Every finding on record at Palomino Place

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 one (Resident #1) of 5 residents, reviewed for infection control. The facility failed on 08/11/2026 to ensure CNA A and CNA B changed hand gloves when they gave bed bath (high contact resident care activity) on Resident #1 who was on enhanced barrier precautions. The facility failed on 08/11/2026 to ensure CNA A and CNA B changed washcloth when they gave bed bath (high contact resident care activity) on Resident #1 who was on enhanced barrier precautions. These failures placed Resident #1 at risk for healthcare associated cross contamination and infections.Findings included: Record review of Resident #1's face sheet dated 08/11/2026 reflected a [AGE] year-old male, admitted on [DATE], with diagnoses of Dysphagia(trouble or difficulty swallowing food, liquids, or even saliva), Polyneuropathy( a medical condition where multiple peripheral nerves throughout the body malfunction at the same time) and Gastrostomy(a surgical opening made through the skin of the abdomen directly into the stomach to insert a feeding tube (G-tube), bypass the mouth and throat, and deliver liquid nutrition, fluids, or medicines) Record review of Resident #1's Physician Orders dated 08/11/2026, revealed, Enhanced Barrier Precautions (EBP) Every Shift related to encounter for attention to gastrostomy Record review of Resident #1's care plan updated 07/02/2026 revealed Resident has an ADL self-care performance deficit related to impaired cognition, muscle weakness and neuropathy with interventions .Resident is total dependent x 1 to 2 staff with bathing, personal hygiene. Enhanced barrier precautions implemented related to feeding tubes with goal- the spread of an MDRO will be reduced., monitor for signs and symptoms of infection. During an observation on 08/11/2026 at 12:30 PM, CNA A and CNA B gave Resident #1 bed bath. CNA A and CNA B used the same washcloth when they gave head to toe bed bath without changing or washing the cloth. CNA A and CNA B used the same hand gloves for the bed bath without changing their gloves or sanitizing hands between clean and dirty body parts. During an interview on 08/11/2026 at 12:50 PM, CNA A and CNA B stated they made a mistake for not changing gloves and washcloth during the entire bed bath of Resident #1. CNA A stated she was aware that Resident #1 was on enhanced barrier precaution and should have observed infection control and standard precautions when performing high contact care on Resident #1. CNA B stated that she was nervous and forgot to change her gloves and washcloth because she was being observed while performing the care. CNA A and CNA B stated that they were trained in infection control and received competency training on bed bath. CNA A and CNA B stated the risk of not changing hand gloves and washcloth between clean and dirty areas was the potential for infection.During an interview on 08/11/2026 at 1:00 PM, CNA C stated that hand gloves and washcloths are changed frequently when giving bed bath. She stated that when dirty areas like armpit and pubic areas are cleaned, CNA was expected to remove hand gloves, do hand hygiene, wear new gloves and continue with new washcloth. CNA C stated that she received competency training on hand washing, bed bath and infection control. During an interview on 08/11/2026 at 1:30 PM, the DON revealed her expectation was that staff should use appropriate PPE and observe standard precaution and infection control while providing care to all residents. She stated the risk to the patients when gloves and washcloth are not changed between patient care was infection. She stated staff had been in-serviced on infection control and Enhance Barrier Precautions. Record review of the facility's policy titled Infection Prevention and Control Program dated 12/1 2025 stated This facility has established and maintains 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 as per accepted national standards and guidelines.All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted when providing resident care services.Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures.All staff shall use personal protective equipment (PPE) according to the established facility policy governing the use of PPE.All staff shall receive training, relevant to their specific roles and responsibilities, regarding the facility's infection prevention and control program, including policies and procedures related to their job function.All staff shall demonstrate competence in relevant infection control practices.Direct care staff shall demonstrate competence in resident care procedures established by our facility.

Based on observation, interview, and record review, the facility failed to assure that medications were secure and inaccessible to unauthorized staff and residents for one (Resident#1) of 5 residents reviewed for medication storage. The facility failed to ensure Resident #1 did not have unsecured nitroglycerin pills (prescription medication used to treat and prevent acute heart attacks) in her room. This failure could place residents at risk for unsafe administration, and increased harm to residents.Findings included: Record review of Resident #1's comprehensive MDS assessment, dated 07/27/26, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her BIMs score was 15, indicating her cognitive status was intact. Her diagnoses included coronary artery disease (a common heart condition where waxy plaque builds up inside the arteries that supply blood to your heart). Record review of Resident #1's active care plan initiated: 07/27/2026 reflected: [Resident #1] has coronary artery disease. Facility interventions :Give all cardiac meds as ordered by the physician. Monitor and document side effects. Record review of Resident #1's active Physician's Orders, dated 8/05/2026, reflected Nitroglycerin Sublingual Tablet Sublingual 0.4 MG(Nitroglycerin) Give 1 tablet sublingually every 5minutes as needed for chest pain take 1 tab under the tongue every 5 minutes, 3 times then call 911 if chest pain is not resolved. Order start date 07/23/2026. There were no orders for Resident #1 to self-administer medications. During an observation on 08/05/2026 at 10:10am revealed Resident #1 was in bed, and a bottle of Nitroglycerin Sublingual Tablet 0.4 MG was on the nightstand with pills in the bottle. During an interview on 08/05/2026 at 10:13am with Resident#1 she stated that she always kept the medication at beside. She stated that no one at the facility had informed her that all medications were to be stored by the nurses only. She stated that she had had two heart attacks prior to admission at the facility and she used the medication in case she got chest pain. During an interview on 08/05/2026 at 1:17pm with LVN A revealed that Resident#1 was not supposed to have medication at bedside. He stated that all medication was to be stored and administered by the nurses. He stated that he did not see the medication before the surveyor notified him. He stated that the risk to the resident was overdosing on the medication. He stated that he had been in-serviced on medication storage. During an interview on 08/05/2026 at 2:08pm with LVN B revealed that Resident #1 was not supposed to have medication at bedside. She stated that unless the resident had orders from the physician to self-medicate and keep medication at bedside, all medication should be under lock and key with the nurses. She stated that the risk to the residents was harming themselves by overdosing or that a wondering resident could have access to the medication and self-administer which could lead to a medical emergency. During an interview on 08/05/2026 at 2:25pm with the DON revealed that the nurses were responsible for medication storage. She stated that Resident #1 was not supposed to have medication at bedside. She stated that the risk to the resident having nitroglycerin at bedside was a medication error and it could interact with other medication that the facility was administering. She stated that the medication had been removed from the resident's room, the resident was educated on facility policy, and the nurses were in serviced on medication storage. Review of the facility's policy Storage of Medication implemented 12/01/2025 reflected the following: Policy Explanation and Compliance Guidelines1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls.b. Only authorized personnel will have access to the keys to locked compartments.c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.

Based on observation, interview, and record review the facility failed to ensure residents had the right to be free from abuse for 1 of 5 residents (Resident #1) reviewed for abuse.The facility failed to ensure Resident #1 was protected from Resident #2 who entered her room and engaged in non-consensual sexual contact with her on 5/21/2026.The failure placed residents at experiencing fear, emotional distress, and unwanted sexual contact, placing residents at risk for abuse and psychological harm.Findings include: Review of Resident #1's Quarterly MDS Assessment, dated 04/15/2026, reflected an [AGE] year-old female admitted to the facility on [DATE]. She had a BIMS score of 10 which indicated moderate cognitive impairment. She had diagnoses that included: vascular dementia with mood disturbance (memory and thinking problems caused by a reduced blood flow or small strokes in the brain, along with emotional changes like irritability, sadness, mood swings, or agitation), depression (persistent sadness, low motivation, loss of interest, hopelessness, or emotional heaviness), anxiety (excessive worry, nervousness, fear, restlessness, or feeling on edge), and insomnia (trouble falling asleep, staying asleep, or getting restful sleep). Record review of Resident #1's Annual Care Plan, dated 04/10/26, noted a dependence on staff for activities of daily living, a risk of falls, impaired hearing and vision, and at risk of depression. Record review of Resident #2's admission MDS Assessment, dated 03/26/26, reflected an [AGE] year-old male who admitted to the facility on [DATE]. He had a BIMS score of 6, which indicated severe cognitive impairment. He had diagnoses that included: Parkinsonism (the brain has trouble controlling body movement) and mood disorder due to known physiological condition (an illness or physical condition affects mood and emotions). The MDS Assessment did not indicate any behavioral issues such as wandering or rejection of care. Record review of Resident #2's Care Plan, dated 03/20/26, reflected he required one person assist for all activities of daily living due to impaired cognition, general weakness, and Parkinson's Disease. The plan reflected Resident #2 had impaired cognitive function/impaired thought process. The plan reflected Resident #2 would often get out of his wheelchair and attempted to ambulate unassisted which resulted in 3 actual falls occurring on 4/1/26, 4/7/26, and 5/4/26. The plan reflected Resident #2 received melatonin (a supplement to help fall asleep) for difficulty falling or staying asleep. Record review of Resident #2' progress note dated 5/22/26, reflected an incident that occurred at approximately 11:45 PM on 5/21/26. The note reflected that nursing staff were responding to call lights on the 800 hall. Staff members observed Resident #2 lying in Resident #1's bed. Staff members immediately separated the two residents and completed head to toe assessments. Resident #2's brief was intact. Attempt to notify Resident #2's family member was made and a message was left. Resident #2 was placed on one-on-one direct observation. Record review of Resident #2's progress note dated 5/22/26, reflected contact was made with Resident #2's family member. It reflected the family member was made aware of Resident # 2's immediate discharge notice and agreed to pick him up from the facility today. During an interview and observation with Resident #1 on 05/22/26 at 12:32 PM, Resident #1 was observed lying in her bed. Resident #1 resided on the 800 hall. She reported last night she was lying in bed attempting to go to sleep when Resident #2 entered her room and shut the door. Resident #1 stated Resident #2 got into her bed and laid next to her and placed his hand over her brief and attempted to move the brief out of the way. Resident #1 stated he was not able to get the brief off or move it out of the way. Resident #1 stated she began yelling at Resident #2 to get off of her and was also yelling for help. Resident #1 stated the police arrived and removed Resident #2 out of the bed. Resident #1 stated she did not think staff could hear her because her door was shut. Resident #1 stated he was not taken to jail and believed he should have been. She stated she was feeling nervous and was worried he would come back. She stated she was also just feeling nervous overall as it was a scary situation. Resident #1 stated she was offered to be transferred to the hospital, and she did not want to go. She reported she had no physical injuries from the incident Resident #1 stated she was unaware that Resident #2 was being discharged . She stated knowing he would be leaving made her feel safer. She stated after the incident happened she spoke with the facility social worker. During an interview with Resident #3 on 05/22/26 at 12:40 PM, she stated she was Resident #1's roommate. She stated she was lying in bed last night when Resident #2 entered their room. She stated the curtain was drawn between her bed and Resident #1's bed so she did not see anything. She stated she heard Resident #1 say she was scared and she asked her why. She said Resident #1 told her there was a man on top of her and trying to get in her pants and rape her. She stated she pushed her call light button and instead of waiting for staff she called 911 and an officer arrived within about 5 minutes of her calling. During an observation and attempted interview on 05/22/26 at 1:00 PM, Resident #2 was observed sleeping in his room. A male staff member was observed sitting in the room with the resident for one-on-one monitoring. After attempts to speak to the resident, he did not fully wake up. On 5/22/26, attempts to make contact with the responding officer were made at 12:25 PM, 2:15 PM, and 3:20 PM and were unsuccessful. During an interview with CNA A on 05/22/26 at 2:27 PM, she reported she observed Resident #2 wandering toward the 800 hall prior to the incident. She reported Resident #2 resided on the 600 hall. She reported she redirected Resident #2 toward the nurses station around 11:30 PM. She stated she then received a light notification and had to leave the area. CNA A reported she left Resident #2 parked near the nurses station and approximately five minutes later police arrived in response to a 911 call reporting a man in Resident #1's room. She reported there were no nurses at the nurse station at that time. She reported the two nurses were providing patient care. CNA A reported she followed behind the officer into Resident #1's room where she said she saw Resident #2 lying next to Resident #1 on his side. She reported it appeared Resident #2 was trying to give her hug, she reported she did not see where his hands where. She denied hearing yelling for help prior to the officer arriving. During an interview with LVN B on 05/22/26 at 2:40 PM, she reported she was at the nurse station when she saw a police officer rushing toward the 800 hall. She reported she followed the officer to Resident #1's room where she observed Resident #2 on top of Resident #1 in her bed. She reported Resident #1 was yelling get him off of me please. LVN denied hearing yelling for help prior to the officer arriving. She denied seeing Resident #2 at the nurse station prior to police arrival. She reported she was responding to a call light prior to police arrival. During an interview with Resident #2's family member on 05/22/26 at 3:30 PM, she reported she was notified of the incident by the administrator. She reported she was not aware of Resident #2 having a history of sexual inappropriate behaviors or wandering. She reported Resident #2 was picked up from the facility on 05/22/26 and went home. During an interview with the SW on 05/22/26 at 2:00 PM, she reported she was notified by the administrator of the incident and immediately completed a trauma assessment with Resident #1. She reported Resident #1 appeared saddened during the interview. The SW reported she requested counseling and psychiatric services for Resident #1. The SW reported Resident #1 had a telehealth session with a therapist today. The SW reported she completed safe surveys on all residents today with no concerns reported. The SW reported she spoke to Resident #2's family member today who reported they were bringing him home from the facility today. The SW reported she had helped arrange in-home services for Resident #2. Record review of Resident #1's Trauma Assessment, dated 5/22/26, reflected no prior history of trauma. The assessment reflected no current symptoms of trauma. During an interview on 05/22/26 at 4:00 PM, with the Regional [NAME] President, she reported Resident #2 was taken home around 3:00 PM today. She reported Resident #2 did not have a history of wandering or sexual aggression. She reported Resident #2 was admitted from a hospital and none of his records indicated any concerning behaviors. She reported the facility did not have any residents that wandered. She stated if a resident was found to display wandering behaviors, they would place them on one-on-one observation until they were able to find appropriate alternative placement. She reported the police did not take Resident #2 into custody because of his health conditions. During an interview with the Regional Director of Clinical Services on 05/22/26 at 5:21 PM, she reported Resident #2 was discharged home. She reported his family member arrived to the facility around 3 PM and took him home. She reported the resident was immediately removed from Resident #1's room and placed on one-on-one observations after the incident. She reported Resident #2's physician was notified and requested a urine analysis test to screen for a UTI due to a change in his behavior. During an interview with the administrator on 05/22/26 at 4:50 PM, he reported he was notified of the incident last night immediately after it happened. He reported he began calling Resident #2's family to initiate an immediate discharge. He stated he was unable to get a hold of the family as it was around midnight. He stated a family member returned his call today and the incident was explained to them and the reason for immediate discharge. He stated the family agreed to pick Resident #2 up which they did today around 3 PM. He stated Resident #2 was immediately placed on one-on-one observation until he was discharged . He reported if a resident was wandering, they would be placed on one-on-one supervision and be discharged from the facility. The administrator reported Resident #1 had a head-to-toe assessment completed with no observable injuries. He reported that the SW completed a trauma assessment with Resident #1 and her physician and family were notified of the incident. He reported Resident #1 was offered to be taken to the hospital and declined. He reported in-service training began on all night shift staff on 05/21/26 for behavioral management and de-escalation techniques and managing inappropriate sexual behaviors. The administrator reported the facility was responsible for ensuring residents remained safe from abuse by other residents in the facility. Record review of the facility Abuse, Neglect and Exploitation policy dated 10/01/2025 reflected in part. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology and/ or resident to resident altercations and encounters. Sexual Abuse is non-consensual sexual contact of any type with a resident. The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse. The facility will develop and implement written policies and procedures that: Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary and comfortable environment for 1 of 8 residents (Resident #64) in that:Resident # 64's refrigerator in her room had food that was moldy and spoiled half-filled cup of coffee on 9/30/2025. This failure could place resident at risk for a diminished quality of life and a diminished clean, homelike environmentThe findings include:Record review of Resident # 64 Quarterly MDS dated [DATE] reflected, Resident #64 was an [AGE] year-old female admitted to the facility on [DATE]. Resident #64 was on Hospice care. Resident #64 BIMS score was 0 which indicated she had severe cognitive impairment. Her pertinent diagnoses included Hypertension (high blood pressure), Diabetes Mellitus (an increased blood glucose levels), Hyperlipidemia (high blood lipid levels), and non-Alzheimer's dementia (cognitive decline that is not caused by Alzheimer's disease).In an observation on 09/30/2025 at 12:21 PM revealed Resident #64 had a refrigerator in the room. The refrigerator had residents have half-filled coffee drink that was spoiled and disposable box of food that was not dated or labeled. In an observation on 10/1/25 at 9:10 AM Resident #64's refrigerator in her room revealed a to-go container of food with no date or label on it and half-filled spoiled coffee cup.In an interview attempted on 10/1/25 at 9:11 AM with Resident #64 revealed she was not able to answer any of the surveyor's questions. In an observation and interview on 10/01/2025 at 9:13 AM along with CNA L revealed that CNA L stated that the refrigerator belonged to Resident #64. She proceeded to open the refrigerator and observed a to-go food container and half-filled coffee cup. She opened the box, and the food inside the box had white and green fungus-like substance on it. CNA L stated that the food was moldy and spoiled. She stated that the coffee inside the cup looked frothy and spoiled. CNA L stated that cleaning refrigerators was joint responsibility of CNAs and Housekeeping staff. She stated that she had not checked the refrigerator for weeks. She added that the resident's family may be bringing food from outside for her. She stated that the risk to the resident with moldy food in the refrigerator was the possibility of resident getting sick and mold growing within the refrigerator. In an interview 10/01/2025 at 9:16 AM with LVN B revealed that she does not usually check refrigerator in resident rooms since she thought it was the responsibility of housekeepers and CNAs. She stated that risks of spoiled food in resident refrigerator can lead to a risk of food poisoning and decreased quality of life.In an interview on 10/01/2025 at 9:21 AM with the DON stated that his expectation was both housekeeping and nursing staff should check resident refrigerator daily to ensure they are clean and free of spoiled food. He stated that the risk of having moldy and spoiled food was possible food borne illness and diminished quality of life. In an interview on 10/02/2025 at 3:14 PM with the Housekeeping Supervisor stated that it was the responsibility of the housekeeping staff to check and clean resident refrigerators daily. He stated that he was aware of spoiled food in Resident #64's refrigerator on 10/01/25 and provided in-service to his staff regarding regular cleaning of refrigerators on the same day. He stated that the Housekeeper forgot to check Resident #64's refrigerator. He stated that the risk of eating spoiled food was Residents can get sick and moldy food in the refrigerator can lead to decreased quality of life.In an interview on 10/02/2025 at 3:35 PM with Housekeeper M revealed that she cleaned Resident # 64's room on Tuesday 6/20/25. She stated that she forgot to check resident #64's refrigerator. She stated that she received an in-service on checking and cleaning refrigerators daily, as needed. She added that the risk of spoiled, moldy food in resident refrigerator can lead to residents getting sick and possibility of mold spreading in the room. Record review of the facility's policy titled Homelike Environment, revised February 2021 reflected the following, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.

Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 5 (Resident #38, Resident #80, Resident #90, Resident# 57 and Resident #18 ) of 16 residents reviewed for quality of life The facility failed to ensure: Resident #38 had his nails cut and cleaned. Resident #80 had her fingernails cleaned and trimmed and chin hair shaved. Resident #18 has his fingernails trimmed. Resident #90 had her fingernails cleaned and trimmed. Resident #57 had her fingernails trimmed and her chin hair shaved. These failures could place residents at risk for not receiving necessary care and services and a decreased quality of life.Findings include: 1- Resident #38Record review of Resident #38's quarterly MDS assessment, dated 09/07/25, reflected a [AGE] year-old male with an admission date of 01/30/25. Resident #38 had a BIMS score of 14 which indicated he was cognitively intact. He required substantial to maximum assistance for personal hygiene and had not refused care. He had functional limitation in range of motion upper extremities on one side and bilateral limitation on lower extremities. Diagnoses included diabetes, cerebral vascular accident (stroke) and hemiplegia (paralysis on one side of the body). She had not received occupational therapy (therapy that focuses on regaining dexterity and strength in fine motor skills) or restorative nursing services in the 7 days look back period. Record review of Resident #38's care plan dated 08/06/25 reflected, The resident had Diabetes Mellitus and is currently receiving a low concentrated sweets diet.Goal.Resident is to have no complications related to diabetes.Interventions.nurse to monitor/document foot care needs and cut long nails.Focus.dated 09/19/25.ADL self-care performance deficit related to hemiplegia. Left resting hand splint 6-8 hours every day.Intervention.Apply left resting hand splint 6-8 hours a day as ordered.Skin Inspection: Observe for redness, open areas, scratches, cuts, bruise and report changes to the Nurse. Record review of Resident #38's CNAs Task list dated 10/02/25 did not list personal hygiene as a task to be provided. In an observation and interview on 09/30/2025 at 12:05 PM Resident #38 was observed lying in bed. Resident #38 had contracted left hand with a resting palm splint in place. His nails on his left hand were approximately an inch in length, jagged and dirty. His thumb nail on his right hand was about an inch in length and very jagged. He stated he needed them trimmed badly. He stated no one had offered to trim his nails. An observation on 10/01/2025 at 9:20 AM revealed Resident #38 up in his wheelchair sitting in the common area next to the nurse's station. The resident was dressed for the day. He had the resting palm Splint on his left hand. All of his nails on his left hand remained long and jagged as well as his right-hand thumb nail. He stated they cleaned him up last night but did not trim his nails. In an interview and observation on 10/01/2025 at 10:00 AM with CNA G she stated she was assigned to Resident #38 today. She stated nursing, Physical therapy or restorative was who put the splints on the residents. She stated she had helped get him up today. She stated today was his shower day on the 2-10 p.m. shift. In an observation made with CNA G of Resident #38's nails, she stated she had not noticed his nails and stated they did need to be trimmed. She stated the nurses were responsible for trimming the diabetics nails and stated she thought he was diabetic. In an observation and interview on 10/01/2025 at 10:05 AM LVN E observed Resident #38 nails and stated they were in great need of trimming. She stated she was not aware they needed trimming because no one had alerted her to the need. She stated Resident #38 was not on insulin or blood sugar checks and she was not aware he was diabetic. She stated having long, jagged nails placed residents at risk of infections and skin tears. In an observation interview on 10/01/2025 at 10:10 AM In an observation of Resident #38 fingernails with RA D she stated, Oh my, they really needed trimming, She stated she put his splint on him this morning and just did not pay any attention to his nails. She stated she should have noticed them and told the nurse. She stated residents with contractures needed to keep their nails cut to prevent them from digging into the palms of their hand and could cause skin infections and skin tears. On 10/01/2025 at 10:15 AM an observation and interview of Resident #38 nails was made with the DON. He stated his nails should not have ever been left in this condition. He stated it placed the resident at risk of skin tears, pressure wounds to the palm of his left hand and increased infection. He stated the staff saw him every day, getting him up, dressing him and putting on his splint and the administrative staff do angel rounds each day to check in on the residents'. He stated someone should have noticed his nails. He stated he would ensure they were trimmed today and would be putting in a new process to ensure all of the residents' nails were maintained properly. Observation and interview 10/02/2025 at 8:49 AM revealed Resident #38 up in his wheelchair in the common area by the nurse's station. His nails had been trimmed and were clean and neat. Resident #38 stated he was glad to get them trimmed and now he will not scratch himself and stated they felt much better. 2- Resident # 80Record review of Resident #80's Quarterly MDS assessment dated [DATE] reflected Resident #80 was an [AGE] year-old female admitted to the facility with initial admission date of 03/21/2025. Her diagnoses included Diabetes Mellitus (high blood glucose levels) , Stroke (occurs when blood flow to the brain is interrupted, causing brain cells to die), Hypertension (high blood pressure), hyperlipidemia (high blood lipid levels) and Muscles weakness - generalized. Resident #80 had a BIMS score of 12 which indicated Resident #80's cognition was moderately impaired. Resident #80 required moderate assistance from facility staff with personal hygiene. Review of Resident #80's Comprehensive Care Plan, revised on 06/05/25, reflected the following: Problem: [Resident #80] has an ADL self-care performance deficit related to Impaired balance, Musculoskeletal impairment, and history of Stroke. Goal: [Resident #80] The resident will improve the current level of function through the review date. Intervention. BATHING/SHOWERING: Check nail length and trim and clean on bath day and asnecessary. Report any changes to the nurse. PERSONAL HYGIENE: [Resident #80] requires extensive by 1 staff with personal hygiene and oral care. In an observation and interview on 09/30/25 at 10:30 AM with Resident #80 revealed she was lying in bed. The nails on both hands were approximately 0.75 centimeters in length extending from the tip of her fingers. Resident #80 also had facial hair on the chin. Resident #80 stated she did not like her long nails and chin hair; she wanted her nails to be cleaned and trimmed as well as facial hair to be shaved. 3- Resident #18 Record review of Resident #18's admission MDS assessment dated [DATE] reflected Resident #18 was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Stroke (occurs when blood flow to the brain is interrupted, causing brain cells to die), Muscle weakness, Cognitive Communication deficit (a condition that affects the brain's ability to perform mental processes, such as attention, memory, reasoning, and problem-solving, which in turn impairs a person's ability to communicate effectively). Resident #18 had a BIMS score of 15 which indicated Resident #18 had intact cognition. Resident #18 required moderate assistance from facility staff with personal hygiene. Review of Resident #18's Comprehensive Care Plan, revised on 07/29/25, reflected the following: Problem: [Resident #18] has an ADL self-care performance deficit related to muscle weakness. Goal: [Resident #18] The resident will maintain the current level of function through the review date. Intervention. BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. In an observation and interview on 09/30/25 at 10:51 AM with Resident #18 revealed he was resting on his bed in his room. The nails on both hands were dirty, jagged and approximately 0.75- 1.00 centimeters in length extending from the tip of her fingers. Resident #18 stated he would like his nails trimmed and cleaned. 4- Resident #90 Record review of Resident #90's Quarterly MDS assessment dated [DATE] reflected Resident #90 was a [AGE] year-old female admitted to the facility with initial admission date of 04/24/2023. Her diagnoses included Diabetes Mellitus (high blood glucose level) , Stroke (occurs when blood flow to the brain is interrupted, causing brain cells to die), Hypertension (high blood pressure levels), Peripheral vascular disease (a condition that affects the blood vessels outside the heart and brain), Hemiplegia (paralysis of one side of the body), Parkinsons disease (a progressive neurodegenerative disorder that affects movement, balance, and coordination), Aphasia (difficulty speaking), and generalized Muscles weakness generalized. Resident #90 was on hospice care. Resident #90 had a BIMS score of 4 which indicated Resident #90's cognition was severely impaired. Resident #90 required substantial assistance from facility staff with personal hygiene. Review of Resident #90's Comprehensive Care Plan, revised on 09/24/25, reflected the following: Problem: [Resident #90] has an ADL self-care performance deficit, [she] requires extensive staff assist with ADLs and transfers. Goal: [Resident #80] The resident will improve the current level of function through the review date. Intervention. BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. In an observation and interview on 09/30/25 at 10:58 AM with Resident #90 revealed she was resting on his bed in his room. The nails on both hands were dirty, jagged and approximately 0.75 centimeters in length extending from the tip of her fingers. Resident #90 resident nodded yes when asked if she would like her fingernails clipped and trimmed. 5- Resident #57Record review of Resident #57's Quarterly MDS assessment dated [DATE] reflected Resident #57 was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Diabetes Mellitus (high blood glucose level), Stroke (occurs when blood flow to the brain is interrupted, causing brain cells to die), Hypertension (high blood pressure level), Hemiplegia (paralysis of one side of the body) . Resident #57 had a BIMS score of 5 which indicated Resident #57's cognition had severe cognitive impairment. Resident #57 required substantial assistance from facility staff with personal hygiene. Review of Resident #57's Comprehensive Care Plan, revised on 10/02/25, reflected the following: Problem: [Resident #57] has an ADL self-care performance deficit, [and] requires extensive staff assist with ADL's and transfers. Goal: [Resident #57] The resident will improve the current level of function through the review date. Intervention. BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. In an observation and interview on 09/30/25 at 2:30 PM with Resident #57 revealed she was sitting in her wheelchair in her room. The nails on both hands were painted and approximately 0.7 centimeters in length extending from the tip of her fingers. Resident #57 stated she did not like her long nails and chin hair; she wanted her nails to be trimmed. In an interview an observation on 09/30/25 at 11:12 AM with LVN N who stated she worked in the facility since December 2024. She stated CNAs and Nurses were responsible for nail care. She added charge nurses were responsible for clipping nails for residents who were diabetics. She added that CNAs were responsible for trimming facial hair on all residents during shower days. She added that Resident #90 was on hospice care and most ADLS completed by outside hospice aide. She added even if Residents were on hospice, nail care should be offered to all residents. She stated the risk of not cutting and cleaning nails was lapses in infection control and decreased quality of life for residents. In an interview and observation on 09/30/25 at 2:03 PM with CNA O stated she provided ADL care to residents that included nail care and shaving facial hair on shower days and as needed. She stated that for Resident # 80 and resident #90 , she may have overlooked to clean their nails. She stated that for diabetic residents, charge nurses were responsible for clipping nails. She stated untrimmed , dirty nails could cause infection and injury and failure to trim facial hair can lead to loss of dignity. In an interview at 12:53 PM on 10/1/25 the DON stated that he was interim DON for the facility and started working in the facility about 3 weeks ago. He stated that Resident #90 was on hospice and hospice aides from outside agency took care of all ADLs for the resident. She also stated that CNAs should be offering ADLs including nailcare for hospice residents on as needed basis. The DON stated his expectation was that nail care should be provided every shower day and as needed. He stated that both CNAs and Nurses were responsible for doing nail care on all residents; except Nurses were responsible for nailcare for diabetic residents. He stated that dirty, long fingernails could cause skin irritation and unwanted facial hair could cause residents to feel unkempt and loss of dignity. He stated as the DON he conducted daily rounding on residents along with the Assistant Director of Nursing. He stated that he will provide in-service to staff regarding ADL care and ensure that ADL care tasks for all residents were carried out daily. In a follow up interview with the DON on 10/02/2025 at 03:30 PM he stated that going forward they were placing a list of all the diabetics in the nurse's binder for each hall so they would be aware of which resident they were responsible for nail care. He stated in addition their daily angel rounds would include looking at each of the residents' nails and their overall hygiene to ensure their ADLs were being met. He stated the DON and ADONs would be responsible for follow up and ensuring those tasks were carried out. Review of the facility policy titled Care of Fingernails/ toenails, revised September 2010 reflected, Purpose: The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. 1. Nail care includes daily cleaning and regular trimming.

Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences for two of three residents (Resident #50, and Resident #26) reviewed for respiratory care. 1.The facility failed to ensure LVN K maintained sterile/aseptic technique during tracheostomy care (a surgical opening in the neck providing a direct airway through the trachea) for Resident #50 on 10/02/25. 2. The facility failed to ensure Resident #26's had a physician order prior to administering oxygen on 9/30/25. These failures could place residents at risk for respiratory infections and at risk of receiving an incorrect amount of oxygen. Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences for two of three residents (Resident #50, and Resident #26) reviewed for respiratory care. 1.The facility failed to ensure LVN K maintained sterile/aseptic technique during tracheostomy care (a surgical opening in the neck providing a direct airway through the trachea) for Resident #50 on 10/02/25. 2. The facility failed to ensure Resident #26's had a physician order prior to administering oxygen on 9/30/25. These failures could place residents at risk for respiratory infections and at risk of receiving an incorrect amount of oxygen.

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 7 of 15 residents (Resident #72, Resident #73, Resident #79, Resident #80, Resident # 78, Resident # 21 and Resident #39) reviewed for infection control. 1. The facility failed to ensure CNA F and RA D utilized Enhanced Barrier Precautions and performed hand hygiene before and after checking Resident #72 for incontinence on 10/01/25. 2. The facility failed to ensure CNA F changed her gloves and performed hand hygiene while providing incontinence care for Resident #73 and failed to ensure both CNA F and RA D used enhanced barrier precautions and failed to perform hand hygiene before leaving the resident's room on 10/01/25. 3. The facility failed to ensure CNA F and RA D performed hand hygiene and glove changes during a check and change of Resident #79's brief on 10/01/25. 4. The facility failed to ensure LVN E followed the manufacture's recommendations for disinfecting the glucometer after obtaining fingerstick blood sugars for Resident #80 and Resident # 78 on 09/30/25. 5. The facility failed to ensure LVN B followed the manufacture's recommendations for disinfecting the glucometer after obtaining fingerstick blood sugars for Resident # 21 on 09/30/25. 6. The facility failed to ensure MA I prepared Resident #39's medication without cross contaminating his medications on 10/01/25. These failures could place residents at risk of cross-contamination and the development of infection. Findings include: 1. Record review of Resident #72's care plan, initiated 08/19/25, reflected a [AGE] year-old male with an admission date of 05/30/25. The care plan reflected the resident required enhanced barrier precautions related to his feeding tube, and he was incontinent of bowel and urine and required checks for incontinence and brief changes. An observation on 10/01/2025 at 11:00 a.m. revealed CNA F and RA D making their check and change rounds on Resident #72. Signage was posted outside of Resident #72's room which indicated Enhanced Barrier Precautions were required. Both staff entered the room without performing hand hygiene or putting on gowns. Both staff put on gloves and CNA F pulled the cover back which revealed the resident had a g-tube in place with a dressing, dated 10/01/25. CNA F unfastened the resident's brief to reveal he had not voided. CNA F with the assistance of RA D rolled the resident on his side to reveal he was dry and clean, and his skin was intact. The staff rolled the resident back onto his back and refastened the brief. The staff repositioned the resident in the bed, adjusted his covers and the boot splints on both his feet. Both staff removed their gloves and left the room without performing hand hygiene and walked down hallway to check Resident #73. 2. Record review of Resident #73's quarterly MDS assessment, dated 09/01/25, reflected a [AGE] year-old female with an admission date of 02/28/24. The facility staff evaluated her cognition as severely cognitively impaired. She was dependent for all ADLs and was frequently incontinent of urine and always incontinent of bowel. Resident #73 received all nutrition through a feeding tube. Resident #73 had active diagnoses which included Huntington's Disease (an inherited condition in which nerve cells in the brain break down over time) and aphasia (language disorder that affects a person's ability to speak). In an observation on 10/01/2025 at11:05 a.m. revealed CNA F and RA D used the hand sanitizer outside of Resident #73's room and put on gloves but no gowns. The signage posted revealed that the resident was on enhanced barrier precautions. Both staff entered the room and CNA F stated she would have to get the nurse to turn off the G-tube pump. CNA F left the room and returned with the DON who entered the room gowned and gloved and CNA F entered with gloves on, but no gown. The DON turned off the G-Tube pump and disconnected the enteral feeding from the G-tube. The DON removed his gown and gloves, performed hand hygiene and left the room. CNA F then unfastened the resident's brief, which revealed she was wet and had a soft bowel movement. CNA F turned the resident onto her left side with RA D's assistance, without first cleaning the resident's perineal area. CNA F wiped the anal area from front to back, which revealed a small nickel sized open area near her anus. CNA F stated she needed to get the treatment nurse to see the area. CNA F placed a clean brief under the resident, still wearing soiled gloves, and covered the resident. CNA F removed her gloves and left the room without performing hand hygiene. Within a few minutes, CNA F returned to the room with the Treatment nurse who was gowned and gloved. CNA F, again only put on gloves. The Treatment Nurse assessed the area and told the staff to put barrier cream on it for now. She stated she would notify the physician. The Treatment nurse stated it appeared to be a moisture related breakdown. CNA F stated the resident was still having bowel movement and again wiped her anal area from front to back to remove the bowel movement. Wearing the same gloves CNA F put barrier cream on the resident's anal area and rolled her back onto the brief and both staff fastened the brief without ever cleaning the resident's perineal area. Both staff repositioned the resident removed their gloves and left the room without performing hand hygiene and went to Resident #79 to check her for incontinence. 3. Record review of Resident #79's annual MDS assessment, dated 09/18/25, reflected an [AGE] year-old female with an admission date of 09/29/22. Resident #79 had a BIMS of 15, which indicated she was cognitively intact. Resident #79 was always incontinent of bowel and bladder and was high risk for pressure ulcers. Resident #79 had a diagnosis which included diabetes. In an observation on 10/01/2025 at 11:25 a.m. revealed CNA F and RA D entered Resident #79 room for a check and change for incontinence. Both staff put on gloves without performing hand hygiene. Both staff uncovered the resident and unfastened her brief, and stated she appeared to be dry. Both staff rolled the resident over on her side which revealed she was dry. Resident #79 had multiple scars from healed pressure ulcers on her entire buttocks area. CNA F stated the brief was torn, and they needed to replace the brief. The staff rolled the resident from side to side to remove the brief and with the same gloves placed a new brief under the resident and applied fresh barrier cream. The staff rolled the resident, who was very large, spread her legs to reveal she also had scarring on her inner thighs and labia. RA D applied barrier cream to her inner thighs, wearing the same gloves used to remove the old brief. Both staff adjusted and fastened the brief, moved the resident up in the bed and recovered her and put her bedside table back over the resident. Both staff removed their gloves and washed their hands in the resident's room sink before leaving the room. In an interview with CNA F and RA D on 10/01/25 at 11:35 a.m., both stated they were to perform hand hygiene before they entered the resident's room and before they left the room. They stated they did not perform hand hygiene when they entered and existed Resident #72's and Resident #73's room, but they had done it before they entered Resident #73's room. Both CNAs stated they both stated they were not sure when they had to perform hand hygiene during incontinent care, they just knew before and after. When asked about Enhanced barrier precautions they both stated residents with g-tubes, they were supposed to wear a gown, and they should have put a gown on for Resident #72 and Resident #73, and they just forgot. They stated they had training about Enhanced Barrier Precautions, and it was to prevent the spread of infection from residents to residents. Both staff stated failures to perform hand hygiene, and the use of proper PPE placed the residents at risk of infections. In an interview on 10/02/25 at 03:40 p.m. with the DON, he stated staff were supposed to wash their hands and change gloves before, and after going from dirty to clean, and after completion of care. He stated any resident with an implanted device required enhanced barrier precautions and they did extensive training. He stated he noticed the staff did not have gowns when he entered Resident # 73's room and he should have corrected them then. He stated the staff were all skills checked and they were all aware of what they were supposed to be doing. He stated the risk of failing to perform hand hygiene and not utilizing Enhanced Barrier Precautions as required was increased infections and cross contamination. 4. During a medication pass observation on 09/30/25 at 10:50 a.m. revealed LVN E was at the medication cart preparing to check Resident #80's blood sugar levels via a fingerstick blood sugar. LVN E retrieved the glucometer from the medication cart and wiped it down with an alcohol prep pad. LVN E sanitized her hands, put on gloves and entered the resident's room. LVN E pricked the residents' fingers and obtained the blood sample for the blood glucose reading. LVN E disposed of the lancet and test strip and returned to the medication cart and placed the glucometer on top of the medication cart. She performed hand hygiene put on gloves and determined the amount of insulin the resident required, drew it up and administered the insulin to the resident. LVN E disposed of the needle, removed her gloves and performed hand hygiene. LVN E then pushed the medication cart to Resident #78's room to obtain her fingerstick blood sugar. LVN E opened a few packets of alcohol prep pads and wiped down the glucometer, put on gloves and entered the resident's room and obtained a blood sample to determine the residents' blood glucose levels. LVN E returned to the medication cart, placed the glucometer on the medication cart, performed hand hygiene and drew up the amount of insulin the resident required and administered the insulin. In an interview with LVN E on 09/30/25 at 11:05 a.m. she stated she was not aware she had to clean the glucometer with a bleach wipe or germicidal wipe rated for disinfected. LVN E stated she always used an alcohol prep pad. LVN E opened her medication cart and revealed she had bleach wipes and germicidal wipes on her cart and stated she would start using these to sanitize the glucometer. 5. During a medication pass observation on 09/30/25 at 11:10 a.m. revealed LVN B was at the medication cart preparing to check Resident # 39's blood sugar levels via a fingerstick blood sugar. LVN B retrieved the glucometer from the medication cart and wiped it down with an alcohol prep pad. LVN B sanitized her hands, put on gloves and entered the resident's room. LVN B pricked the residents' fingers, obtained the blood sample for the blood glucose reading. LVN B disposed of the lancet and test strip and returned to the medication cart and placed the glucometer on top of the medication cart. She performed hand hygiene put on gloves and determined the amount of insulin the resident required, primed the insulin and dialed in the amount of insulin required and administered it to the resident. LVN B disposed of the needle, removed her gloves and performed hand hygiene and opened a few packets of alcohol prep pads and wiped down the glucometer. In an interview with LVN B on 09/30/25 at 11:20 a.m., she stated she was not aware she had to clean the glucometer with a bleach wipe or germicidal wipe rated for disinfected. LVN B stated no one instructed them they could not use an alcohol prep pad. LVN E opened her medication cart and revealed she had bleach wipes and germicidal wipes on her cart and stated she would start using these to sanitize the glucometer. 6. During medication observation on 10/01/25 at 08:41 a.m., MA I was observed at the medication cart. MA I performed hand hygiene and entered Resident #39's room to obtain his blood pressure. MA I returned to the medication cart, put on a pair of gloves, and sanitized the blood pressure cuff with a bleach wipe. MA I put on gloves and opened the medication cart with her gloved hands and pulled out eight blister packs and proceeded to pop the medication into her gloved hand and then placed each tablet into the medication cup. After each medication MA I used her gloved hand to maneuver the mouse of her computer to pull up the medication she was administering and typed in the medication. In an interview on 10/01/25 at 08:50 a.m., MA I stated she was taught she was not supposed to touch the medication with her bare hands, so that was why she put on gloves. She stated she could see once she touched the mouse and computer keyboard her gloved hand was no longer clean. She stated she should pop the pill directly into the medication cup. In an interview on 10/02/25 at 03:40 p.m. with the DON, he stated staff had never been taught to punch medications into a gloved hand. He stated they were taught to punch the medication directly into the medication cup without touching the medication to prevent cross contamination. He stated the staff also had training on disinfecting multiple use equipment such as glucometers, blood pressure cuffs etc. and they were taught to use germicidal wipes and allow the equipment to air dry for the appropriate kill time to ensure the equipment was effectively disinfected. He stated not using the proper disinfectant ran the risk of cross contamination of blood borne pathogens from resident to resident. Record review of the facility's policy titled, Handwashing/Hand hygiene, dated August 2019, reflected The facility considers hand hygiene the primary means to prevent the spread of infection.All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections.Before and after direct contact with residents.before moving from a contaminated body site to a clean body site during resident care.After contact with a resident intact skin.After removing gloves.Before and after entering isolation precaution settings. Record review of the facility's policy titled, Enhanced Barrier Precautions, dated August 2022, reflected Enhanced Barrier Precautions (EHPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents.EBP employ targeted gown and glove use during high contact resident care activities when contact precautions no not otherwise apply.Examples of high-contact resident care activities requiring the use of gown and gloves for EBP's include.device care or use (.feeding tube.)EBPs remain in place for the duration of the residents stay or until resolution.or discontinuation of the indwelling medical device that places them at increased risk.Staff are trained prior to caring for resident on EBPs.Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required. Record review of the facility's, undated, manufactures guidelines for cleaning and disinfecting the Assure prism multi-blood glucose monitoring system reflected, To minimize the risk of transmitting bloodborne pathogens, the cleaning and disinfection procedures should be performed as recommended in the instruction below.Only wipes with EPA registration.have been validated for use in cleaning and disinfecting the meter.Clorox (bleach) germicidal wipes.Sani-Cloth germicidal wipes.Each time the cleaning and disinfecting procedure is performed, two wipes are needed: one wipes to clean the meter and a second wipe to disinfect the meter.Wipe the entire surface of the meter using the towelette at least three times vertically and three times horizontally to clean blood and other body fluids from meter.Repeat above steps with a new towelette to disinfect the meter.Meter surfaces must remain wet according to contact times listed in the wipe manufacturer's instructions. Once complete, wipe meter dry Record review of the facility's policy titled, Administering Medication, dated December 2012, reflected .Staff shall follow established facility infection control procedures.for the administration of medications.

Based on interviews and record review the facility failed to include in the care plan services that will be provided to the resident for 1 (Resident #40) of 10 residents reviewed for comprehensive care plans.The facility failed to ensure Resident #40 was care planned for ADLs. This failure could put Residents at risk of receiving unnecessary treatments, not receiving care or services and further decline of their physical health. Findings included: Record review of a face sheet dated 10/02/25 revealed Resident #40 was an [AGE] year old female admitted on [DATE] with diagnoses including cerebral infraction (interruption of blood flow to the brain), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), acute respiratory failure with hypoxia (the lungs fail to adequately exchange oxygen from the air into the bloodstream), dementia (a decline in cognitive function), and unspecified lack of coordination (impaired balance or coordination). Record review of the most recent MDS dated [DATE] indicated Resident#40 was cognitively intact with a BIMS score of 12. Record review of Resident #40's comprehensive care plan dated 05/19/25 reflected no plan of care for goals and interventions for ADLs. During an interview on 10/01/25 at 1:10 p.m., the MDS Coordinator revealed she did not know the reason ADLs were not included in the care plan. The MDS Coordinator stated ADLS should have been included in the care plan so that CNAs would have known the residents needs. She stated the MDS Coordinator was responsible for writing the care plans. During an interview on 10/2/25 at 2:25 p.m., the DON stated ADLs were needed so staff would know how to take care of the residents. The DON stated it was important to have interventions to reflect the accurate needs of the residents. In an interview with the Administrator on 10/2/25 at 3:01pm revealed the MDS Coordinators and charge nurses were responsible for updating care plans. Review of the facility's policy Care Plans - Comprehensive revised September 2010 .1. Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develop and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. 2. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS. 3. Each resident's comprehensive care plan is designed to: a. Incorporate identified problems areas; b. incorporate risk factors associated with identified problems; .e. reflect treatment goals, timetables and objectives in measurable outcomes; f. Identify the profe3ssional services that are responsible for each element of care; g. aide in preventing or reducing declines in the resident's functional status and/or functional levels.

Based on interviews and record reviews, the facility failed to have the comprehensive care plan reviewed and revised by qualified persons after each assessment for 1 (Resident #26) of 10 residents reviewed for comprehensive care plans.The facility failed to update Resident #26's care plan to reflect doctor's orders to discontinue anticoagulant therapy on 8/14/25. This failure could put Residents at risk of receiving unnecessary treatments, not receiving care or services and further decline of their physical health. Findings included: Record review of Resident #26's admission record dated 10/1/25 reflected a [AGE] year-old female with an original admission date of 2/28/25 and readmission date of 7/21/25. Pertinent diagnoses included Dementia, End Stage Renal Disease (a condition in which the kidneys lose the ability to remove waste and balance fluids), Metabolic Encephalopathy (a condition where the brain does not receive enough oxygen or nutrients, leading to changes in brain function, and Paroxysmal Atrial Fibrillation (a heart rhythm disorder where the hearts chambers beat irregularly and rapidly).Record review of Resident #26's Quarterly MDS assessment, dated 9/1/25 reflected resident was moderately cognitively impaired and had a BIMS of 11. Section N reflected resident continued anti-coagulant therapy. Record review of Resident #26's Order Summary Report dated 10/1/25, reflected no physician order for anti-coagulants.Record review of Resident #26's Order Recap Report dated 8/1/25-10/31/25 reflected Eliquis Oral Tablet 2.5 with a start date of 7/26/25 and end date of 8/14/25. Record review of Resident #26's person-centered care plan updated on 9/2/25 reflected .Focus: Resident #26 is on anticoagulant therapy Eliquis for long term therapy Date Initiated: 09/02/2025 Revision on: 09/02/2025. Goal: Resident #26 will be free from discomfort or adverse reactions related to anticoagulant use through the review date. Date Initiated: 09/02/2025 Revision on: 09/02/2025 Target Date: 10/04/2025. Interventions: Administer ANTICOAGULANT medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT. Date Initiated: 09/02/2025 Revision on: 09/02/2025 family/caregiver teaching to include the following: Take/give medication at the same time each day, Use soft toothbrush, Use electric razor, Avoid activities that could result in injury, take precautions to avoid falls, Signs/symptoms of bleeding, Avoid foods high in Vitamin K. These include greens such as spinach and turnips, asparagus, broccoli, cabbage, Brussels sprouts, milk and cheese. Date Initiated: 09/02/2025 Revision on: 09/02/2025 Daily skin inspection. Report abnormalities to the nurse. Date Initiated: 09/02/2025 Revision on: 09/02/2025 Labs as ordered. Report abnormal lab results to the MD. Date Initiated: 09/02/2025 Revision on: 09/02/2025 Monitor/document/report PRN adverse reactions of ANTICOAGULANT therapy: blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising , blurred vision, SOB, loss of appetite, sudden changes in mental status, significant or sudden changes in v/s. Date Initiated: 09/02/2025 Revision on: 09/02/2025.In an interview with the MDS Coordinator on 10/2/25 at 11:13am revealed she was not the MDS Coordinator responsible for updating Resident #26's care plan but was the only MDS Coordinator at the facility, as the one that was responsible for Resident #26's care plan recently left the position. Once a resident was removed from anti-coagulant therapy, the MDS coordinator would update the care plan to reflect discontinued anticoagulant therapy. She reviewed Resident #26's care plan and noted anti-coagulant therapy was still in the care plan dated 9/2/25. She stated anticoagulant therapy should have been removed from Resident #26's care plan because Eliquis was discontinued prior to the update of the care plan. The risk to the resident of not having had an accurate care plan was staff would not know how to care for the resident appropriately. She stated they had a traveling MDS coordinator who was helping her with the care plans until they hired a new MDS coordinator. She stated nursing staff could have updated the care plans as well. In an interview with LVN B on 10/2/25 at 12:12pm revealed Resident #26 was no longer taking anti-coagulant medications. LVN B stated the MDS Coordinator was responsible for updating the care plans. In an interview with RN C on 10/2/25 at 11:51am revealed nurses did not update care plans, as they were only responsible for Baseline Care plans. In an interview with the Administrator on 10/2/25 at 3:01pm revealed the MDS Coordinators and charge nurses were responsible for updating care plans. Review of the facility's policy Care Plans - Comprehensive revised September 2010 .1. Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develop and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. 2. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS. 3. Each resident's comprehensive care plan is designed to: a. Incorporate identified problems areas; b. incorporate risk factors associated with identified problems; .e. reflect treatment goals, timetables and objectives in measurable outcomes; f. Identify the profe3ssional services that are responsible for each element of care; g. aide in preventing or reducing declines in the resident's functional status and/or functional levels.

Based on observations, interviews and record review, the facility failed to ensure residents toileting facilities were adequately equipped to allow residents to call for assistance for 2 Residents (Resident #57 and Resident #64 ) of 16 residents reviewed for residents' call systems. The facility failed on 09/30/2025 to ensure the call light system was accessible to a resident, lying on the floor in the shared residents' toilets located inside the residents' rooms when the call lights were missing the pull strings, for: Resident #57 and Resident #64 This failure could place residents in the facility at risk of being unable to have a means of directly contacting caregivers from their restroom. Findings included:Observation on 09/30/25 at 12:12 PM revealed residents' toilet call light pull string was missing for Resident #57 and Resident #64 in their shared toilet. In an interview and observation on 10/01/2025 at 9:16 AM with CNA L stated that the cord for the bathroom call light was missing. She stated that she had not noticed the missing cord earlier. She stated that she will let the maintenance personnel know about the missing cord. She added that the risk of not having a call light within reach can lead to the possibility of a fall and the resident not being able to get help on time. In an interview on 10/01/2025 at 9:40 AM with the Maintenance supervisor revealed, he was informed about the missing call light string in the bathroom by the DON just before the interview and he has fixed the issue. He stated he did not know about the missing call lights string before and relies on multidisciplinary team including CNAs, housekeepers, Nurses to let him know regarding any maintenance request. He stated the risk to the resident was a possible fall without any help for hours. In an interview and observation on 10/01/25 at 9:21 PM with the DON stated call light string was supposed to be within the reach of the resident. He stated missing call lights string was a safety concern. In an interview on 10/2/25 3:02 PM with the Administrator stated the call light string should be within resident reach, at all times so they could call for help when they need it. He stated missing string for the bathroom call light could be a safety issue. He added that it was an interdisciplinary approach to ensure residents were safe and any repairs needed should be communicated with maintenance promptly. He stated that there is no specific policy regarding call light strings, however for resident safety, call light should always be in resident's reach. Review of the facility policy titled Call System: Resident, revised September 2022 [NAME] .1. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor.

Based on observation, interview and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles and in compliance with the state laws and regulations, which included the appropriate accessory and cautionary instructions and the expiration date when applicable for the facility's one of two (Whirlaway med room) medication rooms reviewed for storage. The facility failed to ensure a vial of Tuberculin Purified protein derivative (substance used for skin test for tuberculosis), that was opened and used, was dated and stored in its original package in the medication room refrigerator. This failure could place residents at risk of diminished effectiveness and not receiving the therapeutic benefits of the medications.The findings include: An observation on 09/30/2025 at 9:30 a.m. of the medication room refrigerator on Whirlaway hall with the DON revealed an undated opened vial of Tuberculin Purified protein derivative stored in a bag labeled hep lock solution (a very diluted heparin solution used to flush maintain patency of intravenous lines). In an interview with the DON on 09/30/25 at 09:44 a.m., he stated the Tuberculin Purified protein derivative had to be dated when opened. He stated once it was opened it would only be good for 30 days. He stated the risk of not dating it once opened was the potential for false positive or an inaccurate test, which could lead to a missed infection. He stated all the nurses performed the Tuberculin skin test on any new admission and whoever opened the vial was responsible for dating. He stated all medications should be stored in their original containers to prevent mixing up medications. He stated the pharmacy consultant came monthly and checked for outdated medications, and stated the nurses were always supposed to check the date before using any medication. Record review of the facility's policy titled Storage of Medications, dated April 2007, reflected . Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received.The nursing staff shall be responsible for maintaining medication storage.The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed .

Based on observation, interview and record review the facility failed to ensure, based on the comprehensive assessment of the resident, a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one of three residents (Resident #73) reviewed for incontinence care. The facility failed to ensure CNA F and RA D provided appropriate perineal care for Resident #73 when they failed to clean the resident's perineal area, separate the labia and wash downward and clean the inner thighs and groin area on 10/01/25. This failure could place residents at risk for the development and/or worsening of urinary tract infections and skin breakdown.Record review of Resident #73's quarterly MDS assessment, dated 09/01/25, reflected a [AGE] year-old female with an admission date of 02/28/24. The facility staff evaluated her cognition as severely cognitively impaired. She was dependent for all ADLs and was frequently incontinent of urine and always incontinent of bowel. The resident received all nutrition through a feeding tube. Resident #73's active diagnoses included Huntington's Disease (an inherited condition in which nerve cells in the brain break down over time) and aphasia (language disorder that affects a person's ability to speak) Record review of Resident #73's care plan, initiated on 09/24/25, reflected [Resident #73] has bladder and bowel incontinence she is dependent on staff for all incontinence care needs .Interventions.Clean peri-care with each incontinence episode .Monitor for signs and symptoms of urinary tract infections. In an observation on 10/01/2025 at 11:05 a.m. revealed CNA F and RA D used hand sanitizer outside of Resident #73's room and put on gloves but no gowns. Both staff entered the room and CNA F unfastened the residents brief, revealing she was wet and had soft bowel movement. CNA F turned the resident onto her left side with RA D's assistance without first cleaning the resident's perineal area. CNA F wiped the anal area from front to back, revealing a small nickel sized open area near her anus. CNA F stated she needed to get the treatment nurse to see the area. CNA F placed a clean brief under the resident, still wearing soiled gloves, and covered the resident. CNA F removed her gloves and left the room without performing hand hygiene. Within a few minutes, CNA F returned to the room with the Treatment nurse who was gowned and gloved. CNA F, again only put on gloves. The Treatment Nurse assessed the area and told the staff to put barrier cream on it for now. She stated she would notify the physician. CNA F stated the resident was still having bowel movement and again wiped her anal area from front to back to remove the bowel movement. Wearing the same gloves CNA F put barrier cream on the resident's anal area and rolled her back onto the brief and both staff fastened the brief without ever cleaning the resident's perineal area. Both staff repositioned the resident removed their gloves and left the room without performing hand hygiene. In an interview with CNA F and RA D on 10/01/25 at 11:35 a.m., CNA F stated she was supposed to wipe from front to back when performing incontinence care. She stated she thought she could clean the resident's peri area from the back, but stated she could not clean the inner thighs, pubic area or open the resident labia to ensure all fecal matter was removed. RA D stated they should have cleaned her front area first before rolling her on her side to clean her anal area. They both stated by failing to provide proper incontinence care it placed the resident at risk of urinary tract infections. In an interview with the DON on 10/03/2025 at 03:40 p.m., he stated any time the staff provided incontinence care he expected the residents to be cleaned properly, and the staff were to clean the peri-area from front to back and then progress to the anal area. He stated there was no way to ensure a resident was thoroughly cleaned by cleaning them only from the back side. He stated that by not cleaning properly it placed the resident at a high risk of urinary tract infections. He stated they did annual skills checks on the staff and monitored proper care by doing spot checks with the staff throughout the year. Record review of the Facility's policy titled, Incontinence care Protocol, dated September 2024, reflected Maintain the Patient in a clean and dry sated and prevent complications of incontinence by maintain and providing incontinent care to the patient a regular interval.Incontinent care will be provided after each incontinent episode.

Based on interview, observation and record review, the facility failed to complete an assessment that accurately reflects a resident's status for 1 of 5 residents (Resident #26) reviewed for accuracy of assessments.The facility failed to accurately complete Resident #26's Quarterly MDS Assessment related to the need for oxygen therapy. The facility failed to accurately complete Resident #26's Quarterly MDS Assessment related to the discontinued use of anti-coagulant therapy. This failure could place the resident at risk of not having met her needs. Findings includedRecord review of Resident #26's admission record dated 10/1/25 reflected a [AGE] year-old female with an original admission date of 2/28/25 and readmission date of 7/21/25. Pertinent diagnoses included Dementia, End Stage Renal Disease (a condition in which the kidneys lose the ability to remove waste and balance fluids), Metabolic Encephalopathy (a condition where the brain does not receive enough oxygen or nutrients, leading to changes in brain function, and Paroxysmal Atrial Fibrillation (a heart rhythm disorder where the hearts chambers beat irregularly and rapidly).Record review of Resident #26's Quarterly MDS assessment, dated 9/1/25 reflected resident was moderately cognitively impaired and had a BIMS of 11. Section N reflected resident continued anti-coagulant therapy. Section O reflected resident did not require oxygen while residing at the facility. Record review of Resident #26's Order Summary Report dated 10/1/25, reflected no physician order for anti-coagulants and no order to administer oxygen.Record review of Resident #26's Order Recap Report dated 8/1/25-10/31/25 reflected Eliquis Oral Tablet 2.5 with a start date of 7/26/25 and end date of 8/14/25. Record review of Resident #26's person-centered care plan, effective 3/2/25 reflected .COPD Resident #26 HAS : Potential for ineffective airway exchange and infection related to dx of COPD. STATUS: Active (Current) COPD: Resident #26 will have respiratory rate within normal limits and be free of s/s of respiratory distress. STATUS: Active (Current) COPD: Administer bronchodilators, aerosol treatments, nebulizers, and oxygen 2-6 lpm and monitor status. STATUS: Active (Current) Nursing COPD: Administer medications as ordered and monitor for side effects. STATUS: Active (Current).Record review of Resident #26's person-centered care plan updated on 9/2/25 reflected .Focus: Resident #26 is on anticoagulant therapy Eliquis for long term therapy Date Initiated: 09/02/2025 Revision on: 09/02/2025. Goal: Resident #26 will be free from discomfort or adverse reactions related to anticoagulant use through the review date. Date Initiated: 09/02/2025 Revision on: 09/02/2025 Target Date: 10/04/2025. Interventions: Administer ANTICOAGULANT medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT. Date Initiated: 09/02/2025 Revision on: 09/02/2025 [NAME]/family/caregiver teaching to include the following: Take/give medication at the same time each day, Use soft toothbrush, Use electric razor, Avoid activities that could result in injury, take precautions to avoid falls, Signs/symptoms of bleeding, Avoid foods high in Vitamin K. These include greens such as spinach and turnips, asparagus, broccoli, cabbage, Brussels sprouts, milk and cheese. Date Initiated: 09/02/2025 Revision on: 09/02/2025 Daily skin inspection. Report abnormalities to the nurse. Date Initiated: 09/02/2025 Revision on: 09/02/2025 Labs as ordered. Report abnormal lab results to the MD. Date Initiated: 09/02/2025 Revision on: 09/02/2025 Monitor/document/report PRN adverse reactions of ANTICOAGULANT therapy: blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy,bruising , blurred vision, SOB, loss of appetite, sudden changes in mental status, significant or sudden changes in v/s. Date Initiated: 09/02/2025 Revision on: 09/02/2025.Observation of Resident #26 in her room on 9/30/25 at 10:16am revealed resident was asleep and had oxygen on via nasal cannula. The concentrator was set at 2 liters per minute. In an interview with Resident #26 on 9/30/25 at 1:37pm revealed she had been receiving oxygen as needed. She stated staff would check her oxygen levels before turning on the oxygen machine. In an interview with CNA A on 10/1/25 at 1:18pm revealed she had observed Resident #26 with oxygen on at bedside almost daily. In an interview with LVN B on 10/1/25 at 2:02pm revealed Resident #26 required oxygen. LVN B stated Resident #26 should have 2-3 liters per minute of oxygen when her oxygen levels were low. The oxygen was ordered by the physician. LVN B stated Resident #26 was no longer taking anti-coagulants, as the doctor had discontinued them. She was unsure when they were discontinued. LVN B stated she did not update MDS assessments and was not familiar with what needed to be on them. In an interview with the MDS Coordinator on 10/2/25 on 11:13am revealed she was not the MDS Coordinator responsible for updating Resident #26's MDS but was the only MDS Coordinator at the facility, as the one that was responsible for Resident #26's recently left the position. The MDS Coordinator stated she had completed Significant Change MDS for many reasons, some of the reason were when residents had a significant weight loss, 2 or more changes in their care, significant weight gain and if they start or end dialysis or hospice. When it was time to update the resident's Quarterly MDS Assessments she would look at the whole file, it was like starting a new MDS assessment. She stated some of the things she reviewed were ADL documentation, medications, doctors' notes, doctor's orders and progress notes. She would identify Anticoagulant therapy and mark it on an MDS if a resident was prescribed an Anticoagulant. The MDS Coordinator stated Aspirin would not be classified as an anti-coagulant but it would be categorized as an antiplatelet. Once a resident was removed from anti-coagulant therapy, she would update it on the next quarterly MDS assessment. The MDS Coordinator reviewed Resident #23's medical file and she stated anti-coagulant therapy should not have been marked on her 9/1/25 MDS assessment because her anti-coagulant had been discontinued since August. If it is documented the resident was on oxygen she would have noted it on the MDS and a Care Plan as well. MDS Nurse were responsible for completing the CAA sections of the MDS and the nurses were responsible to complete sections pertaining to acute needs. The MDS Coordinator stated there was no risk to the resident of an incorrect MDS because it is used for payment purposes. The MDS was used to accurately complete the care plan. She stated she used RAI manual to completed MDS assessments. In an interview with the DON on 10/2/25at 2:54pm revealed when a resident was administered oxygen it should be noted in the MDS Assessment. When a resident started or stopped anti-coagulant the MDS should have reflected it accurately. The MDS coordinators were responsible for accurately completing the MDS assessments for each resident. The DON was not sure of the risk to the resident of an inaccurate MDS assessment. In an interview with the Administrator on 10/2/258 at 3:01pm revealed the MDS assessments were completed by the designated MDS coordinators for long term or rehab residents. The MDS nurse responsible for Resident #26's MDS recently left the facility and they were using a traveling MDS nurse from the corporate office to help with the MDS assessment for the long term residents. The administrator stated he was not familiar with what needed to go on an MDS assessment. Record review of the facility's policy Electronic Transmission of the MDS revised November 2019 reflected .8. The MDS coordinator is responsible for ensuring that appropriate edits are made prior to transmitting MDS data and that feedback and validation reports from each transmission are maintained for historical purposes and for tracking.Record review of CMS's RAI Version 3.0 Manual effective October 2024 reflected .N0415E2 Anticoagulant: check if there is an indication noted for all anticoagulant medications taken by the resident any time during the observation period (or since admission/entry or reentry if less than 7 days).O0110C1 Oxygen Therapy code continuous or intermittent oxygen administered via mask, cannula, etc., delivered to a resident to relieve hypoxia in this item. Code oxygen use in Bi-level Positive Airway Pressure/Continuous Positive Airway Pressure (BiPAP/CPAP)here. Do not code hyperbaric oxygen for wound therapy in this item. This item may be coded if the resident places or removes their own oxygen mask, cannula. O0110C2, Continuous check if oxygen therapy was continuously delivered for 14 hours or grater per day, O0110C3, Intermittent check if oxygen therapy was intermittent (i.e. not delivered continuously for at least 14 hours per day). O0110C4, High-concentration check if oxygen was provided via a high concentration delivery system.

Based on observations, interviews, and record reviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one (Resident #1) of three residents reviewed for pharmacy services.The facility failed to ensure Resident #1, who was NPO, did not receive a medication by mouth.The failure could place residents at risk for aspiration, choking, and death. An IJ was identified on 08/26/25. The IJ template was provided to the facility on [DATE] at 4:49 PM. While the IJ was removed on 08/27/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimum harm because all staff had not been trained on the Plan of Removal.Findings included:Record review of Resident #1's quarterly MDS assessment dated [DATE], reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. She was sometimes able to understand others and sometimes able to make herself understood. The resident's diagnoses included diabetes and multiple sclerosis (multiple sclerosis is an autoimmune disease that affects the central nervous system, leading to a range of symptoms due to the immune system attacking the nerve fibers.) The resident had a feeding tube.Record review of Resident #1's August 2025 Order Summary Report reflected:Start Date: 06/03/25NPO dietStart Date: 06/03/25G Tube - Flush before and after medication administration. Every shift Flush G Tube with 50 ml water before and after medication administration.Start Date: 06/03/25G-Tube - May mix and flush each medication with 5 - 10 ml's of Water.Record review of Resident #1's August 2025 Medication Administration Record reflected on 08/22/25, RN B administered all 7:00 AM and 9:00 AM medications including Eliquis via Resident #1's feeding tube.Record review of Resident #1's FNP note reflected:08/22/25 10:09 AMPhysician- Progress Note Late Entry:Note Text: Subjective:Resting in bed, has a pill in her mouth. Reports the nurse gave her a pill and she is unable to swallow. I removed pill and notified nurse and DON - patient is NPO. Educated nurse on medication distribution and notified DON of error.An interview on 08/26/25 at 1:35 PM with the FNP revealed on 08/22/25 Resident #1 told her there was a pill in her mouth. The FNP said she removed the pill from Resident #1's mouth and pill was intact. The FNP said the resident did not have adverse effects. The FNP said the risk to the resident was she could have aspirated. The FNP said she notified LVN A of the error and the DON. The FNP said she told the DON to educate the nurses.A follow-up interview on 08/26/25 at 1:55 PM with the FNP revealed LVN A told her the pill in Resident's #1 mouth was the Eliquis that he gave her.An interview on 08/26/25 at 2:35 PM revealed LVN A said he did not give Resident #1 a pill by mouth. He said he was supposed to be receiving orientation but was assigned a hall to work. LVN A said he administered Resident #1's medications by feeding tube. LVN A said he worked a full shift on 08/22/25. An interview on 08/26/25 at 4:10 PM with RN B revealed she was working at the facility the morning of 08/22/25. RN B said she did not know why LVN A would deny administering medications orally to Resident #1. RN B said she saw LVN A go into Resident #1's room at unknown time and then leave the room. RN B said LVN A told her that he tried to give Resident #1 a medication by mouth because he did not know the resident had a feeding tube. RN B said LVN A told her that it was a speech therapist who told him not to give Resident #1 a pill by mouth. RN B said she told LVN A that it was very important to follow the rights of giving medication, including route. RN B said she saw LVN A later that shift and he was counting the medication cart with another nurse. RN B said LVN A called later and said he was not coming back to work at the facility. RN B said she saw the DON and told her to do 1:1 training with LVN A. RN B said she only passed a couple of medications to residents, and she saw LVN A documenting under her name. She said she told LVN A not to document under his name. RN B said she thought it was a speech therapist who had talked to LVN A, not the FNP.An interview on 08/26/25 at 2:30 PM with the DON revealed there were 5 residents who were NPO. She said she was not there when Resident #1 was given a pill by mouth. The DON said she was told by RN B that LVN A gave Resident #1 a pill by mouth instead of by feeding tube and the FNP removed it. The DON said she was told by RN B that the FNP counseled LVN A. The DON said she did not talk to LVN A about the incident. The DON said LVN C was placed to work with LVN A for the rest of the shift. The DON said LVN A did not know the residents at the facility but knew the system of working at the facility and was a transfer from a sister facility. The DON said she saw LVN A and LVN C talking during the shift. The DON said she did not tell LVN C about the incident. The DON said she was supposed to in-service LVN A and she attempted to call him, but he declined all calls. The DON said she did not do any in-services with the other nurses because they knew which residents had feeding tubes. The DON said to determine the route to administer medication, nurses were supposed to read the order. The DON said if a resident had NPO restrictions then they would have a picture posted in their room of a green plant. The DON said normally LVN A would have been trained and orientation for new nurses was 72 hours. The DON said in this case, he was a transfer from a sister facility, and she thought he was good to take over the medication cart until LVN C arrived at 8:00 AM. The DON said going forward, all nurses would be given a 72-hour orientation before passing medications.Review of the facility policy, Medication Administration Through a Feeding Tube, updated March 2019, reflected: PurposeTo provide a route for accurate and timely medication administration for a Patient who cannot or should not take medications orally.GuidelinesA physician's order is required for the administration of any medication via feeding tube.This was determined to be an IJ on 08/26/25. The Administrator and the DON were notified. The Administrator was provided with the IJ template on 08/26/25 at 4:49 PM. The Plan of Removal was accepted on 08/26/25 at 9:48 AM and reflected the following:Immediate Actions1. 08/26/225-Resident #1 was assessed by the DON and was deemed to be at her normal baseline. The Medical Director gave no new orders or guidance.2. The Ombudsman was notified of the content of the immediate jeopardy via email on 08/26/25.3. On 08/26/25 The RDCS in-serviced the DON with test for competency on: Following physicians' orders The 6 Rights of Medication Administration Enteral Administration of Medications (with skill competency and test) [NAME] Foliage Picture Protocol (which identifies NPO residents, Picture above the bed) and green wrist bands4. On 08/26/25 The RDCS and DON completed a 100% audit of all residents who were NPO, who hadthe potential to be affected. The result of the audit yielded that no other residents were affected and were at their normal baseline. The audit consisted of individual review of the residents' orders, visual audit of the residents' rooms to ensure that a [NAME] Foliage Picture was above the bed and that [NAME] Wrist bands were present on the residents who were NPO. In addition, the electronic medical records were audited to ensure a specific care plan denoting NPO status and that the NPO status was also on the CNA's Plan of Care in the electronic medical record.Staff Training and EducationMandatory Training: Starting 08/26/25 All licensed and registered nursing staff will undergo mandatory training with test for competency (must pass 100%) on: Following physicians' orders The 6 Rights of Medication Administration Enteral Administration of Medications (with skill competency and test) [NAME] Foliage Picture Protocol (which identifies NPO residents, Picture above the bed) and green wrist bandsTraining will be conducted by the DON/RDCS and Clinical Designee(s).Competency Assessment: Each licensed or registered nursing staff member will be required to demonstrate competency in Medication Administration via Enteral Feed through hands-on evaluations. Staff who fail to demonstrate competence will not be allowed to work or perform enteral medication administration-related procedures until retraining and reassessment are completed.CNA's and Medication Aides will also be trained with test competency on the: [NAME] Foliage Picture Protocol (which identifies NPO residents, Picture above the bed) and green wrist bands; in addition, a re-in-service that the NPO status is located in their Plans of Care and Care Plans.Systematic Approach1. On 08/26/25 A QAPI meeting was held to discuss the components of this Plan of Removal, in attendance were the Medical Director (via TEAMS), Executive Director, DON, and the Regional Director of Clinical Services, The Director of Clinical Education and the Director of Regulatory Compliance. Policy and Procedures on Medication Administration via Enteral Feeding, the 6 rights of Medication Administration, The [NAME] Foliage and the [NAME] Wrist Band protocols for residents who are NPO. The review deemed that the policy and procedures met state and federal regulations. The [NAME] Foliage and Wrist Bands were adequate. The QAPI Team also decided to add NPO under the picture of each resident who was NPO under their resident profile.2. The facility will incorporate NPO protocols into its annual staff training program and QAPI initiatives to ensure ongoing compliance and resident safety.Monitoringa) The DON/ Unit Manager/ Clinical Designees will review the Order Listing Report, the 24-Hour Summary and Review of All New Admits/readmits to ensure compliance and knowledge of all residents who are NPO and/or who may have had their diet status change. This will occur daily for 2 weeks, weekly for 2 weeks and then monthly x 2. On the weekends and holidays, the Nurse Supervisor/Designee will complete the audit/review. The DON/ Designee will monitor daily, M-F, on the weekends and holidays, the Nurse Supervisor/Designee will complete the review. The DON/Designee will monitor this process.Any staff who are not present to complete the in-service by 08/26/25 will be required to complete the in-service at the start of their next shift before beginning work. New Hires, PRN and any agency staff will also be in-serviced prior to the start of their shift. The education will be conducted and monitored by the DON/Designee.Quality Assurance:Results of all monitoring by DON and Unit Manager shall be brought to the Quality Assessment and Assurance Committee for review and any committee recommendations will be acted upon. The DON will be responsible for bringing the results of the monitoring to the QA committee.Completion Date: 08/26/25This Emergency QAPI plan was reviewed and approved by the QAPI members.Monitoring of the facility's Plan of Removal included the following:Record reviews of the facility Plan of Removal In-services reflected:38 staff were in-serviced on: NPO Protocol, not dated; and The 6 Rights of Medication, not dated.Observations and interviews on 08/27/25 from 10:20 AM to 11:00 AM revealed the rooms of Residents #1, #2, and #3 had a green foliage sign above the resident's bed indicating NPO status and a green armband on their bed. The residents said they had not received medications by mouth. Record review during this time revealed 5 residents were NPO.Interviews with staff from 08/27/25 at 10:55 AM to 08/27/25 at 1:00 PM were completed. 15 staff were interviewed in person/on the phone who worked all shifts at the facility. The interviewed staff were MA D, LVN C, LVN E, CNA F, CNA G, CNA H, LVN I, LVN J, LVN K, CNA L, CNA M, CNA N, LVN O, weekend supervisor, and LVN P. The staff were able to verbalize they were in-serviced on following physicians' orders, the 6 Rights of Medication Administration, Enteral Administration of Medications (with skill competency and test), and [NAME] Foliage Picture Protocol and green wrist bands. Staff were able to identify residents with NPO status. Staff were able to verbalize the procedure of how to know to administer medications through a feeding tube instead of orally.An interview with the DON on 08/27/25 at 12:23 PM revealed she had worked at the facility for 3 years. She said her role in the Plan of Removal would be to review the Order Listing Report, the 24-Hour Summary and Review of All New Admits/readmits to ensure compliance and knowledge of all residents who were NPO and/or who may have had their diet status changed. The DON said the process would occur daily for 2 weeks, weekly for 2 weeks and then monthly x 2. The DON said on weekends and holidays, the Nurse Supervisor/Designee would be completing the audit/review. The DON said new or pulled staff would be trained to pass medications by being in-serviced with 72 hours on the floor as well as a check-off for g-tube medications. The DON said if the issue occurred in the future, she would take immediate action to in-service, educate, and discipline the nurse who did the infraction. The DON said an incident report would be completed, and the resident would be assessed and notify the physician. The DON said she would be completing random observations of medication pass for residents with a feeding tube.An interview on 08/27/25 at 12:50 PM with the Administrator revealed he had worked at the facility for 3 years. The Administrator said his role in the Plan of Removal would be to overlook and ensure everything in the Plan of Removal was completed. The Administrator said a QAPI meeting was held on 08/26/25 and would continue monthly.An IJ was identified on 08/26/25. The IJ template was provided to the facility on [DATE] at 4:49 PM. While the IJ was removed on 08/27/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimum harm because all staff had not been trained on the Plan of Removal.

Based on observation, interview, and record review, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 (Resident #1) of 3 residents reviewed for pressure ulcers.CNA A and CNA B failed to reposition Resident #1 as required by her orders and care plan on 07/30/25.The facility failed to ensure that Resident #1 did not develop 2 stage III wounds while at the facility. This failure could place residents with pressure wounds at risk of the wound worsening, leading to increased pain, infection, delayed healing, serious complications including sepsis, reduced mobility, and a lower quality of life.Findings included:Record Review of Resident 1's quarterly MDS assessment, dated 06/26/25, revealed she was a [AGE] year-old female, admitted to the facility on [DATE]. Resident #1 was sometimes understood and sometimes was able to understand. The resident was dependent on staff to roll her from left to right. Her diagnoses included diabetes, neurogenic bladder (an injury or disease interrupts the electrical signals between your nervous system and bladder function), multiple sclerosis (can cause muscle weakness, vision changes, numbness and memory issues). The resident used a Foley catheter. The resident had one Stage IV pressure ulcer present on admission.Record Review of Resident #1's Care Plans, revised on 06/26/25, reflected,1. Pressure Ulcer Prevention in place to prevent any additional skin alterations.Facility interventions included: Turn and reposition every 2 hours and as needed. Keep body in good alignment.2. Resident has current skin concerns: Stage IV pressure ulcer to sacrum.Facility interventions included:Monitor areas for increase breakdown and signs and symptoms of infection. Report to Physician.Record Review of Resident #1's Order Summary Report, dated 07/02/25, reflected:1. Nursing Intervention: Turn and reposition every 2 hours every shift.Review of Resident #1's Wound Evaluation and Management Summary reflected:6/26/25 Stage IV Pressure Ulcer Sacrum - Greater than 157 days. 5.5 CM x 6.0 CM x 2.0 CM. Surgical Debridement of the wound performed. No wounds on the Left Buttock or Right ButtockWound Progress: Not at goal due to need more time.7/10/25 Stage IV Pressure Ulcer Sacrum - 5.5 CM x 5.0 CM x 3.0 CMWound progress: Exacerbated due to patient non-compliant with wound care.Left buttock Deep Tissue Injury - Greater than 7 days. 3.5 CM x 4.0 CM X 0.2 CMEstimated Time to Heal: 4-6 monthsRight buttock Deep Tissue Injury - Greater than 7 days. 3.0 CM x 3.0 CM x 0.2 CMEstimated Time to Heal: 4-6 months7/17/25 Stage IV Pressure Ulcer Sacrum - 7.0 CM x 5.0 CM x 3.0 CM. Surgical Debridement of the wound performed. Wound Progress: At goalLeft buttock Stage III - 4.0 CM x 2.0 CM x 0.2 CMWound Progress: Not at goal due to need more time.Right buttock Stage III - 5.5 CM x3.0 x 0.2 CM. Surgical Debridement of the wound performed. Wound Progress: Not at goal due to need more time.An observation and interview on 07/30/25 at 10:22 AM revealed the WCN was preparing to do wound care for Resident #1. The resident was lying in bed with the head of bed slightly elevated. CNA A was assisting the WCN and said she last repositioned Resident #1 between 6:15 AM - 6:20 AM. She said she did not reposition the resident at the 8:00 AM time frame, because she was busy passing trays. CNA A said the risk to the resident if she was not repositioned every 2 hours was that she could get more breakdown. CNA A said there were no other residents who were not repositioned every 2 hours. Resident #1 was turned to her right side. Her sacrum and buttocks was covered with 3 drainage soiled dressings, dated 07/29/25. The WCN said the resident had the wounds for less than a year and the WCP came to the facility on Thursdays. The WCN removed the dressings. The sacral wound was large and deep, about the size of 1/2 a baseball. There was slough (slough in wound healing refers to dead tissue within a wound, often appearing as a yellow, tan, or white fibrous material. Slough can cover the wound bed and impede the healing process if not properly managed) The sacral wound was a Stage IV. The resident had a Stage III wound on each buttock that was red and open. There was no slough. The WCN said the resident wounds had improved. The WCN said the resident had previously had a wound vac that was removed due to worsening of the sacral wound. The deep sacral wound was packed lightly with calcium alginate. The WCN debrided and covered all 3 wounds with calcium alginate and foam dressings. An interview on 07/30/25, at 12:40 PM with CNA A revealed staffing was sufficient for the morning shift on 07/30/25. She said she always tried to keep her residents repositioned and the DON expected that all residents were repositioned before passing ice. CNA A said there was a routine the CNAs followed that allowed 2 CNAs to pass trays, and 2 CNAs to reposition residents. CNA A said there was an issue the morning of 07/30/25, because it took two staff to change one resident. CNA A said she did not ask anyone for help to reposition Resident #1 because there was no one to ask. She said LVN C arrived late as well as LVN D. CNA A said the issue did not happen often. She said the DON also assisted with residents and gave a resident a shower the morning of 07/30/25. CNA A said she did not see anyone that she could ask for help until after the State Surveyors arrived at the facility.An interview on 07/30/25 at 2:20 pm with LVN D revealed she clocked in at 6:05 AM on 07/30/25. She said CNA A did not ask her to assist with repositioning Resident #1.An interview on 07/30/25 at 2:23 PM with LVN C revealed he clocked in at 6:30 AM. He said CNA A did not ask him to assist with repositioning Resident #1.An interview on 07/30/25 at 1:25 PM with the WCP revealed failure to reposition Resident #1 could cause worsening of her wounds. The WCP said originally the resident only had the sacral wound and then she developed the new wounds on the buttocks. The WCP said she did not know why she developed the new wounds, but it could be due to not being repositioned. The WCP said she did not know Resident #1 was not repositioned during the 8:00 AM time frame on 07/30/25 because trays had to be passed. The WCP said it was just as important to reposition the resident as it was to pass trays. The WCP said she did not know why it would take 2 hours to pass trays. The WCP said the resident had been doing well for so long, then, she went to the hospital, and after readmission to the nursing facility she Resident #1 had an overall decline in the sacral wound and the development of two new areas. The WCP said the buttocks wounds were avoidable because she went so long without developing them and she was not on Hospice.An interview on 07/30/25 at 4:55 PM with the DON revealed she did not know why Resident #1 was not repositioned during the 8:00 AM hour on 07/30/25. The DON said all staff were responsible to ensure residents were repositioned and the DON was not asked to assist with Resident #1's repositioning. She said failure to reposition could cause further breakdown.An interview with the DON and Administrator on 07/30/25 at 5:50 PM revealed CNA A was not responsible for Resident #1 on 07/30/25 and the State Surveyor did not speak to the CNA responsible for the resident.An interview on 07/30/25 at 5:55 PM with CNA B with the Administrator and DON in the room revealed she was assigned to Resident #1 the morning of 07/30/25. She said she did not reposition the resident during the 8:00 AM hour because she had to pass trays. She said staff could not pass trays and reposition residents at the same time because it was an infection control issue. CNA B said she repositioned Resident #1 after lunch. Record review of the facility policy, Wound Care, revised October 2010, reflected: Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing.17. Reposition the bed covers. Make the resident comfortable. Use supportive devices as instructed.

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 (Resident #1) of 2 residents reviewed for catheter care. The facility failed to ensure Resident #1 had a catheter anchor in place during wound care on 07/30/25. This failure could place residents with foley catheters at risk for pulling and/or trauma to the bladder and urethra. Findings included: Record Review of Resident 1's quarterly MDS assessment, dated 06/26/25, revealed she was a [AGE] year-old female, admitted to the facility on [DATE]. Resident #1 was sometimes understood and sometimes was able to understand. The resident was dependent on staff to roll her from left to right. Her diagnoses included diabetes, neurogenic bladder (an injury or disease interrupts the electrical signals between your nervous system and bladder function), multiple sclerosis (can cause muscle weakness, vision changes, numbness and memory issues). The resident used a Foley catheter. Record Review of Resident #1's Care Plans, not dated, reflected,1. Foley catheter for urinary retention, at risk for infection.Facility interventions included: Ensure leg strap or other method in place to secure catheter. Record Review of Resident #1's Order Summary Report, dated 06/03/25, reflected: Foley Catheter: Check and Change Catheter Anchor if needed every shiftAn observation and interview on 07/30/25 at 10:22 AM revealed the WCN was preparing to do wound care for Resident #1. Resident #1 was lying in bed with the head of bed slightly elevated and she had a Foley catheter. The resident did not have a catheter anchor in place. The staff assisted to turn her to her right side. There was a risk for the catheter to pull during wound care. CNA A said she last saw the catheter anchor in place at around 6:15 AM and without one the resident was at risk of the catheter getting pulled. The WCN said the resident had a catheter anchor in place on 07/29/25. The WCN said it was important to have a catheter anchor in place to prevent pulling on the catheter. The WCN said she would get a catheter anchor off of the medication cart and place it on the resident. An interview on 07/30/25 at 4:55 PM with the DON revealed she did not know why Resident #1 did not have a catheter anchor in place during wound care on 07/30/25. The DON said the CNAs and nurses were responsible for checking to make sure it was in place. The DON said the risk to the resident was it could be pulled or cause trauma. Record review of the facility policy, Foley Catheter Insertion, Female Resident, revised October 2010, reflected: Steps in the Procedure.25.Tape catheter to inner thigh or secure with leg band.

Based on interviews and record reviews, the facility failed to ensure that residents are free of any significant medication errors for 1 of 1 resident (Resident #1) reviewed for medication administration. The facility failed ensure Resident #1, who was at increased risk for stroke due to having history of heart failure and persistent atrial fibrillation as per hospital discharge records dated 05/29/25, was administered her physician-ordered warfarin (Coumadin); which resulted in the resident being sent to emergency room after developing drooping of the left side of the face and slurred speech. An Immediate Jeopardy was identified on 06/26/25. The IJ template was provided to the facility on [DATE] at 03:46:PM. While the Immediate Jeopardy was removed on 06/27/25, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with a potential for more than minimal harm that is not Immediate Jeopardy , due to the facility's need to implement corrective systems. The failure placed residents at risk of decline in the resident's condition and/or the need for hospitalization, prolonged treatment, and death.Findings included: Record review of Resident #1's Comprehensive MDS dated , 06/25/25, reflected a BIMS score of 14, which indicated her cognition was intact. Her diagnoses included heart failure (occurs when the heart muscle cannot pump enough blood to meet the body's needs) and humerus fracture (break in the long bone of the upper arm). The MDS further reflected the resident was on a high risk drug class, specifically, the resident required an anticoagulant (warfarin [Coumadin]). Record review of Resident #1's Care plan, dated 06/09/25, reflected: Focus: [Resident #1] was on Long-term Anticoagulant therapy (Coumadin) due to history of CVA (also known as a stroke, is a medical condition characterized by the sudden interruption of blood flow to the brain, leading to the death of brain cells and potential neurological damage) and recent humerus fracture. Please see physician orders and [MAR ] for wound and treatment. Goal: [Resident #1] will continue to receive the prescribed anticoagulant therapy to help prevent blood clots and/or complications r/t blood clots over the next 90 days or while here for rehabilitation. Interventions: Administer anticoagulant medications as ordered by physician. Monitor for side effects and effectiveness q-shift. Obtain Labs as ordered. Report abnormal lab results to the MD. Record review of Resident #1's physician orders dated 06/03/25 reflected the following: - Warfarin Sodium Oral Tablet 2.5 MG (Warfarin Sodium)give 0.5 tablet by mouth in the afternoon every Tuesday, Thursday, Saturday, Sunday for long term (current) use of anticoagulants (2.5mg(1/2)tab). - Warfarin sodium tablet 5 mg. Give 1 tablet by mouth in the afternoon every Monday, Wednesday and Friday for long term (current) use of anticoagulants. - check for last INR (a standardized way to report the results of a prothrombin time) (PT) test which measures how long it takes for blood to clot) result before next dose. If INR is not within therapeutic range, contact medical doctor. Record review of Resident #1's June 2025 MAR reflected the warfarin was on hold on 06/03/25 and 06/04/25. Further review reflected Resident #1 did not receive warfarin as ordered by her physician on the following dates: Warfarin 2.5 mg - 06/05/25, 06/07/25, 06/08/25, 06/10/25, and 06/12/25. Warfarin 5 mg - 06/06/25, 06/09/25, and 06/13/25. Record review of Resident #1's Progress Notes dated 06/03/25 for the nurse practitioner reflected INR elevated at 3.8. Hold warfarin for 48 hours then resume at lower dose. Record review of Resident #1's Progress Notes dated 06/08/25 for the nurse practitioner reflected doing well. Repeat INR tomorrow. Record review of Resident #1's Progress notes dated 06/10/25 for the nurse practitioner reflected INR not done notified nurse, STAT INR ordered follow-up results. Record review of Resident #1's laboratory results dated [DATE] revealed a PT/INR 1.39. Record review of Resident #1's Progress Notes dated 06/15/25 at 09:00 AM reflected LVN A transferred Resident #1 to the hospital due to a change in condition. Resident#1 speech was slurred and drooping noted to left side of mouth. Record review of Resident #1's Hospital CT (medical imaging technique that uses X-rays to create detailed cross-sectional images of the body) dated 06/15/25 at 09:39 AM to 09:51AM reflected: .3. Small perfusion deficit compatible with ischemia in the left posterior frontal lobe (refers to a stroke affecting the left side of the brain, specifically within the frontal lobe, where blood flow is reduced or blocked, typically by a clot) Telephone interview on 06/20/25 at 11:13 AM with Resident #1 revealed she had history of mini strokes before, and she revealed she was on warfarin and said she has been getting her warfarin, but she was not sure at what time and what were the doses. She stated she was referred to hospital after the staff at the facility noticed her speech was slurred and dropping of one side of the face. She stated she was discharged form hospital on [DATE] to a rehabilitation hospital where she was continuing with her fractured arm therapy. She stated she still feels the speech was affected but no other part of her body. Interview on 06/20/25 at 1:13 PM with ADON B revealed she was one of Resident #1's nurses. She stated she worked on the floor on 06/06/25, 06/10/25 and 06/11/25 when LVN A who worked second shift was on vacation. ADON B stated she knew Resident#1 was supposed to get Coumadin. She said was the one that received the order for the start PTINR on 06/10/25 since the nurse practitioner wanted a repeat and on 06/11/25 she got an order to give since the INR was low. She stated she was aware she was supposed to give Coumadin on 06/06/25 and 6/10/25 and she could not recall what happened those two days whether she administered or not because the administration record was blank. She stated nurses, nurse practitioner, and doctors were responsible of putting the orders on the electronic records to resume Coumadin and also she was responsible of auditing the carts weekly. She stated failure to administer anticoagulant would cause blood clot which could lead to stroke. Interview on 06/20/25 at 3:13 PM with LVN A revealed she was one of Resident #1's charge nurses. LVN A stated she knew Resident#1 was supposed to get Coumadin (warfarin) and she was getting during her shift. She stated she was aware she was supposed to hold Coumadin on 06/03/25 and 06/04/25 and resume on 06/05/25 on a lower dose as she was instructed by the nurse practitioner. She stated she was supposed to restart her with 2.5mgs and 5 mgs but she failed to clarify with the nurse practitioner about the lower doses. She stated nurses ,nurse practitioner and doctors were responsible of putting the orders on the electronic records to resume administering after two days of hold. She stated the nurse practitioner orders were supposed to show on the facility's electronic record, and she was supposed to activate but that did not happen she thought the nurse practitioner failed to put the orders. LVN A stated she never saw Resident #1's electronic health record flag the warning of missed Coumadin dose administration. LVN A stated it was every nurse's responsibility to follow-up with doctor and Nurse Practitioner for order clarification to ensure residents had right orders for medication administration. She stated failure to administer Coumadin as prescribed by the doctor could lead to blood clots and then stroke. Telephone interview on 06/20/25 at 03:20 PM with the DON revealed she was unaware Resident #1 was not receiving her Coumadin as ordered. She stated she knew she was the only resident with Coumadin, and it was the doctor and Nurse practitioner to put orders in the system and nurses to activate the orders so that they can reflect on the medication administration record. The DON stated her expectation was the nurse could have clarified the orders with the doctor, and they administer medication as indicated on the MAR. She stated ADON was responsible of monitoring the labs and ensure the doctors get results and new orders were given and taken care of. She stated failure to administer anticoagulants could lead to clots. Observation on 06/20/23 of the medication cart for 400 halls with LVN A revealed two bubble packs of Coumadin 2.5 mg with 21/2 tablets remaining having received 81/2 tablets on 05/30/25 and Coumadin 5 mg with tablet remaining having received 6 tablets on 05/30/25. Interview on 06/20/25 at 4:31 PM with the Corporate Regional Director of Clinical Nurse it was revealed the nurses received an order to hold the Coumadin on 06/03/35 for two days and follow-on lower dose and as per the records the nurses did not resume administration after the hold. She stated the nurse practitioner, doctors and nurses are responsible of putting the orders in the system and nurse activate them. She stated since they were moving from one system to another she could not tell what had happened. She stated the DON who was out after an oral surgery and the ADON were responsible of monitoring the medications are being administered. Interview on 06/20/25 at 4:45 PM with the Nurse Practitioner revealed Resident #1 was on Coumadin, and she was following her INR closely. She stated on 06/03/25 after the labs results she put the Coumadin on hold for 48 hours. She stated the nurses were supposed to resume Resident #1 with 2.5 mg Tuesday, Thursday, Saturday and Sunday and 5mgs on Monday, Wednesday, and Friday on 06/05/25. She stated she then had orders a repeat of PT/INR on 06/09/25 and when she came for the rounds on 06/10/25 she ordered for STAT labs which were done and then on 06/13/25 she did labs and at that point she orders the nurse to give resident an extra 2.5 mg to make the dose to 7.5 mg and then to continue with the previous doses of 2.5 mg and 5 mg. She stated she was in the facility 3 days in a week and she was not notified the resident was not receiving Coumadin as she had ordered. She stated she was also responsible of putting orders in the system and the nurse also. The Nurse Practitioner stated failure to administer anticoagulant to Resident #1 could lead to development of blood clots and would make the resident be admitted to hospital with signs of stroke. Interview on 06/26/25 at 11:24 AM with DON she stated she had been off sick, and she only received a text message saying Resident #1 was sent to hospital due to drooping of the left face and slurred speech. She stated when she reported back on 06/23/25 she went through Resident #1's MAR, and she noticed Coumadin was supposed to be held for two days 06/3/25 and 06/04/25 and resumed on 06/05/24 at low dose. She stated the nurse and the ADON were responsible for clarifying the orders with doctor or Nurse Practitioner, and the Nurse Practitioner notes reflected they ought to have resumed the Coumadin after it had been placed on hold. She stated she suspended all the nurses that worked with Resident #1 and also the nurse that was responsible for holding the Coumadin and resuming the Coumadin at a low dose. She stated the Nurse Practitioner was responsible for putting the orders in the system, and the nurse was responsible for activatinge the orders. The DON stated it appeared that the Nurse Practitioner told the nurse about the changes regarding Coumadin administration for Resident #1; however, the nurse did not put the orders in the system. She stated the nurse also failed to clarify the Coumadin orders with the Nurse Practitioner. The DON stated she felt there was miscommunication between the nurse and the Nurse Practitioner, and nobody caught the mistake because they were changing over from one computer system to another. Record review of the facility's Anticoagulation Therapy policy, dated 01/04/16, reflected: It is the policy to monitor any patient prescribed an anticoagulant therapy for the side effects and drug interactions. Responsibility:- to test for therapeutic levels of anticoagulant therapy(Coumadin, heparin, lovenox)as prescribed by the physician. Procedures: Orders for all patients on anticoagulation medications (Coumadin, Heparin, Lovenox for example) are entered into the Electronic Medical Record (EMR) system. Lab testing for monitoring is conducted weekly or as requested by physician. Side effect monitoring is completed every shift in the Electronic Medical Record system in the eTAR. This was determined to be an Immediate Jeopardy (IJ) on 06/26/25 at 3:46 PM. The Administrator was notified. The Administrator was provided the IJ template on 06/25/25 at 3:50 PM and a plan of removal was requested. The following plan of removal submitted by the facility was accepted on 06/26/25 at 7:03 PM and included the following: .Date: 06/26/25 Plan of Removal Problem: F760 Resident are free of significant med errors Interventions: The Resident is no longer in the building. The Medical Director was assigned this resident. The Ombudsmen was notified on 06/23/2025. On 06/23/2025 The RDCS in-serviced DON and IP Nurse on Coumadin monitoring and tracking and being responsible for bringing the results of monitoring and tracking to the Ad hoc QAPI committee 6/23/25. On 06/23/2025 The RDCS completed a 100% audit of all residents, and no other residents are on Coumadin at this time. On 06/23/2025 All in-house licensed and registered nurses and medication aides were re in serviced with a test to validate competency by the DON and Unit Manager on: Coumadin toxicity, lab monitoring, Lab review, Notification to Physicians, Identifying Changes in Condition and Assessments. Our Pharmacist completed an audit on all anticoagulants on 6/23/25. It identified no other residents on Coumadin or any other anticoagulants requiring therapeutic monitoring. No concerns were identified in the review. Director of Nursing & Nurse Managers immediately reviewed all residents that have anticoagulants therapy with a visual record audit as well as visual assessment completed on 6/23/25 on review the three residents on anticoagulant therapy did not require any changes. The three nurses identified as not administering the medication were suspended, pending investigation. Systematic Approach: On 06/23/2025 A QAPI meeting was held, in attendance were the Medical Director, Executive Director, DON, the Regional Director of Clinical Services and the Regional Director of Operations. A Root Cause analysis was completed by the Executive Director with the support/collaboration of Regional Director of Clinical Services, Interim Director of Nursing and Regional Director of Operations. Nursing staff was educated on, anticoagulant medications, Coumadin, and labs as well as bringing results to the QA committee. Also discussed with the Medical Director the medication administration form that is utilized in stand up daily with the plan for daily discussion with him for all high-risk medications and required monitoring. In addition, a review of present protocols and/or policies/procedures concerning Coumadin monitoring and tracking, lab monitoring, lab review, Notification to Physicians and Changes in Condition, the present Policies and Procedures were found to be sufficient, but the QAPI Team added a new protocol for pharmacy dispensing--- that each Coumadin order set will include the review of the date and result of the most present INR and New/Change/Readmit orders for Coumadin will not be given without appropriate labs and physician review before administering. On 06/23/2025 A Medication Error Report was completed by the DON Education and monitoring: DON, UM's, and IP were educated on 6/23/25 on the daily process of medication administration and discussion on follow up labs to all high-risk medications and change of status on the change of status log. The monitoring logs will be reviewed daily in morning stand-up by the facility clinical team with additional review in Monthly QA meeting. On the weekends and holidays, the Nurse Supervisor/Designee will complete the review. The DON/Designee will monitor this process. Nurse managers were educated 6/23/25 and will use the Grand Rounds process and logs (High Risk Medication and Change in status) to review all at risk patients daily for 2 weeks, Weekly for 2 weeks and then monthly. On the weekends and holidays, the Nurse Supervisor/Designee will complete the review. The DON/ Designee will monitor daily, M-F, on the weekends and holidays, the Nurse Supervisor/Designee will complete the review. The DON/Designee will monitor this process. All nurses educated by 6/23/25 on new protocol that each Coumadin order set will include the review of the date and result of the most present INR and New/Change/Readmit orders for Coumadin will not be given without appropriate labs and physician review. The DON/ Designee will monitor daily, M-F, on the weekends and holidays, the Nurse Supervisor/Designee will complete the review. The DON/Designee will monitor this process. Charge nurses will review all new admission orders and verify with the physician on all new Coumadin and required lab orders, DON or designee will be responsible for reviewing the admission orders for Coumadin have the appropriate monitoring orders. DON and UM's in-service on 6/23/25. The DON/ Designee will monitor daily, M-F, on the weekends and holidays, the Nurse Supervisor/Designee will complete the review. The DON/Designee will monitor this process. The following plan of removal monitoring was conducted: The resident was sent to the ER on [DATE]. Record review reflected employee coaching and counselling due to failure to administer and/or document medication to be administered by licensed nurse and action taken to staff was suspension. Supervision and training was done by phone and one-on-one. Interview on 06/27/25 at 3:45 PM with DON revealed she had created a log for anticoagulants which she check daily and also document new admitted resident with anticoagulants and the ADONs also were given the forms during the morning meeting and they will be monitoring on respectful halls and report every morning during the meeting. Record review on 06/27/25 revealed monitoring started on 06/23/25 and ongoing daily. Inservice Training Topics: Documentation/Following physician orders /writing physician orders /MARS completion/Labs. A change in dose or time of medication must be highlighted and rewritten in anew space on the MAR. Only RN, LVN or MA that removes the medication from the packages may administer the medications. Orders for all patients on coagulation medications (Coumadin, Heparin, lovenox for example) are entered into the electronic medical record (EMR) system. Date Conducted 06/25/25 Instructor DON Attendees to include: RNA F, RN X, LVN A, ADON B, ADON E, LVN C, LVN G, LVN N, LVN P, LVN O, LVN D, LVN H, MA U, MA T, MA V, MA R, LVN N, LVN E, LVN J, LVN M, LVN K, LVN L, and LVN Q. Pre and posttest:1. Physician orders are to be reviewed daily. True ___ False __ _2. Any missing dose of medication has to be documented. True __ False __3. Orders discontinued or on hold must be reviewed during shift change. TRUE __ False __ _4. Nurses need to monitor residents on anticoagulants for sideeffects? True __ False __5. Labs should be monitored every daily per physician orders for anticoagulants. True ___ False __6. Nurses and medication aides need to review MARS prior to end of shift to ensure .:. medications have been signed off on or documentation shows why med was not given . True_False_ Record review reflected the facility had introduced anticoagulant logs dated 06/23/25, 06/24/25, 06/25/25, 06/26/25 and 06/27/25 that they were monitoring Coumadin and other anticoagulants on all new admits and report to morning meeting daily. Monitoring was done by the ADON and DON Monday through Friday and on weekend by the weekend supervisor. All other residents on anticoagulant medications MAR and TARS were audited by the Pharmacist and all medications were moved to nurses' cart to be administered by nurses and being monitored by the ADON and the DON daily. Interviews were conducted on 06/27/25 at 10:30AM to 4:30PM with RN F, RN X, LVN A, ADON B, ADON E, LVN C, LVN G, LVN N , LVN P, LVN O, LVN D, LVN H, MA U, CMA T, MA V, MA R, LVN N, LVN E, LVN J, LVN M, LVN K,LVN L, and LVN Q indicated they had understanding: They all knew they should review orders daily and clarify orders with the doctor. The staffs stated in case of a missing dose they should document on the MAR/TAR and notify the doctor and management. Orders that were discontinued or put on hold should be reviewed by the outgoing nurse and the incoming nurse and orders verified and documented in 24-hour report. All resident on anticoagulants should be monitored by the nurse through labs and for side effects. Labs should be checked daily as per physician orders and doctor notified and incase of new orders and changes it should be documented on residents MAR and TAR. Before the change of shift the nurse on duty and the medication aide need to review the MAR/TAR to ensure all medications have been signed off and if not there should be a documentation showing why medication was not signed off/given. The Administrator was informed the Immediate Jeopardy was removed on 06/27/2025 at 04:36 PM. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, 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) to meet the needs of each resident for 1 (Resident #1) of 6 residents reviewed for pharmacy services. The facility failed to ensure employees with access to controlled medication properly counted the inventory of the controlled medications. LVN A and LVN B did not adequately count the inventory on their medication cart, and it was later discovered that 120 tablets of Oxycodone (a controlled narcotic drug), belonging to Resident #1, was missing from the medication cart. The medications were never located. The noncompliance was identified as past noncompliance (PNC). The noncompliance began on 10/09/24 and ended on 10/11/24. The facility had corrected the noncompliance before the investigation began. This failure placed residents at risk for unrelieved pain due to their medication not being readily available. Findings included: Review of Resident #1's Face Sheet, dated 10/09/24, reflected he was a [AGE] year-old male, who admitted to the facility on [DATE], with diagnoses including hyperlipidemia (a condition in which there are high levels of fats in the blood), muscle spasm of back (a sudden, involuntary contraction of the muscles in your back, causing a sharp, painful tightness or twinge, often triggered by overuse, injury, poor posture, or lifting heavy objects, and can feel like a sudden locking up of the back muscles, limiting movement), and pain (an unpleasant sensory and emotional experience that signals potential or actual tissue damage). Review of Resident #1's Physician's Orders, dated 02/01/25, reflected he was prescribed Oxycodone 15mg tablet orally every four hours as needed (for pain). The start date of this medication was 09/26/24. Review of the facility's Provider Investigation Report, dated 10/14/24, reflected on 10/09/24, Resident #1's prescription medication of Oxycodone 15mg was noted to be missing (120 tablets were identified as missing). Resident #1's medication was delivered on 10/03/24 (126 tablets), and he was given the medication on 10/05/24 (2 tablets), 10/06/24 (2 tablets), 10/07/24 (1 tablet), and 10/08/24 (1 tablet). The medications were counted on 10/08/24 at 10:00PM (at shift change), but neither nurse who completed the medication count (LVN A and LVN B) could confirm if the blister packs (a form of tamper-evident packaging where an individual pushes individually sealed tablets through the foil in order to take the medication) of medication were there at the time of the count, nor could they remember the last time the medication was seen. It was noted that Resident #1 had not missed a dose of medication, as there was still a blister pack of Oxycodone (prescribed to him) on the medication cart that was being used. All appropriate parties, including the police department, were notified of the missing medication. LVN A and LVN B, who both denied diverting the medications, were suspended pending the outcome of the investigation. Staff statements revealed all individuals who had access to the medication denied taking the medication and/or knowing how the medication went missing. Drug testing revealed all individuals who had access to the medication tested negative for any substances, including Oxycodone. The facility was unable to determine who diverted the medication or how the medication went missing. To prevent further occurrences, the facility implemented a new form for shift count where nurses were required to count the blister packs as well as the individual sheets. There was also a new policy implemented in which the nurses were required to make a copy of all paperwork upon delivery of new narcotics and provide it to nurse management. The facility ordered new medication for Resident #1, at the cost of the facility. Facility staff were in-serviced on procedures for receiving narcotics, narcotic count protocol, the implementation of new narcotic count sheets with card counts, and controlled substance accountability. LVN A and LVN B both received a final warning/action plan due to their failure to ensure narcotics were accounted for during shift change. All staff were in-serviced on the facility's new policies and procedures. Review of the facility's in-service logs, dated from 10/09/24 to 10/11/24, reflected facility staff were in-serviced on procedures for receiving narcotics, narcotic count protocol, the implementation of new narcotic count sheets with card counts, and controlled substance accountability. Review of personnel files for LVN A and LVN B reflected they both received a written final warning/action plan, dated 10/09/24, for failing to count narcotics according to facility policy. Observations of five separate medication carts on 02/01/25 from 11:00AM to 12:00PM, including a review of narcotic logs and count sheets, reflected no evidence of a current drug diversion. It appeared as though facility staff were following the facility's policies and procedures to prevent a drug diversion. These observations were completed with CMA C, LVN D, LVN E, and LVN F. During interviews with multiple staff members (with CMA C, LVN D, LVN E, LVN F, and LVN G) on 02/01/25 from 11:00AM to 12:00PM, they each stated they had been in-serviced on pharmacy services. They were knowledgeable of the facility's policies and procedures related to acquiring, receiving, dispensing, labeling, storing, and administering medications. They were able to verbalize the facility's policies and procedures related to the prevention of drug diversion, including the new policies and procedures implemented as a result of the incident involving Resident #1's prescription medication of Oxycodone (such as what procedures to take when narcotics were received from the pharmacy as well as the procedure for counting medications). During interviews with the Administrator on 02/01/25 at 12:48PM and 3:20PM, he stated a drug diversion occurred with Resident #1's prescription medication of Oxycodone 15mg. The Administrator stated 120 tablets of this medication went missing from the medication cart. He stated a search of the facility, including all medication carts and the drug destruction area, revealed the medication was unable to be located. A review of the facility's staffing schedule, as well as Resident #1's MAR/TAR and narcotic logs, revealed the medication had to have gone missing on either 10/08/24 or 10/09/24. Potential perpetrators included LVN A and LVN B, as they were the last individuals to have access to and complete the narcotic count prior to the medication being identified as missing. However, both LVN A and LVN B were unable to recall if the blister packs of medication were on the cart during their narcotic count. The Administrator stated Resident #1 still had Oxycodone on the cart that was being given as prescribed, so he did not miss any scheduled doses or have any adverse effects. The police department was notified of the drug diversion. LVN A and LVN B were suspended pending the outcome of the investigation. Staff statements revealed all individuals who had access to the medication denied taking the medication and/or knowing how the medication went missing. Drug testing revealed all individuals who had access to the medication tested negative for any substances, including Oxycodone. The facility was unable to determine who diverted the medication. To prevent further occurrences, the facility implemented a new form for shift count where nurses were required to count the blister packs as well as the individual sheets. There was also a new policy implemented in which the nurses were required to make a copy of all paperwork upon delivery of new narcotics and provide it to nurse management. The facility ordered new medication for Resident #1, at the cost of the facility. Facility staff were in-serviced on procedures for receiving narcotics, narcotic count protocol, the implementation of new narcotic count sheets with card counts, and controlled substance accountability. LVN A and LVN B both received a final warning/action plan due to their failure to ensure narcotics were accounted for during shift change. The Administrator stated a potential risk of drug diversion was that the resident may not receive his or her prescribed dose of medication. During an interview with the Director of Nursing on 02/01/25 at 1:17PM, she stated a confirmed drug diversion occurred with Resident #1's prescription medication of Oxycodone 15mg. The Director of Nursing stated as a result of the facility's investigation, new policies were implemented to include: a new form for shift count where nurses were required to count the blister packs as well as the individual sheets and a new policy implemented in which the nurses were required to make a copy of all paperwork upon delivery of new narcotics and provide it to nurse management. The Director of Nursing was monitoring this for timely and proper completion by staff to ensure the prevention of another drug diversion. The Director of Nursing stated a potential risk of drug diversion was that the resident may not receive his or her prescribed dose of medication. On 02/01/25 at 3:47PM, the surveyor attempted to contact LVN B via telephone. The surveyor left a voice message requesting a return telephone call. On 02/01/25 at 3:50PM, the surveyor attempted to contact LVN A via telephone. The surveyor left a voice message requesting a return telephone call. Review of the facility's Narcotic Receipt Procedures and Narcotic Count Protocol Policy, undated, reflected, .The new procedure for receiving Narcotic has become more defined. From this point forward, ALL narcotics forms (there are 3 in total) MUST be signed by 2 Nurses. Those 3 forms include: the delivery manifest, the Class II-V Delivery Record, and the Narcotic Count Sheet (maybe pink or white). Once you have made a copy of these three forms, they are to be stapled together and placed under the ADON's/DON's office door immediately. When counting the narcotics on the oncoming shift, you MUST give the name of the patient, the name of the medication, the strength of the medication, and the quantity of medication on hand. THERE ARE NO EXCEPTIONS TO THE PROCESS. YOU WILL FOLLOW THIS PROTOCOL TO HELP PREVENT ANY MEDICATION FROM BEING MISPLACED OR TAKEN .

Based on observation, interview, and record review, the facility failed to provide the necessary services for residents who were unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident #203) of 8 residents reviewed for quality of life. The facility failed to ensure Resident #203's hair was washed while she was at the facility. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity and a decreased quality of life. Findings include: 1. Record review of Resident #203's Admission MDS assessment dated [DATE], reflected Resident #203 was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Parkinson's disease and diabetes. Resident #203 had a BIMS score of 9 which indicated Resident #203's cognition was moderately impaired. Resident #203 was totally dependent on staff for bathing/showering. Review of Resident #203's Comprehensive Care Plan, dated 08/09/24, reflected the resident required the shower chair and assistance of one staff for grooming. An observation and interview on 08/20/24 at 9:57 AM with Resident #203 revealed she was seated in her wheelchair in her room. Her hair looked oily. She said she had not received a shower since she arrived on 08/09/24 and her hair had not been washed. She said staff would clean her body, but not wash her hair. A follow-up observation and interview 08/22/24 at 10:47 AM with Resident #203, revealed she still had not had her hair washed. She said her hair felt oily and itchy. An interview on 08/22/24 at 11:07 AM with CNA A revealed she said she showered Resident #203 on 08/21/24 and her bathing schedule was Monday, Wednesday, and Friday. She said the resident did not ask for her to be washed and she forgot to ask her. CNA A said she did not wash the resident's hair. She said the resident could get lice if she did not get her hair washed. CNA A said the resident had a care plan but it did not include washing the resident's hair. An interview on 08/22/24 at 12:33 PM with the ADON revealed hair washing during bathing was to be completed if the resident wanted it . The ADON said she did not know that Resident #203 had not had her hair washed since she was admitted on [DATE]. She said Resident #203 had a shower in her room. Record review of the facility policy, Bath-Shower, not dated, reflected: Procedure o Wash your hands, gather equipment. o Explain procedure to patient and provide privacy. o Adjust temperature of water before placing Patient under shower. Check temperature; water should not be above 105-110 degrees F. o Encourage Patient to do as much of his/her own care as possible; supervise and assist Patient as necessary. o Wash face and shampoo hair; rinse well.

Based on observation, interview and record review, the facility failed to ensure fluid intake to maintain proper hydration for two (Resident #1 and Resident #45) of four residents reviewed for hydration status and maintenance was available. 1. The facility failed to offer fluids that were accessible for Resident #1 and the facility failed to offer extra fluids at mealtime for Resident #1 as indicated in the resident's comprehensive plan of care. 2. The facility failed to offer fluids that were accessible for Resident #45 and the facility failed to offer extra fluids at mealtime for Resident #45 as indicated in the resident's comprehensive plan of care. These failures could increase the resident's risk for dehydration, skin breakdown and weight loss. Findings Include: Record Review of Resident #1's Quarterly MDS with an ARD of 06/28/2024 revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #1's active diagnoses included: Dysphagia (Condition with difficulty in swallowing food/liquid) and Hemiplegia and Hemiparesis (one-sided paralysis) affecting the right dominant side. Resident #1 had a BIMS score of 2 indicating a severe cognitive impairment. Resident #1 had no potential indicators of psychosis. Resident #1 required set up assistance for eating, Resident #1's Quarterly MDS revealed the definition for eating was, The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident. Resident #1's Quarterly MDS revealed that Resident #1 required partial/moderate assistance for chair/bed-to-chair transfers (The ability to transfer to and from a bed to a chair (or wheelchair). Record Review of Resident #1's physician order revealed an order for, Honey Thickened Liquids with an order date of 08/1/2023 and status as active (current). Record Review of Resident #1's comprehensive plan of care dated, 08/21/2024 revealed the following: Problems: [Resident #1] is at risk for dehydration related to impaired cognition and honey thick liquids. Status: Active (Current) Interventions: Extra Fluids on Tray, Status: Active (Current) Disciplines: Nutrition Services Director, Nursing. Observation of Resident #1's room on 08/20/24 at 2:15PM revealed Resident #1 was sitting in his wheelchair, in his room, watching television. Observation of Resident #1's room revealed there was no accessible fluids anywhere in Resident #1's room. Observation of Resident #1's room on 08/21/24 at 9:46AM revealed Resident #1 was not in his room at this time. Observation of Resident #1's room revealed there was no accessible fluids anywhere in Resident #1's room. Observation of Resident #1's room on 08/21/24 at 1:48PM revealed Resident #1 was sitting in his wheelchair, in his room, watching television. Observation of Resident #1's room revealed there was no accessible fluids anywhere in Resident #1's room. Observation of Resident #1 during lunch service in the facility's dining room on 08/20/24 from 12:20PM-1:00PM revealed Resident #1 independently utilized utensils to independently consume food and liquids. During the observation of Resident #1 during mealtime revealed Resident #1 consumed 1 glass of honey thickened tea, no additional fluids were offered or given to Resident #1 during his meal. Resident #1 exited the dining room at 1:00PM. Record Review of Resident #1's lunch meal ticket for 08/21/24 revealed Resident #1 was on a Regular-Puree diet with honey thickened liquids. The meal ticket did not reveal Resident #1's care planned intervention of extra fluids on tray. Interview with Resident #1 on 08/22/24 revealed Resident #1 was unable to answer surveyor questions. 2. Record review of Resident #45's quarterly MDS assessment, dated 07/25/24, revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included: non-Alzheimer's dementia and diabetes. Resident #45 had severely impaired cognition and was completely dependent on staff for eating. Resident 45 had a BIMS score of 3 indicating a severe cognitive impairment. Record Review of Resident #45's Comprehensive Care Plan, not dated, reflected: Resident #45 was at risk for dehydration. Facility interventions included: Offer appropriate fluids during activities and care. Extra fluids on tray An observation and interview on 08/20/24 at 2:00PM revealed Resident #45 was lying in bed and she said she was thirsty. Observation revealed no fluids available anywhere in the room. LVN E entered the room and said the resident was able to drink independently and she went to get the resident water. An observation on 08/21/24 at 9:56 AM revealed Resident #45 was lying in bed. The resident's lips were dry. The resident did not have fluids available at the bedside. An observation and interview on 08/21/24 at 1:20 PM revealed CNA D was feeding Resident #45 lunch. The only fluids in the resident's room/tray was approximately 1/2 glass of tea. CNA D said periodically staff would give the resident fluids. She said she gave the resident lemonade about 45 minutes earlier. The ticket on the tray did not say extra fluids. An interview on 08/22/24 at 12:25 PM with ADON H revealed she gave Resident #45 water when she asked for it. She said she did not know the resident's care plan said she was supposed to get extra fluids on her tray. An interview on 08/22/24 at 1:17 PM with LVN G revealed staff passed water every shift and as needed to the residents to keep them hydrated. LVN G said Resident #45 could drink fluids by herself and had to be dependently fed. LVN G said she did not know why the resident did not have fluids available on 08/21/24 or 08/22/24. She said she did not know why the resident did not receive extra fluids on her tray. She said the resident was at risk for dehydration if she did not have access to fluids. Interview with LVN A on 08/22/24 at 1:18PM revealed that she was the nurse for Resident #1 and Resident #45 and worked the 6am-2PM shift. LVN A revealed that direct care staff would pass ice and hydration at the beginning of each shift per the resident's needs and physician orders. LVN A revealed that if residents required thickened liquids per physicians orders, the facility staff would access the thickened liquids in the facility's nutrition room as thickened liquids were not kept in the resident's rooms. LVN A revealed that the facility nutrition room was only accessible by staff. LVN A revealed that residents who had thickened liquid orders would have to ask staff to access the fluids or fluids would be given routinley during med pass and meal times. LVN A revealed that Resident #1 was able to hydrate and feed himself independently while Resident #45 requires assistance for hydration and meals. Observation of the Facility Nutrition Room on 08/22/24 at 1:45PM revealed the door was locked and inaccessible to those without a key or code. An interview on 08/21/24 at 2:00 PM with the DON revealed Resident #45 was supposed to have fluids available at the bedside. She said extra fluids on the tray ticket would require a physician's order. Interview with CNA Q on 08/22/24 at 4:05PM revealed that it was the responsibility of the CNA's in the facility to pass ice, ensure hydration and ensure resident's have accessible fluids in their rooms. CNA Q revealed that any staff member could pass ice and get the resident's a form of hydration, but it was the CNA's who primarily ensure that there was some sort of hydration in the resident's room accessible to them. CNA Q revealed that resident's should have accessible fluids in their rooms at all times. CNA Q revealed that Resident #1 could hydrate and access fluids, if in reach and at bedside, independently. CNA Q revealed that Resident #45 could hydrate and access fluids independently, if in reach and at bedside, but did require cues and set-up assistance. CNA Q revealed a risk to resident's who did not have access to fluids or hydration is an increased risk of dehydration. Interview with ADON H on 08/21/24 at 3:30PM revealed that all residents were supposed to always have hydration in their rooms unless clinically contradictory. ADON H revealed that she was unsure of the facility's protocol or procedure for resident's on thickened liquids and keeping their hydration needs accessible at bedside as she has only been employed at the facility for one week. ADON H was unsure of Resident #1 or Resident #45's functional abilities. ADON H revealed that a risk to the resident's who have inaccessible hydration is an increased risk of hydration. Interview with MDS Nurse A on 08/22/24 at 2:12PM revealed that she was the MDS nurse responsible for all comprehensive care plans. MDS Nurse A revealed that all staff had access to the resident's plan of care and the plan of care should have been followed. MDS Nurse A revealed that resident's who had a care planned focus of risk for dehydration would also have care planned interventions to correspond including, extra fluids. MDS Nurse A revealed she was unaware Resident #1 and Resident #45's care plan for extra fluids on tray during meals was not being followed. MDS Nurse A revealed it is the responsibility of all direct care staff and facility management to ensure all interventions are being followed per the resident's plan of care. MDS Nurse A revealed a risk to resident's who had inaccessible hydration or insufficient hydration needs would be an increased risk for dehydration. Interview with the Dietician on 08/22/24 at 10:49AM revealed that resident's with thickened liquids orders did not have to have direct access to fluids at their bedside as clinical staff would offer fluids during mealtime and med pass. The Dietician revealed that resident's who did not have modified liquid orders should have had a water pitcher at bedside with their choice of fluids. Resident's who had order restrictions such as NPO (nothing by mouth) or fluid restrictions may not have fluids accessible at bedside at all times. The Dietician was not aware Resident #1's or Resident #45's care planned intervention for extra fluids on tray at meals was not being followed. The Dietician revealed that these recommendations or interventions made by nursing staff should have been relayed to the dietary staff so the resident's meal tickets could have been updated to reflect their current needs. The Dietician revealed a risk to resident's who have inaccessible hydration or insufficient hydration needs would be an increased risk of dehydration and skin breakdown. Interview with DON on 08/21/24 at 3:30PM revealed that direct care staff would distribute hydration to resident's during med pass, hydration/snack rounds and mealtimes. The DON revealed it was the responsibility of all nursing staff to ensure hydration needs are met for all resident's no matter their dietary orders regarding hydration. The DON revealed that all resident's had the right to have hydration that is accessible to them at all times, unless the resident is NPO (Nothing by Mouth). The DON revealed that if resident's cannot independently feed or hydrate themselves then it is the responsibility of the nursing staff to frequently encourage and offer fluids to ensure hydration needs are being met. The DON revealed that Resident #1 could hydrate and feed himself independently and Resident #45 needed cues and set-up assistance for meals and hydration, but does require staff assistance at times. The DON revealed that she was not aware Resident #1's or Resident #45's care plan indicated an intervention for extra fluids on tray during meals. The DON revealed that all resident's plan of care should have been followed and accurately reflected their current needs. The DON revealed a risk to resident's who have inaccessible hydration or insufficient hydration needs would be an increased risk of dehydration. Record Review of the facility's policy titled, Hydration Protocol dated February 2022 revealed that, Water pitchers must be filled with fresh ice water frequently and placed at the bedside of each Patient/Resident, unless otherwise ordered . Beverages must be made available to the Patients/Residents during Nutrition Services off-hours.

Based on observations, record review, and interviews, the facility failed to ensure an environment that was free of accident hazards and that each resident received adequate supervision to prevent elopement for 1 (Resident #1) of 6 residents reviewed for quality of care. 1. The facility failed to ensure Resident #1 was provided with adequate supervision to prevent him from eloping from the facility on 01/22/2024. 2. The facility failed to ensure staff recognized Resident #1 eloped and recognize Resident #1 as a resident of the facility when Resident #1 was encountered outside the 500 Hall door. 3. RN A failed to follow their elopement response policy when the 500 Hall door alarm sounded. The facility concluded Resident #1 eloped through the facility's 500 Hall exit and staff did not conduct a thorough search of the facility and its grounds when the alarm sounded. A past non-compliance Immediate Jeopardy (IJ) situation was identified on 02/13/24 at 11:30 AM. The Immediate Jeopardy began on 01/22/2024 and ended on 01/25/2024. The facility remained out of compliance at a scope of isolated and a severity of no actual harm with a potential for more than minimal harm while they completed in-service training and evaluated the effectiveness of their corrective systems. The facility had corrected the non-compliance before the surveyor began. These failures placed residents at risk of harm and/or serious injury. Findings included: Record review of Resident #1's Face Sheet dated 02/13/2024 reflected an [AGE] year old male admitted to the facility with diagnoses that included Atrial Fibrillation (irregular and rapid heart rhythm, Cirrhosis of the Liver (liver damage where healthy cells are replaced with scar tissue), Heart failure (heart muscle don't pump blood as it should), Papilledema associated with increased intracranial pressure (optic disc swelling), and Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities. Record review of Resident #1's MDS assessment dated [DATE] reflected he had a BIMS score of 2 indicating severe cognitive impairment. He was sometimes understood and sometimes able to understand others. The MDS Assessment indicated he performed walking with supervision or touching assistance and used a walker to ambulate. Wandering behaviors were not exhibited. Record review of Resident #1's Care Plan dated 11/10/2023 reflected the following entry: [Resident #1] has a language barrior he speaks Spanish . Interventions: Allow adequate time to express self, complete word or sentence if unable to do so. Ask simple questions that can be answered YES or NO. [Resident #1] is oriented to self only and has a diagnosis of dementia . Record review of Resident #1's Nursing Admission Assessment, dated 11/01/2023, reflected, no risk of elopement, [Resident #1] is able to make decisions regarding tasks of daily living, decisions are consistent and reasonable. Record review of the Elopement Risk assessment dated [DATE] reflected, Moderate risk, patient ambulate or propels self. Patient may go outdoors on occasion but makes no attempts to leave grounds. Record review of the Elopement Risk assessment dated [DATE] reflected, No risk, [Resident #1] is able to make decisions regarding tasks of daily living, decisions are consistent and reasonable. Record review of the Monitoring patient location and activity log, dated 01/22/2024 through 01/26/2024 reflected, Resident #1 was monitored for location and activity every 15 minutes, for three days. Record review of Resident #1's Psychosocial wellbeing assessment dated [DATE], reflected, [Resident #1] needs redirection to environment due to him trying to find his daughter and disorientation. Diagnosis of dementia. Record review of the facility's Provider Investigation Report, dated 01/26/2024, reflected the following: On 01/22/2024 at 4:00 AM [Resident #1] was noted outside of the facility. When Resident #1 was noted outside employee that did not recognize him called 911. Resident #1 was noted to be confused and could not tell the nurse his name. He stated he was looking for his daughter and was not trying to leave but got confused about the time. He was retunred to the facility and placed on frequent monitoring with no negative outcomes or attempts of exit seeking. Staff will continue to monitor patient for any wondering or confusion. The incident was reported to the state, physician and family notified, medication management competed with staff, staff safe surveys completed, and resident safe surveys completed. An elopement risk assessment was completed on 01/22/2024 which indicated moderate risk; rounds checklist was completed, staff in-servicing began on elopment and abuse and neglect began on 1/22/24. RN A received coaching and counseling, dated 01/23/2024 for failure to perform a proper search and identify a resident who was in her care for over two months. A performance improvement plan was initiated on 01/22/2024 the elopement risk procedure was not followed properly. Changes implemented included: 1. Completed in-service to all employees on looking outside before turning the alarm off. 2. Door alarm checks were completed immediately to ensure all door alarms are functioning appropriately. 3. Review of door alarm checks from maintenance to show the alarms have been checked. 4. Review of all elopement assessments to ensure that all patients have a completed assessment. 5. Review of assessment for [Resident #1] showed he was not a risk on admission. New assessment completed to show at risk due to the elopement. 6. Patient on frequent monitoring for 72 hours to ensure safety. All staff were re-educated on the following: The process for when the door alarm sounds and there is a potential elopement. The the importance of checking outside the door where alarm has sounded for any presence of a resident who could have gone out that door. Facility grounds need to be evaluated for any presence of a resident who could have gone out the door alarming. All rooms thoroughly checked to ensure that residents are accounted for. Turning on resident's room lights and ensuring the resident is in the right bed. If resident is not in bed, checking restrooms, under beds, behind door unlocked, and locked. Record review of Resident #1's progress notes revealed the following entries: *01/22/2024 7:04 AM: Patient was noted standing outside the door of 500 Unit. He was unable to communicate and could not say his name. No staff on duty was able to identify him when they were alerted, He was offered a warm blanket and police called. When police arrived, patient was brought inside and then searched. He was identified with a piece of paper in his possession bearing his name. Patient was then taken back into his room and made comfortable. Warm drink was offered, and PRN Tylenol 325mg 2 tabs administered. VS: 118/59, HR 69, temp. 97.4, RR 18. DON, Administrator, and [physician] notified. Patient's POA also notified. Patient is comfortably resting in his bed at this Ume and is now placed on frequent monitoring, signed by RN A. *01/22/2024 20:56 PM: SW met with bedside to assess mood and behavior with staff assistance for translation. Pt pleasant, confused, Pt did not recall opening door this weekend. He reports not wanting to leave but wants to know where his daughter ls. Pt easily redirected. [Psych] referral in process for assessment/med management as appropriate, signed by the Social Worker. *01/24/2024 2:51 AM: Patient is resting comfortably in his bed with call light and water within reach. Pt continued on every 15 minutes frequent monitoring, signed by LVN B. *01/25/2024 1:22 AM: Patient in his bed with call light and water within reach. Pt continued on every 15 minutes frequent monitoring, signed by LVN B. In an interview on 02/13/2024 at 9:50 AM, the Administrator and the DON stated Resident #1 eloped from the facility. They were not sure of the time but estimated it to be after 2:00 AM. They said they were notified at 4:00 PM by RN A. The DON stated RN A told her she heard the door alarm sound but did not know the exact time. She said RN A told her she looked down the hall and saw a CNA in the hall and thought they had opened the door. The DON said a short time later RN A was rounding on 500 hall and saw a man outside the 500-hall door. She said RN A told her she did not recognize the man outside the door but did check resident rooms on 500 hall and found no one was missing. The DON said RN A did not turn the lights on in each resident room to ensure everyone was in their bed. She said RN A then called the nurse from another hall to come to the 500-hall door because she was afraid to open the door for the man standing outside. The DON said CNA C and CNA D came to the hall and did not recognize Resident #1 standing outside the door. She stated CNA C called the police who arrived a short time later and were able to identify Resident #1 when one of the officers spoke Spanish to him. The DON said RN A did not follow the facility's Elopement Response Policy because she did not turn on the lights in resident rooms to ensure everyone was in their bed and staff did not search the perimeter of the facility when the alarm sounded. The Administrator stated the door alarms were working because they sounded. He said the Maintenance director checked and logged the alarms regularly. He said the alarms were checked the morning of 01/22/2024 and they worked, which led him to believe staff did not follow the elopement protocol. The DON said Resident #1 was not an elopement risk and had not displayed any elopement behavior since he had been admitted . She said Resident #1 was confused at times. The DON stated she counseled RN A on the elopement protocol and initiated neglect and elopement protocol in-services. She said Resident #1 was reassessed as a moderate elopement risk and placed on 15-minute checks for three days. The DON said staff should be able to identify residents in the facility. She said resident pictures are in each clinical record. She stated a step-by-step elopement protocol could be found at each nurses' station. An observation on 02/13/2024 at 10:45 AM in the 500 hall, at the exit door, revealed the alarm sounded when opened by the state surveyor. Five staff were observed running to the exit. Staff were observed checking rooms and exit the door to round the perimeter of the facility. When they were done, they turned off the door alarm. In an interview, interpreted by CNA E, on 02/13/2024 at 11:00 AM, Resident #1 revealed he recalled leaving the facility but did not recall where he was going. He said he liked the facility and staff. He said he was able to walk on his own and used a walker but liked to stay in his room. Resident #1 was able to answer questions appropriately however did appear to have problems remembering past events. In an interview on 02/13/2024 at 11:10 AM, Resident #1's roommate said he did not recall Resident #1 leaving the facility recently. He said Resident #1 usually stayed in the room. He stated staff checked on both residents constantly and had no concerns. In an interview on 02/13/2024 at 1:15 PM, CNA C stated she had worked the night when Resident #1 eloped. She said she did not work on the 500 hall, but staff came to get her to see if she could identify a man who was outside the 500 hall exit door. She said she did not know the man but did call the police because she could not be sure who the man was. She stated she did not recall the exact time but thought it to be about 2:30 AM. In a telephone interview on 02/13/2024 at 2:50 PM, RN A stated she did hear the 500 hall door alarm sound on 01/22/2024 but could not recall the time. She said she did not immediately go to the door because she saw a CNA in the hall and thought they had opened the door. She said she did not know who the CNA was because the CNA who regularly worked with her on the 500 hall had called in. She said later when she went down the hall she saw a man outside the door on the 500 hall. She said she did not know the man and was afraid to open the door. She said she did call for other staff to come to the door to see if they knew the man, but they did not. She said she checked the rooms on the 500 hall for missing residents but did not turn the lights on in each room. She said when she looked in Resident #1's room she thought she saw his leg on the bed and moved on. She said the police were called and they found a paper in Resident #1's pocket identifying him. She said she checked the computer, and he was a resident. She said they brought Resident #1 into the facility, and she assessed him. She said she contacted the DON after that but did not know the time. She said she was reprimanded for not following the elopement protocol and in serviced on the policy. In a telephone interview on 02/13/2024 at 3:10 PM, the Maintenance Director said he checked and logged the door alarms regularly. He said he checked the alarms on all the doors when he came to the facility on [DATE] and they were all engaged and working. He said the staff must have turned off the alarm when it went off when Resident #1 exited the facility. In an interview on 02/13/2024 at 1:15 PM, the staffing coordinator stated she completed all the in servicing for all staff. She said she in-serviced on the elopement protocol, and where to find the step-by-step instructions. She said she also in-serviced staff on using the language line for interpreters when residents did not speak English, and the importance of knowing the residents in the facility. In a telephone interview on 02/13/2024 at 5:30 PM, CNA D said he worked on the night Resident #1 eloped from the facility. He said he worked on another hall but was called to see if he knew the man standing outside the door. He said he did not. He said he never worked on the 500 hall which was why he did not recognize him. He said the police came and they found out Resident #1's name and RN A checked the computer and realized he was a resident of the facility. On 01/13/23 at 12:00 PM, a search via WorldWeather revealed the temperature on 01/22/2024 at 2:00 AM in Dallas County, was 34 degrees F. The facility took the following actions to correct the non-compliance prior to the investigation: Record review of the following in-services dated 01/22/2024 through 01/25/2024 reflected,Ongoing checking exit doors and responding to door alarms, rounding every two hours, check outside before shutting off door alarms, Google translate of communication needs to be used, call the Administrator if a resident is exit seeking, ADLs, call lights, responding to safety alarms, doors, fire, abuse, neglect, elopement protocol, and customer service. Attached sign-in sheets reflected staff from all shifts completed the trainings which included return-demonstrations for resetting door alarms and elopement protocols. Record review of the facility's completed door alarms checks confirmed they had been completed regularly on 1/12/24, 1/15/24, 1/16/24, 1/17/24, 1/18/24, 1/19/24, 1/22/24, 1/23/24, 1/24/24, 1/25/24, and 1/26/24. The door alarms were working properly on 01/22/2024. Record review of documentation of emergency IDT meeting was held on 01/22/2024 which addressed the following: 1. Completed in-service to all employees on looking outside before turning the alarm off. 2. Door alarm checks were completed immediately to ensure all door alarms are functioning appropriately. 3. Review of door alarm checks from maintenance to show the alarms have been checked. 4. Review of all elopement assessments to ensure that all patients have a completed assessment. 5. Review of assessment for [Resident #1] showed he was not a risk on admission. New assessment completed to show at risk due to the elopement. 6. Patient on frequent monitoring for 72 hours to ensure safety. 7. All the Staff re-educated on the process for when the door alarm sounds and there is a potential elopement. Reiterate to all nursing staff the importance of checking outside the door where alarm has sounded for any presence of a resident who could have gone out that door. 8. Facility grounds are evaluated for any presence of a resident who could have gone out the door alarming. All rooms are thoroughly checked to ensure that all residents are accounted for. Which means turning on the resident's room lights and ensuring the resident is in the right bed. If the resident is not in bed, checking restrooms, under beds, behind door unlocked, and locked. Record review of Resident #1's latest elopement risk dated 01/26/2024 revealed he was not an elopement risk. Record review of RN A's counseling on the elopement protocol and initiated neglect and elopement protocol in-services, dated 01/23/2024. Interviews on 02/13/2024 from 10:30 AM to 5:30 PM with RN A, LVN B, CNA C, CNA D, CNA E, MA F, MA G, LVN H, LVN I, CNA J, Social Worker, and Nutritional Services Director who worked multiple shifts, revealed they had received in-service training between 01/22/2024 and 01/25/2024. They stated the training had included return demonstrations of how to properly secure the exit doors and reset the alarms. They were able to accurately summarize how to use google translate, the elopement protocol, secure the doors, and report any alarm reactivations to management. Record review of the facility's Elopement Response Protocol, dated May 2016, reflected, Upon the occurrence of an elopement or a suspected elopement, the following steps must be immediately taken: 1. Conduct a thorough search of the Facility and its grounds. 2. If the Patient is not found within 15 minutes notify the Executive Director, DON, Regional Director of Operations, Regional Director of Clinical Services, Chief Clinical Officer, and Director of Operations. 3. Notify the Patient's responsible party and Attending Physician. 4. Notify the local police department. 5. Notify the Department of Aging and Disability (DADS) [PHONE NUMBER] in accordance with the DADS Guidelines for Reportable Incidents. 6. Organize search teams composed of Facility, regional and corporate staff to search the vicinity of the Facility on a continuous basis. Search teams should conduct their searches in one-hour shifts and cover defined areas identified on a street map. Unless the specific circumstances dictate otherwise, searches should begin with an area that consists of a circle with a one-mile diameter with the Facility at its center and then expand to incrementally broader areas. 7. Report hourly to the Chief Clinical Officer, Regional Director of Clinical Services, Director of Operations, and the Regional Director of Operations until the Patient is located or you are directed to report at a different frequency. 8. If the Patient is not located within 8 hours, or if the Patient is not located during a search of the facility, facility grounds, and immediate vicinity, and there is a circumstances that place the patient's health, safety, and or welfare at risk, the report must be made as soon as the facility becomes aware the Patient is missing and cannot be located, and discuss approval from the Director of Operations and the Chief Clinical Officer for the engagement of an outside private detection agency to assist in the search. 9. A complete head to toe nursing assessment must be completed upon return of the Patient In addition, the physician and responsible party must be notified and document. 10. Based on the elopement risk; the Patient may be discharged .

Based on observation, interview, and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #48) reviewed for accident hazards/supervision. The facility failed to use a two-person mechanical lift transfer from the wheelchair to the bed leading to Resident #48's sustaining a deep laceration to the left shin that required Resident #48's transfer to the local emergency room . The noncompliance was identified as PNC. The noncompliance started on 06/10/2022 and ended on 6/10/2022. The facility had corrected the noncompliance before the survey began. This failure could result in residents experiencing accidents, injuries and/or a diminished quality of life. The findings include: Record review of Resident #48's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: Heart failure, pneumonia, cerebral infarction, dementia without behaviors, hypoosmolality and [CONDITION(S)], muscle weakness, fatigue, [CONDITION(S)], localized [CONDITION(S)], dysphagia, anxiety disorder, difficult walking, and history of falling. Record review of Resident #48's quarterly MDS assessment dated [DATE], revealed a BIMS score of 8 (moderate cognition impairment). Resident #48 required total - extensive assistance with two-person physical assistance with bed mobility, dressing, and toileting. Resident #48 required total assistance with two-person physical assistance with transfers. The MDS reflected Resident #48's range of motion was not impaired in the upper and lower extremity and she utilized a wheelchair. Record review of Resident #48's Care Plan dated 06/14/2022 revealed: Resident #48 was at risk for falls related to decreased mobility and safety awareness. One of the goals was for Resident #48 to be without falls and injury and the intervention was for Resident #48 to call for assistance before moving from bed to chair and from chair to bed, also to provide reminders to use ambulation and transfer assist devices. Observation on 06/15/22 at 11:15 AM of Resident #48 revealed she was in the wheelchair with LVN A (Treatment Nurse). The wound was noted on her left shin with about 20 sutures. The wound was held intact with the sutures, no drainage or foul odor was noted. Resident #48 denied pain on the wound. LVN A stated the wound was monitored daily. Observation and interview on 06/13/22 at 01:53 PM of the Resident# 48 revealed she needed assistance to get in and out of bed and to the wheelchair . Resident #48 stated the staff used a mechanical lift to transfer her. She stated she did not have issues with the transfers because the staff transferred her safely to the chair and back to bed with the mechanical lift. Resident #48 stated she did not complain of the sling hurting her to CNA B. In an interview with Resident #48 on 06/14/22 at 16:24 regarding the incident she stated CNA B was transferring her from the chair to the bed when she tore her leg. Resident #48 stated CNA B had never used a mechanical lift before to transfer her. She stated CNA B normally picked her from underneath her arms and transferred her to bed. The resident stated on the day of the incident, CNA B did not want to use the mechanical lift and she did not call anyone to help her to transfer her. The resident stated she did not refuse to use the mechanical lift, rather it was the CNA B who said she was not going to use the mechanical lift. The resident stated CNA B was the only one who never used a mechanical lift when she transferred her; all other staff used the mechanical lift when they transferred her. The resident stated CNA B did not transfer her properly leading to her being injured on her left shin and treated with 20 sutures to close the wound. In an interview on 06/14/22 at 10:30 AM with LVN A, she revealed she was the treatment nurse and she provided treatment to Resident #48's laceration. LVN A stated she was made aware the day of the incident and she assessed the resident's injury before Resident #48 was transferred to the local hospital. LVN A stated the resident sustained the laceration when CNA B was transferring the resident from the chair to the bed without the use of the mechanical lift. LVN A stated the laceration on the left shin was deep and bled actively. LVN A stated she provided first aid to the resident and the resident was transferred to the hospital. Resident #48 was treated in the hospital with 20 sutures applied to the laceration. The laceration measured about 18cm by 0.5cm. Since Resident #48 had been back to the facility, LVN A had been providing treatment to the laceration daily and monitoring for any signs or symptoms of infection. LVN A stated, after the incident, she was in-serviced on proper transfers. In an interview via telephone on 06/14/22 at 10:46 AM CNA B revealed she was the one who was transferring Resident #48 when the resident sustained the injury. CNA B stated she had gone to the resident's room before lunch on 06/10/22, and she informed Resident #48 she was going to transfer the resident to bed, to provide incontinent care to the resident before lunch . CNA B stated the resident refused to use the mechanical lift because Resident #48 indicated the Hoyer sling was hurting her. CNA B then told Resident #48 to hold her around her neck and the CNA B grabbed the resident's pants. CNA B lifted the resident and transferred her from the chair to the bed and sat the resident on the side of the bed, then assisted the resident to lay down in bed. CNA B stated after the resident was in bed, she noticed the resident's pants were wet on the left leg. when CNA B opened the resident's pants on the left leg, she noted the resident was bleeding on her shin from a cut. CNA B immediately notified LVN C, who was the charge nurse, and LVN C attended to the resident. CNA B stated LVN A provided treatment to the laceration. When CNA B was asked if she transferred Resident #48 per the resident's care plan and facility protocol, CNA B stated, that was where I messed up, CNA B stated she did not use the Hoyer lift and she failed to tell the nurse in charge that Resident #48 had refused to use the mechanical lift for the transfer. CNA B stated it was almost lunch time and she just wanted to change the resident. If she did not change the resident, the resident would be calling her family to report that she had not been changed. CNA B also stated she did not use the gait belt because it was in another room. Again she stated, I messed up, I just wanted to change the resident. CNA B stated she knew Resident #48 required a mechanical lift for transfers with two staff members. CNA B stated if she asked for another staff's assistance and used the mechanical lift, it could have prevented Resident #48's injury. CNA B stated, prior to the incident, she had been trained on proper transfers with a mechanical lift and the use of gait belt, and after the incident she was in-serviced on proper transfers. CNA B stated she was still on suspension upon the investigation of the incident. On 06/14/22 at 01:35 PM with CNA D and CNA E, an observation of Resident #48 was completed with a mechanical lift transfer. The CNAs transferred the resident from the wheelchair to bed without any concerns. Resident #48 did not voice any concerns of the sling hurting her. In an interview with CNA D and CNA E revealed they were aware Resident #48 required a mechanical lift for transfer and two staff had to be present. They both stated on 06/10/22 they received any in-service on proper transfer with a mechanical lift. In an interview via telephone on 06/14/22 at 04:03 PM with LVN C revealed she was the charge nurse on the day Resident #48 sustained an injury to her left shin. LVN C stated it was around 12 pm when CNA B asked her to go to Resident #48's room. When LVN C got to the resident's room, she noted the resident was calm, in bed. Then CNA B showed the cut on the resident's left shin. LVN C stated it was a deep laceration and it was actively bleeding. LVN C stated she provided first aide and notified the nurse supervisor and LVN A (Treatment nurse). LVN C also notified Resident #48's responsible party and primary care provider. Primary care provider gave orders for Resident #48 to be transferred to the local hospital for evaluation and treatment. LVN C stated when she asked CNA B why she did not ask for assistance to transfer the resident, CNA B could not give a reason why she did not ask for assistance or use a mechanical lift to transfer the resident. LVN C stated Resident #48 required a two-person transfer with the use of the mechanical lift; failure could lead to resident injury. LVN C stated she received an in-service after the incident on proper mechanical lift transfer on 06/10/22. In an interview on 06/14/22 at 03:32 PM with the DON revealed she was not present when the incident happened, but she was made aware. DON stated when she interviewed CNA B, CNA B stated Resident #48 declined to use the Hoyer lift during transfer, but CNA B failed to follow the facility protocol of notifying the charge nurse and transferring the resident improperly leading to resident getting injured. DON stated she was sent a picture of the injury and it was a significant laceration. Resident #48 sustained a laceration to her left shin from the improper transfer, and the resident had to be transferred to the local hospital for evaluation and treatment. DON stated CNA B was aware not transfer the resident without a Hoyer lift and that there had to be to staff in the room during the transfer. DON also stated CNA B had been trained on proper transfers using a mechanical lift and gait belt, and after the incident CNA B was in-serviced on proper transfers before being suspended pending the investigation. The incident was reported to HHS because the resident sustained an injury that required the resident to be treated at the local hospital. DON stated after the incident, the facility put the following measures in place, and they would be reviewed in 30 days. The following documents were also reviewed; - All the staff members were in-serviced on Abuse and Neglect and proper transferring techniques - Skills check off were completed on mechanical lift transfer - Random rounds - Hospice aides were not allowed to transfer the resident without charge nurse or nurse manager being present - There had to be always be two staff during Hoyer transfer - CNA B was terminated In an interview on 06/15/22 at 04:28 PM with the Administrator, he stated he completed an interview with Resident #48 and the resident stated she did not know what caused the laceration. The Administrator stated the laceration was discovered after CNA B transferred the resident. Administrator stated after the investigation, it was confirmed CNA B completed an improper transfer on Resident #48. Administrator stated when he interviewed CNA B, CNA B stated, she was not thinking, and she messed up. The Administrator stated CNA B took full responsibility and acknowledged she was at fault. CNA B was terminated from the facility. The Administrator stated failure of CNA B to follow the facility protocol led to Resident #48 sustaining injury that led to Resident #48 being transferred to the hospital. Review of the facility policy revised July 2017 not dated and titled Lifting Machine, Using a Mechanical, .1. At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift.

Based on observation, interview, and record review, the facility failed to implement written policies and procedures to prohibit and prevent abuse and neglect for 1 (Resident #1) of 10 residents reviewed for abuse. LVN A failed to monitor and assess Resident #1, who had [MEDICAL CONDITION], during and after a breathing treatment and failed to put his oxygen, which he needed at 5 LPM, back on him for approximately three hours. The resident was unattended and experienced respiratory distress, became unresponsive, and subsequently expired in the facility. An Immediate Jeopardy was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of isolated because the facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of Removal. This failure could affect the 9 residents receiving nebulizer treatments by placing them at risk for respiratory distress, lack of medical treatment, improper medical treatment, and death. Findings included: Review of the facility's current policy and procedure on Nebulizer Treatment, dated [DATE] and provided by the Interim DON on [DATE] at 2:20 PM reflected: - Administer therapy until medication is depleted, treatment require a minimum of 15 minutes. (Drug.com website: https://www.drugs.com/dosage/[MEDICATION NAME].html revealed usual adult dose for [MEDICAL CONDITION] - Acute . Nebulizer inhalation solution: -2.5 mg three or four times a day by nebulization, over approximately 5 to 15 minutes) - Monitor patient for side effects of treatment (a) Nervousness, (b) [MEDICATION NAME], (c) Hypoventilation/Hyperventilation, (d) Infection, (e) [MEDICAL CONDITION]/>- Monitor heart rate, respiratory rate, and breath sounds before, during and after treatment - Instruct the patient to take slow deep breaths - When treatment is completed instruct the patient to take deep breath and cough, observing the nature of the cough and any sputum produced . - Document treatment in patient's chart . - Documentation: Date and time of treatment, type of treatment ., equipment used for the treatment, duration of the treatment, breath sounds before and after treatment, heart rate and respiratory rate before, during and after treatment . Review of the facility's current policy and procedure on Abuse Protocol, dated (MONTH) (YEAR) reflected: 1. The patient/resident has the right to be free from Abuse, neglect, mistreatment of [REDACTED]. 7. The following definition are provided to assist out Facility's staff members in recognizing incidents of Patient/Resident Abuse: l. Neglect is the failure of the facility, it's employees or service providers to provide goods and services to a Patient/Resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of Resident #1's face sheet, dated [DATE] reflected a [AGE] year-old male, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He had an advance directive for do not resuscitate. Review of Resident #1's MDS assessment dated [DATE] reflected he had moderately impaired cognition with no behaviors. He needed assistance of one to two staff with his activities of daily living (ADLs). The resident had shortness of breath or trouble breathing with exertion (e.g. walking, bathing, transferring), shortness of breath or trouble breathing when sitting at rest, and shortness of breath or trouble breathing when lying flat. Resident #1 was always continent if urine and occasionally incontinent of bowel. Review of Resident #1's Care Plan Report with a date range of [DATE] to [DATE] reflected, resident has potential for ineffective airway exchange and infection related to [DIAGNOSES REDACTED].Administer [MEDICATION NAME][MEDICATION NAME], aerosol treatments, nebulizers, and oxygen as ordered and monitor status, administer medications as ordered and monitor for side effects for [MEDICAL CONDITION] . The Care plan revealed Resident #1 required hospice as evidenced by terminal illness of [MEDICAL CONDITION]. Interventions are monitor for signs and symptoms of increased pain, discomfort-give medication and treatments, monitor for relief Review of Provider Progress Soap (subjective, objective, assessment, and plan) Note dated [DATE] revealed the chief complaint was shortness of breath without relief from present medical regimen. History of present illness was end stage lung disease of [MEDICAL CONDITION] with severe anxiety not responsive to present dosage of medication. Overall assessment and plan revealed conference with resident and resident's family who requested hospice for end of life care. Provider Progress Soap Note dated [DATE] overall assessment and plan revealed that resident had hypoxic [MEDICAL CONDITION] (failure to maintain adequate blood oxygen level) with oxygen dependence. Review of Resident #1's (MONTH) (YEAR) Physician order [REDACTED]. -- Keep saturation at or greater than 91%, monitor with pulse oximetry; by shift; order date [DATE] -- Oxygen 5L/min with humidification; order date [DATE] (Providers Progress Note dated [DATE] reflected continue with oxygen OER (Oxygen Enhancement Ratio) NC (nasal cannula) but maintain saturation at goal of ,[DATE]%). -- [MEDICATION NAME]-[MEDICATION NAME] 0.5mg-3mg (2.5mg base)/3mL nebulization solution (1 vial) ampul (sealed glass bottle with premeasured medication) for nebulization (ml) inhalation; as needed every four hours; physical monitor - breath sounds/Pulse/ Pulse Oximetry/Respiration; order date [DATE] -- Incruse Ellipta 62.5 mcg/actuation powder for inhalation (1 puff) with inhalation device; one time daily; order date [DATE] -- [MEDICATION NAME] (anti-[MEDICAL CONDITION]) 10 mg 1 tablet once daily; order date [DATE] -- Post respiratory nebulizer treatment: physical monitor - minutes for treatment/pulse/pulse oximetry/respiration; as needed, order date [DATE] Review of the Nurses' Notes for Resident #1 revealed the following: -- On [DATE] at 9:39 PM: Resident is admitted to hospice care service today, with . No new medication and all previous medication remain as ordered. Breathing treatment given as ordered, as needed every 4 hours. Resident continued to request for treatment more than ordered. Responsible party notified. Resident is not in acute distress at this time. Entered by LVN D. -- On [DATE] at 3:30 AM: Resident noted unresponsive and no pulse by the side of his bed. Hospice nurse made aware, called placed to resident's daughter (name) and call placed to MD (Medical Doctor), nursing awaits call back. Note was entered by LVN A. -- On ,[DATE] at 4:48 AM: Resident family and Hospice nurse at bedside. Note was entered by LVN A Telephone interview with LVN A on [DATE] at 11:07 AM revealed that she gave Resident #1 a PRN breathing treatment during the morning of [DATE] (she could not recall exactly what time) and did not remember if she used a mask or mouthpiece. She stated that the resident had both. LVN A stated that Resident #1 requested the breathing treatment. She stated this happened a long time ago and she did not remember everything that happened that day. LVN A stated she assessed the resident before she provided the treatment. She stated she removed Resident #1's nasal cannula (device used to deliver supplemental oxygen or airflow to a patient or person in need of respiratory help), to administer the breathing treatment. She revealed she stayed in the resident's room during the nebulizer treatment, but lights in the hall were going off close by and across the hall from the resident's room so she left to answer them. LVN A stated she could not remember exactly how long she was gone but returned after the treatment was done. She said when she returned to Resident #1's room, she found him unresponsive. She stated she repositioned him back into bed and placed his oxygen back on him, and no pulse was found. LVN A stated she then left the room to get help with resident. LVN A revealed the aide got the other nurse working in hall that morning. She stated she reassessed the resident when she returned to resident's room and no pulse was found. LVN A revealed she found Resident #1 with his legs off the bed with the head of bed elevated and his head over towards the side rails. She revealed she then contacted hospice, the doctor and family. She stated she only gave him the one treatment that night. LVN A stated she was aware that resident had an electronic monitoring sign posted outside his room but was not sure it was recording. When revealed to LVN the length of time the video showed she was gone, LVNA stated she did not think she was gone that long. Review of Resident #1's (MONTH) (YEAR) MAR indicated [REDACTED]. Observation on [DATE] at 1:30 PM of the motioned activated in room video surveillance recording for the morning of [DATE] between the time of 12:27 AM to 3:35 PM (approximately 3 hours timeframe) provided by Resident #1's family revealed the following: -- At 12:27 AM Resident #1 sitting on the side of the bed with the head of the bed elevated and the bedside table in front of him. There were several items on the bedside table obstructing complete view of the resident. His television was on. A female staff entered Resident #1's room and asked him what he needed. It was unclear what the resident said due to television noises. She stated the nurse? Okay and left room. -- At 12:29 AM A female staff returned to his room, applied gloves and gathered trash off his bedside table and picked up the trash can and left the room. She returned a short time later and put the trash can back and walked to the bathroom. As she walked towards the restroom, she told Resident #1 she got your breathing treatment and then LVN A entered the room. LVNA applied gloves, retrieved the nebulizer mask from the bed and applied the medication to the mask portal. At 12:31 AM, she removed the resident's nasal cannula and applied the breathing treatment mask over the resident's nose and mouth. She then turned on the nebulizer and mist came from the mask. -- At 12:33 AM, LVN A was still in the room, moving things around and making sure the nebulizer treatment was going. She then walked out the door. -- At 1:25 AM Resident #1 was lying his head on his bedside table in front of him. He had a difficult time lifting his head off the table. The table slid to the side as the resident pushed off it. He was not wearing his nasal cannula, so he was not receiving oxygen at 5LPM. No staff entered the room during this video. -- At 1:30 AM the resident was still sitting on the bedside, with arms on table and head hanging over arms. The strap from the nebulizer mask was on his cheeks and around toward the back of his head. He was moving his head from the bedside table to lean towards the bed, appeared to be saying help several times but hard to hear clearly over the television sounds. He was not wearing his nasal cannula, so he was not receiving oxygen at 5 LPM No staff entered his room during this video. Length of this video was 3:09 minutes. -- At 1:34 AM Resident #1 was more upright, the nebulizer mask was on his face. He was leaning into the bedside table and rocking the table slightly. A box with items in it fell off the bedside table and hit the floor with a noticeable noise. He was not wearing his nasal cannula, so he was not receiving oxygen at 5LPM. -- At 1:49 AM Resident #1 was still wearing his nebulizer mask. He sat up and then leaned/fell back on his bed, lying across the bed. He was able to sit back up after a few moments. He then fell back across his bed again. His breaths were short and deep. His whole chest moved with each breath taken. He sat back up and leaned over the bedside table again. His head appeared to slip off the table and could can be seen hanging between his legs under the table. He lifted his head and then dropped it again between his legs several times. At one point, he sat upright and tried to say something, or took open mouth breaths (sounds unclear). He was not wearing his nasal cannula, so he was not receiving oxygen at 5LPM. No staff entered his room, video length is 3:06 minutes. -- At 1:52 AM, 1:59 AM and 2:03 AM: Resident #1 slumped over his bedside table and leaning toward the head of bed. He was moving his head around during these videos. He was not wearing his nasal cannula, so he was not receiving oxygen at 5LPM. No staff entered his room during any of these videos. -- At 2:07 AM Resident #1 said help me and help several times. At 1:31 minutes into the video, he hit his bedside table with his fist several times. At the end of the video, he leaned over his legs with his right arm on the bedside table. He was not wearing his nasal cannula, so he was not receiving oxygen at 5LPM. No staff entered the room during this video. Video length was 2:32 minutes. -- At 3:35 AM Resident #1 slumped over his legs on the side of the bedside table. His back showed no signs of movement. LVN A entered his room applying gloves and there was another female staff with her in the doorway. LVN A moved the bedside table aside and called out sir. She lifted his right arm, and there was no response from the Resident #1. The female staff stood to the side observing the nurse. LVN A rolled the resident's head onto his bed and picked up the oxygen tubing. She applied the nasal cannula to him. LVN A asked the female staff to get someone (words unclear as to what was said exactly, due to music playing in the background). After applying oxygen to the resident, LVN A moved his legs onto the bed and left the room. A male staff member entered the room, looked at the resident and left. LVN A and the female staff returned to Resident #1's room as the male staff left. LVN A lowered the head of bed slightly and the female staff picked up items from the resident's bed and floor around the side of the bed closest to the restroom. LVN A and the female staff member left the room at 2:32 minutes into the video, approximately 3:37 AM. -- At 3:38 AM LVN A and the female staff returned to Resident #1's room with a male staff. The male staff and LVN A went to each side of the resident's bed. The female staff picked items off the floor and placed the resident's urinal in front of the camera blocking the view. The female staff pulled at the bed sheets and picked up items. Unable to see what the other staff were doing with the resident. Staff talked amongst themselves, but the conversation was unclear due to television noise. -- At 3:44 AM, 3:45 AM, 3:49 AM, 3:53 AM, 3:58 AM, 4:01 AM and 4:06 AM: The camera was blocked by the urinal. Staff could be seen coming and going from lower corners of the video. The staff conversation was unclear. -- At 4:09 AM Staff removed the urinal from in front of the camera and left the resident's room. Resident #1was lying in bed with sheets covering him and the room was straightened. -- At 4:20 AM Resident #1's family entered his room with LVN A and female staff. Interview on [DATE] at 10:34 AM with the Interim DON revealed LVN A was terminated due to failure to document the resident's assessment into the Medical Assessment Records (MARs) for the treatment provided. LVN A was terminated on [DATE]. She stated nursing staff should stay with a resident during a nebulizer treatment to monitor the resident. The Interim DON stated that facility policy did not state that staff had to stay in the room with the resident, but facility trained staff to stay and monitor the resident before, during and after treatment. Review of LVN A personnel file revealed Employee Coaching and Counseling Records that reflected the following: On [DATE] revealed Violation of Substandard Work and Suspended for failure to document with employee remarks stating breathing tx (treatment) was given to my patient and I wasn't sure for how long, and it was a PRN tx given to him. Approximately ,[DATE] min. There were lights going off on the hall and across from him. Nurse went to answer and came back noted resident removed mask and was not responding. On [DATE] revealed LVN A's remarks reflected, It was an emergency situation and I was coming back to document every care provided to this patient. A message for was left for Resident #1's Hospice nurse on [DATE] at 2:17 PM but no return call was received. A message was left for Resident #1's primary care provider on [DATE] at 9:53 AM but no return call was received. Review of Resident #1's Record of Death, undated revealed Resident #1 expired on [DATE] at 3:35 AM with LVN A present at time of death. The physician was notified on [DATE] at 3:40 AM. Remarks on record revealed hospice nurse was at facility and did all the notifications. An Immediate Jeopardy was identified on [DATE] at 7:12 PM. The administrator was notified by telephone because she was not in the facility at the time Immediate Jeopardy was identified and a Plan of Removal was requested at that time. The Plan of Removal was accepted on [DATE] at 12:04 PM and reflected the following steps be taken to remove the immediacy: -- Registered Respiratory Therapist is conducting respiratory in-services and skills checks related to facility nebulizer treatment protocol and appropriate monitoring with licensed nursing staff. -- The DON and ADON are conducting competency testing, in-servicing and skills checks related to facility nebulizer treatment protocol related to training provided by Registered Respiratory Therapist with licensed nursing staff. The training included appropriate monitoring of nebulizer treatment which revealed monitoring for side effects such as nervousness, [MEDICATION NAME], hypoventilation/hyperventilation, infection and [MEDICAL CONDITION] Process also included monitor heart rate, respiratory rate, and breath sounds before during and after treatment. -- All current orders of residents receiving nebulizer treatments have been assessed for physical monitors such as heart rate, respiratory rate, breath sounds and O2 saturation. Review of Personnel Status Form for LVN A revealed a termination date of [DATE] for failure to document accordingly. LVN A's last day worked was [DATE]. Administrator signed form on [DATE]. Interview with the facility's Medical Director on [DATE] at 2:53 PM revealed the facility made him aware of the IJ on the evening of [DATE] at 8:30 PM. He stated that he was not the primary care provider for Resident #1 and was unfamiliar with his care situation. The Medical Director stated that the IJ most likely occurred because the nurse had provided a nebulizer treatment and did not return to assess the resident. Medical Director revealed that the IJ could have been avoided by retraining the staff and monitoring and assessing the residents. During an interview on [DATE] at 3:46 PM, the Administrator revealed I think it (IJ) occurred because we weren't following policies and procedure of nebulizer treatments. The Administrator revealed that to prevent the reoccurrence of the IJ the facility had done extensive training. She stated she had a Registered Respiratory Therapist come and provide comprehensive training on nebulizer treatments and had staff do return demonstrations. The Administrator revealed they reviewed the facility's policies and procedures to make sure everyone understood what was expected. Interview with the Interim DON on [DATE] at 4:48 PM revealed the IJ occurred because of the nurse's actions and the facility was unaware of the situation. She stated the facility was providing in-services to all nurses to prevent a reoccurrence. She stated no nurse would be working the floor without taking the training for nebulizer treatments. The Interim DON revealed the training could be provided by the respiratory therapist, DON or ADON (managers). She stated the Respiratory Therapist would also do quarterly assessments with staff. She revealed she would prefer that the nurse not leave a resident during the nebulizer treatment. She stated there are two nurses were on a unit at all times. During interview with Unit Manager on [DATE] at 10:12 AM revealed the IJ occurred due to staff's carelessness. The Unit Manager stated that to prevent the reoccurrence of the incident, the facility was conducting in-services, talking to staff about skills, covering check off lists by reviewing treatment process and reviewing protocols that staff needed to follow in different situations. Observations on [DATE] at 12:31 PM and 12:55PM and [DATE] at 11:52 AM and 12:10 PM of four nebulizer treatments performed by four different nurses from different halls throughout facility revealed the nurses followed policies and procedures for nebulizer treatments and documentation of treatments. All residents tolerated the procedures well with no adverse reactions. Interviews on [DATE] from between 10:00 AM and 1:30 PM with five Residents #2, #5, #6, #7, and #8 revealed they received nebulizer treatments in the facility. All the residents interviewed felt had no concerns regarding the nebulizer treatments they received. Interviews on [DATE] at 12:45 PM through [DATE] at 3:27 PM with LVNs B, C, and H who worked 6:00 AM to 2:00 PM; Unit Manager D, LVN L, and the ADON who worked on the day shift; LVNs E, J and K who worked 2:00 PM to 10:00 PM; LVNs F and G who worked the 10:00 PM to 6:00 AM shift; and LVN I who worked as needed, revealed that nursing staff received nebulizer training from Respiratory therapist and return demonstration was required for all nursing staff. Staff stated that pulse, respiratory rate, lung sounds, and oxygen saturation needed to be assessed before, during and after each nebulizer treatment. Staff revealed that residents need to be monitored for side effects such as nervousness, [MEDICATION NAME] and [MEDICAL CONDITION] Nursing staff stated that residents need to be observed throughout entire treatment process. On [DATE] the IJ was removed. On [DATE] at 3:52 PM the Administrator, Regional Nurse Consultant, Interim DON and Unit Manager were informed the IJ was removed. While the IJ was removed, the facility remained out of compliance at a severity level of actual harm that is not an IJ and a scope of isolated because the facility was continuing to in-service staff and monitor the effectiveness of the Plan of Removal. The Interim DON provided a list on [DATE] of 9 residents who received nebulizer treatments.

Based on observation, interview, and record review, the facility failed to ensure a that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #1) of 10 residents reviewed for care and treatment. LVN A failed to monitor and assess Resident #1, who had [MEDICAL CONDITION], during and after a breathing treatment and failed to put his oxygen, which he needed at 5 LPM, back on him for approximately three hours. The resident was unattended and experienced respiratory distress, became unresponsive, and subsequently expired in the facility. An Immediate Jeopardy was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of isolated because the facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of Removal. This failure could affect the 9 residents receiving nebulizer treatments by placing them at risk for respiratory distress, lack of medical treatment, improper medical treatment, and death. Findings included: Review of Resident #1's face sheet, dated [DATE] reflected a [AGE] year-old male, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He had an advance directive for do not resuscitate. Review of Resident #1's MDS assessment dated [DATE] reflected he had moderately impaired cognition with no behaviors. He needed assistance of one to two staff with his activities of daily living (ADLs). The resident had shortness of breath or trouble breathing with exertion (e.g. walking, bathing, transferring), shortness of breath or trouble breathing when sitting at rest, and shortness of breath or trouble breathing when lying flat. Resident #1 was always continent if urine and occasionally incontinent of bowel. Review of Resident #1's Care Plan Report with a date range of [DATE] to [DATE] reflected, resident has potential for ineffective airway exchange and infection related to [DIAGNOSES REDACTED].Administer [MEDICATION NAME][MEDICATION NAME], aerosol treatments, nebulizers, and oxygen as ordered and monitor status, administer medications as ordered and monitor for side effects for [MEDICAL CONDITION] . The Care plan revealed Resident #1 required hospice as evidenced by terminal illness of [MEDICAL CONDITION]. Interventions are monitor for signs and symptoms of increased pain, discomfort-give medication and treatments, monitor for relief Review of Provider Progress Soap (subjective, objective, assessment, and plan) Note dated [DATE] revealed the chief complaint was shortness of breath without relief from present medical regimen. History of present illness was end stage lung disease of [MEDICAL CONDITION] with severe anxiety not responsive to present dosage of medication. Overall assessment and plan revealed conference with resident and resident's family who requested hospice for end of life care. Provider Progress Soap Note dated [DATE] overall assessment and plan revealed that resident had hypoxic [MEDICAL CONDITION] (failure to maintain adequate blood oxygen level) with oxygen dependence. Review of Resident #1's (MONTH) (YEAR) Physician order [REDACTED]. -- Keep saturation at or greater than 91%, monitor with pulse oximetry; by shift; order date [DATE] -- Oxygen 5L/min with humidification; order date [DATE] (Providers Progress Note dated [DATE] reflected continue with oxygen OER (Oxygen Enhancement Ratio) NC (nasal cannula) but maintain saturation at goal of ,[DATE]%). -- [MEDICATION NAME]-[MEDICATION NAME] 0.5mg-3mg (2.5mg base)/3mL nebulization solution (1 vial) ampul (sealed glass bottle with premeasured medication) for nebulization (ml) inhalation; as needed every four hours; physical monitor - breath sounds/Pulse/ Pulse Oximetry/Respiration; order date [DATE] -- Incruse Ellipta 62.5 mcg/actuation powder for inhalation (1 puff) with inhalation device; one time daily; order date [DATE] -- [MEDICATION NAME] (anti-[MEDICAL CONDITION]) 10 mg 1 tablet once daily; order date [DATE] -- Post respiratory nebulizer treatment: physical monitor - minutes for treatment/pulse/pulse oximetry/respiration; as needed, order date [DATE] Review of the Nurses' Notes for Resident #1 revealed the following: -- On [DATE] at 9:39 PM: Resident is admitted to hospice care service today, with . No new medication and all previous medication remain as ordered. Breathing treatment given as ordered, as needed every 4 hours. Resident continued to request for treatment more than ordered. Responsible party notified. Resident is not in acute distress at this time. Entered by LVN D. -- On [DATE] at 3:30 AM: Resident noted unresponsive and no pulse by the side of his bed. Hospice nurse made aware, called placed to resident's daughter (name) and call placed to MD (Medical Doctor), nursing awaits call back. Note was entered by LVN A. -- On ,[DATE] at 4:48 AM: Resident family and Hospice nurse at bedside. Note was entered by LVN A Telephone interview with LVN A on [DATE] at 11:07 AM revealed that she gave Resident #1 a PRN breathing treatment during the morning of [DATE] (she could not recall exactly what time) and did not remember if she used a mask or mouthpiece. She stated that the resident had both. LVN A stated that Resident #1 requested the breathing treatment. She stated this happened a long time ago and she did not remember everything that happened that day. LVN A stated she assessed the resident before she provided the treatment. She stated she removed Resident #1's nasal cannula (device used to deliver supplemental oxygen or airflow to a patient or person in need of respiratory help), to administer the breathing treatment. She revealed she stayed in the resident's room during the nebulizer treatment, but lights in the hall were going off close by and across the hall from the resident's room so she left to answer them. LVN A stated she could not remember exactly how long she was gone but returned after the treatment was done. She said when she returned to Resident #1's room, she found him unresponsive. She stated she repositioned him back into bed and placed his oxygen back on him, and no pulse was found. LVN A stated she then left the room to get help with resident. LVN A revealed the aide got the other nurse working in hall that morning. She stated she reassessed the resident when she returned to resident's room and no pulse was found. LVN A revealed she found Resident #1 with his legs off the bed with the head of bed elevated and his head over towards the side rails. She revealed she then contacted hospice, the doctor and family. She stated she only gave him the one treatment that night. LVN A stated she was aware that resident had an electronic monitoring sign posted outside his room but was not sure it was recording. When revealed to LVN the length of time the video showed she was gone, LVNA stated she did not think she was gone that long. Review of Resident #1's (MONTH) (YEAR) MAR indicated [REDACTED]. Observation on [DATE] at 1:30 PM of the motioned activated in room video surveillance recording for the morning of [DATE] between the time of 12:27 AM to 3:35 PM (approximately 3 hours timeframe) provided by Resident #1's family revealed the following: -- At 12:27 AM Resident #1 sitting on the side of the bed with the head of the bed elevated and the bedside table in front of him. There were several items on the bedside table obstructing complete view of the resident. His television was on. A female staff entered Resident #1's room and asked him what he needed. It was unclear what the resident said due to television noises. She stated the nurse? Okay and left room. -- At 12:29 AM A female staff returned to his room, applied gloves and gathered trash off his bedside table and picked up the trash can and left the room. She returned a short time later and put the trash can back and walked to the bathroom. As she walked towards the restroom, she told Resident #1 she got your breathing treatment and then LVN A entered the room. LVNA applied gloves, retrieved the nebulizer mask from the bed and applied the medication to the mask portal. At 12:31 AM, she removed the resident's nasal cannula and applied the breathing treatment mask over the resident's nose and mouth. She then turned on the nebulizer and mist came from the mask. -- At 12:33 AM, LVN A was still in the room, moving things around and making sure the nebulizer treatment was going. She then walked out the door. -- At 1:25 AM Resident #1 was lying his head on his bedside table in front of him. He had a difficult time lifting his head off the table. The table slid to the side as the resident pushed off it. He was not wearing his nasal cannula, so he was not receiving oxygen at 5LPM. No staff entered the room during this video. -- At 1:30 AM the resident was still sitting on the bedside, with arms on table and head hanging over arms. The strap from the nebulizer mask was on his cheeks and around toward the back of his head. He was moving his head from the bedside table to lean towards the bed, appeared to be saying help several times but hard to hear clearly over the television sounds. He was not wearing his nasal cannula, so he was not receiving oxygen at 5 LPM No staff entered his room during this video. Length of this video was 3:09 minutes. -- At 1:34 AM Resident #1 was more upright, the nebulizer mask was on his face. He was leaning into the bedside table and rocking the table slightly. A box with items in it fell off the bedside table and hit the floor with a noticeable noise. He was not wearing his nasal cannula, so he was not receiving oxygen at 5LPM. -- At 1:49 AM Resident #1 was still wearing his nebulizer mask. He sat up and then leaned/fell back on his bed, lying across the bed. He was able to sit back up after a few moments. He then fell back across his bed again. His breaths were short and deep. His whole chest moved with each breath taken. He sat back up and leaned over the bedside table again. His head appeared to slip off the table and could can be seen hanging between his legs under the table. He lifted his head and then dropped it again between his legs several times. At one point, he sat upright and tried to say something, or took open mouth breaths (sounds unclear). He was not wearing his nasal cannula, so he was not receiving oxygen at 5LPM. No staff entered his room, video length is 3:06 minutes. - - At 1:52 AM, 1:59 AM and 2:03 AM: Resident #1 slumped over his bedside table and leaning toward the head of bed. He was moving his head around during these videos. He was not wearing his nasal cannula, so he was not receiving oxygen at 5LPM. No staff entered his room during any of these videos. -- At 2:07 AM Resident #1 said help me and help several times. At 1:31 minutes into the video, he hit his bedside table with his fist several times. At the end of the video, he leaned over his legs with his right arm on the bedside table. He was not wearing his nasal cannula, so he was not receiving oxygen at 5LPM. No staff entered the room during this video. Video length was 2:32 minutes. -- At 3:35 AM Resident #1 slumped over his legs on the side of the bedside table. His back showed no signs of movement. LVN A entered his room applying gloves and there was another female staff with her in the doorway. LVN A moved the bedside table aside and called out sir. She lifted his right arm, and there was no response from the Resident #1. The female staff stood to the side observing the nurse. LVN A rolled the resident's head onto his bed and picked up the oxygen tubing. She applied the nasal cannula to him. LVN A asked the female staff to get someone (words unclear as to what was said exactly, due to music playing in the background). After applying oxygen to the resident, LVN A moved his legs onto the bed and left the room. A male staff member entered the room, looked at the resident and left. LVN A and the female staff returned to Resident #1's room as the male staff left. LVN A lowered the head of bed slightly and the female staff picked up items from the resident's bed and floor around the side of the bed closest to the restroom. LVN A and the female staff member left the room at 2:32 minutes into the video, approximately 3:37 AM. -- At 3:38 AM LVN A and the female staff returned to Resident #1's room with a male staff. The male staff and LVN A went to each side of the resident's bed. The female staff picked items off the floor and placed the resident's urinal in front of the camera blocking the view. The female staff pulled at the bed sheets and picked up items. Unable to see what the other staff were doing with the resident. Staff talked amongst themselves, but the conversation was unclear due to television noise. -- At 3:44 AM, 3:45 AM, 3:49 AM, 3:53 AM, 3:58 AM, 4:01 AM and 4:06 AM: The camera was blocked by the urinal. Staff could be seen coming and going from lower corners of the video. The staff conversation was unclear. -- At 4:09 AM Staff removed the urinal from in front of the camera and left the resident's room. Resident #1was lying in bed with sheets covering him and the room was straightened. -- At 4:20 AM Resident #1's family entered his room with LVN A and female staff. Interview on [DATE] at 10:34 AM with the Interim DON revealed LVN A was terminated due to failure to document the resident's assessment into the Medical Assessment Records (MARs) for the treatment provided. LVN A was terminated on [DATE]. She stated nursing staff should stay with a resident during a nebulizer treatment to monitor the resident. The Interim DON stated that facility policy did not state that staff had to stay in the room with the resident, but facility trained staff to stay and monitor the resident before, during and after treatment. Review of LVN A personnel file revealed Employee Coaching and Counseling Records that reflected the following: On [DATE] revealed violation of substandard work and suspended for failure to document with employee remarks stating breathing tx (treatment) was given to my patient and I wasn't sure for how long, and it was a PRN tx given to him. Approximately ,[DATE] min. There were lights going off on the hall and across from him. Nurse went to answer and came back noted resident removed mask and was not responding. On [DATE] revealed LVN A's remarks reflected, It was an emergency situation and I was coming back to document every care provided to this patient. A message for was left for Resident #1's Hospice nurse on [DATE] at 2:17 PM but no return call was received. A message was left for Resident #1's primary care provider on [DATE] at 9:53 AM but no return call was received. Review of Resident #1's Record of Death, undated revealed Resident #1 expired on [DATE] at 3:35 AM with LVN A present at time of death. The physician was notified on [DATE] at 3:40 AM. Remarks on record revealed hospice nurse was at facility and did all the notifications. Review of the facility's current policy and procedure on Nebulizer Treatment, dated [DATE] and provided by the Interim DON on [DATE] at 2:20 PM reflected: - Administer therapy until medication is depleted, treatment require a minimum of 15 minutes. (Drug.com website: https://www.drugs.com/dosage/[MEDICATION NAME].html revealed usual adult dose for [MEDICAL CONDITION] - Acute . Nebulizer inhalation solution: -2.5 mg three or four times a day by nebulization, over approximately 5 to 15 minutes) - Monitor patient for side effects of treatment (a) Nervousness, (b) [MEDICATION NAME], (c) Hypoventilation/Hyperventilation, (d) Infection, (e) [MEDICAL CONDITION]/>- Monitor heart rate, respiratory rate, and breath sounds before, during and after treatment - Instruct the patient to take slow deep breaths - When treatment is completed instruct the patient to take deep breath and cough, observing the nature of the cough and any sputum produced . - Document treatment in patient's chart . - Documentation: Date and time of treatment, type of treatment ., equipment used for the treatment, duration of the treatment, breath sounds before and after treatment, heart rate and respiratory rate before, during and after treatment . An Immediate Jeopardy was identified on [DATE] at 7:12 PM. The administrator was notified by telephone because she was not in the facility at the time Immediate Jeopardy was identified and a Plan of Removal was requested at that time. The Plan of Removal was accepted on [DATE] at 12:04 PM and reflected the following steps be taken to remove the immediacy: -- Registered Respiratory Therapist is conducting respiratory in-services and skills checks related to facility nebulizer treatment protocol and appropriate monitoring with licensed nursing staff. -- The DON and ADON are conducting competency testing, in-servicing and skills checks related to facility nebulizer treatment protocol related to training provided by Registered Respiratory Therapist with licensed nursing staff. The training included appropriate monitoring of nebulizer treatment which revealed monitoring for side effects such as nervousness, [MEDICATION NAME], hypoventilation/hyperventilation, infection and [MEDICAL CONDITION] Process also included monitor heart rate, respiratory rate, and breath sounds before during and after treatment. -- All current orders of residents receiving nebulizer treatments have been assessed for physical monitors such as heart rate, respiratory rate, breath sounds and O2 saturation. Review of Personnel Status Form for LVN A revealed a termination date of [DATE] for failure to document accordingly. LVN A's last day worked was [DATE]. Administrator signed form on [DATE]. Interview with the facility's Medical Director on [DATE] at 2:53 PM revealed the facility made him aware of the IJ on the evening of [DATE] at 8:30 PM. He stated that he was not the primary care provider for Resident #1 and was unfamiliar with his care situation. The Medical Director stated that the IJ most likely occurred because the nurse had provided a nebulizer treatment and did not return to assess the resident. Medical Director revealed that the IJ could have been avoided by retraining the staff and monitoring and assessing the residents. During an interview on [DATE] at 3:46 PM, the Administrator revealed I think it (IJ) occurred because we weren't following policies and procedure of nebulizer treatments. The Administrator revealed that to prevent the reoccurrence of the IJ the facility had done extensive training. She stated she had a Registered Respiratory Therapist come and provide comprehensive training on nebulizer treatments and had staff do return demonstrations. The Administrator revealed they reviewed the facility's policies and procedures to make sure everyone understood what was expected. Interview with the Interim DON on [DATE] at 4:48 PM revealed the IJ occurred because of the nurse's actions and the facility was unaware of the situation. She stated the facility was providing in-services to all nurses to prevent a reoccurrence. She stated no nurse would be working the floor without taking the training for nebulizer treatments. The Interim DON revealed the training could be provided by the respiratory therapist, DON or ADON (managers). She stated the Respiratory Therapist would also do quarterly assessments with staff. She revealed she would prefer that the nurse not leave a resident during the nebulizer treatment. She stated there are two nurses were on a unit at all times. During interview with Unit Manager on [DATE] at 10:12 AM revealed the IJ occurred due to staff's carelessness. The Unit Manager stated that to prevent the reoccurrence of the incident, the facility was conducting in-services, talking to staff about skills, covering check off lists by reviewing treatment process and reviewing protocols that staff needed to follow in different situations. Observations on [DATE] at 12:31 PM and 12:55PM and [DATE] at 11:52 AM and 12:10 PM of four nebulizer treatments performed by four different nurses from different halls throughout facility revealed the nurses followed policies and procedures for nebulizer treatments and documentation of treatments. All residents tolerated the procedures well with no adverse reactions. Interviews on [DATE] from between 10:00 AM and 1:30 PM with five Residents #2, #5, #6, #7, and #8 revealed they received nebulizer treatments in the facility. All the residents interviewed felt had no concerns regarding the nebulizer treatments they received. Interviews on [DATE] at 12:45 PM through [DATE] at 3:27 PM with LVNs B, C, and H who worked 6:00 AM to 2:00 PM; Unit Manager D, LVN L, and the ADON who worked on the day shift; LVNs E, J and K who worked 2:00 PM to 10:00 PM; LVNs F and G who worked the 10:00 PM to 6:00 AM shift; and LVN I who worked as needed, revealed that nursing staff received nebulizer training from Respiratory therapist and return demonstration was required for all nursing staff. Staff stated that pulse, respiratory rate, lung sounds, and oxygen saturation needed to be assessed before, during and after each nebulizer treatment. Staff revealed that residents need to be monitored for side effects such as nervousness, [MEDICATION NAME] and [MEDICAL CONDITION] Nursing staff stated that residents need to be observed throughout entire treatment process. On [DATE] the IJ was removed. On [DATE] at 3:52 PM the Administrator, Regional Nurse Consultant, Interim DON and Unit Manager were informed the IJ was removed. While the IJ was removed, the facility remained out of compliance at a severity level of actual harm that is not an IJ and a scope of isolated because the facility was continuing to in-service staff and monitor the effectiveness of the Plan of Removal. The Interim DON provided a list on [DATE] of 9 residents who received nebulizer treatments.

Based on interview and record review; it was determined the facility failed to ensure each resident received nebulizer treatment and care in accordance with professional standards of practice for 1 (Resident #1) of 9 residents reviewed for neglect. LVN A failed to monitor and assess Resident #1, who had [MEDICAL CONDITION], during and after a breathing treatment and failed to put his oxygen, which he needed at 5 LPM, back on him for approximately three hours. The resident was unattended and experienced respiratory distress, became unresponsive, and subsequently expired in the facility. An Immediate Jeopardy was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of isolated because the facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of Removal. This failure could affect the 9 residents receiving nebulizer treatments by placing them at risk for respiratory distress, lack of medical treatment, improper medical treatment, and death. Findings included: Review of Resident #1's face sheet, dated [DATE] reflected a [AGE] year-old male, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He had an advance directive for do not resuscitate. Review of Resident #1's MDS assessment dated [DATE] reflected he had moderately impaired cognition with no behaviors. He needed assistance of one to two staff with his activities of daily living (ADLs). The resident had shortness of breath or trouble breathing with exertion (e.g. walking, bathing, transferring), shortness of breath or trouble breathing when sitting at rest, and shortness of breath or trouble breathing when lying flat. Resident #1 was always continent if urine and occasionally incontinent of bowel. Review of Resident #1's Care Plan Report with a date range of [DATE] to [DATE] reflected, resident has potential for ineffective airway exchange and infection related to [DIAGNOSES REDACTED].Administer [MEDICATION NAME][MEDICATION NAME], aerosol treatments, nebulizers, and oxygen as ordered and monitor status, administer medications as ordered and monitor for side effects for [MEDICAL CONDITION] . The Care plan revealed Resident #1 required hospice as evidenced by terminal illness of [MEDICAL CONDITION]. Interventions are monitor for signs and symptoms of increased pain, discomfort-give medication and treatments, monitor for relief Review of Provider Progress Soap (subjective, objective, assessment, and plan) Note dated [DATE] revealed the chief complaint was shortness of breath without relief from present medical regimen. History of present illness was end stage lung disease of [MEDICAL CONDITION] with severe anxiety not responsive to present dosage of medication. Overall assessment and plan revealed conference with resident and resident's family who requested hospice for end of life care. Provider Progress Soap Note dated [DATE] overall assessment and plan revealed that resident had hypoxic [MEDICAL CONDITION] (failure to maintain adequate blood oxygen level) with oxygen dependence. Review of Resident #1's (MONTH) (YEAR) Physician order [REDACTED]. - Keep saturation at or greater than 91%, monitor with pulse oximetry; by shift; order date [DATE] - Oxygen 5L/min with humidification; order date [DATE] (Providers Progress Note dated [DATE] reflected continue with oxygen OER (Oxygen Enhancement Ratio) NC (nasal cannula) but maintain saturation at goal of ,[DATE]%). - [MEDICATION NAME]-[MEDICATION NAME] 0.5mg-3mg (2.5mg base)/3mL nebulization solution (1 vial) ampul (sealed glass bottle with premeasured medication) for nebulization (ml) inhalation; as needed every four hours; physical monitor - breath sounds/Pulse/ Pulse Oximetry/Respiration; order date [DATE] - Incruse Ellipta 62.5 mcg/actuation powder for inhalation (1 puff) with inhalation device; one time daily; order date [DATE] - [MEDICATION NAME] (anti-[MEDICAL CONDITION]) 10 mg 1 tablet once daily; order date [DATE] - Post respiratory nebulizer treatment: physical monitor - minutes for treatment/pulse/pulse oximetry/respiration; as needed, order date [DATE] Review of the Nurses' Notes for Resident #1 revealed the following: - On [DATE] at 9:39 PM: Resident is admitted to hospice care service today, with . No new medication and all previous medication remain as ordered. Breathing treatment given as ordered, as needed every 4 hours. Resident continued to request for treatment more than ordered. Responsible party notified. Resident is not in acute distress at this time. Entered by LVN D. - On [DATE] at 3:30 AM: Resident noted unresponsive and no pulse by the side of his bed. Hospice nurse made aware, called placed to resident's daughter (name) and call placed to MD (Medical Doctor), nursing awaits call back. Note was entered by LVN A. - On ,[DATE] at 4:48 AM: Resident family and Hospice nurse at bedside. Note was entered by LVN A Telephone interview with LVN A on [DATE] at 11:07 AM revealed that she gave Resident #1 a PRN breathing treatment during the morning of [DATE] (she could not recall exactly what time) and did not remember if she used a mask or mouthpiece. She stated that the resident had both. LVN A stated that Resident #1 requested the breathing treatment. She stated this happened a long time ago and she did not remember everything that happened that day. LVN A stated she assessed the resident before she provided the treatment. She stated she removed Resident #1's nasal cannula (device used to deliver supplemental oxygen or airflow to a patient or person in need of respiratory help), to administer the breathing treatment. She revealed she stayed in the resident's room during the nebulizer treatment, but lights in the hall were going off close by and across the hall from the resident's room so she left to answer them. LVN A stated she could not remember exactly how long she was gone but returned after the treatment was done. She said when she returned to Resident #1's room, she found him unresponsive. She stated she repositioned him back into bed and placed his oxygen back on him, and no pulse was found. LVN A stated she then left the room to get help with resident. LVN A revealed the aide got the other nurse working in hall that morning. She stated she reassessed the resident when she returned to resident's room and no pulse was found. LVN A revealed she found Resident #1 with his legs off the bed with the head of bed elevated and his head over towards the side rails. She revealed she then contacted hospice, the doctor and family. She stated she only gave him the one treatment that night. LVN A stated she was aware that resident had an electronic monitoring sign posted outside his room but was not sure it was recording. When revealed to LVN the length of time the video showed she was gone, LVNA stated she did not think she was gone that long. Review of Resident #1's (MONTH) (YEAR) MAR indicated [REDACTED]. Observation on [DATE] at 1:30 PM of the motioned activated in room video surveillance recording for the morning of [DATE] between the time of 12:27 AM to 3:35 PM (approximately 3 hours timeframe) provided by Resident #1's family revealed the following: - At 12:27 AM Resident #1 sitting on the side of the bed with the head of the bed elevated and the bedside table in front of him. There were several items on the bedside table obstructing complete view of the resident. His television was on. A female staff entered Resident #1's room and asked him what he needed. It was unclear what the resident said due to television noises. She stated the nurse? Okay and left room. - At 12:29 AM A female staff returned to his room, applied gloves and gathered trash off his bedside table and picked up the trash can and left the room. She returned a short time later and put the trash can back and walked to the bathroom. As she walked towards the restroom, she told Resident #1 she got your breathing treatment and then LVN A entered the room. LVNA applied gloves, retrieved the nebulizer mask from the bed and applied the medication to the mask portal. At 12:31 AM, she removed the resident's nasal cannula and applied the breathing treatment mask over the resident's nose and mouth. She then turned on the nebulizer and mist came from the mask. - At 12:33 AM, LVN A was still in the room, moving things around and making sure the nebulizer treatment was going. She then walked out the door. - At 1:25 AM Resident #1 was lying his head on his bedside table in front of him. He had a difficult time lifting his head off the table. The table slid to the side as the resident pushed off it. He was not wearing his nasal cannula, so he was not receiving oxygen at 5LPM. No staff entered the room during this video. - At 1:30 AM the resident was still sitting on the bedside, with arms on table and head hanging over arms. The strap from the nebulizer mask was on his cheeks and around toward the back of his head. He was moving his head from the bedside table to lean towards the bed, appeared to be saying help several times but hard to hear clearly over the television sounds. He was not wearing his nasal cannula, so he was not receiving oxygen at 5 LPM No staff entered his room during this video. Length of this video was 3:09 minutes. - At 1:34 AM Resident #1 was more upright, the nebulizer mask was on his face. He was leaning into the bedside table and rocking the table slightly. A box with items in it fell off the bedside table and hit the floor with a noticeable noise. He was not wearing his nasal cannula, so he was not receiving oxygen at 5LPM. - At 1:49 AM Resident #1 was still wearing his nebulizer mask. He sat up and then leaned/fell back on his bed, lying across the bed. He was able to sit back up after a few moments. He then fell back across his bed again. His breaths were short and deep. His whole chest moved with each breath taken. He sat back up and leaned over the bedside table again. His head appeared to slip off the table and could can be seen hanging between his legs under the table. He lifted his head and then dropped it again between his legs several times. At one point, he sat upright and tried to say something, or took open mouth breaths (sounds unclear). He was not wearing his nasal cannula, so he was not receiving oxygen at 5LPM. No staff entered his room, video length is 3:06 minutes. - At 1:52 AM, 1:59 AM and 2:03 AM: Resident #1 slumped over his bedside table and leaning toward the head of bed. He was moving his head around during these videos. He was not wearing his nasal cannula, so he was not receiving oxygen at 5LPM. No staff entered his room during any of these videos. - At 2:07 AM Resident #1 said help me and help several times. At 1:31 minutes into the video, he hit his bedside table with his fist several times. At the end of the video, he leaned over his legs with his right arm on the bedside table. He was not wearing his nasal cannula, so he was not receiving oxygen at 5LPM. No staff entered the room during this video. Video length was 2:32 minutes. - At 3:35 AM Resident #1 slumped over his legs on the side of the bedside table. His back showed no signs of movement. LVN A entered his room applying gloves and there was another female staff with her in the doorway. LVN A moved the bedside table aside and called out sir. She lifted his right arm, and there was no response from the Resident #1. The female staff stood to the side observing the nurse. LVN A rolled the resident's head onto his bed and picked up the oxygen tubing. She applied the nasal cannula to him. LVN A asked the female staff to get someone (words unclear as to what was said exactly, due to music playing in the background). After applying oxygen to the resident, LVN A moved his legs onto the bed and left the room. A male staff member entered the room, looked at the resident and left. LVN A and the female staff returned to Resident #1's room as the male staff left. LVN A lowered the head of bed slightly and the female staff picked up items from the resident's bed and floor around the side of the bed closest to the restroom. LVN A and the female staff member left the room at 2:32 minutes into the video, approximately 3:37 AM. - At 3:38 AM LVN A and the female staff returned to Resident #1's room with a male staff. The male staff and LVN A went to each side of the resident's bed. The female staff picked items off the floor and placed the resident's urinal in front of the camera blocking the view. The female staff pulled at the bed sheets and picked up items. Unable to see what the other staff were doing with the resident. Staff talked amongst themselves, but the conversation was unclear due to television noise. - At 3:44 AM, 3:45 AM, 3:49 AM, 3:53 AM, 3:58 AM, 4:01 AM and 4:06 AM: The camera was blocked by the urinal. Staff could be seen coming and going from lower corners of the video. The staff conversation was unclear. - At 4:09 AM Staff removed the urinal from in front of the camera and left the resident's room. Resident #1was lying in bed with sheets covering him and the room was straightened. - At 4:20 AM Resident #1's family entered his room with LVN A and female staff. Interview on [DATE] at 10:34 AM with the Interim DON revealed LVN A was terminated due to failure to document the resident's assessment into the Medical Assessment Records (MARs) for the treatment provided. LVN A was terminated on [DATE]. She stated nursing staff should stay with a resident during a nebulizer treatment to monitor the resident. The Interim DON stated that facility policy did not state that staff had to stay in the room with the resident, but facility trained staff to stay and monitor the resident before, during and after treatment. Review of LVN A personnel file revealed Employee Coaching and Counseling Records that reflected the following: On [DATE] revealed violation of substandard work and suspended for failure to document with employee remarks stating breathing tx (treatment) was given to my patient and I wasn't sure for how long, and it was a PRN tx given to him. Approximately ,[DATE] min. There were lights going off on the hall and across from him. Nurse went to answer and came back noted resident removed mask and was not responding. On [DATE] revealed LVN A's remarks reflected, It was an emergency situation and I was coming back to document every care provided to this patient. A message for was left for Resident #1's Hospice nurse on [DATE] at 2:17 PM but no return call was received. A message was left for Resident #1's primary care provider on [DATE] at 9:53 AM but no return call was received. Review of Resident #1's Record of Death, undated revealed Resident #1 expired on [DATE] at 3:35 AM with LVN A present at time of death. The physician was notified on [DATE] at 3:40 AM. Remarks on record revealed hospice nurse was at facility and did all the notifications. Review of the facility's current policy and procedure on Nebulizer Treatment, dated [DATE] and provided by the Interim DON on [DATE] at 2:20 PM reflected: - Administer therapy until medication is depleted, treatment require a minimum of 15 minutes. (Drug.com website: https://www.drugs.com/dosage/[MEDICATION NAME].html revealed usual adult dose for [MEDICAL CONDITION] - Acute . Nebulizer inhalation solution: -2.5 mg three or four times a day by nebulization, over approximately 5 to 15 minutes) - Monitor patient for side effects of treatment (a) Nervousness, (b) [MEDICATION NAME], (c) Hypoventilation/Hyperventilation, (d) Infection, (e) [MEDICAL CONDITION]/>- Monitor heart rate, respiratory rate, and breath sounds before, during and after treatment - Instruct the patient to take slow deep breaths - When treatment is completed instruct the patient to take deep breath and cough, observing the nature of the cough and any sputum produced . - Document treatment in patient's chart . - Documentation: Date and time of treatment, type of treatment ., equipment used for the treatment, duration of the treatment, breath sounds before and after treatment, heart rate and respiratory rate before, during and after treatment . Review of the facility's current policy and procedure on Abuse Protocol, dated (MONTH) (YEAR) reflected: 1. The patient/resident has the right to be free from Abuse, neglect, mistreatment of [REDACTED]. 7. The following definition are provided to assist out Facility's staff members in recognizing incidents of Patient/Resident Abuse: l. Neglect is the failure of the facility, it's employees or service providers to provide goods and services to a Patient/Resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. An Immediate Jeopardy was identified on [DATE] at 7:12 PM. The administrator was notified by telephone because she was not in the facility at the time Immediate Jeopardy was identified and a Plan of Removal was requested at that time. The Plan of Removal was accepted on [DATE] at 12:04 PM and reflected the following steps be taken to remove the immediacy: - Registered Respiratory Therapist is conducting respiratory in-services and skills checks related to facility nebulizer treatment protocol and appropriate monitoring with licensed nursing staff. - The DON and ADON are conducting competency testing, in-servicing and skills checks related to facility nebulizer treatment protocol related to training provided by Registered Respiratory Therapist with licensed nursing staff. The training included appropriate monitoring of nebulizer treatment which revealed monitoring for side effects such as nervousness, [MEDICATION NAME], hypoventilation/hyperventilation, infection and [MEDICAL CONDITION] Process also included monitor heart rate, respiratory rate, and breath sounds before during and after treatment. - All current orders of residents receiving nebulizer treatments have been assessed for physical monitors such as heart rate, respiratory rate, breath sounds and O2 saturation. Review of Personnel Status Form for LVN A revealed a termination date of [DATE] for failure to document accordingly. LVN A's last day worked was [DATE]. Administrator signed form on [DATE]. Interview with the facility's Medical Director on [DATE] at 2:53 PM revealed the facility made him aware of the IJ on the evening of [DATE] at 8:30 PM. He stated that he was not the primary care provider for Resident #1 and was unfamiliar with his care situation. The Medical Director stated that the IJ most likely occurred because the nurse had provided a nebulizer treatment and did not return to assess the resident. Medical Director revealed that the IJ could have been avoided by retraining the staff and monitoring and assessing the residents. During an interview on [DATE] at 3:46 PM, the Administrator revealed I think it (IJ) occurred because we weren't following policies and procedure of nebulizer treatments. The Administrator revealed that to prevent the reoccurrence of the IJ the facility had done extensive training. She stated she had a Registered Respiratory Therapist come and provide comprehensive training on nebulizer treatments and had staff do return demonstrations. The Administrator revealed they reviewed the facility's policies and procedures to make sure everyone understood what was expected. Interview with the Interim DON on [DATE] at 4:48 PM revealed the IJ occurred because of the nurse's actions and the facility was unaware of the situation. She stated the facility was providing in-services to all nurses to prevent a reoccurrence. She stated no nurse would be working the floor without taking the training for nebulizer treatments. The Interim DON revealed the training could be provided by the respiratory therapist, DON or ADON (managers). She stated the Respiratory Therapist would also do quarterly assessments with staff. She revealed she would prefer that the nurse not leave a resident during the nebulizer treatment. She stated there are two nurses were on a unit at all times. During interview with Unit Manager on [DATE] at 10:12 AM revealed the IJ occurred due to staff's carelessness. The Unit Manager stated that to prevent the reoccurrence of the incident, the facility was conducting in-services, talking to staff about skills, covering check off lists by reviewing treatment process and reviewing protocols that staff needed to follow in different situations. Observations on [DATE] at 12:31 PM and 12:55PM and [DATE] at 11:52 AM and 12:10 PM of four nebulizer treatments performed by four different nurses from different halls throughout facility revealed the nurses followed policies and procedures for nebulizer treatments and documentation of treatments. All residents tolerated the procedures well with no adverse reactions. Interviews on [DATE] from between 10:00 AM and 1:30 PM with five Residents #2, #5, #6, #7, and #8 revealed they received nebulizer treatments in the facility. All the residents interviewed felt had no concerns regarding the nebulizer treatments they received. Interviews on [DATE] at 12:45 PM through [DATE] at 3:27 PM with LVNs B, C, and H who worked 6:00 AM to 2:00 PM; Unit Manager D, LVN L, and the ADON who worked on the day shift; LVNs E, J and K who worked 2:00 PM to 10:00 PM; LVNs F and G who worked the 10:00 PM to 6:00 AM shift; and LVN I who worked as needed, revealed that nursing staff received nebulizer training from Respiratory therapist and return demonstration was required for all nursing staff. Staff stated that pulse, respiratory rate, lung sounds, and oxygen saturation needed to be assessed before, during and after each nebulizer treatment. Staff revealed that residents need to be monitored for side effects such as nervousness, [MEDICATION NAME] and [MEDICAL CONDITION] Nursing staff stated that residents need to be observed throughout entire treatment process. On [DATE] the IJ was removed. On [DATE] at 3:52 PM the Administrator, Regional Nurse Consultant, Interim DON and Unit Manager were informed the IJ was removed. While the IJ was removed, the facility remained out of compliance at a severity level of actual harm that is not an IJ and a scope of isolated because the facility was continuing to in-service staff and monitor the effectiveness of the Plan of Removal. The Interim DON provided a list on [DATE] of 9 residents who received nebulizer treatments.