z's instruction because the emergency cart and backboard were needed for Resident #1. ADON T stated she grabbed the AED but could not find the facility's backboard that is supposed to be kept next to the emergency cart. ADON T stated she remained outside of Resident #1's room at the door until she saw the fire department's arrival and she went outside to direct them to the room. ADON T stated while standing outside the room she heard the AED recording several times saying the chest compressions needed to be "deeper" ADON T also stated shortly after their arrival a member of the fire department's rescue staff went back to their truck and brought a backboard to place under Resident #1. In an interview [DATE] at 2:00 pm the DON stated she had not ensured the facility backboard was available in the event of an emergency. The DON added the backboard should remain behind the emergency cart when it is not in use. The DON went on to say the 10:00 pm to 6:00 am licensed staff are assigned to complete the daily Emergency Cart check list, which included locating the backboard, but no one is assigned to monitor the validity of the signatures on the daily log to indicate a backboard is available and located next to the emergency cart. C. In an interview on [DATE] at 2:40 pm ADON T stated on [DATE] MA B came to get her at LVN Z's instruction because the emergency cart and backboard were needed for Resident #1. ADON T stated she grabbed the AED but could not find the facility's backboard that is supposed to be kept next to the emergency cart. ADON T stated she took the AED to the room and by that time 2 other nurses were heading to the Resident #1's room. ADON T stated saw LVN Z doing chest compressions when she went into the room to deliver the AED. ADON T stated she remained outside of Resident #1's room at the door until she saw the fire department's arrival and she went outside to direct them to the room. ADON T stated while standing outside the room she heard the AED recording several times saying the chest compressions needed to be "deeper" ADON T also stated shortly after their arrival a member of the fire department's rescue staff went back to their truck and brought a backboard to place under Resident #1. ADON T stated when Resident #1 left the facility with EMS she thought he was being ventilated with an ambu bag and she did not see an ambu bag being used at any time when facility staff were doing chest compressions. The ADON admitted in a follow up interview on [DATE] at 10:00 am that part of her role as an ADON is she is responsible for supervising care provided, but did not intervene with Resident#1's care during his respiratory and [MEDICAL CONDITION]. The ADON confirmed her CPR certification was current and she had received the facility provided training for [MEDICAL CONDITION] care. Review of the Certificates of the [MEDICAL CONDITION] Care Training provided by a licensed Respiratory Therapist revealed ADON T had received the training on [DATE]. In an interview on [DATE] at 11:00 am the corporate DCS stated it was the expectation that licensed staff would use a backboard during CPR when a resident is morbidly obese without a deflating mattress and/or unable to be moved to the floor. It was also the expectation the licensed staff (to include management level nurses) should have used an ambu bag for rescue breathing and cue each other during an emergency situation to ensure everything possible is being done for a resident in a respiratory and/or [MEDICAL CONDITION]. D. In an interview on [DATE] at 1:50 pm with the DON and DCS, the DON stated the facility did not have a policy and procedure for CPR and licensed staff are not required to provide proof of current CPR certification when they are hired even though the facility offers CPR for residents with Advance Directives for Full Code. The DCS stated this is from direction at the corporate level. The DCS confirmed the facility had no procedure in place to ensure at least one licensed staff is CPR certified per shift. In an interview on [DATE] at 2:00 pm the DCS added she was a CPR instructor for medical professionals and would train all licensed staff that did not have current CPR certification to include management of advanced airways. Resources: American Heart Association, Brainandspinalcord.org/[MEDICAL CONDITION] Review of the most recent American Heart Association Guidelines for CPR reflected the following: -The 2010 AHA Guidelines for CPR and ECC once again emphasize the need for high-quality CPR, including ? A compression rate of at least 100/min -? A compression depth of at least 2 inches (5 cm) in adults Component Adults .- Whether 1 or more rescuers are present, initiation of CPR with chest compressions ensures that the victim receives this critical intervention early, and any delay in rescue breaths should be brief. -Ventilation's with advanced airway 1 breath every ,[DATE] seconds (,[DATE] breaths/min) Asynchronous with chest compressions About 1 second per breath Visible chest rise -Education, Implementation and Teams The current 2-year certification period for basic and advanced life support courses should include periodic assessment of rescuer knowledge and skills, with reinforcement or refresher information provided as needed Debriefing is a learner-focused, nonthreatening technique to help individual rescuers and teams reflect on and improve performance The facility did not have a policy and procedure for CPR or required licensed staff to have current CPR certifications. The facility Administrator-, the DON, and the corporate DCS were notified on [DATE] at 4:35 that an IJ situation had been identified due to the above failures. The final Plan of Removal was accepted by the investigator on [DATE] at 8:25 pm. The facility provided the following plan of removal: 1. Will ensure at least 1 CPR certified nurse available every shift. [DATE]. Monday we will initiate CPR certification for current full time nurses to be completed by [DATE]. Part time nurses will be CPR certified by if not in attendance on [DATE] or [DATE] will not be scheduled to work. CPR certified according to American Heart Association Guidelines to include advanced airways. CPR certifications will be audited and maintained by the PSR and audited weekly and documentation will be reviewed by the administrator to include knowledge on advanced airway perfusion during CPR. If CPR not current will be immediately removed from the schedule. New hires will be required to provide proof of CPR certification prior to completing orientation. Nurses assigned a tracheotomy resident has received tracheotomy training at the are as follows with verbalization of knowledge of advanced airway and assessment and knowledge of resident with respiratory distress. Specialized Medical Services Respiratory Therapist will conduct an in-serve to be completed at 8 am on [DATE]. Upon a new nurse hired they will be educated with return demonstration and checked off on competency prior to assignment to a tracheotomy patient. RT on call 24 hours, all nurse staff has phone number posted at nurse ' s station. (The facility provided a list of names of staff for each shift that were either CPR certified or had received [MEDICAL CONDITION] training from [DATE] 2:00 pm-6:00 pm through [DATE] 10:00 pm - 6:00 am) 2. [DATE] in serviced direct care staff on deflating bed for a bariatric resident before commencing CPR to serve as a back board hard surface. Bariatric resident in room [ROOM NUMBER] has a STAT 5000C bed that has a CPR mode that will deflate the bed and serve as a back board/hard surface in the event CPR needs to be performed. Continue to be in serviced direct care staff prior to starting their shift, on the STAT 5000C capability of the CPR mode. DON will audit for compliance. 3. Crash cart supplied with back board [DATE]. [DATE] 5:30 pm initiated each shift will be audited ever day by ,[DATE] shift. If not available DON will be notified immediately. Head board will be used if back board is not available. [DATE] in serviced on current ,[DATE] staff to remove the headboard to serve as a back board and continuing to in service all direct care staff prior to receiving their assignment. DON will conduct audit weekly. To ensure continued compliance current full time nurses and new nurses will be required to maintain CPR certification. During Morning Clinical Meeting/IDT the facility will discuss bariatric/tracheotomy residents prior to admission to ensure residents safety needs are met in the event of emergency. Ensure everyone assigned to a tracheotomy patient to have demonstrated competency and have been checked off by facility prior to accepting assignment. In an interview on [DATE] at 11:00 am the corporate DCS stated it was the expectation that licensed staff would use a backboard during CPR when a resident is morbidly obese without a deflating mattress and/or unable to be moved to the floor. It was also the expectation the licensed staff should have used an ambu bag for rescue breathing and cue each other during an emergency situation to ensure everything possible is being done for a resident in a respiratory and/or [MEDICAL CONDITION]. The investigator monitored the current plan of removal as follows: On [DATE] and [DATE] staff listed on the schedule for current CPR certification and [MEDICAL CONDITION] care training (to include the use of an ambu bag if rescue breathing is needed in a patient with a [MEDICAL CONDITION]) were observed to be on duty and they were interviewed as to the expectations (assessments) and their responsibilities in the event a resident experienced respiratory distress or arrest and/or [MEDICAL CONDITION]. Licensed staff was interviewed on the location of the facility backboard and what to do in the event it cannot be located i.e. resident bed head/foot boards. Staff was interviewed on the operation of a bariatric bed with a mattress that can be deflated in the event of an emergency and CPR is needed. Staff was able to answer questions according to the training they received from [DATE] to [DATE]. In a follow up interview on [DATE] at 11:00 am LVN Z stated had just completed training at the facility on assessing a resident in respiratory distress provided by a licensed respiratory therapist. LVN Z stated Resident #1 did not receive any assisted ventilation when he went into respiratory distress and he should have. LVN Z added she would " have done things differently " and made sure Resident #1 was thoroughly assessed and received ventilation with an ambu bag and she would have taken a head or foot board from another resident ' s bed to use when the facility backboard could not be found. In a follow up interview on [DATE] RN Y at 1:20 pm stated she completed she completed her CPR certification online on [DATE] and it included training of advanced airways ([MEDICAL CONDITION]). She stated the training for assessment of respiratory distress included checking for the rise and fall of the chest, oxygen saturation levels and using an ambu bag to assist with ventilation in a patient with respiratory distress. RN Y stated she was there to assist LVN Z with the code because Resident #1 was her patient; therefore she did not question if the ambu bag should be used and did not direct staff to get a foot or head board from another resident ' s bed to use for a backboard. RN Y also stated none of the licensed staff thought of getting a head or foot board from another resident ' s bed to use for Resident #1 during CPR. RN Y stated it had been months since she had seen the facility ' s backboard that was normally kept next to the emergency cart. Review of in-services for licensed staff conducted from [DATE] to [DATE] reflected the following: -Assessment of a resident in respiratory distress- suction resident as needed to clear airway. If unsuccessful notify MD or call 911. If resident is unresponsive and no pulse or respirations Start CPR with chest compressions and rescue breathing with an ambu bag. An ambu bag is necessary for positive pressure and adequate air perfusion. Ensure chest is rising. -If backboard is unavailable from the crash cart- utilize head/foot board of bed as a backboard. -How to deflate the bed mattress on a STAT 5000 C bariatric bed in the event CPR is indicated. -Use of Manual Resuscitators for rescue breathing in non-[MEDICAL CONDITION] and [MEDICAL CONDITION] patients; assessing a resident in respiratory distress, tracheal [MEDICATION NAME] suctioning and [MEDICAL CONDITION] care. (Conducted by a licensed respiratory therapist). On [DATE] at 4:33 pm, the Administrator and DCS were informed the IJ was removed. However, the facility remained out of compliance at a severity of harm with a scope as isolated due to the facility requiring time to train all staff and monitor their Plan of Removal. The facility DON provided a list of one resident with a [MEDICAL CONDITION] and 44 residents with Full Code Advance Directives.

Based on observation, interview, and record review, the facility failed to ensure residents receive the necessary care and services to attain or maintain the highest practical physical well-being in accordance with the comprehensive assessment and plan of care for one of two residents reviewed for being at risk for respiratory distress with a [MEDICAL CONDITION] (Resident #1). Resident #1 had a [MEDICAL CONDITION] (a tube surgically placed through the neck into the trachea-windpipe to provide an airway), a history of respiratory distress, and was morbidly obese (415 lbs.). On [DATE] Resident #1 called out for help stating he was having difficulty breathing and then went into respiratory arrest followed by [MEDICAL CONDITION]. Four licensed nursing staff (LVN Z, LVN X, ADON T, and RN Y) failed to check his airway for a blockage, provide oxygenation (rescue breathing) via an ambu bag, and use a backboard for CPR for a bariatric resident with a trachesotomy. Resident #1 was diagnosed with [REDACTED]. 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 a severity of actual harm with a scope of isolated. This deficient practice could place 1 resident with a [MEDICAL CONDITION], and 44 residents with Full Code (all possible measures are taken to revive a person and sustain life) Advance Directives at risk for delayed and/or ineffective emergency nursing interventions which could result in [MEDICAL CONDITIONS] and/or death if respiratory distress and/or [MEDICAL CONDITION] should occur. The Findings Include: Review of a face sheet for Resident #1 reflected he was [AGE] years old and was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of a MDS for Resident #1 dated [DATE] reflected he was dependent on two staff for bed mobility and transfers and dependent on 1 or 2 staff for hygiene and dressing. Resident #1 had a BIMS score of 13 on admission from the hospital and was alert and oriented to person, place and time. Resident #1 had an admission weight of 401 lbs. Review of a Care Plan for Resident #1dated [DATE] reflected the following: Monitor Vital signs per physician orders, Monitor for Shortness of breath; Resident has a [MEDICAL CONDITION] and is at risk for increased secretions/congestion and infections- Monitor resident for needed suctioning, Provide resident with oxygen, [MEDICAL CONDITION] care and tubing change per physician orders; Monitor resident for shortness of breath, notify physician of shortness of breath not relieved by medications; Impaired cardiac function and gas exchange related to [MEDICAL CONDITION], Chronic Obstructive Airway Disease-oxygen and suction as ordered- Monitor for signs and symptoms of shortness of breath to include panting, sweating, changes in skin color, very low blood pressure, check oxygen saturation as ordered and if less than 89 % contact the physician. Review of physician orders [REDACTED]. suction every ,[DATE] hours, continuous aresol mist via [MEDICAL CONDITION] with oxygen at 3 liters per minute, Keep oxygen saturates greater than or equal to 92%. nebulizer treatments 4 times a day and as needed. Review of a local EMS Patient Care Report dated [DATE] reflected the following: - Dispatch received call from the facility at 4:13 pm. - EMS at the scene at 4:24 and at patient ' s bedside at 4:25 pm. Local fire department performing compressions and oxygen level at 96 %. At 4:38 pm a blood pressure and pulse were obtained- -Transported from facility at 4:48 pm. -5:04 pm arrived at destination- local hospital. - Narrative- Patient reportedly called out for help at nursing home and staff found patient unresponsive with agonal (intense suffering) gasping respirations. 911 contacted and CPR initiated. Local fire department arrived and took over compressions. EMS finds patient in the above condition. Bag valve mask (ambu bag) adjusted from face mask to patient ' s [MEDICAL CONDITION]. Review of hospital admission records for Resident #1 dated [DATE] reflected- [AGE] year old male with [MEDICAL CONDITION] and morbidly obesity (415 lbs) admitted after having shortness of breath episode followed by [MEDICAL CONDITION]. This patient is critically ill and unresponsive with no purposeful movements. Review of a hospital Computerized Tomography-CT of the Head without Contrast report dated [DATE] reflect- global [MEDICAL CONDITION] (total lack of oxygen) injury. In a telephone interview on [DATE] at 1:01 pm Resident #1's family member stated he was removed from life support due to his [DIAGNOSES REDACTED]. An observation on [DATE] at 5:00 pm revealed Resident #1 ' s bed and suctioning equipment were still in his room since his discharge on [DATE]. Resident #1's bed was an older style bariatric bed that did not have a mattress that would deflate in the event CPR is needed and did not have a removable head/foot board. There was a deflated overlay mattress (a removable inflatable mattress to aid with comfort) on top of the permanent mattress. In an interview on [DATE] at 3:43 pm MA B stated on [DATE] at approximately sometime between 3:00 and 4:00 pm he was passing medications and heard Resident #1 calling for help and he was saying he was having trouble breathing. MA B stated he took Resident #1 ' s oxygen saturation level and got a reading of, he thinks 62 %, and then immediately went to get LVN Z who was in another resident ' s room doing a dressing change. MA B stated he told LVN Z he needed her " stat " (defined as immediately-without delay). MA B stated when LVN Z came to the room in a minute or so and she instructed him to call 911 (emergency services) and instructed CNA A to get the mobile vital signs equipment and inform the other nurses to get the emergency cart and backboard. MA B stated he stayed in the room while he was on his cell phone with emergency services to continue to give them information. MA B stated staff could not locate the facility ' s backboard for emergencies. In a telephone interview on [DATE] at 2:10 pm LVN Z stated on [DATE] she was in a resident ' s room wrapping his legs with dressings when MA B came to the room and informed her she was needed immediately in Resident #1 ' s room because his oxygen saturation level was very low, she thought he stated it was 46 % but couldn ' t ' remember. LVN Z stated she finished the leg wrapping, which reportedly took approximately one minute, and then went to Resident #1's room and found him sitting in bed at approximately a 45 degree angle. LVN Z stated he "didn't look like he was breathing and he was turning blue." LVN Z stated she had a wrist blood pressure monitor device with her and she took his vital signs and they were ,[DATE] with a pulse of 111 and an oxygen saturation rate of 45%, and he was cyanotic. LVN Z stated she did not attempt any other oxygen saturation levels because the device in his room had fallen to the floor when she attempted to use it afterwards and it had "no reading." LVN Z added she had just given Resident #1 a breathing treatment an hour or so before and he was " fine " LVN Z stated when she initially found Resident #1 cyanotic she checked the oxygen tubing connections, but did not attempt to suction him or check for a mucus plug that could be blocking his airway. LVN Z stated she told MA B to call 911 and CNA A to get the emergency cart and the backboard. LVN Z stated she attempted to do chest compressions but she could not maintain positioning while trying to kneel in his bed and do deep compressions because of Resident #1's size. When asked how Resident #1 was [MEDICATION NAME] when he went into respiratory and [MEDICAL CONDITION] she responded " I wasn't worried about his breathing I wanted to get his heart rate back. " LVN Z stated RN Y came into the room and applied the AED monitor (a portable electronic device that automatically [DIAGNOSES REDACTED]. LVN Z denied using an ambu bag (a medical device used to provide assisted ventilation to people who are either not breathing or having trouble breathing) or a backboard at any time during the resuscitative efforts for Resident #1. LVN Z stated her CPR certification had expired and she wasn't sure when, but she had received training on the care of a residents with a [MEDICAL CONDITION] a few months ago. LVN Z was not able to explain the discrepancy in her nusrse's notes that Resident #1 was not breathing, but had respirations of 24 (see notes below). Review of nurse's notes for Resident #1 dated [DATE] (no time was noted) reflected the following: "Aide came and got me out of the room because patient was having a hard time breathing. I left my patient and went to his room. When I arrived he was blue and unresponsive. Told aid to call 911. Started chest compressions. Oxygen saturation level was 45% vital signs ,[DATE] (blood pressure) pulse 121, respirations 24. Also, other nurse started AED machine. Machine kept prompting to do chest compressions-other nurses did chest compressions until EMS arrived. EMS stated they got his pulse to a regular beat and his oxygen saturation to 100 %. Patient continued to be unresponsive. ' EMS took him to a local hospital. In an interview on [DATE] at 2:20 pm RN Y stated on [DATE] she was walking to the nurses' station and heard CNA A yelling LVN Z "needs help" RN Y stated when she went into the room LVN Z was putting the side rails down and deflating the overlay mattress and no one was doing chest compressions. RN Y stated ADON T handed her the AED and she applied it and made sure everyone stood back away from the machine in case an electrical shock was needed. RN Y stated when the AED indicated chest compressions were needed she started doing them and had to stand on the side rails of the bed to have the best position possible (RN Y reported being 68 inches tall). RN Y stated she became fatigued and CNA A took over the chest compressions. RN Y stated the AED device instructed her to do deeper compressions when she became fatigued and that no one was able to locate the facility backboard prior to the fire department ' s arrival. When asked how Resident #1's oxygenation was maintained during the resuscitative efforts for Resident #1 RN Y stated that " first of all current guidelines for CPR does not require rescue breathing and secondly he had oxygen attached to his [MEDICAL CONDITION]. " RN Y ended by saying her CPR certification was not current and she did not know when it expired. In an interview on [DATE] at 1:05 pm LVN X stated she was working on [DATE] when Resident #1 went into respiratory distress. LVN X stated she was called into the room and she saw that Resident #1's mattress did not deflate so she ran out of the room to find the backboard, but could not find it. She stated she then went to call the family and when she returned to the room she relieved CNA A from compressions because the AED device was saying " go deeper/harder compressions. " LVN X added no backboard was used during the resuscitation and she did not think to get one from a resident ' s bed. She also stated she could not recall an ambu bag being used. In an interview on [DATE] at 2:40 pm ADON T stated on [DATE] MA B came to get her at LVN Z ' s instruction because the emergency cart and backboard were needed for Resident #1. ADON T stated she grabbed the AED but could not find the facility ' s backboard that is supposed to be kept next to the crash cart. ADON T stated she took the AED to the room and by that time 2 other nurses were heading to the Resident #1's room. ADON T stated she saw LVN Z doing chest compressions when she went into the room to deliver the AED. ADON T stated she remained outside of Resident #1 's room at the door until she saw the fire department ' s arrival and she went outside to direct them to the room. ADON T stated while standing outside the room she heard the AED recording several times saying the chest compressions needed to be "deeper." ADON T also stated shortly after their arrival a member of the fire department ' s rescue staff went back to their truck and brought a backboard to place under Resident #1. ADON T stated when Resident #1 left the facility with EMS she thought he was being ventilated with an ambu bag and she did not see an ambu bag being used at any time when facility staff were doing chest compressions. The ADON admitted in a follow up interview on [DATE] at 10:00 am that part of her role as an ADON is she is responsible for supervising care provided, but did not intervene with Resident #1's care during his respiratory and [MEDICAL CONDITION]. She also confirmed she had received [MEDICAL CONDITION] care training in ,[DATE]. In an interview on [DATE] at 3:00 RN W stated he is the owner and one of the instructors for a local company in Austin, Texas that provides CPR training to medical personnel and first responders; including the local city/county fire and ambulance services. RN W stated when a patient is in respiratory distress it is imperative first of all to assess for possible causes for the respiratory distress and intervene immediately to try and maintain oxygenation to the brain. RN W stated if a patient is in respiratory and [MEDICAL CONDITION], assisted ventilation with an ambu bag is required because the positive pressure is needed to move the oxygen and applying oxygen to an established [MEDICAL CONDITION] does not replace rescue breathing. In an interview on [DATE] at 1:50 pm with the DON and DCS, the DON stated the facility did not have a policy and procedure for CPR and licensed staff are not required to provide proof of current CPR certification when the are hired even though the facility offers CPR for residents with Advance Directives for Full Code. The DCS stated this is from direction at the corporate level. The DCS confirmed the facility had no procedure in place to ensure at least one licensed staff is CPR certified per shift. In an interview on [DATE] at 2:00 pm the DCS went on to say some licensed staff had been trained on [MEDICAL CONDITION] care to include suctioning, [MEDICAL CONDITION] change and cleaning the [MEDICAL CONDITION] in ,[DATE] and she would provide documentation of the certificates. The DCS added she was a CPR instructor for medical professionals and would train all licensed staff that did not have current CPR certification to include management of advanced airways. Review of the Certificates of the [MEDICAL CONDITION] Care Training provided by a licensed Respiratory Therapist revealed LVN Z and ADON T had received the training on [DATE] and RN Y received it on [DATE]. Further review of the Certificates of [MEDICAL CONDITION] Care Training reflected two licensed nurses on the ,[DATE] pm shift had not received the training RN U and LVN V. Review of the most recent American Heart Association Guidelines for CPR refelcted the following: -The 2010 AHA Guidelines for CPR and ECC once again emphasize the need for high-quality CPR, including ? A compression rate of at least 100/min -? A compression depth of at least 2 inches (5 cm) in adultsComponent Adults .- Whether 1 or more rescuers are present, initiation of CPR with chest compressions ensures that the victim receives this critical intervention early, and any delay in rescue breaths should be brief. -Ventilations with advanced airway 1 breath every ,[DATE] seconds (,[DATE] breaths/min) Asynchronous with chest compressions About 1 second per breath Visible chest rise -Education, Implementation and Teams The current 2-year certification period for basic and advanced life support courses should include periodic assessment of rescuer knowledge and skills, with reinforcement or refresher information provided as needed Debriefing is a learner-focused, nonthreatening technique to help individual rescuers and teams reflect on and improve performance Resources: American Heart Association, Brainandspinalcord.org/[MEDICAL CONDITION] The facility did not have a policy and procedure for CPR or required licensed staff to have current CPR certifications. The facility Administrator-, the DON, and the corporate DCS were notified on [DATE] at 4:35 that an IJ situation had been identified due to the above failures. In an interview with the Medical Director on [DATE] at 4:21 pm he stated due to Resident #1's history of [MEDICAL CONDITIONS] and [MEDICAL CONDITION] he had questioned the administrator prior to his admission to the facility and he assured him that staff would be trained on [MEDICAL CONDITION] care and [MEDICAL CONDITION]. The Medical Director was informed there were staff that had not been trained. Two of three licensed nurses that worked the night shift and in some incidences worked the same shifts had not received [MEDICAL CONDITION] care training and/or were CPR certified. The Medical Director was also informed that the facility did not require staff to be current with CPR certifications. The Medical Director expressed his disappointment in Resident #1's care during the respiratory and [MEDICAL CONDITION] on [DATE] and stated he would ensure the matter would be corrected. The final Plan of Removal was accepted by the investigator on [DATE] at 8:25 pm. The facility provided the following plan of removal: 1. Will ensure at least 1 CPR certified nurse available every shift. [DATE]. Monday we will initiate CPR certification for current full time nurses to be completed by [DATE]. Part time nurses will be CPR certified by if not in attendance on [DATE] or [DATE] will not be scheduled to work. CPR certified according to American Heart Association Guidelines to include advanced airways. CPR certifications will be audited and maintained by the PSR and audited weekly and documentation will be reviewed by the administrator to include knowledge on advanced airway perfusion during CPR. If CPR not current will be immediately removed from the schedule. New hires will be required to provide proof of CPR certification prior to completing orientation. Nurses assigned a tracheotomy resident has received tracheotomy training at the are as follows with verbalization of knowledge of advanced airway and assessment and knowledge of resident with respiratory distress. Specialized Medical Services Respiratory Therapist will conduct an in-serve to be completed at 8am on [DATE]. Upon a new nurse hired they will be educated with return demonstration and checked off on competency prior to assignment to a tracheotomy patient. RT on call 24 hours, all nurse staff has phone number posted at nurse ' s station. (The facility provided a list of names of staff for each shift that were either CPR certified or had received [MEDICAL CONDITION] training from [DATE] 2:00 pm-6:00 pm through [DATE] 10:00 pm - 6:00 am) 2. [DATE] in serviced direct care staff on deflating bed for a bariatric resident before commencing CPR to serve as a back board hard surface. Bariatric resident in room [ROOM NUMBER] has a STAT 5000C bed that has a CPR mode that will deflate the bed and serve as a back board/hard surface in the event CPR needs to be performed. Continue to be in serviced direct care staff prior to starting their shift, on the STAT 5000C capability of the CPR mode. DON will audit for compliance. 3. Crash cart supplied with back board [DATE]. [DATE] 5:30pm initiated each shift will be audited ever day by ,[DATE] shift. If not available DON will be notified immediately. Head board will be used if back board is not available. [DATE] in serviced on current ,[DATE] staff to remove the headboard to serve as a back board and continuing to in service all direct care staff prior to receiving their assignment. DON will conduct audit weekly. To ensure continued compliance current full time nurses and new nurses will be required to maintain CPR certification. During Morning Clinical Meeting/IDT the facility will discuss bariatric/tracheotomy residents prior to admission to ensure residents safety needs are met in the event of emergency. Ensure everyone assigned to a tracheotomy patient to have demonstrated competency and have been checked off by facility prior to accepting assignment. In an interview on [DATE] at 11:00 am the corporate DCS stated it was the expectation that licensed staff would use a backboard during CPR when a resident is morbidly obese without a deflating mattress and/or unable to be moved to the floor. It was also the expectation the licensed staff should have used an ambu bag for rescue breathing and cue each other during an emergency situation to ensure everything possible is being done for a resident in a respiratory and/or [MEDICAL CONDITION]. The investigator monitored the current plan of removal as follows: On [DATE] and [DATE] staff listed on the schedule for current CPR certification and [MEDICAL CONDITION] care training (to include the use of an ambu bag if rescue breathing is needed in a patient with a [MEDICAL CONDITION]) were observed to be on duty and they were interviewed as to the expectations (assessments) and their responsibilities in the event a resident experienced respiratory distress or arrest and/or [MEDICAL CONDITION]. Licensed staff was interviewed on the location of the facility backboard and what to do in the event it cannot be located i.e. resident bed head/foot boards. Staff was interviewed on the operation of a bariatric bed with a mattress that can be deflated in the event of an emergency and CPR is needed. Staff was able to answer questions according to the training they received from [DATE] to [DATE]. In a follow up interview on [DATE] at 11:00 am LVN Z stated had just completed training at the facility on assessing a resident in respiratory distress provided by a licensed respiratory therapist. LVN Z stated Resident #1 did not receive any assisted ventilation when he went into respiratory distress and he should have. LVN Z added she would " have done things differently " and made sure Resident #1 was thoroughly assessed and received ventilation with an ambu bag and she would have taken a head or foot board from another resident ' s bed to use when the facility backboard could not be found. In a follow up interview on [DATE] RN Y at 1:20 pm stated she completed her CPR certification online on [DATE] and it included training of advanced airways ([MEDICAL CONDITION]). She stated the training for assessment of respiratory distress included checking for the rise and fall of the chest, oxygen saturation levels and using an ambu bag to assist with ventilation in a patient with respiratory distress. RN Y stated she was there to assist LVN Z with the code because Resident #1 was her patient; therefore she did not question if the ambu bag should be used and did not direct staff to get a foot or head board from another resident ' s bed to use for a backboard. RN Y also stated none of the licensed staff thought of getting a head or foot board from another resident ' s bed to use for Resident #1 during CPR. RN Y stated it had been months since she had seen the facility ' s backboard that was normally kept next to the emergency cart. Review of in-services for licensed staff conducted from [DATE] to [DATE] reflected the following: -Assessment of a resident in respiratory distress- suction resident as needed to clear airway. If unsuccessful notify MD or call 911. If resident is unresponsive and no pulse or respirations Start CPR with chest compressions and rescue breathing with an ambu bag. An ambu bag is necessary for positive pressure and adequate air perfusion. Ensure chest is rising. -If backboard is unavailable from the crash cart- utilize head/foot board of bed as a backboard. -How to deflate the bed mattress on a STAT 5000 C bariatric bed in the event CPR is indicated. -Use of Manual Resuscitators for rescue breathing in non-[MEDICAL CONDITION] and [MEDICAL CONDITION] patients; assessing a resident in respiratory distress, tracheal [MEDICATION NAME] suctioning and [MEDICAL CONDITION] care. (Conducted by a licensed respiratory therapist). On [DATE] at 4:33 pm, the Administrator and DCS were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm with a scope as isolated due to the facility requiring time to train all staff and monitor their Plan of Removal. The facility DON provided a list of one resident with a [MEDICAL CONDITION] and 44 residents with Full Code Advance Directives.

Based on observation, interview and record review the facility failed to implement policies and procedures that prohibit neglect for two (2) of 6 residents reviewed for falls (Residents #1 and #2) . a) On [DATE] at 5:00 PM, CNA A accompanied Resident #1 to the dining room where he left her standing beside a dining room chair. CNA A did not ensure Resident #1 was seated in her chair. Resident #1 fell hitting the back of her head on the floor. Resident #1 sustained a head injury, was transported to the hospital where she died on [DATE]. b) On [DATE] CNA B attempted to transfer Resident #2 utilizing a one person assist with slide board, resulting in Resident #2 falling forward and injuring the surgical site of a recent amputation. Resident #2's Care Plan reflected she required a a two person assist with the Hoyer lift. These deficient practices were determined to be a Past Immediate Jeopardy (IJ) from [DATE] through [DATE] because the facility had put a plan of removal in place prior to the Investigator's entrance to the facility. However, the facility was out of compliance at a Severity level of Actual Harm that is not IJ at Scope of Pattern at exit on [DATE] because the facility had not had sufficient opportunity to monitor and supervise the CNAs for compliance in identifying the type/amount of assistance that residents require for safe transfers. These deficient practices had potential to contribute to falls, injuries and even death to 25 residents identified by the facility staff as having a fall risk. Findings include: a) Review of the face sheet in Resident #1 ' s closed clinical record indicated this resident was admitted to the facility on [DATE],. Her admitting [DIAGNOSES REDACTED]. An Incident/ Accident report dated [DATE] indicated Resident #1 was found lying on her back on the floor of the dining room on [DATE] at 5:30 PM with an egg sized bump on the back of her head. Resident #1 was transported on [DATE] at 6:00 PM by EMS to the hospital where she subsequently expired on [DATE]. Review of a facility form titled Falls Investigation Worksheet dated [DATE] indicated the following: There was no witness to the fall; Activity at time of fall: resident was trying to sit down in the dining room; the resident required supervision, and there was no malfunction or damage to the resident ' s rolling walker. The Fall Investigation Worksheet also listed Resident #1 ' s medical considerations including [DIAGNOSES REDACTED], Hypertension, and [DIAGNOSES REDACTED], low level of physical activity, Spinal Stenosis, and Fatigue. A Fall Risk Evaluation completed [DATE] rated the resident at 22 (note: a score of 10 or higher indicates high risk). An ADL Plan of Care dated [DATE] indicated the resident required a one person physical assist for ambulation and a one person physical assist for transfers. During an interview on [DATE] Resident #1 ' s family member and Power of Attorney stated the resident died in the hospital on [DATE]. Resident #1 ' s family member also stated the cause of death listed on Resident #1 ' s death certificate was [MEDICATION NAME] force trauma to the head. During an interview on [DATE] at 3:00 PM CNA A stated he was asked by a nurse (LVN K) to take Resident #1 to the dining room in the late afternoon on [DATE]. CNA A stated Resident #1 used her walker. He stated he went with Resident #1 to her table and left Resident #1 standing beside her dining chair. CNA A stated he noticed another resident leaving the dining room so he went to get her, and then went to the hall to answer call lights. CNA A stated he knows he is supposed to get instructions regarding what level of assistance a resident needs from the Care Plan in the automated AccuNurse system He stated he had the headset for AccuNurse on the day Resident #1 fell however he did not access the residents ADL information. CNA A stated he knew how to use AccuNurse to call up the Care Plan for any resident. AccuNurse was a computer based system utilized by the facility that allowed CNA's to access parts of the data base such as the ADL Plan of Care for the purpose of hearing the details for a particular resident such as method of transfer. ADL Plan of Care A plan this facility utilizes to inform CNAs and other staff how to assist residents with, ambulation, transfer, and other ADLs.) This plan of care is generated by the ADON based on a screening or assessment completed by the Physical Therapist for newly admitted residents. CNAs wear a headset and can obtain an oral transcript of this plan at any time during their shift. CNA A stated after the incident on [DATE] involving Resident #1, he was suspended and then "got a talking to" from the Administrator telling him he would need to be more careful and he should not make assumptions. He stated he had additional training after the incident. CNA A stated he took responsibility for what happened. CNA A stated and he "just wasn ' t ' t thinking " when he left Resident #1 beside the chair. Review of CNA A's personnel file indicated he started work on [DATE]. CNA A's file included a Confidential Employee Corrective Action Form dated [DATE] issuing a written and final warning to CNA A. The form indicated the " employee left a resident standing by her chair in the dining room to retrieve another resident". Resident (Resident #1) fell backward hitting her head on the floor. The form indicates the conduct that was substantiated was: "employee did not ensure resident was seated in dining room before leaving. The form indicated the resident should have been seated in her chair. During an interview on [DATE] at 9:00 AM the ADON stated she generates an ADL Plan for CNA ' s within a day or two of admission, based on a Physical Therapy evaluation and any information known about the resident ' s functioning at placement. She stated she generated a plan for Resident #1 the morning of [DATE]. The ADON further stated CNAs can access the care plans at any time through their headset and hear an oral version of the ADL plan. The ADON stated each CNA ' s headset is connected to AccuNurse, an automated program to document resident care and access resident data. During an interview on [DATE] at 3:10 PM, LVN K stated she did not witness Resident #1 ' s fall however she rushed to the scene, saw Resident #1 lying on the floor on her back and went to the nurses ' station to call EMS (911). LVN K stated around 5:00 PM on [DATE] she was in Resident #1 ' s room and told CNA A to take Resident #1 to the dining room and seat her. During an interview on [DATE] at 2:50 PM the Physical Therapist stated he completed Resident #1's assessment and determined she was able to walk with contact guard and she was cleared to walk to meals with someone with her. The Physical Therapist stated the terms contact guard refers to a resident being escorted by a staff in a position so the staff member can steady the resident to prevent a fall. He stated the term contact guard is similar to what the nurses refer to as one person assist. He stated that the facility practice is that when a resident is assisted to the dining room, the assist is not over until the resident is safely seated. The Physical Therapist stated these safety issues are covered in CNA training at the time of hire. Review of In-service record dated [DATE]; Transfer Training/ -the training included the following instruction - When transferring a resident, make sure that you check your AccuNurse to be sure you are using the proper amount of CNAs to help the resident transfer. Remember you can find this information out by AccuNurse with the following steps: Select Room Number, review, and transfers. Transferring a resident without a gait belt and without the proper assistance is subject for termination. Note: CNA A's signature is on the roster for this in-service. Review of training after the incident of [DATE]. Individual Training was provided on [DATE] CNA (A) on the topic of Safe Ambulation and Transfer. According to Employee Corrective Action Form dated [DATE] the training covered resident safety and specific instructions regarding ambulation and level of assistance. b) Review of Resident #2's clinical record indicated the resident was admitted to the facility on [DATE] An Incident/Accident Report dated [DATE] indicated Resident #2 fell out of her wheelchair during a one person transfer performed by CNA B. The form listed medical considerations including impaired vision and fatigue. Resident #2's ADL plan of care in AccuNurse dated [DATE] indicated Resident #2 required two person assist for positioning, and two person transfer with Hoyer lift. A Fall Risk Evaluation dated [DATE] indicated Resident #2 was rated as 12 (a score of 10 or higher indicates high risk for fall). During an interview on [DATE] at 9:15 AM Resident #2 stated she was admitted to the facility after a recent amputation of her right lower leg. Resident #2 stated her leg was amputated after a series of falls at her home damaged her leg. Resident #2 stated she had been waiting for an aide to help get her out of bed. CNA (B) responded to the call light and placed a wooden board on the seat of Resident #2's chair and the other on the side of the board on Resident #2 ' s bed. Resident #2 stated as she was sliding from the bed to the chair she fell off the wheelchair bumping her face on the bedside table and landing on her stump. Resident #2 stated it hurt when it happened and it worried her that the wound might break open. Resident #2 was alert and oriented throughout the interview. Observation of Resident #2 on [DATE] during the 9:15 AM interview revealed the resident sitting in her wheelchair beside her bed. Resident #2 had a surgical scar on her right leg where her lower leg had been amputated. The scar was approximately 6 inches long, it appeared to be healing however there were two places approximately ? inch each that appeared bruised and more open and darker (red) than the rest of the scar. Resident #2 had a fading bruise on the right side of her face. In an interview during this observation Resident #2 indicated the bruising and redness on her leg and the bruise on her face was the result of her fall. During an interview on [DATE] at 2:50 PM the Physical Therapist stated he assessed Resident #2 the day after the resident was admitted and submitted information to the ADON for the care plan; he included instructions to provide a 2 person Hoyer lift for Resident #2. The Physical Therapist stated he knows CNA (B) attended training in the gym regarding transfers including Hoyer lifts because he remembered seeing her name on the sign in sheet. The Physical Therapist stated the resident requested the use of the transfer board instead of a Hoyer and he and the nursing staff agreed because it was a more independent way to transfer. He stated staff is trained on the slide board and the facility requires 2 staff to be present for transfers via the slide board. Review of CNA (B) ' s personnel file indicated her employment was suspended on [DATE] and her employment terminated on [DATE] as a result of her trying to transfer Resident #2 without a second staff. Note: Several attempts were made on [DATE] and [DATE] to contact CNA (B) by phone for an interview without success. Review of a written statement provided to the facility by CNA B on [DATE] reflected: "Today at 8:15 AM I was helping Resident #2 in transfer to a chair. Resident got on to chair but when I told her to lean over for me to get the slide board from under her she fell forward out of the chair. " Review of training prior to the [DATE] incidents reflected an In-service dated [DATE], topic - Transfer Safety - Note: The training roster was signed by CNA B. During an interview on [DATE] at 3:10 PM the Director of Nurses stated the checklists to document CNA proficiency and skills were not completed until [DATE]. When asked, the DON stated she did not have a system to ensure follow up with CNAs who received written warnings related to inadequate resident care. During an interview on [DATE] at 2:00 PM, CNA C stated he has received training on how to perform safe transfers. CNA C further stated the training includes instructions on how to assist residents who walk and seeing them safely seated is a requirement when helping a resident who is ambulatory. During an interview on [DATE] at 2:10 PM, CNA D stated she receives training on how to perform safe transfers. CNA D stated the training includes escorting ambulatory residents. CNA D further stated she has been trained to see that a resident is safely seated even if the resident was able to walk. The facility took the following actions prior to the investigator's entrance to the facility to correct the deficiency: Review of training records ([DATE]) indicated the facility completed CNA skills checklists for CNAs. Review of the skills checklist indicated the form included a section for transfer of residents. During an interview on [DATE] at In aan interview on with the Administrator on [DATE] at contains In [DATE] a facility internal audit found the facility out of compliance with requirements and internal policies for verifying Certified Nurse Aid competency and skills. All CNAs were reviewed by [DATE]. A memo to nurses from the current Administrator dated [DATE] lists CNA Skills checklist and orientation as a priority for improvement. During an interview on [DATE] at 8:30 AM the current Administrator stated she developed an improvement plan upon arrival to the facility that included a fall review committee, processes to improve quality improvement review of accidents in the facility. The committee was appointed prior to [DATE] and was scheduled to meet during [DATE]. The Adminsitrator also stated she developed a memo for nursing staff dated [DATE] that clarified nursing duties and identified action plans to get critical systems back on track. The Adminsitrator stated the list included falls, incident and accidents. Review of the Administsrator's plan (not dated) Included instituting an Acute Care Plan for use after injuries, falls and accidents. As of [DATE], the current Administrator was using a written performance improvement plan with a nurse that included monitoring and periodic check in meetings to verify compliance and progress on improvement goals. As of [DATE] the Administrator began developing ways to insure this is done with all nursing staff including CNAs. As of [DATE] the Administrator was addressing non-performance issues with the Director of Nurses, the administrative staff position designated to ensure quality performance of nursing staff. Correction for this area was not complete but there was substantial improvement. Per interviews with the administrator and Physical Therapist the facility's process for developing immediate goals and plans for new residents in areas of risk has been implemented as of [DATE]. This process further defines new residents as potential fall risks and requires close supervision of transfers and ambulation until the comprehensive care plan is completed and all therapy assessments completed. This process was verified with review of the ADL Care Plans placed on AccuNurse for the 6 residents reviewed (various dates). - Policies related to fall prevention and resident safety have been emphasized through communications with staff over the past 30 days. Review of the facility s Nursing Policies: Transfer Techniques (2006) indicated Transfer training refers to teaching techniques involved in moving a resident from on position to another. Review of Resident #1's Plan of Care dated [DATE] indicated she required one person assist with transfer. The facility Roster/Sample Matrix (CMS Form 802) provided by the facility on [DATE] reflected 25 residents with fall risk.

Based on observation, interview and record review the facility failed to provide adequate supervision for two (2) of 6 residents reviewed for falls (Residents #1 and #2) . a) On [DATE] at 5:00 PM, CNA A accompanied Resident #1 to the dining room where he left her standing beside a dining room chair. CNA A did not ensure Resident #1 was seated in her chair. Resident #1 fell hitting the back of her head on the floor. Resident #1 sustained a head injury, was transported to the hospital where she died on [DATE]. b) On [DATE] CNA B attempted to transfer Resident #2 utilizing a one person assist with slide board, resulting in Resident #2 falling forward and injuring the surgical site of a recent amputation. Resident #2's Care Plan reflected she required a a two person assist with the Hoyer lift. These deficient practices were determined to be a Past Immediate Jeopardy (IJ)) from [DATE] through [DATE] because the facility had put a plan of removal in place prior to the Investigator's entrance to the facility. However, the facility was out of compliance at a Severity level of Actual Harm that is not IJ at Scope of Pattern at exit on [DATE] because the facility had not had sufficient opportunity to monitor and supervise the CNAs for compliance in identifying the type/amount of assistance that residents require for safe transfers. These deficient practices had potential to contribute to falls, injuries and even death to 25 residents identified by the facility staff as having a fall risk. Findings include: a) Review of the face sheet in Resident #1 ' s closed clinical record indicated this resident was admitted to the facility on [DATE],. Her admitting [DIAGNOSES REDACTED]. An Incident/ Accident report dated [DATE] indicated Resident #1 was found lying on her back on the floor of the dining room on [DATE] at 5:30 PM with an egg sized bump on the back of her head. Resident #1 was transported on [DATE] at 6:00 PM by EMS to the hospital where she subsequently expired on [DATE]. Review of a facility form titled Falls Investigation Worksheet dated [DATE] indicated the following: There was no witness to the fall; Activity at time of fall: resident was trying to sit down in the dining room; the resident required supervision, and there was no malfunction or damage to the resident ' s rolling walker. The Fall Investigation Worksheet also listed Resident #1 ' s medical considerations including [DIAGNOSES REDACTED], Hypertension, and [DIAGNOSES REDACTED], low level of physical activity, Spinal Stenosis, and Fatigue. A Fall Risk Evaluation completed [DATE] rated the resident at 22 (note: a score of 10 or higher indicates high risk). An ADL Plan of Care dated [DATE] indicated the resident required a one person physical assist for ambulation and a one person physical assist for transfers. During an interview on [DATE] Resident #1 ' s family member and Power of Attorney stated the resident died in the hospital on [DATE]. Resident #1 ' s family member also stated the cause of death listed on Resident #1 ' s death certificate was blunt force trauma to the head. During an interview on [DATE] at 3:00 PM CNA A stated he was asked by a nurse (LVN K) to take Resident #1 to the dining room in the late afternoon on [DATE]. CNA A stated Resident #1 used her walker. He stated he went with Resident #1 to her table and left Resident #1 standing beside her dining chair. CNA A stated he noticed another resident leaving the dining room so he went to get her, and then went to the hall to answer call lights. CNA A stated he knows he is supposed to get instructions regarding what level of assistance a resident needs from the Care Plan in the automated AccuNurse system He stated he had the headset for AccuNurse on the day Resident #1 fell however he did not access the residents ADL information. CNA A stated he knew how to use AccuNurse to call up the Care Plan for any resident. AccuNurse was a computer based system utilized by the facility that allowed CNA's to access parts of the data base such as the ADL Plan of Care for the purpose of hearing the details for a particular resident such as method of transfer. ADL Plan of Care A plan this facility utilizes to inform CNAs and other staff how to assist residents with, ambulation, transfer, and other ADLs.) This plan of care is generated by the ADON based on a screening or assessment completed by the Physical Therapist for newly admitted residents. CNAs wear a headset and can obtain an oral transcript of this plan at any time during their shift. CNA A stated after the incident on [DATE] involving Resident #1, he was suspended and then "got a talking to" from the Administrator telling him he would need to be more careful and he should not make assumptions. He stated he had additional training after the incident. CNA A stated he took responsibility for what happened. CNA A stated and he "just wasn ' t ' t thinking " when he left Resident #1 beside the chair. Review of CNA A's personnel file indicated he started work on [DATE]. CNA A's file included a Confidential Employee Corrective Action Form dated [DATE] issuing a written and final warning to CNA A. The form indicated the " employee left a resident standing by her chair in the dining room to retrieve another resident". Resident (Resident #1) fell backward hitting her head on the floor. The form indicates the conduct that was substantiated was: "employee did not ensure resident was seated in dining room before leaving. The form indicated the resident should have been seated in her chair. During an interview on [DATE] at 9:00 AM the ADON stated she generates an ADL Plan for CNA ' s within a day or two of admission, based on a Physical Therapy evaluation and any information known about the resident ' s functioning at placement. She stated she generated a plan for Resident #1 the morning of [DATE]. The ADON further stated CNAs can access the care plans at any time through their headset and hear an oral version of the ADL plan. The ADON stated each CNA ' s headset is connected to AccuNurse, an automated program to document resident care and access resident data. During an interview on [DATE] at 3:10 PM, LVN K stated she did not witness Resident #1 ' s fall however she rushed to the scene, saw Resident #1 lying on the floor on her back and went to the nurses ' station to call EMS (911). LVN K stated around 5:00 PM on [DATE] she was in Resident #1 ' s room and told CNA A to take Resident #1 to the dining room and seat her. During an interview on [DATE] at 2:50 PM the Physical Therapist stated he completed Resident #1's assessment and determined she was able to walk with contact guard and she was cleared to walk to meals with someone with her. The Physical Therapist stated the terms contact guard refers to a resident being escorted by a staff in a position so the staff member can steady the resident to prevent a fall. He stated the term contact guard is similar to what the nurses refer to as one person assist. He stated that the facility practice is that when a resident is assisted to the dining room, the assist is not over until the resident is safely seated. The Physical Therapist stated these safety issues are covered in CNA training at the time of hire. Review of In-service record dated [DATE]; Transfer Training/ -the training included the following instruction - When transferring a resident, make sure that you check your AccuNurse to be sure you are using the proper amount of CNAs to help the resident transfer. Remember you can find this information out by AccuNurse with the following steps: Select Room Number, review, and transfers. Transferring a resident without a gait belt and without the proper assistance is subject for termination. Note: CNA A's signature is on the roster for this in-service. Review of training after the incident of [DATE]. Individual Training was provided on [DATE] CNA (A) on the topic of Safe Ambulation and Transfer. According to Employee Corrective Action Form dated [DATE] the training covered resident safety and specific instructions regarding ambulation and level of assistance. b) Review of Resident #2's clinical record indicated the resident was admitted to the facility on [DATE] An Incident/Accident Report dated [DATE] indicated Resident #2 fell out of her wheelchair during a one person transfer performed by CNA B. The form listed medical considerations including impaired vision and fatigue. Resident #2's ADL plan of care in AccuNurse dated [DATE] indicated Resident #2 required two person assist for positioning, and two person transfer with Hoyer lift. A Fall Risk Evaluation dated [DATE] indicated Resident #2 was rated as 12 (a score of 10 or higher indicates high risk for fall). During an interview on [DATE] at 9:15 AM Resident #2 stated she was admitted to the facility after a recent amputation of her right lower leg. Resident #2 stated her leg was amputated after a series of falls at her home damaged her leg. Resident #2 stated she had been waiting for an aide to help get her out of bed. CNA (B) responded to the call light and placed a wooden board on the seat of Resident #2's chair and the other on the side of the board on Resident #2 ' s bed. Resident #2 stated as she was sliding from the bed to the chair she fell off the wheelchair bumping her face on the bedside table and landing on her stump. Resident #2 stated it hurt when it happened and it worried her that the wound might break open. Resident #2 was alert and oriented throughout the interview. Observation of Resident #2 on [DATE] during the 9:15 AM interview revealed the resident sitting in her wheelchair beside her bed. Resident #2 had a surgical scar on her right leg where her lower leg had been amputated. The scar was approximately 6 inches long, it appeared to be healing however there were two places approximately ? inch each that appeared bruised and more open and darker (red) than the rest of the scar. Resident #2 had a fading bruise on the right side of her face. In an interview during this observation Resident #2 indicated the bruising and redness on her leg and the bruise on her face was the result of her fall. During an interview on [DATE] at 2:50 PM the Physical Therapist stated he assessed Resident #2 the day after the resident was admitted and submitted information to the ADON for the care plan; he included instructions to provide a 2 person Hoyer lift for Resident #2. The Physical Therapist stated he knows CNA (B) attended training in the gym regarding transfers including Hoyer lifts because he remembered seeing her name on the sign in sheet. The Physical Therapist stated the resident requested the use of the transfer board instead of a Hoyer and he and the nursing staff agreed because it was a more independent way to transfer. He stated staff is trained on the slide board and the facility requires 2 staff to be present for transfers via the slide board. Review of CNA (B) ' s personnel file indicated her employment was suspended on [DATE] and her employment terminated on [DATE] as a result of her trying to transfer Resident #2 without a second staff. Note: Several attempts were made on [DATE] and [DATE] to contact CNA (B) by phone for an interview without success. Review of a written statement provided to the facility by CNA B on [DATE] reflected: "Today at 8:15 AM I was helping Resident #2 in transfer to a chair. Resident got on to chair but when I told her to lean over for me to get the slide board from under her she fell forward out of the chair. " Review of training prior to the [DATE] incidents reflected an In-service dated [DATE], topic - Transfer Safety - Note: The training roster was signed by CNA B. During an interview on [DATE] at 3:10 PM the Director of Nurses stated the checklists to document CNA proficiency and skills were not completed until [DATE]. When asked, the DON stated she did not have a system to ensure follow up with CNAs who received written warnings related to inadequate resident care. During an interview on [DATE] at 2:00 PM, CNA C stated he has received training on how to perform safe transfers. CNA C further stated the training includes instructions on how to assist residents who walk and seeing them safely seated is a requirement when helping a resident who is ambulatory. During an interview on [DATE] at 2:10 PM, CNA D stated she receives training on how to perform safe transfers. CNA D stated the training includes escorting ambulatory residents. CNA D further stated she has been trained to see that a resident is safely seated even if the resident was able to walk. The facility took the following actions prior to the investigator's entrance to the facility to correct the deficiency: Review of training records ([DATE]) indicated the facility completed CNA skills checklists for CNAs. Review of the skills checklist indicated the form included a section for transfer of residents. During an interview on [DATE] at In aan interview on with the Administrator on [DATE] at contains In [DATE] a facility internal audit found the facility out of compliance with requirements and internal policies for verifying Certified Nurse Aid competency and skills. All CNAs were reviewed by [DATE]. A memo to nurses from the current Administrator dated [DATE] lists CNA Skills checklist and orientation as a priority for improvement. During an interview on [DATE] at 8:30 AM the current Administrator stated she developed an improvement plan upon arrival to the facility that included a fall review committee, processes to improve quality improvement review of accidents in the facility. The committee was appointed prior to [DATE] and was scheduled to meet during [DATE]. The Adminsitrator also stated she developed a memo for nursing staff dated [DATE] that clarified nursing duties and identified action plans to get critical systems back on track. The Adminsitrator stated the list included falls, incident and accidents. Review of the Administsrator's plan (not dated) Included instituting an Acute Care Plan for use after injuries, falls and accidents. As of [DATE], the current Administrator was using a written performance improvement plan with a nurse that included monitoring and periodic check in meetings to verify compliance and progress on improvement goals. As of [DATE] the Administrator began developing ways to insure this is done with all nursing staff including CNAs. As of [DATE] the Administrator was addressing non-performance issues with the Director of Nurses, the administrative staff position designated to ensure quality performance of nursing staff. Correction for this area was not complete but there was substantial improvement. Per interviews with the administrator and Physical Therapist the facility's process for developing immediate goals and plans for new residents in areas of risk has been implemented as of [DATE]. This process further defines new residents as potential fall risks and requires close supervision of transfers and ambulation until the comprehensive care plan is completed and all therapy assessments completed. This process was verified with review of the ADL Care Plans placed on AccuNurse for the 6 residents reviewed (various dates). - Policies related to fall prevention and resident safety have been emphasized through communications with staff over the past 30 days. Review of the facility s Nursing Policies: Transfer Techniques (2006) indicated Transfer training refers to teaching techniques involved in moving a resident from on position to another. Review of Resident #1's Plan of Care dated [DATE] indicated she required one person assist with transfer. The facility Roster/Sample Matrix (CMS Form 802) provided by the facility on [DATE] reflected 25 residents with fall risk.

Based on observation, interview and record review the facility failed to implement policies and procedures that prohibit neglect for two (2) of 6 residents reviewed for falls (Residents #1 and #2) . a) On [DATE] at 5:00 PM, CNA A accompanied Resident #1 to the dining room where he left her standing beside a dining room chair. CNA A did not ensure Resident #1 was seated in her chair. Resident #1 fell hitting the back of her head on the floor. Resident #1 sustained a head injury, was transported to the hospital where she died on [DATE]. b) On [DATE] CNA B attempted to transfer Resident #2 utilizing a one person assist with slide board, resulting in Resident #2 falling forward and injuring the surgical site of a recent amputation. Resident #2's Care Plan reflected she required a a two person assist with the Hoyer lift. These deficient practices were determined to be a Past Immediate Jeopardy (IJ) from [DATE] through [DATE] because the facility had put a plan of removal in place prior to the Investigator's entrance to the facility. However, the facility was out of compliance at a Severity level of Actual Harm that is not IJ at Scope of Pattern at exit on [DATE] because the facility had not had sufficient opportunity to monitor and supervise the CNAs for compliance in identifying the type/amount of assistance that residents require for safe transfers. These deficient practices had potential to contribute to falls, injuries and even death to 25 residents identified by the facility staff as having a fall risk. Findings include: a) Review of the face sheet in Resident #1 ' s closed clinical record indicated this resident was admitted to the facility on [DATE],. Her admitting [DIAGNOSES REDACTED]. An Incident/ Accident report dated [DATE] indicated Resident #1 was found lying on her back on the floor of the dining room on [DATE] at 5:30 PM with an egg sized bump on the back of her head. Resident #1 was transported on [DATE] at 6:00 PM by EMS to the hospital where she subsequently expired on [DATE]. Review of a facility form titled Falls Investigation Worksheet dated [DATE] indicated the following: There was no witness to the fall; Activity at time of fall: resident was trying to sit down in the dining room; the resident required supervision, and there was no malfunction or damage to the resident ' s rolling walker. The Fall Investigation Worksheet also listed Resident #1 ' s medical considerations including [DIAGNOSES REDACTED], Hypertension, and [DIAGNOSES REDACTED], low level of physical activity, Spinal Stenosis, and Fatigue. A Fall Risk Evaluation completed [DATE] rated the resident at 22 (note: a score of 10 or higher indicates high risk). An ADL Plan of Care dated [DATE] indicated the resident required a one person physical assist for ambulation and a one person physical assist for transfers. During an interview on [DATE] Resident #1 ' s family member and Power of Attorney stated the resident died in the hospital on [DATE]. Resident #1 ' s family member also stated the cause of death listed on Resident #1 ' s death certificate was [MEDICATION NAME] force trauma to the head. During an interview on [DATE] at 3:00 PM CNA A stated he was asked by a nurse (LVN K) to take Resident #1 to the dining room in the late afternoon on [DATE]. CNA A stated Resident #1 used her walker. He stated he went with Resident #1 to her table and left Resident #1 standing beside her dining chair. CNA A stated he noticed another resident leaving the dining room so he went to get her, and then went to the hall to answer call lights. CNA A stated he knows he is supposed to get instructions regarding what level of assistance a resident needs from the Care Plan in the automated AccuNurse system He stated he had the headset for AccuNurse on the day Resident #1 fell however he did not access the residents ADL information. CNA A stated he knew how to use AccuNurse to call up the Care Plan for any resident. AccuNurse was a computer based system utilized by the facility that allowed CNA's to access parts of the data base such as the ADL Plan of Care for the purpose of hearing the details for a particular resident such as method of transfer. ADL Plan of Care A plan this facility utilizes to inform CNAs and other staff how to assist residents with, ambulation, transfer, and other ADLs.) This plan of care is generated by the ADON based on a screening or assessment completed by the Physical Therapist for newly admitted residents. CNAs wear a headset and can obtain an oral transcript of this plan at any time during their shift. CNA A stated after the incident on [DATE] involving Resident #1, he was suspended and then "got a talking to" from the Administrator telling him he would need to be more careful and he should not make assumptions. He stated he had additional training after the incident. CNA A stated he took responsibility for what happened. CNA A stated and he "just wasn ' t ' t thinking " when he left Resident #1 beside the chair. Review of CNA A's personnel file indicated he started work on [DATE]. CNA A's file included a Confidential Employee Corrective Action Form dated [DATE] issuing a written and final warning to CNA A. The form indicated the " employee left a resident standing by her chair in the dining room to retrieve another resident". Resident (Resident #1) fell backward hitting her head on the floor. The form indicates the conduct that was substantiated was: "employee did not ensure resident was seated in dining room before leaving. The form indicated the resident should have been seated in her chair. During an interview on [DATE] at 9:00 AM the ADON stated she generates an ADL Plan for CNA ' s within a day or two of admission, based on a Physical Therapy evaluation and any information known about the resident ' s functioning at placement. She stated she generated a plan for Resident #1 the morning of [DATE]. The ADON further stated CNAs can access the care plans at any time through their headset and hear an oral version of the ADL plan. The ADON stated each CNA ' s headset is connected to AccuNurse, an automated program to document resident care and access resident data. During an interview on [DATE] at 3:10 PM, LVN K stated she did not witness Resident #1 ' s fall however she rushed to the scene, saw Resident #1 lying on the floor on her back and went to the nurses ' station to call EMS (911). LVN K stated around 5:00 PM on [DATE] she was in Resident #1 ' s room and told CNA A to take Resident #1 to the dining room and seat her. During an interview on [DATE] at 2:50 PM the Physical Therapist stated he completed Resident #1's assessment and determined she was able to walk with contact guard and she was cleared to walk to meals with someone with her. The Physical Therapist stated the terms contact guard refers to a resident being escorted by a staff in a position so the staff member can steady the resident to prevent a fall. He stated the term contact guard is similar to what the nurses refer to as one person assist. He stated that the facility practice is that when a resident is assisted to the dining room, the assist is not over until the resident is safely seated. The Physical Therapist stated these safety issues are covered in CNA training at the time of hire. Review of In-service record dated [DATE]; Transfer Training/ -the training included the following instruction - When transferring a resident, make sure that you check your AccuNurse to be sure you are using the proper amount of CNAs to help the resident transfer. Remember you can find this information out by AccuNurse with the following steps: Select Room Number, review, and transfers. Transferring a resident without a gait belt and without the proper assistance is subject for termination. Note: CNA A's signature is on the roster for this in-service. Review of training after the incident of [DATE]. Individual Training was provided on [DATE] CNA (A) on the topic of Safe Ambulation and Transfer. According to Employee Corrective Action Form dated [DATE] the training covered resident safety and specific instructions regarding ambulation and level of assistance. b) Review of Resident #2's clinical record indicated the resident was admitted to the facility on [DATE] An Incident/Accident Report dated [DATE] indicated Resident #2 fell out of her wheelchair during a one person transfer performed by CNA B. The form listed medical considerations including impaired vision and fatigue. Resident #2's ADL plan of care in AccuNurse dated [DATE] indicated Resident #2 required two person assist for positioning, and two person transfer with Hoyer lift. A Fall Risk Evaluation dated [DATE] indicated Resident #2 was rated as 12 (a score of 10 or higher indicates high risk for fall). During an interview on [DATE] at 9:15 AM Resident #2 stated she was admitted to the facility after a recent amputation of her right lower leg. Resident #2 stated her leg was amputated after a series of falls at her home damaged her leg. Resident #2 stated she had been waiting for an aide to help get her out of bed. CNA (B) responded to the call light and placed a wooden board on the seat of Resident #2's chair and the other on the side of the board on Resident #2 ' s bed. Resident #2 stated as she was sliding from the bed to the chair she fell off the wheelchair bumping her face on the bedside table and landing on her stump. Resident #2 stated it hurt when it happened and it worried her that the wound might break open. Resident #2 was alert and oriented throughout the interview. Observation of Resident #2 on [DATE] during the 9:15 AM interview revealed the resident sitting in her wheelchair beside her bed. Resident #2 had a surgical scar on her right leg where her lower leg had been amputated. The scar was approximately 6 inches long, it appeared to be healing however there were two places approximately ? inch each that appeared bruised and more open and darker (red) than the rest of the scar. Resident #2 had a fading bruise on the right side of her face. In an interview during this observation Resident #2 indicated the bruising and redness on her leg and the bruise on her face was the result of her fall. During an interview on [DATE] at 2:50 PM the Physical Therapist stated he assessed Resident #2 the day after the resident was admitted and submitted information to the ADON for the care plan; he included instructions to provide a 2 person Hoyer lift for Resident #2. The Physical Therapist stated he knows CNA (B) attended training in the gym regarding transfers including Hoyer lifts because he remembered seeing her name on the sign in sheet. The Physical Therapist stated the resident requested the use of the transfer board instead of a Hoyer and he and the nursing staff agreed because it was a more independent way to transfer. He stated staff is trained on the slide board and the facility requires 2 staff to be present for transfers via the slide board. Review of CNA (B) ' s personnel file indicated her employment was suspended on [DATE] and her employment terminated on [DATE] as a result of her trying to transfer Resident #2 without a second staff. Note: Several attempts were made on [DATE] and [DATE] to contact CNA (B) by phone for an interview without success. Review of a written statement provided to the facility by CNA B on [DATE] reflected: "Today at 8:15 AM I was helping Resident #2 in transfer to a chair. Resident got on to chair but when I told her to lean over for me to get the slide board from under her she fell forward out of the chair. " Review of training prior to the [DATE] incidents reflected an In-service dated [DATE], topic - Transfer Safety - Note: The training roster was signed by CNA B. During an interview on [DATE] at 3:10 PM the Director of Nurses stated the checklists to document CNA proficiency and skills were not completed until [DATE]. When asked, the DON stated she did not have a system to ensure follow up with CNAs who received written warnings related to inadequate resident care. During an interview on [DATE] at 2:00 PM, CNA C stated he has received training on how to perform safe transfers. CNA C further stated the training includes instructions on how to assist residents who walk and seeing them safely seated is a requirement when helping a resident who is ambulatory. During an interview on [DATE] at 2:10 PM, CNA D stated she receives training on how to perform safe transfers. CNA D stated the training includes escorting ambulatory residents. CNA D further stated she has been trained to see that a resident is safely seated even if the resident was able to walk. The facility took the following actions prior to the investigator's entrance to the facility to correct the deficiency: Review of training records ([DATE]) indicated the facility completed CNA skills checklists for CNAs. Review of the skills checklist indicated the form included a section for transfer of residents. During an interview on [DATE] at In aan interview on with the Administrator on [DATE] at contains In [DATE] a facility internal audit found the facility out of compliance with requirements and internal policies for verifying Certified Nurse Aid competency and skills. All CNAs were reviewed by [DATE]. A memo to nurses from the current Administrator dated [DATE] lists CNA Skills checklist and orientation as a priority for improvement. During an interview on [DATE] at 8:30 AM the current Administrator stated she developed an improvement plan upon arrival to the facility that included a fall review committee, processes to improve quality improvement review of accidents in the facility. The committee was appointed prior to [DATE] and was scheduled to meet during [DATE]. The Adminsitrator also stated she developed a memo for nursing staff dated [DATE] that clarified nursing duties and identified action plans to get critical systems back on track. The Adminsitrator stated the list included falls, incident and accidents. Review of the Administsrator's plan (not dated) Included instituting an Acute Care Plan for use after injuries, falls and accidents. As of [DATE], the current Administrator was using a written performance improvement plan with a nurse that included monitoring and periodic check in meetings to verify compliance and progress on improvement goals. As of [DATE] the Administrator began developing ways to insure this is done with all nursing staff including CNAs. As of [DATE] the Administrator was addressing non-performance issues with the Director of Nurses, the administrative staff position designated to ensure quality performance of nursing staff. Correction for this area was not complete but there was substantial improvement. Per interviews with the administrator and Physical Therapist the facility's process for developing immediate goals and plans for new residents in areas of risk has been implemented as of [DATE]. This process further defines new residents as potential fall risks and requires close supervision of transfers and ambulation until the comprehensive care plan is completed and all therapy assessments completed. This process was verified with review of the ADL Care Plans placed on AccuNurse for the 6 residents reviewed (various dates). - Policies related to fall prevention and resident safety have been emphasized through communications with staff over the past 30 days. Review of the facility s Nursing Policies: Transfer Techniques (2006) indicated Transfer training refers to teaching techniques involved in moving a resident from on position to another. Review of Resident #1's Plan of Care dated [DATE] indicated she required one person assist with transfer. The facility Roster/Sample Matrix (CMS Form 802) provided by the facility on [DATE] reflected 25 residents with fall risk.