Every finding on record at Paradigm at the Creek

Based on observation, interview, and record review the facility failed to ensure that the services provided or arranged by the facility, as outlined by the comprehensive care plan, were provided by qualified persons in accordance with each resident's written plan of care for 1(Resident #1) of 3 residents reviewed for personal property in that : The facility failed to ensure Van Driver A, who was not trained to handle financial transactions for residents, was requested to accompany Resident #1 to the bank to obtain bank statements.This failure could place residents at risk of not having the right personnel to manage their services. Findings included: Record review of Resident #1's face sheet dated 01/20/2025 revealed he was a [AGE] year-old male admitted with the following diagnoses: dementia (symptoms related to decline in thinking), psychosis(loss of contact with reality-seeing things do not exist, disorganized thinking), depression , (feeling of sadness, loss of interest and emotional problems), encephalopathy( disease that affects the brain leading to confusion and coma) and cellulitis ( bacteria skin infection that causes swelling, redness and pain). Record review of Resident #1's MDS dated [DATE] revealed resident was unable to complete the interview. Section E0800 revealed Resident #1 wanders sometimes. Section GG functional abilities reveal staff sets up prior to the following: eating, oral hygiene, toileting hygiene, shower, upper and lower body dressing, putting and taking off footwear and personal hygiene. Section H0300 revealed resident is occasionally incontinent of urine. Record review of Resident #1's Care plan dated 01/20/2025. Preferred language is Spanish. Goal: Will be able to communicate basic needs. Interventions: Assign bilingual staff members or those who speak the resident's language, include resident's family in communication and translation if able, provide translation through the translation line as needed, use simple language and speak slowly ensuring they are understood. Cognitive impairment. Goal: Needs will be met. Intervention: explain procedures using terms and gestures the resident can understand, repeat information as needed. In an interview with Resident #1 on 08/18/2026 at 11:18 a.m., he was not coherent.In an interview with RN A on 08/18/2026 at 12:06 p.m., she said Van Driver A should be responsible for transporting residents to appointments and other activities. She said the BOM and not the Van Driver should handle finances. In an interview with Van Driver A on 08/18/2026 at 1:37 p.m., she said she was a van driver and appointment scheduler.She said she was asked in June of 2026 by ADM A to take Resident #1 to the bank to request four bank statements. She said she followed instructions but that she knew all facility financial transactions for the residents were and should be handled by the BOM. She said handling financial transactions for the residents was not her job description. She said the BOM gave her Resident #1's ID and told her to look at the account balance because she wanted his account balance to even at $1200. In an interview with RN B on 08/18/2026 at 2:55 p.m., she said it was the responsibility of the BOM to manage the residents' finances. She said the Van Driver being assigned to take Resident #1 to the bank by the ADM and BOM was a wrong assignment. She said she expected the Van Driver to take residents to appointments, assist in scheduling their appointments and help in resident care because she was a certified nurse assistant. In an interview with the DON on 08/18/2026 at 3:20 p.m., she said she expected the Van Driver to take residents to their appointments. She said it was the responsibility of the BOM to handle anything that had to do with funds. If the residents had ID and debit cards, she expected the BOM to be the only staff to have access to those. The DON said if she had to delegate duties, she would not delegate the Van Driver to take Resident #1 to the bank to get bank statements and read them to see the account balance and to have access to the resident's ID. In an interview with ADM A on 08/18/2026 at 5:15 p.m., she said if Resident #1 was not cognitively impaired she expected the ID and debit cards would be with the BOM. She said she expected the Van Driver to be assigned to transportation only. ADM A said she expected the BOM or the SW to accompany the residents to the bank, but primarily the BOM because the BOM had financial responsibility. The BOM knew what questions to ask when it entailed finances. She said the Van Driver should have transported Resident #1 to the bank and the BOM should have met them at the bank to complete the financial transaction which was her job description. In an interview with the SW on 08/18/2026 at 5:32 p.m., [NAME] said anything financial was handled by the BOM. She said if she received an ID or debit card from the residents or their families she handed them to the BOM who locked them up in a safe with other financial documents. She said if a resident had to go to the bank, the BOM would do that or ask her to do so. The SW said she would not hand a van driver a resident's ID to assist them in obtaining bank statements. She said the van driver should be responsible for transportation. In a telephone interview with the RDO on 08/19/2026 at 10:45 a.m., he said Resident #1 was taken to the bank by the Van Driver to get statements. In a telephone interview with ADM B on 08/19/2026 at 9:24 a.m., she said the BOM was responsible for all financial transactions. She said the Van Driver scheduled and took residents to their appointments and expected to complete transportation tasks only. ADM B said she assigned the Van Driver but did not know that the BOM gave her Resident #1's ID to assist with bank transactions. She said if she knew the driver had Resident #1's ID and was going to request statements, she would have asked the BOM to accompany the resident. Record review of facility's document undated and titled: Job Description: Driver - Certified Nurse Aide: Summary/Objective: In keeping with our organization's goals, this position is responsible for transporting residents to and from medical and other appointments in a timely manner. The position is also required to deliver quality daily routine nursing care to residents requiring short-term, skilled, and long-term nursing care, as directed by the supervisor, the facility's policies and procedures, and good nursing judgment. Record review of facility's document undated and titled: Job Description: Business Office Director : Summary/Objective In keeping with our organization's goal of improving the lives of the Resident's we serve, the Business Office Director is responsible for the daily accounting functions of the facility including financial record keeping, billing, and making financial deposits and withdraws from various accounts. This position administers the resident trust fund and petty cash account, provides billing and collection services, and operates the residents' bank.

Based on observation, interviews and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency) in accordance with State law through established procedure. In response to a suspected allegation of exploitation for 1 of 1 resident (Resident #1) reviewed for reporting of abuse and neglect. The facility Van Driver A failed to report a suspected misappropriation of Resident # 1's financial discrepancy that occurred on or about April 2026 to the Administrator. The facility Administrator failed to report a suspected misappropriation of Resident #1's funds to the Ombudsman's office. The Administrator failed to report Resident #1's suspected misappropriation of funds not later than 24 hours to other officials (including the State Survey Agency) in accordance with State law through established procedure. This failure could place residents at risk of continuous ANE violations.Findings included: Record review of Resident #1's face sheet dated 01/20/2025 revealed he was a [AGE] year-old male admitted with the following diagnoses: dementia (symptoms related to decline in thinking), psychosis(loss of contact with reality-seeing things do not exist, disorganized thinking), depression , (feeling of sadness, loss of interest and emotional problems), encephalopathy( disease that affects the brain leading to confusion and coma) and cellulitis ( bacteria skin infection that causes swelling, redness and pain).Record review of Resident #1's MDS dated [DATE] revealed resident was unable to complete the interview. Section E0800 revealed Resident #1 wanders sometimes. Section GG functional abilities reveal staff sets up prior to the following: eating, oral hygiene, toileting hygiene, shower, upper and lower body dressing, putting and taking off footwear and personal hygiene. Section H0300 revealed resident is occasionally incontinent of urine.Record review of Resident #1's Care plan dated 01/20/2025. Preferred language is Spanish. Goal: Will be able to communicate basic needs. Interventions: Assign bilingual staff members or those who speak the resident's language, include resident's family in communication and translation if able, provide translation through the translation line as needed, use simple language and speak slowly ensuring they are understood. Cognitive impairment. Goal: Needs will be met. Intervention: explain procedures using terms and gestures the resident can understand, repeat information as needed. In an interview with Resident #1 on 08/18/2026 at 11:18 a.m., he was not coherent. In an interview with RN A on 08/18/22026 at 12:06 p.m., she said misappropriation of residents' property meant taking a resident's property without their consent. She said Resident #1's suspected missing funds should have been reported immediately to ADM A for investigations to be initiated. RN A said if misappropriation was not reported in a timely manner the incident might continue, and other residents would be affected. In an interview with Van Driver A on 08/18/2026 at 1:37 p.m., she said she was trained to report any suspected abuse, neglect or exploitation to the facility abuse and neglect coordinator who was the administrator. She said she saw a suspicious debit card transaction on Resident #1's bank statement that was collected at HEB groceries store. The Van Driver said she shared this information with the activity manager. She said she did not tell the ADM because the ADM was not trustworthy with incidents that occurred at the facility, as she did not keep them confidential. She said she would henceforth report any suspicious incidents to ADM B. In an interview with the DON on 08/18/2026 at 3:20 p.m., she said if the facility did not report suspected misappropriation to the state office in a timely manner, the facility will receive a violation. She said she learnt of the suspected misappropriation on July 17th, 2026, at night and she notified ADM A the next morning. She said if the reporting was delayed it could affect the residents and the staff. She said if she knew about the suspected misappropriation on the day the Van Driver said it occurred; she would have reached out to ADM A on the same day. The DON said she expected the Van Driver to have reported the alleged misappropriation immediately to ADM A. In an interview with ADM B on 08/18/2026 at 5:15 p.m., she said she expected the Van Driver to have reported her findings to the ADM immediately. She said ADM A should have notified state office within 2 hours before she started the investigations. In a telephone interview with ADM A on 08/19/2026 at 9:24 a.m., she said the Van Driver did not report the alleged misappropriation to her. She said the staff were trained in reporting suspected and actual allegations to her. She said she forgot to report to the Ombudsman office. She said delayed reporting to the appropriate state offices would result to a violation, and act of misappropriation could continue. In a telephone interview with Ombudsman A on 08/19/2026 at 2:48 p.m., she said she expected the facility to notify the Ombudsman's office and state office as well.In a telephone interview with Ombudsman B on 08/20/2026 at 11:15 a.m., she said she expected the facility to notify the Ombudsman's office so the misappropriation could be investigated. Record review of facility's document dated: 10/2024 titled: Policies and Procedures: Abuse, Neglect, and Exploitation (ANE) Prohibition. Policy: The Nursing Facility strictly prohibits abuse, neglect, exploitation, or any mistreatment of residents by anyone at the Facility, including: staff, residents, volunteers, visitors, and others. This policy includes 7 key components: Screening, Training, Prevention, Identification, Investigation, Protection, and Reporting/Response. The Administrator or appointed designee serves as the ANE Prohibition Coordinator, overseeing the policy and investigations. Misappropriation: The deliberate exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Reporting and Response: Do report an incident that does not result in serious bodily injury but that involves misappropriation of resident property immediately, but not later than 24 hours after the incident occurs or is suspected.

Based on observation, interview, and record review, the facility failed to ensure that residents received sufficient supervision to prevent avoidable accidents for 1 (CR#1) out of 5 residents reviewed for accidents. The facility failed to provide sufficient supervision to CR#1 on 7/15/2026 - 7/16/2026 when he eloped at an unknown time through his room window ,from the facility secure unit. CR#1 was not supervised for behaviors of wandering per physician order resulting in elopement.CR #1 was not identified to be missing from the facility until 7/16/2026 at 7:00 am. The failure could place residents at risk for injury, hospitalization, or death. An Immediate Jeopardy (IJ) was identified on 7/23/2026 at 5:59 pm. While the IJ was removed on 7/25/2026, the facility remained out of compliance at a severity level of NO actual harm with potential for more than minimal harm that is not Immediate Jeopardy and a scope of isolated as the facility continued to monitor the implementation and effectiveness of their plan of removal. Findings included:Record review of CR#1's face sheet dated 7/21/2026 revealed he was a [AGE] year-old male admitted to the secure unit of the SNF on 7/10/2026 and discharged to Acute Care hospital on 7/16/2026. Diagnoses included Altered Mental Status, Type 2 Diabetes, Depression, Dementia, Cognitive Communication Deficit, Behavioral Syndrome with Physiological Disturbances and Physical Factors Record review of CR#1's hospital discharge date d 7/10/2026 revealed in part [AGE] year-old male who presented to the hospital with altered mental status. Reported that the patient has been having increasing issues with memory going on for the last 6 months. He is not able to drive and had to move in with family member. was driving and was pulled over. He was noted to be confused with elevated blood sugars and hence brought into the hospital. He had been trying to leave, however had to be medicated. He has been refusing some treatments. Patient had crisis intervention called as he was trying to leave. Record review of CR#1's order summary dated 7/10/2026 revealed an order for Observation: Behaviors. Target Behaviors (wandering, agitation, refusing care) Every shift monitor CR#1 for presence of behaviors and document Yes or No to whether Behaviors were observed. Notify MD as needed for Behaviors. Record review of CR#1's MDS dated [DATE] revealed the resident had severe cognitive impairment with a BIMS score of 7. Record review of CR#1's Care Plan initiated on 7/10/2026 revealed a focus area for behavior revealed in part [CR#1] has episodes of behaviors and is at risk for further increased episodes and injury as evident by. 7/11/2026 removed fire extinguisher from location. 7/16/2026 elopement attempt broke a window to leave the facility without authorization. Goals for CR#1 were to decrease behavioral episodes through behavioral monitoring and interventions through the review date 7/23/2026. Staff interventions included monitor and chart behaviors as they occur and report progress/ decline to MD, monitor resident closely, especially during identified high-risk periods, observe for early warning signs of behavior - approach in a calm manner, call by name, remove from unwanted stimuli. Further review of CR#1's Care Plan initiated on 7/11/2026 revealed a focus area for elopement risk revealed in part [CR#1] is at risk for wandering and elopement. Goal for CR#1 was not to wander outside facility or elope through review date 7/23/2026, as well as [CR#1] safety will be maintained through a structured environment. Staff interventions included conduct frequent checks on the resident, especially during high-risk times, maintain resident safety during increased episodes of wandering, monitor resident's location frequently throughout shift. Record review of CR#1's Skin assessment dated [DATE] revealed CR#1 was assessed by LVN. CR# 1 skin was intact with no new areas identified. Record review of CR#1's SBAR dated 7/16/2026 revealed a Change in Condition of elopement. Further review of CR#1 revealed recommendation of hospital transfer. Further review of CR#1's medication administration record dated 7/15/2026 at 6:00 PM revealed in part Beh. O [Behavior Observation]: NODes [Description]: Y at 1800 (6:00 pm) - Initialed by RN E.Record review of the PIR dated 7/16/2026 revealed CR#1 was identified as missing from the SNF at 7:35am on 7/16/2026. Investigation summary revealed in part The charge nurse called the administrator and notified her that she could not locate the resident (CR#1). The nurse was instructed to initiate the protocol for a missing resident, code orange. The building was checked and police were called. During the building check, it was noted that the resident pushed out the top half of the window, it had been removed. The resident was found by the police less than one mile away outside a local restaurant in the parking lot. The police ran the resident's name and was detained for an open warrant. The resident was brought back to the facility where he was placed under 1:1 supervision for a short time until he could be transferred to an acute care hospital for stabilization. The facility issued a 30-day discharge to the resident/family as the facility will not be able to meet the needs of this resident. Further review of the PIR revealed the Provider Action Taken Post-Investigation was update the care plan and ongoing education as needed, signed by the Administrator on 7/23/2026.Record review of Police Report Health assessment dated [DATE] at 10:52am read in part Patient was brought to jail on an active warrant after reportedly leaving his memory care facility. Per report, the patient was last seen by facility staff at approximately 2200 [10:00 pm] after receiving his scheduled medication. Nursing was informed that the patient has a history of insulin-dependent Type 2 diabetes and reportedly has not received insulin since the previous day . Assessment: Vital Signs: T [temperature] 97.6, Heart Rate 88 beats per minute, Respiratory Rate 18 breaths per minute, Blood Pressure 133/78 . Blood Glucose [Sugar] 219 milligrams per deciliter (unit of fluid volume) [revealed high blood glucose/sugar] . Patient denied pain during assessment . Patient denied oral fluids when offered and stated he was not hungry at the time of assessment . Patient denied having any open wounds . No acute distress observed during this assessmentRecord review of facility's Critical Behavior Monitoring Log dated 7/16/2026 revealed 15-minute checks started at 12:30 pm - 2:15pm completed by ADON with no significant concern.Record review of facility 's Rounding: Visual Resident Checks dated 7/16/2026 revealed CR#1's room was vacant as CR#1 was transferred to hospital. on 7/16/2026 from 6 pm to7/17/2026 12pm. Further review revealed that Rounding: Visual Resident Checks were completed until 7/20/2026 for the secure unit. Rounding Visual Checks Prior to 7/16/2026 were not completed prior to 7/16/2026. Record review of ongoing education in-service dated 7/16/2026 revealed the topic included elopement, Rounds - visual, change of shift - 2 person rounds - on coming to off going, and Abuse Neglect and Exploitation. The policy used during the in-service regarding rounds, visual, and 2 person rounds as well as monitoring and 1:1 supervision was not provided upon email request on 7/21/2026 at 5:22 pm and verbal request on 7/22/2026 at 1:32pm and 7/23/2026 at 12:21pm to Administrator and DON . Record review of CR#1 Progress Note dated 7/16/2026 at 8:09 am by the LVN revealed in part upon making rounds walking around noted resident not in room, checked dining area and noted resident not in dining area, performed a thorough search thorough hallway and rooms and noted window open. DON, Administrator were notified immediately, protocols for missing resident initiated, police were called to perform search, family member aware as well. In an interview on 7/21/2026 at 12:28 pm the ADON said she completed in-services in the past to inform staff who to notify and what to do when residents were not in building. The ADON said there were 2 staff in the locked unit, either a CNA, a medication assistant or the Activities Assistant. The ADON said the purpose of 2 staff in the secure unit was for resident safety. The ADON said monitoring was to round every 2 hours and know residents were safe and staff were to put eyes on residents. The ADON was aware of the CR#1's elopement the morning on 7/16/2026 she came in around 7 am and the LVN and CNA E were attempting to locate CR#1. CR#1 was located at a restaurant before 9 am and was taken to jail due to a warrant and then to the emergency room. The ADON was told by the LVN and CNA E that CR#1 busted through the window in his bedroom and was able to elope from the facility. The ADON said CR#1 was an ex-police officer which was how he managed to get out of the window and told them he would do it again when he returned to the facility after found by the police. The ADON said she was not aware that CR#1 was an elopement risk or had elopement behavior however he was placed in the secure unit for safety and monitoring. In an observation on 7/21/2026 at 12:32 pm with the ADON and CNA E of windows in locked unit revealed room [ROOM NUMBER], 230 and 231 window not CR#1 room, was seen partially peeled from frame at corner of plexiglass window and frame. In an interview on 7/21/2026 At 12:45pm CNA E stated she was present when CR#1 was found to have eloped from his room. CNA E said she completed resident rounds with the LVN present to complete medications on the secure unit. CNA E said she went into CR#1's room at approximately 7:00 am and did not see CR#1. CNA E lifted the blinds and saw the window hanging out in the middle of the frame and flipped. The LVN called the police to report CR#1 was not in the building. CNA E received report from CNA S and was not told CR#1 was not in his room or missing from facility. CNA E said CNA S was called to ask when the last time CR#1 was seen and was told CNA S was not aware that CR#1 was missing and last saw CR#1 at 10 pm on 7/15/2026. CNA E said CR#1 was aggressive and unable to hold complete conversations however they did not get reports of any aggression on 7/15/2026. CNA E said CR#1's room door was closed when she went to complete rounds on 7/16/2026 and CR#1 did not have a roommate. CNA E was not aware of any supervision precautions or interventions in place for CR#1 and did not see him attempt to push out the window before. CNA E said rounds or monitoring of residents was not documented by the CNA's and would report anything verbally to nursing staff. CNA E said there were 2 staff on the secure unit, either a CNA and another staff like an activity assistant or a medication aide. CNA E said residents in the secure unit needed to be redirected all the time due to not knowing where they were and be redirected to their own rooms. In an interview on 7/21/2026 at 2:06 pm the Maintenance Director said the windows in the secure unit were either glass or plexiglass. The Maintenance Director said the plexiglass was a safety precaution due to broken glass in the past when residents hit the window. The Maintenance Director said the plan since the elopement was to change all windows in the secure unit to glass and was given a quote either Thursday 7/16/2026 or Friday 7/17/2026 last week to change the reminding windows. The Maintenance Director said an outside company was to complete the work on the windows. The Maintenance Director said the plexiglass was not broken from CR#1 elopement on 7/16/2026 - 7/17/2026 but was knocked out and slid to the ground outside the unit by CR#1. The Maintenance Director said he walked around and inspected the windows and caulked the windows that were not sealed. The Maintenance Director said he inspected the windows once a month, however did not have written inspection of the windows he inspected when CR#1 eloped. The Maintenance Director said completed inspections like the fire alarm system, water sprinkler system, HVAC (Heating, Ventilation, and Air Conditioning) unit, and security lock were weekly or monthly and entered into the online maintenance system. The Maintenance Director said heat can possibly melt and separate the window from the seal since the window was plexiglass and not glass, in the secure unit and did not believe further maintenance would help seal the plastic over time with the heat and sun. The Maintenance Director said with glass windows there was a better chance of hearing if the window was pounded on or attempted to be opened versus the plexiglass windows just pop out. In an interview on 7/21/2026 at 4:35pm with the LVN said she completed rounds on the secure unit at approximately 7:30am to get the blood sugar from CR#1. The LVN went to CR#1 room then dining room to locate him on the secure unit but was unable to find him when the LVN search in all rooms on the secure unit at 7:30 am. The LVN said she notified the DON and told the DON the window in CR#1's room was broken. The LVN said CR#1's family member informed the facility CR#1 had removed a window before. The LVN said CR#1 did not exhibit any elopement behaviors when he admitted and an assessment was completed on admission. The LVN said the overnight nurse, RN Z, did not inform her that CR#1 eloped when she received report over the phone and was told nothing in particular about CR#1. The LVN said at the end of their shift nursing staff was to account for all residents and have report written down and if anything needed to be communicated to the next shift like orders, or incidents. The LVN said CR#1 was placed on a 1:1 supervision after he was returned to the facility on 7/16/2026 however the LVN was not aware of any interventions prior or documented supervision or monitoring for CR#1. In an interview on 7/22/2026 at 11:25 am CNA F said she was not sure what the facility policy was for rounding on residents in the secure unit however what she did was go room to room and would ask another aide where the resident was if a resident was not present and also get shift report for another aide from the previous shift. CNA F said rounding on the residents was every 2 hours but overnight was every 1 hour for every resident and they documented on an observation paper located in the Administrator's office. CNA F said there was an observation paper on the locked unit, but it was no longer there and did not know where it was, or why it was not used. CNA F said CR#1 would wander the secure unit and would be confused in his speech. CNA F said she was not present when CR#1 eloped but was told he was able to get out of his window and was found at a restaurant. CNA F said the elopement process was to notify the Administrator, the DON and the charge nurse, and they took it from there. CNA F said a statement would be written on where the staff was at the time the resident was able to elope. CNA F said on the secure unit there was supposed to be 2 staff, however, sometimes there was only 1. CNA F said last weekend she was the only staff in the secure unit. CNA F said the DON was aware she was the only staff last weekend on the 7/18/2026 and 7/19/2026 and the DON came to the unit for a brief while then left until another nurse came to the unit the next day to assist CNA F on and off. CNA F did not remember the name of the nurse. CNA F said the secure unit was for residents that were elopement risk or would wander and needed to be monitored for safety. CNA F said 2 staff were needed to be sure enough eyes were on the unit to keep residents safe. An attempted interview on 7/22/2026 at 1:20 pm with overnight RN N by phone. Left a voicemail with call back information. An attempted interview on 7/22/2026 at 1:21pm with overnight RN V by phone. Left a voicemail with call back information In an interview on 7/22/2026 at 1:30 pm the DON said the facility policy for residents with behaviors was to administer medications, involve activities, and redirect. The DON said CR#1 was observed missing about 7am by the LVN. The DON said they searched in every room, notified the police and looked at any businesses in the area like hotels, hospital, until CR#1 was found by the police at a restaurant. The DON said CR#1 was transferred out due to the facility not being able to meet CR#1's needs and CR#1 said I will do it again. The DON said windows on the secure unit were all glass a few years ago before she worked at the facility but they were replaced with plexiglass. The DON said it looked like CR#1 pushed the plexiglass out onto the ground and crawled out of the window. The DON said the Maintenance Director did a sweep on every window to replace them with glass however did not know the condition of the windows. The DON said the plexiglass would not shatter, be heard if kicked or pushed, or cut someone. The DON said she did not look at any other windows and did not know if other windows were loose or not fitted on the secure unit. The DON said the purpose of secure unit was due to residents that wandered or were an elopement risk. The DON said overnight nursing staff completed 2-hour checks on residents and documented the resident status on paper. The DON said the staff on the secure unit was either a nurse, the DON, or a CNA. The DON said she was not aware there was 1 staff on the secure unit recently and said the purpose of 2 staff on the locked unit was due to behaviors in the past. However, the secure unit could be managed with 1 staff now that there were no longer behaviors on the secure unit. In an interview on 7/22/2026 at 6:56pm RN Z said she was the nurse assigned to CR#1 and remembered around 8 pm or 9 pm was the last direct interaction with CR#1, to administer medication. RN Z said CR#1 was standing in the hallway of the secure unit and asked if he was okay. RN Z said CR#1 he was showed her his muscles on his arm and used that gesture to assess his behavior in which she did not see anything unusual with him. RN Z said around 10 pm she was finished and left the secure unit. RN Z said CNA S called her around 12:30am, and said that she needed assistance with a different resident in the secure unit to use the restroom and left the secure unit again. RN Z said in the secure unit there would be 1 CNA that stayed on the unit. Before she left for the day on 7/16/2026, she gave report on any behaviors and did count of the medications however she did not go back to secure unit. RN Z said CNA S did not report any issues to her or concerns other than the 1 resident at 12:30 am to use the rest room. RN Z shift ended at 6:07am and at 7:30am she received a call from the LVN who asked where CR#1 was. RN Z said she told the LVN what she provided during her shift and learned that CR#1 eloped from the facility and was found at a restaurant. RN Z said on the secure unit the staffing was 1 CNA during the day and overnight. RN Z said last year there were 2 staff assigned to the secure unit. RN Z said on the secure unit supervision was for the CNAs to call the nurse station and report any concerns and the nurse would go to the secure unit and assess the situation. RN Z was not sure if rounding on the secure unit was every 1 or 2 hours. RN Z said recently there had been in-services but was not sure about any elopement in-services RN Z said 1 staff would not be enough to monitor all secure unit residents due to wandering and elopement risk. The purpose of the secure unit was for residents with behaviors of elopement and to prevent elopement of residents, provide a safe environment for them and reduce risk of injury with them wandering. RN Z said would have prevented CR#1 from elopement was better monitoring for residents that wandered on the secure unit. In an interview on 7/23/2026 at 8:35 on 7/23/2026 CNA S said she was terminated on the 07/17/2026 due to CR#1's elopement from SNF. CNA S said after snack around 8:30 pm and CR#1 walked up and down halls of the secure unit until 10pm and went to his room. CNA S said CR#1 did not come back out of his room and she assumed he went to sleep. CNA S there were residents that wandered to different rooms and ere to be monitored. CNA S said another resident was wandering in the shower/bathroom area of the secure unit and was busy with him all night. CNA S said she did not check on CR#1 as he did not like to be bothered and assumed he was sleep. CNA S said she had 15 residents on her own in the secure unit and was to make rounds to change the residents' briefs. CNA S said she left the SNF around 6:15am and was called around 8am asking where CR#1 was but she thought he was still in his room sleeping. CNA S said she did not know how she was to monitor CR#1 if she did not check on him throughout the shift. CNA S said she was not trained for the locked unit and the type of people that wandered on the unit. Record review of Resident Care Special schedule and Licensed Nurse schedule dated July 2026 6pm - 6am rotation as scheduled on July 15 - July 16 2026 revealed 3 CNAs including CNA S and 4 Licensed Nurse's including RN Z to assist 4 units of the facility during that shift. In an interview on 7/23/2026 at 12:21pm the Administrator said she was alerted by the LVN at 7:30 am on 7/16/2026 that CR#1 was not found on the secure unit. The Administrator said it was noticed that the window was pushed out of CR#1's room and outside on the ground. The Administrator said the missing resident protocol was initiated and the police were notified. The Administrator said CR#1 was found less than a mile away at a restaurant. The Administrator said the last time CR#1 was seen was 10pm by CNA S and that CNA S told her that CR#1 did not want anyone to go in his room. The Administrator said there was not a policy for rounding/supervision needs and that room rounding was a nursing standard of every 2 hours. The Administrator said the nurses were to follow physician's orders for any special supervision needs. The Administrator said there were 2 people in the secure unit for both shifts and 1 would not be correct staffing. The Administrator said she was not aware of only 1 staff in the secure unit any time recently. The Administrator said the SNF did not have a policy on 2 staff staying in the secure unit however it was implemented since she began at the facility. The Administrator said 2 staff were needed to ensure there was adequate rounding and monitoring of residents in the secure unit. Record review of facility Elopement policy and procedure dated 5/2024 revealed in part Elopement mitigation strategies - The facility will implement the following mitigation strategies: providing the resident with appropriate supervision, completing environmental modifications as needed. Record review of facility Secure Unit policy and procedure dated 1/2026 revealed in part Resident Care - Residents will receive supervision based on assessed needs. Safety - The facility will monitor the environment for safety hazards. Staff Responsibilities - Staff assigned to the secure unit will monitor residents for safety concerns, follow facility policies related to supervision and emergency response. An IJ was identified on 7/23/2026 at 5:59pm with the Administrator, DON and ADON . The IJ template was provided to the Administrator on 7/23/2026 at 5:59pm and a Plan of Removal was requested. The following Plan of Removal submitted by the facility was accepted on 7/24/2026 at 12:48pm 7/23/2026Plan of RemovalF689 Alleged deficient practice: The facility failed to provide sufficient supervision to CR#1 on 7/15/2026 through 7/16/2026 when CR#1 eloped from the facility secure unit. Interventions implemented in response to the elopement:1) CR #1 was found on 7/16/26 approximately 8am. Police Department noted CR #1 had a warrant for his arrest, and CR #1 was taken to the police station. CR #1 returned to the facility from the police station on 7/16/26 around noon. CR #1 was placed on 1:1 observation and was transferred to an inpatient psychiatric hospital on 7/16/26 around 2:15pm.2) The charge nurse completed a head-to-toe assessment, SBAR, pain assessment, BIMS assessment, and elopement assessment on 7/16/2026.3) The Director of Support Services conducted an elopement drill with all staff on 7/16/26 at 2:59pm, staff responded appropriately.4) The Director of Nursing initiated education with all staff on 7/16/26, topics included: elopement policy and procedure, rounding expectations, visual checks of residents, abuse/neglect prohibition. As of 7/23/26 47 staff members received the education. Staff understanding was confirmed through interactive discussion, and question-and-answer sessions.5) The ADON updated/assessed 100% of resident's elopement risk assessments on 7/16/26.6) The investigation identified determined the root cause that the integrity of the window seal was weaker than anticipated, potentially due to prolonged heat exposure and environmental wear. The window was repaired, resealed, and tested to ensure it is secure and functioning properly. The Director of Support Services conducted a 100% audit of all windows, doors, lock screens, and alarms on the secure unit on 7/16/26, and all were secure/functioning properly. The window involved in the incident was immediately repaired, resealed, and secured.7) RN and CNA A [RN Z and CNA S]assigned to the resident on the date of the elopement were suspended pending investigation on 7/16/26; and terminated on 7/20/26 as root cause revealed failure to appropriately round.8) The Administrator, Director of Nursing, Social Worker, and Medical Director held an ad hoc QAPI meeting on 7/16/26 related to the elopement incident.9) The Regional Director of Operations in-serviced the Administrator and Director of Nursing on 7/16/26, topics included: supervision, rounding, and staffing expectations on the secure unit.10) The Administrator submitted the initial self-report to HHSC on 7/16/26 for the elopement incident. Interventions in response to the IJ: The Administrator, Director of Nursing, Medical Director and Regional Nurse Consultant repeated an AD HOC QAPI on 7/23/2026 to review the IJ template and Plan of Removal related to supervision, elopement prevention, secure unit staffing, and rounding expectations. Root Cause Analysis: the two staff members assigned to CR #1's care failed to complete rounding expectations and were terminated. On 7/23/2026, the Regional Nurse Consultant [NAME]-serviced the Administrator and Director of Nursing, topics included: supervision, rounding, and staffing expectations on the secure unit. On 7/23/2026, the Director of Nursing initiated education with licensed nurses, CNAs, activity staff assigned to the secure unit, and any staff who may provide coverage in the secure unit. Topics Include: Elopement Policy (including elopement prevention), personal care delivery (rounding), supervision of residents with wandering/exit seeking behaviors, secure unit staffing expectations, rounding expectations (with visual checks), and following physician orders. Education completion date: 7/24/2026. Staff will complete education prior to working their next shift, and education will be provided in orientation for new hires. On 7/23/2026, the Administrator reviewed the elopement policy, physician's orders policy, and personal care delivery (rounding) policy and no changes were required. Facility AccountabilityFacility leadership will ensure a minimum of two staff members are assigned to the secure unit at all times. Staff will perform routine and ongoing visual rounds of all residents throughout each shift, ensuring resident safety and adherence to physician-ordered interventions. Charge Nurses will ensure adequate coverage during their shifts and report any concerns to leadership immediately. The facility maintains at least two staff members in the secure unit at all times, including weekends and after-hours. If a staff member calls in, the supervisor follows the staffing contingency plan by contacting available nurse manager, supervisor, or designated on-call staff, offering overtime, or reassigning trained staff to ensure continuous two-person coverage. Monitoring of the Plan of Removal included the following: Record review of the QAPI attendance sheet dated 7/16/2026 revealed the Administrator, Director of Nursing, Social Worker and Physician were in attendance. Record review of the facility secure unit window audit dated 7/16/2026 revealed windows were free of cracks, locks were in place, and the frames were intact. Record review of the facility policy titled Personal Care Delivery (CNA) dated 1/2026 revealed a policy detailing providing resident-centered personal care and routine rounding throughout each shift. The procedure detailed General Care Expectations of personal care is provided throughout the shift and is not limited to morning or evening routines, care is individualized based on resident preference, condition, acuity and plan of care. Routine rounding included rounding may occur more frequently based on resident needs, change in condition, safety concerns, toileting needs, or resident request, during rounding staff address resident comfort, safety, positioning, toileting needs, and immediate care request. The scope of Personal Care included maintaining a clean, safe, and organized resident environment. Observation and Reporting included observe for changes in behavior, mood or cognition, and Documentation included CNAs document person care provided in the plan of car or designated CNA documentation sections within online system, CNA documentation is completed each shift and reflects care delivered during the shift. Record review of the facility in-services dated 7/23/2026, topic: supervision of residents with wandering/exit seeking behaviors, secure unit staffing expectations, rounding expectations with visual checks, revealed the DON in-serviced the nursing staff on above the topics. Record review of the facility in-service dated 7/23/2026, topic: Elopement Policies and Procedures (Elopement Prevention), revealed the DON in-serviced the nursing staff on above the topic. Record review of Wander/Elopement Drill dated 7/16/ 2026 at 2:59 pm during 6am - 6 pm shift was conducted by Maintenance Director and Observed by Administrator. Interview and observations on 7/24/2026 and 7/25/2026 from the 1st (6am - 6pm), and 2nd shift (6pm - 6am), of the secure unit revealed two CNAs present on the unit and monitoring of 14 residents. Residents were seen walking up and down the secure unit and CNA redirected residents to the dining area or room. Observation of rounding with off going and oncoming staff of the secure unit visually checked each resident room with residents in rooms or in the dining area during rounds. No concerns were observed during monitoring of the secure unit. Interviews were conducted 7/24/2026 and 7/25/2026 with the Administrator, ADON, DON, CNAs, and nurses from the 1st (6am - 6pm), and 2nd shift (6pm - 6am), to verify the in-services were conducted and to validate the staff understanding of the information presented to them. No concerns were found regarding understanding of requirements, training material and expectations. The above staff interviewed were able to explain elopement prevention and procedure, understanding of rounding and visual requirement of residents, staffing requirements on secure unit, and following physician orders and documentation. The Administrative staff, including the Administrator, ADON, and DON were able to voice how to ensure facility policies were being followed and residents were receiving adequate supervision and care. The Administrator was informed the Immediate Jeopardy was removed on 7/25/2026 at 9:35pm. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety. The facility failed to ensure the handwashing sink #1's garbage receptacle was in good repair with a secure fitting lid and trash liner in the garbage receptacle. The facility failed to ensure food items in the dry storage room were properly stored and labeled with a best by or expiration date. The facility failed to ensure that stored canned goods had uncompromised seals and were free from dents. The facility failed to ensure food items in the walk-in refrigerator included a best by date, an expiration date, were properly stored, sealed, and protected from exposure to air.These failures could place residents at risk for food-borne illness, cross contamination, and infection.During an observation on 07/21/2026 at 8:42 a.m., of the handwashing sink #1's garbage receptacle the following was revealed: handwashing sink #1's garbage receptacles foot pedal failed to lift the lid, when [NAME] A went to throw paper towels away the foot pedal would not open the lid, he used his clean hands to manually open the garbage receptacles lid to throw his paper towels away.handwashing sink #1's garbage receptacles did not have a liner for the disposal of used paper towels.During an observation on 07/21/2026 at 8:44 a.m., in the facility's only kitchen a fly was observed hovering around an uncovered, large trash receptacle, which contained discarded food, plastic wrap, and cardboard debris. The immediate area was unattended, as no kitchen staff were present in the immediate area. In an interview on 07/21/2026 at 8:45 a.m., [NAME] A said that the foot pedal on the handwashing sink #1's garbage receptacle had been broken for quite some time and has not been replaced. He added the handwashing sinks #1's garbage receptacle usually had a plastic liner inside, but he did not know why it was missing. He said he did not see a problem with lifting the lid with his hands because everyone's hands are clean when they lift the lid to throw their paper towels away. During an observation on 07/21/2026 at 8:48 a.m., of the kitchen dry storage room the following was revealed:A tray contained eighteen square pieces of chocolate cake or brownies packed in separate bags, none of which bore an identifying label or date.Toasted corn flakes in a plastic cereal container with a written date of 6/30/2026, there was no best by date.1 plastic container with a tiny, light-tan ring, no identifying label, and no date.2 bags of wide egg noodles, 80 oz., each, no best by date or use by date visible, both bags were half used.1 can of mixed fruit in light syrup 106 oz., a written date of 07/14/2026, with no best by date or use by date and a dent on the bottom seal.1 can of chicken noodle soup 50 oz., a written date of 07/14/2026, with a best by date of 06/14/2028, and a dent on the top left side of can.1 can of chicken noodle soup 50 oz., a written date of 07/14/2026, with a best by date of 06/14/2028, and a dent on the top right side of the can.3 cans of chicken noodle soup 50 oz., a written date of 07/14/2026, with a best by date of 06/14/2028, and a dent on the top left side of both cans.1 can of spaghetti sauce 106 oz., a written date of 07/01/2026, with no best by date, and a large dent on the front middle of the can.During an interview on 07/21/2026 at 9:02 a.m., [NAME] A said inventory duties were performed by whichever staff member was scheduled to work on that specific day. He said that the facility had a policy regarding dented cans, but he was unsure of the specific requirements. While inspecting the spaghetti sauce can, [NAME] A said, the dent is okay, there is no issue using it.During an observation on 07/21/2026 at 9:07 a.m., of the walk-in refrigerator the following was revealed:1 metal serving container filled with an unidentified yellow liquid with a written date of 07/09/2026. The only identifying marker consisted of the letters SG. The container lacked any other labeling and was open to the air.1 package of sliced Swiss cheese, 5 lbs., was half used, with no open date written on the package, the manufacturer's printed best by date was 09/16/2026.1 bag of mozzarella cheese 80 oz., was half used, a written date of 06/16/2026, with no open date written on the package, the manufacturer's printed best by date was 09/06/2026. 1 gallon zipper bag with sliced ham, open to air, with a written open date of 07/03/2026.During an interview on 07/21/2026 at 9:13 a.m., the DM said monitoring dented cans was a shared responsibility among all staff members, although she was ultimately responsible. She said any dented can, regardless of the size of the dent, must be set aside on the designated dented can shelf inside her office. She clarified that the dates on both the toasted cornflakes and the unidentified yellow liquid, which she identified as chicken noodle soup, indicated when those items were opened; but the handwritten dates on the canned goods and the mozzarella cheese were their delivery dates. She said that staff members likely mistook the delivery date on the mozzarella cheese for its opening date, which resulted in the missing label. She said that the failure to distinguish between opening and delivery dates could cause confusion among the kitchen staff. She said that all opened items required a date indicating when the item was opened. She stated that she had written the word soup on the container's plastic wrap the previous evening and was unaware that the marking had rubbed off. She said the handwashing sinks #1's garbage receptacle foot pedal was broken for a long time, so staff opened the lid by hand; she added that she did not realize it was an issue. She said that residents faced risks of botulism from dented cans and severe food poisoning from unlabeled, undated, unsealed, or expired item.In a record review of the facility's Nutrition Services Policies and Procedures policy, dated 08/12/2019, revealed: Subject: Food Safety in Receiving and Storage.Receiving Guidelines.6. Inspect food when it is delivered to the facility and prior to storage for signs of contamination. Food packages shall be in good condition to protect the integrity of the contents so that the food is not exposed to adulteration or potential contaminants. Examples of signs of contamination include:Cans with badly swollen sides or ends, flawed seals or seams, rust, dents, or leaks.7. Check expiration dates and use-by dates to assure the dates are within acceptable parameters.General Food Storage Guidelines.3. Place food that is repackaged in a leak-proof, pest-proof, non-absorbent, sanitary container with a tight fitting lid. Label both the container and its lid with the common name of the contents and the date it was transferred to the new container. It is recommended that food stored in bins (e.g. flour or sugar) be removed from its original packaging.Dry Storage Guidelines.3. Containers holding food or food ingredients that are removed from their original packages such as cooking oils, flour, sugar, herbs, and spices are identified with the common name of the food.Refrigerated Storage Guidelines.12. Refrigerated, ready to eat Time/Temperature Control for Safety Foods (TCS) are properly covered, labeled, dated with a use-by date and refrigerated immediately. [NAME] them clearly to indicate the date by which the food shall be consumed or discarded. The day of preparation or day original container is opened shall be considered day 1. Discard after three days unless otherwise indicated. Refer to Cold Storage Chart.In a record review of the facilities Nutrition Services Policies and Procedures revised 6/2019 revealed: Subject: Waste Disposal.Procedures:.Dispose of waste in closed trash bags.Cover waste containers and close dumpsters at all times. Keep area around refuse dumpsters clean, odor and rodent free.Review of the U.S. FDA Food Code 2022, Chapter 3, 3-501.17 revealed: . Commercially processed foodOpen and hold cold(B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet residents' mental and psychosocial needs, for 5 of 6 residents (Resident #1, Resident #2, Resident #3, Resident #32, and Resident #39) reviewed for care plans.The facility did not develop and implement a comprehensive person-centered care plan to address the discharge plans of Resident #2, Resident #3, Resident #32, and Resident #39.The facility did not address Resident #1's Oxygen treatments via nasal cannula and nebulizer in the care plan This failure could place residents at risk of not having their discharge goals met. Resident #1 Record review of Resident #1's Quarterly MDS dated [DATE] reflected he was an [AGE] year-old male that was initially admitted on [DATE] and again on 05/24/2026. His BIMS score was 03, indicating he was severely impaired cognitively. His active diagnoses included: Cerebrovascular Accident (the sudden loss of blood flow to part of the brain, Transient Ischemic Attack (a mini stroke where blood flow to the brain is briefly blocked.), and dementia. Record review of Resident #1's care plan, dated 06/25/2026 reflected Goal: Respiratory Illness: Resident #1 is at risk for developing viral respiratory illnesses. Resident #1's oxygen treatment via nasal canula was not addressed in his care plan. Record review of Resident #1's MD-A ORDERS reflected an active order dated 07/09/2026 for Oxygen @ 2-3 LPM via nasal cannula continuously. Monitor 02 sat.Active order dated 05/24/2026 by MD-S, admit to Hospice (end of life care)under the care of MD-S directions specified for order 07/14/2026 AT 6:00 PM, Nebulizer Kit Change: Change Nebulizer Kit (mask/mouthpiece, cup, tubing) & Storage Bag Weekly. Date Mask/mouthpiece. Findings included: Resident #1 Record review of Resident #1's Quarterly MDS dated [DATE] reflected he was an [AGE] year-old male that was initially admitted on [DATE] and again on 05/24/2026. His BIMS score was 03, indicating he was severely impaired cognitively. His active diagnoses included: Cerebrovascular Accident (the sudden loss of blood flow to part of the brain, Transient Ischemic Attack (a mini stroke where blood flow to the brain is briefly blocked.), and dementia. Record review of Resident #1's care plan, dated 06/25/2026 reflected Goal: Respiratory Illness: Resident #1 is at risk for developing viral respiratory illnesses. Resident #1's oxygen treatment via nasal canula was not addressed in his care plan. Resident #2 Record review of Resident #2's Face Sheet reflected a 66 years-old male who was re-admitted to the facility on [DATE] with diagnoses including: cerebral infarction (a stroke; when blood supply to part of the brain is blocked or reduced), sepsis (a life-threatening reaction to an infection), toxic encephalopathy (a change in how the brain works due to exposure to a toxic/poisonous exposure), abdominal aortic aneurysm (a bulge in the body's lower main artery), and dementia (a condition that affects memory, thinking, and the ability to perform daily activities). Record review of Resident #2's admission MDS, dated [DATE], reflected Resident #2's overall goal for discharge was to remain in the facility, and active discharge planning was not already occurring for the resident to return to the community. Record review of Resident #2's comprehensive care plan dated 06/11/26 reflected no focus, goals, or interventions were documented for Resident #2's discharge goals. Resident #3 Record review of resident #3's face sheet reflected a 61 years-old female who was re-admitted to the facility on [DATE] with diagnosis including: acute respiratory failure with hypoxia (inability of the body to maintain an adequate blood oxygen level), bipolar disorder (mental health condition causing extreme mood swings), hypertension (blood pushing to forcefully against the artery walls; high blood pressure), and heart failure (the heart cannot pump enough blood to meet the body's needs). Record review of resident #3's admission MDS, dated [DATE], reflected Resident #3's overall goal for discharge was to discharge to the community, and active discharge planning was not already occurring for the resident to return to the community. Record review of resident #3's comprehensive care plan, dated 06/25/26 reflected no focus, goals, or interventions were documented for resident #3's discharge goals. Resident #32 2) Record review of Resident #32's face sheet reflected a 76 years-old female who was admitted to the facility on [DATE] with diagnosis including in part: essential hypertension (high blood pressure not due to another condition), candidiasis, unspecified (yeast infection caused by the Candida fungus), and vascular dementia (changes in thinking and memory when their isn't enough blood flow to part of the brain). Record review of Resident #32's admission MDS, dated [DATE], identified Resident #32's overall goal for discharge was to remain in the facility and that active discharge planning was not already occurring for the resident to return to the community. Record review of Resident #32's comprehensive care plan, dated 06/11/26 reflected no focus, goals, or interventions were documented for resident #32's discharge goals. Resident #39 Record review of Resident #39's face sheet reflected a 80 years-old female who was readmitted to the facility on [DATE] with diagnosis including in part: chronic respiratory failure with hypoxia (not enough oxygen in the blood), chronic obstructive pulmonary disease (ongoing lung condition caused by damage to the lungs), chronic pulmonary edema (an ongoing buildup of fluid in the lungs), and hypothyroidism (the thyroid gland does not release enough hormone into the blood). Record review of Resident #39's admission MDS, dated [DATE], identified Resident #39's overall goal for discharge was to remain in the facility and active discharge planning was not already occurring for the resident to return to the community. Record review of Resident #39's comprehensive care plan dated 06/25/26 reflected no focus, goals, or interventions were documented for Resident #39's discharge goals. During an observation and attempted interview with Resident # 1 on 07/21/2026 at 10:10 AM, he was observed lying in bed and his eyes were partially opened. Resident #1 was not interviewed due to being asleep. In an interview on 07/22/2026 at 2:30 p.m., Resident #3 stated no one had asked her about her discharge plans but that her discharge plans had been, I want to get married, but I don't know what I'm going to do after that. She denied any concerns about her discharge planning. In an interview on 07/22/2026 at 2:40 p.m., Resident #2 stated no one at the facility had asked him about his discharge plans. He stated his plans had been, I don't know. I can't afford anything and I have this catheter. He denied any concerns about his discharge planning. In an interview on 07/22/2026 at 02:48 p.m., Resident #39 stated no one asked her about her discharge plans but that her plan had been to stay here. I know everything here. She denied any concerns about her discharge planning. In an interview on 07/22/2026 at 3:07 p.m., Resident #32 stated that no one at the facility had asked her about her discharge plans. She stated her discharge plans were, I would have to stay here. My [family member] is the only place I could go, and she is taking care of her no-good son. She denied any concerns about her discharge planning. In an interview on 7/22/2026 at 3:10 p.m., LVN A stated that she was the MDS nurse and that the MDS nurse was responsible for completing the comprehensive care plan and that the nurses were responsible for completing the baseline care plan. She stated that residents' plans for discharge were included in the comprehensive care plan when they did have a plan to discharge. Usually if they were just going to be a short stay. She stated that the discharge plans were assessed and placed on every MDS by the Social Worker. She stated that placing the resident's discharge plans on the care plan was important, so we can reference to see what the resident's plans are. In an interview on 07/23/26 at 02:45 p.m., the ADM stated that the comprehensive care plan was the responsibility of the MDS nurse, the DON, and the interdisciplinary team. She stated it was her expectation that the residents' discharge goals were placed on the care plans. She stated it was important for the discharge goals to be on the care plan so that, we know what we are working towards. In an interview on 07/23/26 at 02:50 p.m., the DON stated that the MDS nurse was responsible for the comprehensive care plan. She stated that it was her expectation that resident's discharge goals were placed on the care plan if the resident was a short-term resident. She stated, Long term residents don't have any discharge goals. She stated it was important to place short term residents' discharge goals on the care plans, so we know what they need to meet to be able to go. In an interview on 7/23/26 at 02:55 p.m., the Regional Nurse stated that the facility MDS coordinator was responsible for the comprehensive care plan. She stated it was her expectation that residents' discharge plans were placed on the care plan. She stated it was important for the residents' discharge goals to be on the care plan, so we know what to expect when we discharge the patient. During an interview on 07/23/2026 at 2:05 PM, the ADON stated she was not aware that Resident's #1 care plan didn't address his oxygen and nebulizer treatments. The ADON stated that Resident #1 received continuous oxygen, and the MD ordered nebulizer treatments. She stated it was important for the care plan to address the resident oxygen and nebulizer treatments to prevent treatment and address in his comprehensive individualized plan. Failing to address the goal and treatment could result in respiratory complications. During an interview on 07/23/2026 at 2:08 PM the DON stated she did not know that Resident's #1's care plan failed to include his oxygen treatments. She was aware that oxygen was being administered to the resident continuously. DON stated it was the MDSC's responsibility to ensure care plans were updated to reflect the residents individualized treatments. DON provided a paper copy of Resident #1's care plan later with an unknown date. The care plan addressed Resident #1's oxygen treatments via nasal cannula. A second record review of the EMR revealed the treatments were not addressed in the care plan dated 06/25/26. The DON did not address the risk to the resident in not addressing treatments. During an interview on 07/23/2026 at 4:03 PM the Corporate Nurse (CN) stated that Resident 1 was recently ordered oxygen via nasal cannula and was not updated. She provided no additional information during the interview. Reviewed facility policy titled, Discharge/Transfer dated 06/2024, which stated, Discharge planning will commence upon admission and be updated throughout the resident's stay. A comprehensive discharge plan will be developed collaboratively with the resident, their family or legal representative, the attending physician, and other relevant healthcare providers, addressing post-discharge care needs including medical care, medications, equipment, and community resources. Reviewed facility policy titled, Care Planning dated 06/2019, which stated, It is the policy of this facility the interdisciplinary team shall develop a comprehensive care plan for each resident.

Based on interview and record review, the facility failed to notify the resident and/or resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand and send a copy of the notice to a representative of the Office of the State LTC Ombudsman for 3 of 6 residents (Resident #6, Resident #12, and Resident #40) reviewed for discharge planning. The facility failed to notify the residents or the residents' representative or POA of the transfer or discharge with the reasons for the move in writing in a language and manner they understand for Resident #6, Resident #12, and Resident #40.The facility failed to send a copy of the notice of discharge to a representative of the Office of the State LTC Ombudsman for Resident #6, Resident #12, and Resident #40.This failure could place residents at risk of being discharged without alternative placement, discharge options, their rights to appeal and access to advocacy services. In a record review of Resident #6's quarterly MDS assessment, dated 07/02/2026, revealed a [AGE] year-old female initially admitted to the facility on [DATE] and discharged to the hospital on [DATE]. Her diagnoses included Heart Failure (the heart cannot pump enough blood to meet the body's needs), Cerebrovascular Accident (occurs when blood flow to a part of the brain is interrupted or reduced, depriving brain tissue of oxygen and nutrients), Schizophrenia (persistent psychosis of hallucinations, delusions, and/or disorganized speech), and Cerebral Infarction (when a blood vessel in the brain is blocked or severely narrowed). Resident #6's BIMS score was 11/15, which indicated moderate impairment in cognitive function. Resident #6 required supervision or touching assistance (which meant staff provided verbal cues and/or touching/steadying and/or contact guard assistance as Resident #6 completed the activity) with care.In a record review of Resident #6's progress notes, dated 07/17/2026, revealed that she was discharged to the hospital due to increased behaviors but was expected to return to the facility. There was no evidence that a transfer or discharge notice was provided to Resident #6 in writing or to the State LTC Ombudsman.Attempted interview on 07/21/2026 at 3:13 p.m., with Resident #6's family member, it was unsuccessful, a voice message was left for them to return the call.In a record review of Resident #12's quarterly MDS assessment, dated 06/24/2026, revealed a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. His diagnoses included Hyperlipidemia (high levels of fat in the blood), Rhabdomyolysis (damaged skeletal muscle tissue breaks down rapidly), Protein-calorie malnutrition (life-threatening condition caused by an inadequate intake or absorption of protein, carbohydrates, and fats), Nodular Prostate without Lower Urinary Tract Symptoms (prostate gland is enlarged with non-cancerous, firm bumps), and Alzheimer's Disease (irreversible brain disorder that slowly destroys memory, thinking skills, and the ability to carry out simple tasks). Resident #12's BIMS score was 00/15, which indicated severe cognitive impairment. Resident #12 required partial to moderate assistance (which indicated staff did less than half the effort) with care.In a record review of Resident #12's progress notes, dated 02/22/2026, revealed that he was discharged to the hospital due to lethargy with even and unlabored breathing. There was no evidence that a transfer or discharge notice was provided to Resident #12 in writing or to the State LTC Ombudsman. During an interview on 07/22/2026 at 1:23 p.m., Resident #12 said he remembered going to the hospital but could not remember the reason why. He said that nobody gave him an official letter about what happened, and a written explanation would have helped him understand the reason for his hospitalization.In a record review of Resident #40's quarterly MDS assessment, dated 06/01/2026, revealed a [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE]. His diagnoses included Hypertensive (a severe elevation in blood pressure), Chronic Obstructive Pulmonary Disease (a long-term lung disease that blocks airflow and makes breathing hard), Chronic Kidney Disease (irreversible loss of kidney function), and Mood disorder due to known physiological condition with mixed features (emotional and mood changes stem directly from a physical health problem rather than a primary mental illness). Resident #40's BIMS score was 03/15, indicated severe cognitive impairment. Resident #40 required supervision or touching assistance (which meant staff provided verbal cues and/or touching/steadying and/or contact guard assistance as Resident #40 completed the activity) with care.In a record review of Resident #40's progress notes, dated 04/09/2026, revealed that he was discharged to the hospital due to aggressive behaviors. There was no evidence that a transfer or discharge notice was provided to Resident #40 in writing or to the State LTC Ombudsman.During an interview on 07/22/2026 at 10:23 a.m., Resident #40 said he was sent to the hospital but was unsure of the exact date or the reason. He said that the facility never provided a written letter, explaining that a written notice would have been helpful to remember the dates and the reasons for his hospitalization.During an interview on 07/21/2026 at 3:17 p.m., the SW said she did not provide written transfer or discharge notifications to residents or their representatives, noting that nursing staff sent the residents to the hospital with documentation for the hospital, but she was not aware if any documentation was for the residents. She clarified that she only reported resident names to the LTC Ombudsman when a resident is involuntary discharged .During an interview on 07/23/2026 at 2:29 p.m., the DON said the nursing staff only completed an SBAR and called the resident's responsible party, but they did not provide a written letter to the resident or the responsible party. She said the SW only reported resident names to the LTC Ombudsman for immediate or 30-day discharges, but not on a regular basis.During an interview on 07/23/2026 at 2:34 p.m., the Administrator said the facility did not provide a written letter to the resident or the responsible party, she said she knew a list of resident's needed to be sent to the LTC Ombudsman and added, It's too much to remember and just more (work) for us to do. She said that the lack of written discharge letters posed no negative impact or risk to the residents because nursing staff notified families by telephone, adding that the failure to notify the LTC Ombudsman resulted in no adverse consequences.In a record review of the facility's Discharge/Transfer policy, revised 6/2024, revealed: .Involuntary DischargesThe Facility will obtain orders from the Physician for the involuntary discharge.The discharge planning process will be followed.The resident, the resident's representative (if applicable), and the Long-Term Care Ombudsman Program will receive written notice of discharge at least 30 days before the planned discharge date in a language and manner the resident can understand.The notice will includeThe reason, effective date, and location of the discharge.A statement that informs the resident of his or her rights to appeal the discharge by requesting a hearing through the Health and Human Services Commission (HHSC) within 90 days.Information on how to obtain an appeal form and assistance in completing and submitting it. The statement of appeal rights must:Inform the resident that he or she has the right to appeal the action as outlined in HHSC's Fair and Fraud Hearings Handbook by requesting a hearing within 90 days of the date of the notice.Provide information on how to obtain an appeal form and assistance in completing the form and submitting the fair hearing request.Inform the resident that, if the resident requests the hearing before the discharge date , the resident has the right to remain in the facility until the hearings officer makes a final determination unless failure to discharge would endanger the health or safety of the resident or individuals in the facility.Contact information of the managing local ombudsman and the toll-free number for the Long-Term Care Ombudsman Program, which is [PHONE NUMBER].If applicable, for residents with a mental illness, contact information of the state mental health authority.If applicable, for residents with an intellectual or developmental disability (IDD), contact information for the authority for individuals with IDD, along with the contact information for the agency responsible for the protection and advocacy of individuals with IDD.If applicable, The Facility must document how a failure to discharge a resident would present a danger to the resident or others.The Facility must provide a discharge notice as soon as practicable before the 30 days described above if:The safety of an individual in the facility would be endangered.The health of an individual in the facility would be endangered.The resident's health improves sufficiently to allow a more immediate discharge.The discharge is necessary for the resident's welfare because the resident's needs cannot be met in the facility.The resident has not resided in the facility for 30 days.The Facility should provide as much specific information as possible in the discharge notice to notify the resident why he or she is being discharged and how the discharge meets discharge criteria.All discharge notices and related communications will be documented in the resident's medical record.

Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly for the facility's only dumpster reviewed for garbage and refuse disposal.The facility failed to keep the outside garbage storage area clean.These failures could affect residents by placing them at risk of exposure to germs, disease, and an environment which could attract pests and rodents.During an observation on 07/21/2026 at 9:23 a.m., of the facility's only outside trash dumpster area the following was revealed:More than 3 used medical gloves, a soda can, empty trash liners, and several papers around the outside area of the dumpster stuck to the side of the wooden gate, and on the ground. During an interview on 07/21/2026 at 9:23 a.m., the DM said that refuse collection occurred twice per week, with the upkeep of the dumpster area being a shared responsibility between the kitchen staff and the Maintenance Director. She said the impact of failing to secure trash inside the dumpster could attract various pests, including flies and raccoons.During an interview on 07/22/2026 at 1:23 p.m., the Maintenance Director said trash collection occurred twice per week and that cleaning the surrounding area was shared between himself and the kitchen staff. He said that the scattered debris surrounding the dumpster typically fell from the garbage truck during the emptying process because the drivers would not exit their vehicles to retrieve spilled items. He added that on multiple occasions, he had to walk down the street to collect trash that the garbage truck had dropped.During an interview on 07/23/2026 at 2:34 a.m., the Administrator said that her expectation was for the dumpster area to always remain clean. She said that the Maintenance Director maintained primary responsibility, and any staff member who took trash outside shared the duty to clean up trash around the dumpster. She said she was unaware of the accumulated trash surrounding the dumpster and added that there would be no negative impact to the residents if trash was left outside of the dumpster.In a record review of the facility's Nutrition Services Policies and Procedures revised 6/2019 revealed: Subject: Waste Disposal.Procedures:.Dispose of waste in closed trash bags.Cover waste containers and close dumpsters at all times. Keep area around refuse dumpsters clean, odor and rodent free.Review of the U.S. Public Health Service Food Code, dated 2022, reflected: 5-501.112 Outside Storage Prohibitions. (A) Except as specified in (B) of this section, REFUSE receptacles not meeting the requirements specified under 5-501.13(A) such as receptacles that are not rodent-resistant, unprotected plastic bags and paper bags, or baled units that contain materials with FOOD residue may not be stored outside. (B) Cardboard or other packaging material that does not contain FOOD residues and that is awaiting regularly scheduled delivery to a recycling or disposal site may be stored outside without being in a covered receptacle if it is stored so that it does not create a rodent harborage problem. 5-501.113 Covering Receptacles. Receptacles and waste handling units for REFUSE, recyclables, and returnable(s) shall be kept covered: (A) Inside the FOOD ESTABLISHMENT if the receptacles and units: (1) Contain FOOD residue and are not in continuous use; or (2) After they are filled; and (B) With tight-fitting lids or doors if kept outside the FOOD ESTABLISHMENT.6-501.114 Maintaining Premises, Unnecessary Items and Litter. The PREMISES shall be free of: (A) Items that are unnecessary to the operation or maintenance of the establishment such as EQUIPMENT that is nonfunctional or no longer used; and (B) Litter.

Based on observation, interviews and record reviews, the facility failed to ensure the assessment accurately reflected the resident's status for 2 (Resident #1 and Resident #9) of 3 residents reviewed for accuracy of assessments. The facility staff failed to ensure Resident #1's quarterly MDS dated [DATE] addressed his oxygen and nebulizer treatments in Section O (Special Treatments). The facility staff failed to ensure that Resident #9's MDS dated [DATE] addressed nebulizer treatments in Section O (Special Treatments).This failure could result in Resident missing essential treatments and interventions for care. Resident #1During an observation and interview on 07/22/2026 at 9:45 AM with Resident #1 he was observed lying in bed on his back with Nasal Cannula in his nose. His eyes were open and he reported that he was breathing fine. Resident #1 was very weak and had a soft voice and his speech was difficult to understand, so the interview ended. Record review of Resident# 1's Quarterly MDS dated [DATE] reflected he was an [AGE] year-old male that was admitted on [DATE] and again on 05/24/2026. His BIMS score was 03, indicating he was severely impaired cognitively. Resident has limited mobility and requires staff assistance for all ADLs. Resident #1 uses a manual wheelchair for mobility, and he has impairment in his upper and lower extremities. His active DX included: Cerebrovascular Accident, CVA (the sudden loss of blood flow to part of the brain, Transient Ischemic Attack, TIA (a mini stroke where blood flow to the brain is briefly blocked). Section O: Special Treatments and Procedures, did not address his oxygen and nebulizer treatments. Record review of Resident #1's care plan, dated 06/25/2026 had cognitive impairment.impaired cognition and was at risk for further decline and injury AEB BIMS.communication impairment: He has impaired communication and is at risk for further decline and injury AEB has difficulty with hearing at times, requires extra time with understanding others and making himself understood.Respiratory Illness: Resident #9 is at risk for developing viral respiratory illnesses such as, but not limited to: Covid-19, Influenza (respiratory virus), and RSV (a very common germ that infects the nose, throat, and lungs. It usually causes mild, cold-like signs, but it can turn into a serious lung illness for babies and older adults.)Record review of Resident #1's NP-A orders reflected an active order dated 07/09/2026 for Oxygen @ 2-3 LPM via nasal cannula continuously. Monitor 02 sat.Active order dated 05/24/2026 by MD-S, admit to Hospice (end of life care) under the care of MD-S directions specified for order. An active order dated 07/14/2026 AT 6:00 PM, Nebulizer Kit Change: Change Nebulizer Kit (mask/mouthpiece, cup, tubing) & Storage Bag Weekly. Date Mask/mouthpiece.Resident #9Record review of Resident #9's quarterly MDS dated [DATE] reflected that he had a BIMS score of 06, indicating he was severely impaired cognitively. He uses a manual wheelchair for mobility, and he requires assistance with most ADLs and set up and clean up with meals. DX included Hemiplegia (partial paralysis on 1 side of the body), Asthma/COPD (asthma (long term lung disease), Acute respiratory failure with hypoxia, lungs cannot get enough oxygen in your blood). Resident #1's MDS did not address nebulizer treatments in Section O: Special Treatments and Procedures. Record review of Resident #9's quarterly MDS assessment dated [DATE], did not address his nebulizer treatments in Section O: Special Treatments and Procedures. Record review of Resident #9's care plan dated 06/11/2026 reflected he is at risk for SOB and complication. Monitor for s/sx of acute (sudden, severe, medical change) respiratory insufficiency: Anxiety, Confusion, Restlessness, SOB at rest, bluish color of skin and nails.Respiratory illness: Resident is at risk for developing viral respiratory illness .Monitor resident for signs/symptoms of respiratory illnesses (fever, chills, fatigue, cough, runny nose, headache, among others*).Notify the Physician for new symptom onset of respiratory illnesses and recommend testing for viral respiratory illnesses where appropriate. Monitor/document and report PRN any s/sx of respiratory infection signs/symptoms of respiratory.Notify the Physician (MD) for new symptom onset of respiratory illnesses and recommend testing for viral respiratory illnesses where appropriate.Goal: Residents has Emphysema /COPD (a long-term lung disease that makes it hard to breathe, mainly caused by emphysema, chronic bronchitis, and cigarette smoking.) r/t smoking and is at risk for SOB and complications. Interventions Advair Diskus Aerosol Powder (dry powder inhaler) Breath active 250-50 MCG/ (tiny metric unit) Dose Give aerosol (a tiny mix of solid or liquid particles floating in the air or another gas. ) or bronchodilators (machine that relaxes your muscles.) as ordered. Monitor/document any side effects and effectiveness. ipratropium-Albuterol Solution (liquid medicine that makes breathing easier.) 0.5-2.5 (3) MG/3ML nebulizer as ordered.Record review of Resident #9's MD orders reflected an active order dated 06/04/2026 reflected, Change Nebulizer Kit (mask/mouth cup, tubing) & Storage Bag Weekly. Date Mask/mouth every night shift every Sunday. Active order dated 10/16/2025, reflected document total minutes of direct resident bedside care for nebulized medication administration two times a day for wheezing (whistling sound when breathing.) active order dated 10/18/2025 reflected ipratropium-Albuterol Solution (liquid medicine that makes breathing easier.) 0.5-2.5 (3) MG/3ML 1 vial orally two times a day for COPD.active order dated 10/16/2025 reflected, Observations of post nebulizer treatment: document respirations, and 02 sats, post Nebulizer treatment, assess lung sounds and document follow up: (improved, no change, stable two times a day for wheezing.Active order dated 03/31/2026 reflected Pre-Nebulizer treatment: document respirations and 02 sat, pre nebulizer treatment and assess lung sounds 3: Rales (abnormal crackling in breath) 4: Wheezing (whistling sound made when breathing.)two times a day for COPD. During an observation and interview on 07/21/2026 at 10:30 AM with Resident #9 propelling independently the resident was observed coming down the hall in his wheelchair. Resident #9 stated that he does receive Nebulizer treatments and quickly entered his room shutting the door. Observation revealed Resident #9's nebulizer equipment was stored and bagged appropriately on his nightstand. During an interview on 07/23/2026 at 2:00 PM MDSC stated that the oxygen treatment and nebulizer treatment for Residents #1 and Resident #9 was captured and provided on her computer. A copy was requested via email. Upon receiving the email from MDSC, the MDS for Resident #9's quarterly MDS did not address his nebulizer treatment. In a second record review of both Resident #1 and Resident #9's Quarterly MDS, reflected no documentation addressing their special treatments for oxygen and nebulizer treatment. During an interview on 07/23/2026 at 2:05 PM ADON stated she was not aware that Resident #1 and Resident #9's MDS did not address oxygen and nebulizer treatments. She stated that Resident #1 receives continuous oxygen and Resident #9 receives Nebulizer treatments at night. ADON stated that MDS assessments should be accurate and address all resident treatments and care needs. She said failure to capture the treatments could result in the resident not receiving respiratory treatments. During an interview on 07/23/2026 at 2:08 PM with DON stated she was not aware that Resident #1 and Resident #9's MDS did not address oxygen and nebulizer treatments. She stated that both residents receive respiratory treatments for illnesses related to breathing and complications. She stated it was the MDSC responsibility to ensure accuracy in assessments. DON said failure to capture the treatments could result in the resident not receiving respiratory treatments. An attempted interview on 07/23/2026 at 3:30 PM with the Resident #9's legal guardian was unsuccessful, and a message was left to return call. During an interview on 07/23/2026 at 4:00 PM ADM, stated I don't know anything about MDS. She provided no response. 1)Record review of facility policy titled Minimum Data Set Policy, dated June 2019 reflected the following: Review the resident's medical record. This review may include pre-admission activities. Identify2)resident's status, care and services rendered during the Observation Period for the current assessment. Review is to include, but not be limited to: pre-admission, admission, and transfer notes; current plan of care, physicians orders, progress notes, history and physical; nursing, dietary, activity, social service, and therapy notes and assessments; monthly summaries, lab and x-ray reports, consultations, medication administration records, and treatment administration records.3)4)If a Care Area Assessment (CAA) is triggered, the facility will further assess the resident to determine whether the resident is at risk of developing or currently has a weakness or need associated with that CAA, and how the risk, weakness or need affects the resident. Supplemental information must be gathered and analyzed by the facility based on the triggered CAAs prior to developing the comprehensive care plan. Documentation of the facility's rationale for deciding whether or not to proceed with care planning for each area triggered is recorded in the medical record. The Facility addresses all risks identified within the context of the MDS assessment, even if they do not cause a CAA to trigger.5)6)Interview, observe and physically assess the resident to obtain validation of items identified on the7)medical record and to collect information for items where no documentation exists. Documentation of8)Review the resident's medical record. This review may include pre-admission activities. Identifyresident's status, care and services rendered during the Observation Period for the current assessment. Review is to include, but not be limited to: pre-admission, admission, and transfer notes; current plan of care, physicians orders, progress notes, history and physical; nursing, dietary, activity, social service, and therapy notes and assessments; monthly summaries, lab and x-ray reports, consultations, medication administration records, and treatment administration records.9)If a Care Area Assessment (CAA) is triggered, the facility will further assess the resident to determine whether the resident is at risk of developing or currently has a weakness or need associated with that CAA, and how the risk, weakness or need affects the resident. Supplemental information must be gathered and analyzed by the facility based on the triggered CAAs prior to developing the comprehensive care plan. Documentation of the facility's rationale for deciding whether or not to proceed with care planning for each area triggered is recorded in the medical record. The Facility addresses all risks identified within the context of the MDS assessment, even if they do not cause a CAA to trigger.10)Interview, observe and physically assess the resident to obtain validation of items identified on the medical record and to collect information for items where no documentation exists. Documentation of

Based on observations, interviews and record review, the facility failed to provide a safe, functional, sanitary and comfortable environment for 1 of 5 residents (Resident #49) reviewed for physical environment and quality of life The facility failed to maintain Resident #49's in-room bathroom resulting in physical deterioration and foul odors, including a urine odor. The floor materials showed visible erosion, the lower wall baseboard was damaged, and the ring seal at the base of the toilet was degraded and/or broken with signs of water. This failure could place residents' health and safety at risk due to frequent exposure to unsanitary environment and diminishing residents' quality of life. Findings include: Record review of Resident# 49's face sheet generated on 7/21/2026 revealed a [AGE] year-old male admitted to SNF on 1/20/2025. Diagnoses included unspecified Dementia (a general diagnosis given when a person has significant mental decline that affects daily life), unspecified Psychosis (symptoms such as hallucinations or delusions however not a clear condition like schizophrenia or bipolar disorder), Metabolic Encephalopathy (a brain function disorder caused by systemic chemical imbalances, organ failure, or vitamin deficiencies) Record review Resident# 49's MDS dated [DATE] revealed a BIMs score of 00 out of 15, indicating cognition impairment. Hearing, Speech and Vision indicated Resident #49 was sometimes unable to make self-understood and sometimes unable to understand others. Functional abilities of self -care revealed the need for set up or clean up assistance with toileting hygiene and toilet transfer. Further review revealed Resident #49 did not have a presence or frequency with rejection of care related to ADL assistance. Record review of Resident# 49's Care Plan as of 7/21/2026 revealed a focus area of Urinary Incontinence related to Cognitive Impairment with staff interventions/ task to remind and assist the resident to use the toilet regularly as indicated/ able. Observation on 7/22/2026 at 11:21am of the secure unit revealed a foul smell of urine. Further observation revealed the in-room bathroom in Resident #49 room had a strong, foul smell of urine upon entrance. The corner of the wall behind the toilet revealed a rubber baseboard was peeled, cracked, exposed and not attached to wall. The base of the toilet revealed liquid. In an interview on 7/22/2026 at 11:25am with CNA F revealed Resident# 49 frequently urinated on the floor of the bathroom near the side of the toilet instead inside the toilet. CNA F said Resident# 49 was difficult to understand and would ramble, however was able to gesture if Resident# 49 needed assistance. CNA F said housekeeping had cleaned the floor and toilet, but the smell of urine had not gone away because the urine was in the floor and wall. CNA F said maintenance was told, but did not remember when, that the floor, wall and toilet needed to be repaired. In an interview on 7/22/2026 at 3:21pm the Maintenance Director said they completed inspections either weekly or monthly for physical environment of the facility including resident rooms. The Maintenance Director said staff submitted work orders in an online system to be completed and tracked by the Maintenance Director. The Maintenance Director said he was told last week, Thursday 7/16/2026 or Friday 7/17/2026, the wall and floor in Resident #49's bathroom needed to be repaired, however, due to time constraints, extent of the repair and other duties assigned the bathroom had not been repaired. The Maintenance Director was not sure if a maintenance request was submitted in the online system. The Maintenance Director said the wall and floor needed repair because Resident #49 would urinate on the floor although housekeeping would clean the bathroom. The Maintenance Director said he was to inform the Administrator that materials needed to be purchased, to repair the damaged floor and wall. Record review of facility policy titled Operation Policies and Procedure. Subject: Environmental: Resident's Room, Resident's Rights dated 6/2019 revealed in part The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. Record review of facility policy titled Maintenance Request dated 1/2025 revealed in part Submitting Request:Staff must submit all maintenance requests through online system or another facility-approved method.Response Time:Emergency Request - Respond immediately (examples: life safety systems, electrical, gas, water, or HVAC failures)High Priority Requests: Respond within 24 hours (examples: equipment affecting resident care, infection control issues)Routine Requests: Addressed within 3-5 business days (examples: minor repairs, cosmetic issues).

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 1 of 4 halls (Hall 100) reviewed for environment.The facility failed to provide a safe and comfortable environment for residents, staff and public by placing items in the hallway. This failure could place residents, staff and public at risk of accidents. Findings included:During an observation on 07/21/2026 at 10:26 AM, there were two plastic trash cans placed on top of a folded blanket in the hallway, which was placed along the wall next to Resident #17's room, used to collect condensation from the air conditioner vent in the ceiling. There was not a wet floor sign near this area. During an interview on 07/21/2026 at 10:30 AM with Resident #17 revealed; he stated the items have been in the hallway ever since he had been in the facility. He stated he did not like them outside his room. During an interview on 07/22/2026 at 1:17 PM, the DON revealed she did not know if there was a risk to the residents for the trash cans and folded towel placed in the hallway outside of Resident #17's room. She indicated that the Administrator needed to be asked. During an interview on 07/22/2026 at 1:18 PM, the Administrator revealed she did not know these items were in the hallway. She stated she did not know the timeframe of the issue or when it would be resolved. When asked about the risk to residents, she did not provide a response and indicated that the maintenance staff needed to be asked.During an interview on 07/22/2026 at 1:20 PM, the Maintenance Director revealed the items were placed in the hallway because there was a current issue with the air conditioning. The items were placed in the hallway on Sunday, 07/19/2026. He stated it was unknown how long the items would remain in the hallway, but a vendor was currently in the building addressing the air condition issue. He stated it was safe to put the items there because if not then there would be water on the floor. He stated he thought there was a wet floor sign to alert residents but was not sure who removed the sign. He stated there was not a risk for the residents because they could walk around it. Record review of the facility's Resident's Room, Resident's Rights policy, revised June 2019, reflected: The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests in 1 of 2 halls (100 and 200) reviewed for pests, and the main dining room. The facility failed to ensure an effective pest control program was implemented to prevent the presence of roaches within Resident #38's restroom. This failure placed residents at risk for foodborne illness and/or disease spread by pests. Findings included: Record review of Resident #38's quarterly MDS dated [DATE] revealed a [AGE] year-old male with an initial admission on [DATE] and re-admitted to the facility on [DATE]. Resident #38 was cognitively intact with a BIMS score of 14. The resident's diagnoses included: cancer, coronary artery disease, heart failure, and hypertension. Record review of Resident # 38's Care plan revealed the resident had an ADL self-care deficit and was at risk for further decline in ADL function and injury. Interventions: Encourage independent function as able, encourage resident to ask for assistance for ADL care as needed. During an interview/observation on 07/21/2026 at 1:40 PM Resident #38 stated he was unhappy because there were roaches in his restroom and he had requested from staff that they treat the restroom to resolve the pests. He stated he suggested various types of at home pest control remedies, such as a brown paste around the outlets. Observation of the resident's restroom revealed evidence of two live roaches once the lights were turned on. They were crawling on the floor and the wall behind the toilet. During an interview on 07/22/2026 at 2:00 PM Resident #38 stated the pest control services came in and sprayed stuff in the restroom, The resident did not believe they were fixing the problems with pest because they were using the same stuff to spray and would have to come back again.During an interview on 07/23/2026 12:16 PM with Housekeeping revealed Resident #38's room was cleaned daily, and she had never seen a roach. She stated pest control was in the building on 07/22/2026 and Resident #38's room was treated for pests. During an interview on 07/23/2026 at 5:04 PM the Administrator stated that she was not aware of an issue with pest control. She stated they encouraged residents to keep their rooms clean to reduce the opportunity for pests in the building. She stated they had pest control that would treat the facility monthly. Record review the pest control log dated 07/21/2026 revealed service would be completed on the first Monday of each month, and the most recent service was completed on 07/21/2026Record review of the Pest Management Service Agreement dated 08/27/2025 revealed the pest control services that addressed both reported and observed site issues and records actions and observations for staff records. Every visit, logbooks were checked and issues were addressed. Treats specific problem areas upon request. Record review of the facility's Pest Control policy, revised June 2024, reflected that .the facility will implement measures to prevent, monitor, and address pest activity in a manner that does not compromise resident safety, infection control, or environmental standards.

Based on observation, interview and record review the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 6 residents (CR #1) reviewed for comprehensive care plans. The facility failed to develop a care plan area for CR #1's hyperammonemia. The facility failed to implement CR #1's care plan interventions related to medication management and behaviors by not administering prescribed routine dosage of lactulose from 5/4/2026 - 5/23/2026 resulting in approximately 57 missed doses. These failures could place residents at risk for unmanaged medical conditions, worsening mental status and behaviors, and a decline in physical and psychosocial well-being. Findings included: Record review of CR #1's facesheet revealed a [AGE] year-old male admitted on [DATE] and discharged to the hospital on 5/23/2026. His diagnoses included: Alzheimer's Disease (progressive, irreversible brain disorder that slowly destroys memory and thinking skills), Major Depressive Disorder (mental health condition that affects a person's mood, thoughts, and ability to participate in normal activities), and Disorder of Urea Cycle Metabolism (condition in which the body cannot properly remove waste ammonia from the blood). Record review of CR #1's admission MDS dated [DATE] revealed a BIMS score of 6 out of 15 indicating severe cognitive impairment. Further review of the MDS revealed behaviors were assessed 0 (not exhibited) in the Behaviors Section. Record review of CR #1's care plan, initiated 3/5/2026, revealed a care area for behaviors: Resident had episodes of behaviors and was at risk for further increased episodes and injury as evidenced by:3/22/26: altercation with another resident, received physical aggression from another resident. Interventions included: Staff intervened immediately, resident removed from situation. Assessed for injuries, skin issues or pain. Provide psych consult as ordered4/24/26: became combative during peri care and kicked a CNA in the foot. Interventions included: Resident redirected and encouraged to allow staff to complete perineal care (the gentle cleaning of the genital and anal area to prevent infection, manage irritation, and promote healing).5/23/26: resident altercation, punched another male resident in the mouth and scratched his hand. Interventions included: Residents separated. Encouraged resident to not get physical, no visible injuries noted to resident. Resident transferred to psychiatric hospital per NP orders.Encourage to attend social activities of preference.Explain procedures using terms/gestures the resident can understand.Give medications as ordered - monitor labs - report results to MD.Monitor and chart behaviors as they occur and report progress/declines to MDObserve for early warning signs of behavior - approach in a calm manner, call by name, remove from unwanted stimuli. Record review of CR #1's care plan, initiated on 3/5/2026 and cancelled on 6/15/2026, revealed no care area addressing risk or development of hyperammonemia (metabolic condition characterized by toxic levels of ammonia in the blood). Record review of CR #1's physician order started on 3/5/2026 and discontinued on 4/29/2026 revealed an order for Lactulose (a synthetic sugar used to lower blood ammonia levels) give 30 ml by mouth three times a day. Record review of CR #1's March 2026 and April 2026 MAR revealed order for lactulose 30ml by mouth three times a day was administered from 3/5/2026- 4/29/2026. Record review of CR #1's progress note by NP A dated 3/24/2026 revealed Staff reports patient had a confrontational behavior with another patient including physical altercation Record review of CR #1's Progress Note by NP B dated 4/27/2026 revealed 12:17 pm PMHNP received a call from DON who states that resident kicked staff twice today. DON states that resident has been displaying verbal/physical aggression towards others for several days now. PMHNP ordered Depakote (prescription medication primarily used to treat epilepsy, prevent migraine headaches, and manage the manic phase of bipolar disorder) 125mg 1 tablet po BID for Mood Disorder, Ammonia and Valproic Acid level (labs testing levels of Ammonia and Valproic Acid in the blood, Valproic Acid can elevate blood ammonia levels) in the AM and every 6 months (October/April) thereafter. Record review of CR #1's Behavioral Health Solution Diagnostic Assessment by LP dated 4/27/2028 revealed Patient is a 68-yr-old Caucasian male who presents with symptoms of depression and withdrawal. Patient also appears to have some moderate memory loss and confusion and his chart indicates a history of being combative with staff when providing care or refusing ADL's. He was referred following an altercation with another resident, Record review of CR #1's ammonia lab results collected on 4/28/2026 at 9:35 AM and resulted on 4/28/2026 at 11:41 am revealed a high Ammonia level of 51.0 with reference range of 10.0-47.0 ug/dL. Record review of CR #1's progress note by NP A dated 4/28/2026 revealed, F/U status of chronic conditions including, Behaviors, elevated ammonia. Staff reports patient has elevated ammonia and he will receive increased lactulose, he had combative behavior with altercation with a staff member, usually patient is calm and cooperative, guardian reports patient has not had behaviors at the other facility, another patient had an altercation with him Further review of progress note revealed Urea cycle metabolism disorder/hyperammonemia - Chronic illness poses a threat to bodily function-start increase lactulose x 3 days then continue lactulose previous dosage. Record review of CR #1's progress noted dated 4/29/2026 at 5:06 pm by LVN A revealed, received new order to increase lactulose for 3 days due to elevated ammonia level and to collect urinalysis due to increased behaviors Record review of CR #1's physician order by NP A started on 4/29/2026, revealed an order for lactulose 45ml by mouth three times a day for 3 days. Record review of CR #1's April 2026 and May 2026 MAR revealed order for lactulose 45ml by mouth three times a day for 3 days was administered from 4/30/2026 - 5/3/2026. Further review of May 2026 MAR revealed no lactulose was administered from 5/4/2026 - 5/23/2026. Record review of CR #1's Chronic Care Management (CCM) note by NP A dated 4/30/2026 revealed, CCM Activity Log 4/1/2026 Coordination of Care with Community Provider - Notes: patient .also has issues with elevated ammonia currently treated with lactulose. Record review of CR #1's progress note by NP A dated 5/21/2006 revealed History - F/U status of chronic conditions including elevated Ammonia, agitation and confrontational behavior, Staff reports patient was transferred from another facility due to his behaviors, he is at high risk for increased agitation and confrontational behavior with staff and patients, he is calm and cooperative, he had a slightly elevated ammonia level and he was given lactulose. Further review of Progress Note revealed Assessment & Plan - Urea cycle metabolism disorder/hyperammonemia- Chronic illness poses threat to bodily function- continue lactulose. Record review of CR #1's progress note dated 5/23/2026 at 9:36 am by LVN A revealed, Med Aid called for nurse stating overheard resident cursing at male resident and by the time cma was able to get to residents, resident was physical with male resident, cma had redirected resident to dining room at this time, both residents separated. resident unable to state what happened and denied getting physical. encouraged resident to not get with physical, no visible injuries noted to resident, resident in dining room at this time. don and administrator aware, np made aware, called guardian and left message to call back Record review of CR #1's progress note dated 5/23/2026 at 9:45 am by LVN A revealed, resident placed with one-on-one monitoring Record review of CR #1's Chronic Care Management(CCM) note by NP A dated 5/23/2026 revealed, CCM Activity log 5/7/2026 -discussed patient's worsening behavior, he is confrontational, he has anger management issues, he may need to be transferred to another facility,. his ammonia level was elevated and his lactulose was increased. Record review of CR #1's progress note dated 5/23/2026 at 3:38 pm by LVN A revealed, city ambulance transport in facility to transport resident to psych hospital for aggressive behavior Interview on 6/16/2026 at 12:44 pm, NP A said Resident's ammonia level was found to be high on 4/29/2026 so she gave an order to increase the dose for lactulose for 3 days to address high ammonia level. She said it was written in her progress note the plan was to increase lactulose for 3 days and then continue the regular dose after the 3-day increase. NP A said if it was written in her progress note then that was the verbal order she gave the staff. She stated her expectation was for them to increase lactulose for 3 days and continue the previous dose of lactulose after the increased dose was completed. NP A said she was not aware CR #1 was not receiving lactulose at all from 5/4/2026 - 5/23/2026. She said she did not know the risk associated of him not receiving lactulose or at what point not receiving lactulose would affect him. She was not sure how long it would take for ammonia to build up because he had just received the very high dose. NP A said high ammonia levels could affect CR #1's behaviors. NP A stated there was not a follow-up ammonia lab ordered before CR #1 was discharged to the psych hospital on 5/23/2026. Interview on 6/16/2026 at 4:20 pm, Corporate Nurse said they were addressing CR #1's increased behaviors by target behavior monitoring every shift, side effect monitoring on all the medications, psychotherapy by Psych Services, and metabolic management. The Corporate Nurse stated CR #1 was receiving Lactulose for metabolic management for his ammonia levels. She said high level of ammonia could cause increased behaviors which was why they increased his lactulose for 3 day when lab results showed elevated ammonia levels. The Corporate Nurse was not aware lactulose was not continued after the 3 day increase and said she would have to go check with the staff. Interview on 6/16/2026 at 4:54 pm, MDS Nurse said she created and edits all resident care plans. She said she makes the resident's MDS and it triggers the care areas for the care plan. During morning IDT/staff meetings the team discuss items that may need to be added to care plan. She was not aware of CR #1's urea cycle metabolism diagnosis or that he had increased ammonia levels. She said if she heard about his high ammonia levels she would not necessarily put high lab values on the care plan. She stated the risk of not putting urea cycle metabolism diagnosis in the care plan is that interventions like labs and medications may not be monitored. Interview on 6/16/2026 at 5:59 pm, LVN A said she did not know why she did not hold previous lactulose order and discontinued it. She said she knew the procedure for when a temporary order was given they should place the routine order on hold until the temporary order was finished and then have it set to resume. LVN A said she thought the order to increase lactulose for CR #1 was given over the phone and remembered NP A saying, go ahead and increase the order for 3 days. She said the risk of CR #1 not receiving lactulose was an increase in ammonia levels and possibly in aggressive behaviors. Interview on 6/16/2026 at 6:44 pm, DON said she talked to LVN A, the lactulose 45ml was done for 3 days and his regular dose of 30ml was not resumed after completion of temporary order. DON said if the order the NP gave did not specify to resume regular maintenance dose of lactulose the nurse should clarify the order. DON was not sure why CR #1 was taking lactulose without looking at his records but stated it was probably for encephalopathy. DON said the risk of CR #1 not getting lactulose was his ammonia being high and could affect his behaviors. DON said her expectation is that Care Plans are updated when issues arise or something changes with the residents. DON stated to her knowledge CR #1 was still at the psych hospital and she was not sure of his current condition but stated no adverse effects regarding ammonia levels had been reported back to the facility. Record review of CR #1's discharge summary from the psych hospital dated 6/18/2026 revealed resident had a history of hyperammonemia and noted order for lactulose 20ml by mouth three times and to hold if greater than three bowel movement in 24 hours. Further review of discharge record revealed CR #1 was discharged to a different nursing facility on 6/18/2026 and had no mention of ammonia labs or levels. The discharge noted improvement in CR #1's behavior and becoming stable by the time of discharge after medication adjustments were made. Record review of facility Care Planning policy revised 6/2019 revealed It is the policy of this facility that interdisciplinary team (IDT) shall develop a comprehensive care plan for each resident.

Based on interview and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 6 residents (CR #1) reviewed for medication errors. The facility failed to provide CR #1 with lactulose 30mg three times a day to manage ammonia levels from 5/4/2026 - 5/23/2026 resulting in approximately 57 missed doses. This failure placed residents at risk for elevated ammonia levels which could seriously impair him or cause increased behaviors. Findings include: Record review of CR #1's face sheet revealed a [AGE] year-old male admitted on [DATE] and discharged to the hospital on 5/23/2026. His diagnoses included: Alzheimer's Disease (progressive, irreversible brain disorder that slowly destroys memory and thinking skills), Major Depressive Disorder (mental health condition that affects a person's mood, thoughts, and ability to participate in normal activities), and Disorder of Urea Cycle Metabolism (condition in which the body cannot properly remove waste ammonia from the blood). Record review of CR #1's admission MDS dated [DATE] revealed a BIMS score of 6 out of 15 indicating severe cognitive impairment. Further review of the MDS revealed behaviors were assessed 0 (not exhibited) in the Behaviors Section. Record review of CR #1's care plan, initiated on 3/5/2026, revealed a care area for behaviors: Resident had episodes of behaviors and was at risk for further increased episodes and injury as evidenced by:3/22/26: altercation with another resident, received physical aggression from another resident. Interventions included: Staff intervened immediately, resident removed from situation. Assessed for injuries, skin issues or pain. Provide psych consult as ordered4/24/26: became combative during peri care and kicked a CNA in the foot. Interventions included: Resident redirected and encouraged to allow staff to complete perineal care (the gentle cleaning of the genital and anal area to prevent infection, manage irritation, and promote healing).5/23/26: resident altercation, punched another male resident in the mouth and scratched his hand. Interventions included: Residents separated. Encouraged resident to not get physical, no visible injuries noted to resident. Resident transferred to psychiatric hospital per NP orders.Encourage to attend social activities of preference.Explain procedures using terms/gestures the resident can understand.Give medications as ordered - monitor labs - report results to MD.Monitor and chart behaviors as they occur and report progress/declines to MDObserve for early warning signs of behavior - approach in a calm manner, call by name, remove from unwanted stimuli. Record review of CR #1's physician order started on 3/5/2026 and discontinued on 4/29/2026 revealed an order for Lactulose (a synthetic sugar used to lower blood ammonia levels) give 30 ml by mouth three times a day. Record review of CR #1's March 2026 and April 2026 MAR revealed order for lactulose 30ml by mouth three times a day was administered from 3/5/2026- 4/29/2026. Record review of CR #1's progress note by NP A dated 3/24/2026 revealed Staff reports patient had a confrontational behavior with another patient including physical altercation Record review of CR #1's Progress Note by NP B dated 4/27/2026 revealed 12:17 pm PMHNP received a call from DON who states that resident kicked staff twice today. DON states that resident has been displaying verbal/physical aggression towards others for several days now. PMHNP ordered Depakote (prescription medication primarily used to treat epilepsy, prevent migraine headaches, and manage the manic phase of bipolar disorder) 125mg 1 tablet po BID for Mood Disorder, Ammonia and Valproic Acid level (labs testing levels of Ammonia and Valproic Acid in the blood, Valproic Acid can elevate blood ammonia levels) in the AM and every 6 months (October/April) thereafter. Record review of CR #1's Behavioral Health Solution Diagnostic Assessment by LP dated 4/27/2026 revealed Patient is a 68-yr-old Caucasian male who presents with symptoms of depression and withdrawal. Patient also appears to have some moderate memory loss and confusion and his chart indicates a history of being combative with staff when providing care or refusing ADL's. He was referred following an altercation with another resident, Record review of CR #1's ammonia lab results collected on 4/28/2026 at 9:35 AM and resulted on 4/28/2026 at 11:41 am revealed a high Ammonia level of 51.0 with reference range of 10.0-47.0 ug/dL. Record review of CR #1's progress note by NP A dated 4/28/2026 revealed, F/U status of chronic conditions including, Behaviors, elevated ammonia. Staff reports patient has elevated ammonia and he will receive increased lactulose, he had combative behavior with altercation with a staff member, usually patient is calm and cooperative, guardian reports patient has not had behaviors at the other facility, another patient had an altercation with him Further review of progress note revealed Urea cycle metabolism disorder/hyperammonemia - Chronic illness poses a threat to bodily function-start increase lactulose x 3 days then continue lactulose previous dosage. Record review of CR #1's progress noted dated 4/29/2026 at 5:06 pm by LVN A revealed, received new order to increase lactulose for 3 days due to elevated ammonia level and to collect urinalysis due to increased behaviors Record review of CR #1's physician order by NP A started on 4/29/2026, revealed an order for lactulose 45ml by mouth three times a day for 3 days. Record review of CR #1's April 2026 and May 2026 MAR revealed order for lactulose 45ml by mouth three times a day for 3 days was administered from 4/30/2026 - 5/3/2026. Further review of May 2026 MAR revealed no lactulose was administered from 5/4/2026 - 5/23/2026. Record review of CR #1's Chronic Care Management (CCM) note by NP A dated 4/30/2026 revealed, CCM Activity Log 4/1/2026 Coordination of Care with Community Provider - Notes: patient .also has issues with elevated ammonia currently treated with lactulose. Record review of CR #1's progress note by NP A dated 5/21/2006 revealed History - F/U status of chronic conditions including elevated Ammonia, agitation and confrontational behavior, Staff reports patient was transferred from another facility due to his behaviors, he is at high risk for increased agitation and confrontational behavior with staff and patients, he is calm and cooperative, he had a slightly elevated ammonia level and he was given lactulose. Further review of Progress Note revealed Assessment & Plan - Urea cycle metabolism disorder/hyperammonemia- Chronic illness poses threat to bodily function- continue lactulose. Record review of CR #1's progress note dated 5/23/2026 at 9:36 am by LVN A revealed, Med Aid called for nurse stating overheard resident cursing at male resident and by the time cma was able to get to residents, resident was physical with male resident, cma had redirected resident to dining room at this time, both residents separated. resident unable to state what happened and denied getting physical. encouraged resident to not get with physical, no visible injuries noted to resident, resident in dining room at this time. don and administrator aware, np made aware, called guardian and left message to call back Record review of CR #1's progress note dated 5/23/2026 at 9:45 am by LVN A revealed, resident placed with one-on-one monitoring Record review of CR #1's Chronic Care Management(CCM) note by NP A dated 5/23/2026 revealed, CCM Activity log 5/7/2026 -discussed patient's worsening behavior, he is confrontational, he has anger management issues, he may need to be transferred to another facility,. his ammonia level was elevated and his lactulose was increased. Record review of CR #1's progress note dated 5/23/2026 at 3:38 pm by LVN A revealed, city ambulance transport in facility to transport resident to psych hospital for aggressive behavior. Interview with the NP A on 6/16/2026 at 12:44pm revealed she gave verbal orders to increase CR #1's lactulose for 3 days in response to high ammonia lab and to then continue with his regular dose after of 30mg three times a day. The NP was not aware that he had not been getting the lactulose prior to him being transferred to the psych hospital. The NP stated she was not sure of the risk of CR #1 going without his lactulose for that long. She stated he just had the increased dose of lactulose so it would maybe take a while for ammonia levels to build up and she could not say for certain the impact of not getting the medication would have on him. The NP said some side effects of increased ammonia levels could be increased behaviors or disorientation. Interview with Corporate Nurse 6/15/2026 at 4:40 pm revealed, metabolic management was one of the many interventions being used to address CR #1's behaviors and they were doing this by monitoring his ammonia labs and giving lactulose to control ammonia levels since increased ammonia levels could possibly cause increased behaviors. The Corporate Nurse was not sure why the medication was not being given after he finished the increased dose. Interview with LVN A on 6/16/2026 at 5:59 pm revealed, she received the order to increase CR #1 lactulose for 3 days and said she was aware that he needed to continue his regular dose after. She would typically place the regular order on hold until the temporary order is finished. She could not say why she discontinued CR #1 routine lactulose order and said it was done in accident. She stated she had already been in-serviced by the corporate nurse and DON about the situation and how she needs to enter temporary orders. Interview with the DON on 6/16/2026 at 6:44 pm revealed, LVN A should have entered the temporary increase order for the lactulose and placed his routine dose on hold. The DON said LVN A made an error when she entered to the order into the system. The DON said going forward they will start to review new orders every morning and ensure they have been entered accurately and are being followed. The DON said she was not sure why CR #1 was getting lactulose but stated a side effect of increased ammonia levels could be increased behaviors. Record review of CR #1's Psychiatric Hospital Discharge summary dated [DATE] revealed resident had a history of hyperammonemia and noted order for lactulose 20ml by mouth three times and to hold if greater than three bowel movement in 24 hours. Further review of discharge record revealed CR #1 was discharged to a different nursing facility on 6/18/2026 and had no mention of ammonia labs or levels. The discharge noted improvement in CR #1's behavior and becoming stable by the time of discharge after medication adjustments were made. Record review of the facility Physician Orders policy revised 12/2024 revealed in part, .If an order is received verbally or via telephone: A licensed nurse or authorized staff member must document the order in the medical record immediately. The order must include: Resident's name, Date and time of the order, Specific details of the order, The name and title of the prescribing practitioner. The facility staff must transcribe and verify the order accurately into the medical record. Facility staff are responsible for: Reviewing the order promptly, Ensuring that all orders are correctly implemented within the timeframe specified, Communicating any barriers to implementation to the prescribing practitioner. If clarification is required, the staff member must: Contact the prescribing practitioner for clarification, Document the clarification conversation and any modifications in the medical record.

Based on interview and review the facility failed to report alleged violations of abuse, neglect, exploitation of mistreatment, including injuries of unknown source. Immediately but no later than two hours if the events that cause the allegation involve abuse or result in serios bodily injury for 1 out of 1 incident (Resident # 1) sampled for abuse and neglect.The facility failed to report an unwitnessed fall of Resident # 1 that resulted in a fracture of clavicle.This failure places residents at risk of not receiving complete or accurate investigation of incidents that resulted in emergency services implementing interventions.Findings includedRecord review of Resident # 1 face sheet revealed an [AGE] year-old male with readmission date of 5/24/2026. Diagnoses include pain, age-related osteoporosis (a condition where bones become weak, brittle, and porous due to a decrease in bone mass and density), cellulitis (a common, potentially serious bacterial skin infection) of the lower right limb, acute hematogenous osteomyelitis (a bone infection caused by bacteria that travel to the bone through the bloodstream), osteoarthritis (the most common form of arthritis. It is a degenerative joint disease where the protective cartilage cushioning the ends of the bones gradually wears away), muscle wasting and atrophy (the loss or thinning of muscle tissue, leading to weakness and reduced mass), lack of coordination, adult failure to thrive,Record review of Resident # 1 Care Plan dated 4/22/2026 indicated a risk for spontaneous fracture due to diagnoses of Osteoporosis. Interventions revealed to provide reducing and positioning devices as needed. Goal dated 4/22/2026 indicated Resident # 1 will not experience any spontaneous fractures over the next 90 days. Record review of Resident # 1 progress note dated 5/2/2026 created by LVN C read in part Heard thump and looked up to find Resident # 1 lying on left side of his body on the floor. Rolled Resident # 1 slowly to his back. No bleeding skin tears noted. Reports pain to his left shoulder and head. Alert able to verbally respond to questions appropriately. Resident assisted to wheelchair per 3 persons and returned to bed. NP notified and orders received to send out for CT scan. 911 called for transport. DON notified and POA notified.Record review of x-ray exam dated 5/2/2026 read in part left shoulder: Nondisplaced fracture involving the distal portion of the clavicle without extension to the acromioclavicular joint.Record review of facility Incident by Incident Type list date range 4/15/2026 - 6/15/2026 did not indicate Resident # 1 had an incident. Attempted interview on 6/16/2026 at 3:49 with LVN C left voicemail for call backInterview on 6/16/2026 at 4:00 with RN said she did not see how Resident # 1 fell and was not the nurse monitoring Resident # 1 at that time. Interview on 6/16/2026 at 7:40 pm with DON said Resident # 1 was at the nurses station and RN saw him begin to lean forward and couldn't catch him as she was clocking out. Resident # 1 did not have any devices in place but was going to get a device of cushion to be placed in wheelchair. Fall was witnessed, which was why it was not reported to HHSC. DON said the nurses knew to put pillows in place every time Resident # 1 was in wheelchair or would use a blanket as Resident # 1 did not have good trunk control and would slouch in the chair. DON was not aware of other staff present monitoring Resident # 1 other than RN. Interview on 6/16/2026 at 7:40pm with Administrator said the facility did not need to report Resident # 1 fall because the fall was not a cause of abuse or neglect and was witnessed. Administrator said there were staff around Resident # 1 at the nurses station in his wheelchair. Administrator stated, I have no problem reporting incidents but yall (HHSC) said this was not reportable because we (facility) know Resident # 1 fell from his wheelchair, no one pushed him it was not abuse. Resident # 1 was found on the floor after RN looked up from the nurses station. Record review of facility policy Risk Management- Incidents & Accidents dated 1/2024 read in part The facility will conduct thorough investigations as indicated to determine underlying causes and contributing factors to incidents and accidents; and will put interventions in place from the investigative findings and IDT input. Facility leadership will review reporting requirements and report incidents to the state agency as indicated. The Facility Administrator should determine incidents/accidents that require thorough investigations and ensure completion. Incident logs, history, and trends will be reviewed by the IDT team in QAPI, and Performance Improvement Plans will be implemented as indicated. The facility should follow the policies and procedures referencing the nature of the incident/accident (example: Fall Policy and Procedure or Elopement Policy and Procedure).Record review of facility policy Abuse Neglect and Exploitation dated 4/2024 read in part reporting and Response Type of Incident: Abuse with or without bodily injury, Neglect, Exploitation, or Mistreatment, Injuries of unknown source that result in serious bodily injury

Based on interview and record review the facility failed to conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity for 1 out of 4 (Resident #1) residents reviewed for resident assessmentsThe facility failed to revise Resident # 1 MDS to address cellulites (a common, potentially serious bacterial skin infection)of right lateral foot and right ankle and the intervention of antibiotics. This failure causes a risk to residents not receiving current or updated treatment and monitoring of infections based on MDS triggered Care Plans Area.Findings includeRecord review of Resident # 1 face sheet dated 6/16/2026 revealed an [AGE] year-old male with an original admission date of 8/27/2021readmission date of 5/24/2026. Diagnoses included pain, age-related osteoporosis (a condition where bones become weak, brittle, and porous due to a decrease in bone mass and density), cellulitis (a common, potentially serious bacterial skin infection) of the lower right limb, acute hematogenous osteomyelitis (a bone infection caused by bacteria that travel to the bone through the bloodstream), osteoarthritis (the most common form of arthritis. It is a degenerative joint disease where the protective cartilage cushioning the ends of the bones gradually wears away), muscle wasting and atrophy (the loss or thinning of muscle tissue, leading to weakness and reduced mass). Record review of Resident # 1's hospitalization on 5/14/2026, chief complaint of cellulitis and ulcer on right ankleRecord review of Resident # 1's mobile wound care dated 3/10/2026 - 3/24/2026 indicated not healed cellulitis of right lateral foot and not healed trauma wound of right ankle. Record review of Resident # 1's mobile wound care dated 3/31/2026 - 5/5/2026 indicated not healed trauma wound of right ankleRecord review of Resident # 1's medication order dated 4/3/2026 indicated Doxycycline (antibiotic used to treat bacterial infections) for cellulitis of the right foot for 10 daysRecord review of Resident # 1's MDS dated [DATE] and 5/12/2026 Section M. Skin Conditions, indicated Resident #1 did not have an unhealed pressure ulcer or injury in the last 7 days.Record review of Resident # 1 facility reviewed and completed Care Plan dated 4/22/2026 did not indicate pressure wounds or that Resident # 1 was at risk for further skin breakdown, infections, and worsening of existing pressure wounds. Care Plan indicated resolved cellulitis of lower right limb and antibiotic use dated 2/27/2026. Focus area did not indicate recent diagnosis of cellulites of right lateral foot or trauma wound of right ankle according to physician order date of 3/10/2026 - 3/24/2026 or focus area of antibiotics start date of 4/3/2026. Interventions also did not indicate antibiotic use state date of 4/3/2026.In an interview on 6/15/2026 at 2:16pm, CNA A said Resident # 1 has two wounds on his heel and said wounds on foot have been there since he arrived last year. CNA A said she was not aware of Resident # 1 having any infections and would assume the nurse would tell her that he has an infection that was being treated.In an interview on 6/15/2026 at 4:20 pm, LVN B said Resident # 1 had cellulitis on his foot which was there for months and on his ankle. LVN B said Resident # 1 was on antibiotics for that infection. LVN B said Resident # 1 wound on the foot was no longer infected and pictures were sent to the wound care doctor.In an interview on 6/16/2026 at 1:09 pm, the NP said the wound on Resident # 1's foot was resolved. The NP said cellulitis indicates a red, hot and swollen area that may need antibiotics. The NP said if she wrote an order for antibiotics, it was for the foot. The NP said either the ankle and/or the lateral foot would be addressed with the antibiotic order. The NP said Resident # 1's wound on the foot was to be resolved and the medication order was for the foot either the ankle or lateral foot even if the order read cellulitis of right foot.In an interview on 6/16/2026 at 2:59 pm, the MDS Coordinator said she completed residents care plans by entering information in the MDS assessment and that information would trigger Care Areas focus and interventions. The MDS Coordinator stated information from the morning meetings, progress notes, and physician orders were used to update care areas and MDS assessments when due or a change in condition happens. The MDS Coordinator stated she was not aware Resident # 1 had cellulitis or an infection and was ordered antibiotics in the timeframe of the quarterly MDS. The MDS Coordinator said Resident # 1 had resolved cellulitis care areas in their care plan and previous orders of antibiotics. The MDS Coordinator stated Resident # 1's MDS was coded incorrectly in Section M regarding pressure ulcers or not healing wounds.Record review of the facility policy Nursing Policies and Procedures Subject: Minimum Data Set dated 6/2019 read in part It is the policy of this facility that a registered nurse will conduct or coordinate each assessment with the interdisciplinary team. An MDS, which is a comprehensive, accurate, standardized reproducible assessment will be completed for each resident. Quarterly and Significant Change assessments are completed as required. The facility is responsible for addressing all needs and strengths of each resident. Each staff member will note their liability for the accuracy of the data recorded by signing their name and identifying the MDS sections and questions to which they provided responses.significant change is a major decline or improvement in a resident's status that: Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions and the decline is not considered self-limiting. Impacts more than one area of the resident's health status. Requires interdisciplinary review and/or revision of the care plan.

Based on observations, interviews, and record review, the facility failed to ensure each resident was free from abuse for 1 of 16 residents (Resident #1) reviewed for abuse. Resident #2 was physically abusive to Resident #1 on 3/5/26 when he punched her with a closed fist in the head after which Resident #1 was observed crying and upset. The noncompliance was identified as past noncompliance (PNC). The noncompliance began on 3/5/26 and ended on 3/6/26. The facility corrected the noncompliance before the survey began. These failures placed residents, who resided in the facility, at risk of abuse, pain and emotional distress. The findings included: Resident #1 Record review of Resident #1's admission Record generated on 5/22/26 revealed she was admitted to the facility on [DATE] and had diagnoses of dementia (an umbrella term for a decline in mental ability-such as memory, thinking, and reasoning-severe enough to interfere with daily life), schizophrenia (a chronic brain disorder that disrupts how a person interprets reality. It presents as a combination of hallucinations, delusions, and disorganized thinking), Parkinson's disease (develops when brain cells responsible for producing dopamine die, leading to tremors, muscle stiffness, slow movement, and balance issues) and type II diabetes type (a chronic condition where your body becomes resistant to insulin or cannot produce enough of it). She was [AGE] years old. Record review of Resident #1's annual MDS assessment dated [DATE] revealed she had a BIMS of 7, indicating she had severe cognitive impairment. The assessment indicated that she used a wheelchair for mobility. Record review of Resident #1's Change of Condition progress note dated 3/5/26 revealed Resident #1 was hit by a fist on the right posterior (back or rear) side of her head. Record review of Resident #1's Nursing Note dated 3/5/26 at 1:34pm, LVN A documented that she asked Resident #1 what happened and she said, he was trying to get my coffee, and he hit me in the head ma. LVN A assessed the resident and determined there were no visible injuries and gave Resident #1 two tablets of Tylenol 325mg for pain rated at a 4 .on a numerical scale. The resident was sent to the emergency room for evaluation. Record review of Resident #1's acute hospital records dated 3/5/26 revealed she arrived to the hospital with a complaint of assault/trauma and received patient education regarding physical assault. In an observation and attempted interview on 5/20/26 at 9:45am, Resident #1 was seated in her room in a wheelchair. She could not recall being involved in an altercation with another resident. In an interview on 5/22/26 at 11:29am, when asked how Resident #1 would feel if she were hit by someone at the facility, Resident #1's family member said she would be mad if she were hit. The family member stated Resident #1 may not remember the incident but would remember the way they made her feel. The family member said Resident #1 could state if she liked another person or not. Resident #2 Record review of Resident #2's admission Record generated on 5/22/26 revealed he was admitted to the facility on [DATE] and had diagnoses of dementia with psychotic disturbance, anxiety disorder (a group of treatable mental health conditions that cause persistent, excessive fear or worry that is out of proportion to the situation), paranoid schizophrenia (a chronic mental health disorder characterized by intense paranoia, including delusions of persecution and auditory hallucinations), and schizoaffective disorder (a chronic mental health condition that combines symptoms of schizophrenia, like hallucinations or delusions, with a mood disorder, such as depression or bipolar disorder). He was [AGE] years old. He was discharged from the facility on 3/6/26. Record review of Resident #2's care plan dated 5/15/25 revealed he had the potential to be physically aggressive related to diagnoses of dementia and schizophrenia and had a history of being physically aggressive with other residents on 8/31/25, 9/4/25 and 2/9/25. Interventions included, administer medications as ordered. Monitor/document for side effects and effectiveness.Analyze times of day, places, circumstances, triggers and what de-escalates behavior and document. assess and address for contributing sensory deficits. assess and anticipate resident's needs. encourage activity attendance. when the resident becomes agitated: Intervene before agitation escalates, guide away from source of distress; engage calmly in conversation, if response is aggressive, staff to walk calmly away and approach later. Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed he had a BIMS of 3, indicating he had severe cognitive impairment. The assessment indicated he required supervision or touching assistance for walking and transfers from chair/bed-to-chair and did not use a mobility device. Record review of Resident #2's Change of Condition progress note dated 3/5/26 at 1:07pm, LVN A documented the following: Resident sitting at table stated, 'she tried to seal (sic) my coffee; she is a liar and a thief.' When this nurse asked him what happen (sic), and what was wrong. (sic) Resident asked if he wanted to leave the dining room, he stated 'no.' Nurse redirected resident accepted redirect (sic) and is calm at this time. Other resident involved already moved from altercation prior to nurse entering the unit. Record review of Resident #2's nurse progress note dated 3/6/26 at 10:07am revealed LVN B documented that the DON and Administrator informed the nurse to send resident to the emergency room for further evaluation due to recent physical aggression and increased behaviors. Record review of the Provider Investigation Report dated 3/12/26, under Investigation Summary, it was determined that Resident #2 and another resident were arguing and the Activity Assistant redirected the other resident to his room. Resident #2 turned to Resident #1 and tried to grab her coffee, then Resident #2 grabbed Resident #1's hair. In an interview on 5/22/26 at 9:55am, the Activity Assistant stated on the day of the incident between Resident #1 and Resident #2, Resident #2 was fussing with Resident #3 verbally in the dining room in the memory care unit. She said she removed Resident #3 from the room. She said she could not remember what she saw when she returned to the dining room and said the incident had already happened. She said CNA B was in the dining room when she left. In an interview on 5/22/26 at 10:02am, CNA A said she did not see the incident between Resident #1 and Resident #2, but she was present in the memory care unit. She said after the altercation, Resident #1 was crying and upset and said she was going to file charges. In an interview on 5/22/26 at 10:10am, CNA B, when asked about the incident between Resident #1 and Resident #2, she said she was in the dining room in the mc unit and saw Resident #2 trying to fight with Resident #3 and they were swinging at each other. She said the Activity Director removed Resident #3 from the room. CNA B said, all of a sudden, (Resident #2) went over there and hit (Resident #1). She said she heard Resident #2 hollering, and she ran over to them and that is when Resident #2 hit Resident #1 with a closed fist to the side of her head. She said she removed Resident #2 from the room and reported it to the DON and Administrator. She said Resident #1 was crying. Record review of the facility policy and procedure regarding Abuse, Neglect and Exploitation Prohibition dated 4/2024 stated, The Nursing Facility strictly prohibits abuse, neglect, exploitation, or any mistreatment of residents by anyone at the Facility, including: staff, residents, volunteers, visitors, and others. The facility took the following action to correct the non-compliance on 3/6/26: Record review of Resident #2's progress note dated 3/6/26 at 11:27am revealed Resident #2 returned from the acute care hospital and was placed on one-on-one supervision (continuous patient observation to ensure the safety of at-risk individuals) and behavioral monitoring. Record review of Resident #2's progress note dated 3/6/26 at 2:30pm revealed Resident #2 was accepted to a local behavioral hospital and left the facility using the facility's transportation van. Record review of Resident #2's progress note dated 3/6/26 at 4:42pm revealed Social Services Personnel spoke to Resident #2's responsible party about resident's behavior and 30-day discharge notice. Record review of an Education In-service Attendance Record dated 3/5/26 revealed nursing facility staff were educated on the topic of abuse, neglect, resident-to-resident altercations and behavioral support. Interviews with facility staff, including CNA C, CNA D, CNA E, CNA F, LVN B, Activity Assistant, Staffing Coordinator, and LVN C between 5/20/26 and 5/22/26 revealed they could state what to do if they became aware of an allegation of abuse, neglect and resident-to-resident altercations.

Based on interviews and record reviews, the facility failed to have evidence that the alleged violation was thoroughly investigated in response to allegations of abuse or neglect for 7 of 16 residents reviewed for freedom from abuse and neglect (Residents #1, #4, #5, #6, #7, #9, and #11). The Administrator failed to have evidence that an alleged violation of an injury of unknown origin was thoroughly investigated and included witness statements from staff members when Resident #4 was found to have a fractured toe on 2/26/26. The Administrator failed to have evidence that an alleged violation of abuse was thoroughly investigated and included witness statements from staff members when Resident #1 was hit in the head by Resident #2 on 3/5/26. The Administrator failed to have evidence that an alleged violation of abuse was thoroughly investigated and included witness statements from staff members when there was an allegation that Resident #5 and Resident #6 kicked each other and Resident #6 spilled coffee on Resident #5 on 3/22/26. The Administrator failed to have evidence that an alleged violation of an injury of unknown origin was thoroughly investigated and included witness statements from staff members when Resident #9 was found to have swelling and bruising to his left 4th finger on 3/25/26. An x-ray determined that he had a small bony fragment in the volar middle phalangeal base (the middle bone of your finger). The Administrator failed to have evidence that an alleged violation of abuse was thoroughly investigated and included witness statements from staff members when there was an allegation that Resident #8 hit Resident #7 in the eye on 3/26/26. The Administrator failed to have evidence that an alleged violation of abuse was thoroughly investigated and included witness statements from staff members when there was an allegation that Resident #10 scratched Resident #11 after a verbal altercation on 4/21/26. This failure could place residents at risk for further abuse and neglect and could place the residents at risk of harm. Findings included: Record review of a provider investigation report, HHSC Form 3613-A, dated 3/6/26 indicated Resident #4 had an injury of unknown origin. An assessment on 2/26/26 at 11:45am revealed Resident #4 had swelling on his toe. The Investigation Summary section stated Attach additional sheets, including but not limited to interview summaries with all parties involved in the incident, clinical records, lab and imaging reports. The section was completed and stated, This resident has serious vascular issues which have led him to have several toes amputated, one of which was done recently. Resident has no safety awareness but will propel himself around the facility at times will (sic) bump into objects, walls, and even people. Despite education and redirection resident will still be found moving about the facility. It does appear that this was accidental with the resident's feet being in a more fragile state at this time. The Investigation Findings section of the report stated unfounded. The report was signed by the Administrator. Attached to the investigation report were Resident #4's medical records but did not include any interview summaries or witness statements. Record review of a provider investigation report, HHSC Form 3613-A, dated 3/12/26 indicated on 3/4/26 at 12:50pm in the secure unit dining room, a CNA reported a resident-to-resident incident. The Alleged Perpetrator section was blank. CNA B and the Activity Assistant were listed as witnesses. LVN A assessed Resident #1 on 3/5/26 at 1:45pm and found she had some of her hair pulled out by the aggressor and was sent to the emergency room to rule out internal injuries. The Investigation Summary section stated Attach additional sheets, including but not limited to interview summaries with all parties involved in the incident, clinical records, lab and imaging reports. The section was completed and stated, [Resident #2] and a third resident, were starting to argue when the activities assistant redirected the third resident to his room. [Resident #2] then turned to [Resident #1] and tried to grab her coffee. [Resident #1] refused to give up her coffee so [Resident #2 grabbed her hair and pulled it. The CNA on the unit tried to intervene before contact but was unable to reach him in time. The Investigation Findings section of the report stated unfounded. The report was signed by the Administrator. Attached to the investigation report were Resident #1 and Resident #2's medical records but did not include any interview summaries or witness statements. In an interview on 5/22/26 at 10:10am, CNA B, when asked about the incident between Resident #1 and Resident #2, she said she was in the dining room in the mc unit and saw Resident #2 trying to fight with Resident #3 and they were swinging at each other. She said the Activity Director removed Resident #3 from the room. CNA B said, all of a sudden, (Resident #2) went over there and hit (Resident #1). She said she heard Resident #2 hollering, and she ran over to them and that is when Resident #2 hit Resident #1 with a closed fist to the side of her head. Record review of a provider investigation report, HHSC Form 3613-A, dated 3/29/26 indicated on 3/22/26 at 10:30am, a staff member reported a resident-to-resident altercation that occurred in the hallway. The staff member was not identified. Resident #5 was listed as the alleged perpetrator and did not indicate how the alleged perpetrator was identified. No witnesses were listed. LVN C assessed Resident #5 and Resident #6 and found no injuries. The Investigation Summary section stated Attach additional sheets, including but not limited to interview summaries with all parties involved in the incident, clinical records, lab and imaging reports. The section was completed and stated, [Resident #5] was coming out of the shower when the other was in the hallway just outside the shower. One resident asked the other to move out of the way however it was unclear if this request was heard. Both residents started arguing and then escalated to kicking each other that is when [Resident #6] threw his coffee at [Resident #5]. They were separated and redirected to their respective rooms. [Resident #6] ended up having some seizure activity and was sent out for observation. He was diagnosed with a UTI (a common bacterial infection in the urinary system) and he came back to the facility. Administrator spoke with [Resident #6] and he stated he doesn't know why he acted out and he acknowledged that was not the way he normally acts. It is thought that the UTI contributed to the out of character behavior and the seizures for [Resident #6]. The Investigation Findings section of the report stated unfounded. The report was signed by the Administrator. Attached to the investigation report were Resident #5 and Resident #6's medical records but did not include any interview summaries or witness statements. In an interview on 5/21/26 at 3:00pm, when asked about the incident between Resident #5 and Resident #6, CNA E said she did not witness the incident but saw they were arguing. She said she was in the shower room changing or showering another resident. She said when she left the shower room, she saw Resident #6 had a cup in his hand and Resident #5's shirt was wet. In an interview on 5/21/26 at 3:30pm, when asked about the incident between Resident #5 and Resident #6, CNA F said she did not witness the incident but saw them arguing. She said she was in the shower room with another resident when she left and saw Residents #5 and #6 in the hallway. She said she noticed Resident #5's shirt was wet. She said Resident #5 was kicking at her (CNA F), but not intentionally. Record review of a provider investigation report, HHSC Form 3613-A, dated 4/2/26, indicated on 3/26/26 at 2:30pm, a CNA reported a resident-to-resident incident that occurred in the hallway. The CNA was not identified. Resident #8 was listed as the alleged perpetrator and was identified by description. There were no witnesses listed. Under the assessment section, it stated an assessment was completed on 3/26/26 at 2:45pm, but did not state who completed the assessment. Description of assessment stated, [Resident #7], the receiver of the aggression, reported that [Resident #8] hit him in the eye. [Resident #8] admitted to hitting [Resident #7]. The Investigation Summary section stated Attach additional sheets, including but not limited to interview summaries with all parties involved in the incident, clinical records, lab and imaging reports. The section was completed and stated, [Resident #8] was in the hall trying to get around [Resident #7]. [Resident #8] asked [Resident #7] to move out of the way, and it seems that [Resident #7] possibly did not hear [Resident #8] ask him to move. [Resident #8], according to [Resident #7] pushed past him and simultaneously hit [Resident #7] in the eye. [Resident #7] was assessed for injury and there was none. The Investigation Findings section of the report stated unfounded. The report was signed by the Administrator. Attached to the investigation report were Resident #7 and Resident #8's medical records but did not include any interview summaries or witness statements. Record review of a provider investigation report, HHSC Form 3613-A, dated 4/2/26, indicated on 3/25/26, a staff member reported an injury of unknown origin. The staff member was not identified. There were no witnesses listed. An assessment was completed by LVN C on 3/25/26 at 12:30pm and found Resident #9 had swelling to his left 4th finger and the area was purple in color. The Investigation Summary section stated Attach additional sheets, including but not limited to interview summaries with all parties involved in the incident, clinical records, lab and imaging reports. The section was completed and stated, This resident has been rolling around the facility at times without having any safety awareness. Resident is non verbal and unable to say if he bumped into anything. Initial x-ray showed that there was no dislocation or fracture, yet also said that the volar middle phalangeal base small bony fragment is visualized. The resident was send (sic) out to [local emergency room] for clarification. Second x-ray corroborated appearance of small foreign body. Resident was noted in both reports to have osteoporatic (sic) bones and degenerative changes. The Investigation Findings section of the report stated unfounded. The report was signed by the Administrator. Attached to the investigation report were Resident #9's medical records but did not include any interview summaries or witness statements. Record review of a provider investigation report, HHSC Form 3613-A, dated 4/28/26 indicated on 4/21/26 at 12:00pm, a nurse reported a resident-to-resident incident that occurred in the dining room. Resident #10 was listed as the alleged perpetrator. There were no witnesses listed. An assessment was completed by LVN C on 4/21/26 at 12:15pm and found Resident #11 sustained a skin tear to her left forearm. The Investigation Summary section stated Attach additional sheets, including but not limited to interview summaries with all parties involved in the incident, clinical records, lab and imaging reports. The section was completed and stated, Both ladies arrived into the dining room in anticipation of lunch, when the nurse heard the two ladies arguing. Nurse went to go (sic) into the dining room and noted another nurse was already separating the ladies. During the argument, [Resident #10] struck out at [Resident #11] which resulted in a superficial skin tear. The Investigation Findings section of the report stated unfounded. The report was signed by the Administrator. Attached to the investigation report were Resident #10 and 11's medical records but did not include any interview summaries or witness statements. In an interview on 5/21/26 at 3:30pm, when asked about the incident between Resident #10 and Resident #11, CNA F said she was in the dining room and heard and saw Resident #10 and Resident #11 cussing at each other. She said she did not witness any physical contact. She said the residents were at the dining room table, and someone was trying to tell the other one something, and they started yelling at each other. In an interview on 5/22/26 at 3:00pm, when asked about the incident between Resident #10 and Resident #11, LVN said she was at the nurse's station and could hear Resident #10 and #11 starting to fight verbally. She said she went into the dining room and when the staff were separating the two residents, she saw Resident #10 scratch Resident #11. In an interview on 5/22/26 at 1:07pm, the Administrator stated to complete an investigation of an allegation of abuse or neglect, she spoke to staff and started in-servicing right away. She said if the allegation was a resident-to-resident altercation, she would make sure the residents were separated and start one-to-one supervision to make sure they were safe. She said she interviewed residents to see what happened and put together a story. She said the staff reported who the witnesses were and they would identify the alleged perpetrator. She said for injuries of unknown origin, she determined what happened before the incident and goes off what was documented in the chart. She stated for the incident regarding Resident #10 and #11, she went off what LVN C witnessed. She said she did not remember talking to other staff about the incident. She said there were no witness statements for the incident regarding Resident #8 and #9. She said she could not remember who she spoke to and/or who was present during the incident. She said she remembered that Resident #8 was furious after it happened and he was generally truthful and would not have made it up. She said regarding the injury of unknown origin for Resident #4, she used the results of the x-ray to determine the injury and then determined there was no suspicion of abuse or neglect. She said she spoke to staff who worked with Resident #4 prior to discovery of the injury. She said they looked at his record to determine what happened prior to injury, including to determine if he had any falls. She said there were no incidents reported. She said that when completing the HHSC Form 3613-A, selecting unconfirmed under Investigation Findings indicated that the facility did not abuse or neglect the resident. She said a finding of unconfirmed did not mean that a resident-to-resident altercation occurred, but that the facility did not cause abuse or neglect. Record review of the HHSC website at https://www.hhs.texas.gov/regulations/forms/3000-3999/form-3613-a-snf-nf-icfiid-alf-dahs-including-iss-providers-ppecc-provider-investigation-report-cover accessed on 6/2/26 at 1:37pm revealed the instructions for completing Form 3613-A for skilled nursing facilities and nursing facilities. The Instructions were last updated 4/2024. The instructions read, .Investigation Summary - Summarize the provider's investigative procedures concisely, factually and objectively. Summarize the investigator's analysis of supporting documents, such as interviews, witness statements, injury reports, diagrams, life satisfaction surveys, observations and other appropriate evidence. Clearly state the investigator's conclusion about the allegation and any contributing facility practice(s) and the investigator's recommendation(s). Summarize how the investigator arrived at these conclusions and recommendation(s). Include the name(s) and position(s) of the investigator(s).Facility Investigation Findings - Check the term that best describes the facility's investigation.Confirmed: The allegation is supported by the strength of the evidence that best concurs with reason and probability, for example, the facts are more probably one way than another.Unconfirmed: It is reasonable to conclude the allegation did not occur or is unlikely to have occurred.Inconclusive: There is insufficient evidence to support or refute the allegation.Unfounded: The allegation is untrue or patently without factual basis. Record review of the facility policy and procedure regarding Abuse, Neglect and Exploitation Prohibition dated 4/2024 stated, .Investigation. The Facility will conduct a timely investigation of any alleged abuse/neglect, exploitation, mistreatment, injuries of unknown origin, or misappropriation of resident property. The investigation should include: gathering evidence, interviewing witnesses, conducting surveys as indicated, reviewing medical records, and examining any relevant documentation. The Facility will record all investigation findings, interviews, and actions taken. The Facility will assess gathered evidence to review and determine the extent and nature of the allegation. Investigative findings will be documented on appropriate state forms as applicable.

Based on observation, interview, and record review the facility failed to ensure each resident's environment remained free of accident hazards for 1 of 6 residents (Resident #2) reviewed for accident hazards.The facility failed to ensure Resident #2 had an adequate assistance device in that his wheelchair brake was inoperable, resulting in a fall on 3/10/26. Resident #2 had been using the wheelchair between 3/10/26 and 5/6/26. This failure could place residents at risk for falls, pain and injuries. Findings included:Record review of Resident #2's admission Record generated on 5/6/26 revealed he was admitted to the facility on [DATE] with diagnosis of osteomyelitis (serious infection of the bone, causing inflammation and pain, often triggered by bacteria or fungi. He was [AGE] years old. Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed he had a BIMS of 12, indicating he had moderate cognitive impairment. He used a wheelchair for mobility and required substantial/maximal assistance for chair/bed-to-chair transfers. He weighed 282 pounds. The MDS indicated he did not experience any falls since admission to the facility. Record review of Resident #2's care plan dated 12/5/25 indicated he was at risk for falls and injuries. Interventions included anticipating the resident's needs, encouraging the resident to ask for assistance of staff, encouraging resident to lock wheels prior to transfers and keep frequently used items at the resident's bedside. Record review of Resident #2's nurse progress note dated 3/10/26 at 3:45pm completed by LVN E, it read, cna called for nurse stated (sic) resident on the floor, upon observation noted resident lying on right side in between bed and w/c. resident stated that he was trying to get in bed by himself and the w/c slid from under him and he fell. rom performed to all extremities, no c/o pain or discomfort noted, no visible injuries noted, assisted resident to bed with use of [mechanical] lift and staff x4. Record review of Resident #2's Form Summary Progress Note dated 3/12/26 at 9:18am, the DON documented that an interdisciplinary review of the fall, including circumstances and environmental factors, was completed. The summary stated he was transferring to bed without assistance and there were no environmental or situational factors that contributed to the fall. Educated resident on calling for assistance when transferring- he states he will. In an observation and interview on 5/6/26 at 2:15pm, Resident #2 stated he fell once while self-transferring to his wheelchair from his bed. He said that he did not like his wheelchair because the brakes did not work. He said the wheelchair moved back during the transfer and he fell to the floor hitting his bottom and back, with no injuries or pain. He said the facility staff ordered a wheelchair for him but it was not here yet. He admitted that he transferred himself when he should have asked for staff assistance. Surveyor looked at his wheelchair located next to his bed and observed that the left brake was loose and did not lock the tire. The wheelchair was easily pushed back. In an interview on 5/6/26 at 3:25pm, the Director of Rehabilitation said she attended post-fall IDT meetings where they discussed fall circumstances and look at what they could do to prevent future falls. She said after Resident #2's fall, they evaluated his mattress to see if there were any issues. She said his wheelchair had a broken brake. She said the maintenance staff tried to fix it but was unsuccessful. She said before Resident #2 fell, he complained that his wheelchair was not large enough and had pain in the groin area, so they ordered him a 22-inch chair, but it had not arrived. She said there was no risk to using a chair with a broken brake because Resident #2 knew it was broken and could not get out of bed without staff assistance. In an interview on 5/6/26 at 4:56pm, LVN E said Resident #2's fall in March 2026; he self-transferred and the resident reported his wheelchair slipped from underneath him. She said maybe it slipped due to his weight but could not remember exactly why the wheelchair slipped. In an interview on 5/6/26 at 5:12pm, the DON said in the IDT post-fall meetings, they discussed why a resident fell and implemented new interventions. After Resident #2's fall, they told him not to not transfer by himself. She stated she was aware his wheelchair's brake was broken and they ordered a new wheelchair for him. When asked if someone should use a wheelchair with a broken brake, the DON said that it was hard to answer, but she knew that Resident #2 was not going to self-transfer. Record review of the facility policy regarding Wheelchair Safety: Use and Maintenance dated 6/2019 read, The Facility promotes patient, resident and staff safety through the appropriate use and maintenance of wheelchairs. Evaluate an educate the patient/resident regarding wheelchair use and safety, including but not limited to:. accident prevention: Tipping and falling are the most common wheelchair accidents which can be caused by: e. Propelling he chair too fast. F. Improper use or failure to use brakes/wheel locking devices. Safety Tips: a. Lock brakes before getting into or out of the wheelchair. resident, patients and staff remove equipment from service that is defective or requires maintenance or repair.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (CR#1) of 6 residents reviewed for comprehensive care in that:-The facility failed to ensure CR#1's care plan interventions had not been updated since 2024 despite recent falls including falls with injury. CR#1 had unwitnessed falls on 07/08/25 and another on 07/10/25. CR#1 was transported to the hospital where she was diagnosed with rib fractures and had a chest tube placed.An Immediate Jeopardy (IJ) situation was identified on 8/1/2025 at 3:30pm. While the IJ was removed on 8/4/2025 at 6:45pm, the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of not having their individual medical, psychological and/or emotional needs met. Findings Included: Record review of CR#1's face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. CR#1 had diagnoses which included unspecified psychosis (a mental disorder characterized by a disconnection from reality), insomnia (persistent problems falling and staying asleep), dementia mild with agitation (agitation in dementia refers to a range of behaviors and sometimes aggression by individuals with cognitive decline), cerebral infarction due to embolism (occurs when blood flow to the brain is blocked, causing brain tissue to die) and brief psychotic disorder (a short-term psychotic condition that involves the sudden onset of at least positive psychotic symptom for more than a day but less than a month). Record review CR#1's quarterly MDS, dated [DATE], revealed:Section C500- Brief Interview of Mental Status was coded as 3, which represented severe cognitive impairment.Section GG- Functional Abilities revealed:Mobility devices was coded as Z. NoneGG0130- C. Toileting, E. shower/bath were coded as (3) for partial moderate assistance needed. Upper and lower dressing was coded as (5)- which required setup assistance. Record review of CR#1's care plan, dated 3/23/2024, revealed: Focus: CR#1 has had an actual fall with minor injury.4/17/24- unwitnessed fall in room-bump on left side of head raised area with bruising.6/18/25: CR#1 found on the floor in her room. Date Initiated: 03/23/2024Goal: CR#1 will be free from further falls and injuries over the next 90 days. Date Initiated: 04/17/2024Target Date: 07/01/2025Interventions: 6/18/25: Head to toe assessment completed, noted bleeding from forehead. NP andDON notified. Transferred to ER for evaluation. Date Initiated: 06/18/2025 Check range of motion twice times daily.Date Initiated: 04/12/2024 Continue interventions on the at-risk plan.Date Initiated: 04/12/2024 Floor mat in place at bedsideDate Initiated: 03/23/2024 For no apparent acute injury, determine and address causative factors of the fall.Date Initiated: 04/12/2024 MD to review for sleep aide 6/18/25Date Initiated: 06/18/2025 Monitor for pain and report to MD if pain is noted.Date Initiated: 05/04/2024 Record review of fall assessments revealed:6/18/2025- Score of 20, she was deemed high risk7/10/2025- Score of 11, she was deemed high risk .Record review of nursing progress note dated 6/18/2025 revealed CR#1 was found in her room bleeding from laceration to left eye. CR#1 was sent out to emergency room due to unwitnessed fall and returned the same day with no new orders.Record review of nursing progress note dated 7/8/2025 revealed RN D noted CR#1 had bruising to her left flank. She was assessed and determined from her grimacing she had pain. SBAR was completed due to the change in condition, PRN Tylenol given, NP and RP notified.Record review of nursing progress note dated 7/10/2025 revealed during room checks CR#1 was heard yelling. Upon entrance CR#1 stated, I fell ma'am. Full assessment, vitals taken, PCP and RP notified. PCP instructed nurse to send CR#1 to ER. Bed was observed to be locked in lowered position, call bell in reach and monitored until EMS arrived.Record review of CR#1's hospital record dated 7/11/2025 revealed she was diagnosed with bruising in various stages, fractures on the left 6th-8th ribs, a mildly displaced fracture to the T11-L-1, and left side pneumothorax with chest tube placed.An observation and interview on 7/14/25 at 11:02 AM, with CR#1 revealed the resident had a sitter provided by the hospital who stated CR#1 was trying to get out of bed and she pulled her chest tube out that was why she was sitting with her. She said someone was sitting with her everyday due to behaviors like trying to get out of bed and yelling. CR#1 was observed with a dark purplish bruise to her left eye. She was asked what happened. She responded she was walking through the door and hit her eye. CR#1 was not interview able. An interview with CR#1's RP on 7/11/2025 at 3:50 PM, she said she was called and told CR#1 must have had a fall and was found with a bloody eye sometime in June 2025 and again last week when observed a bruise on her left side. She said the facility sent CR#1 to the emergency room on about 7/8/2025. But, the facility did an x-ray the same day they saw the bruise on her side, and it said she had no fractures on or about 7/9/2025. She said she was still at the local hospital, they said she had broken ribs and a lung collapse. She said she the falls started after CR#1 had multiple strokes. She said prior to coming to the facility, CR#1was having falls at home, and she realized she should be in a facility and not living alone. She said it got better for a while, she returned to the facility and had been doing pretty good. An interview with the Interim DON on 7/15/2025 at 4:01 PM, revealed she had been the Interim DON for about 1 week. She stated that her expectation was care plans were completed at admission, significant changes, quarterly and as needed. She stated that the MDS Coordinator is responsible for ensuring all care plans are accurate and current.An interview with the ADON on 7/15/2025 at 4:01 PM, revealed he had been employed at the facility since April 2025. He stated the care plans were supposed to be done when a resident was admitted , after a change in condition, quarterly and as needed. He stated during morning meetings care was discussed and the MDS Nurse made necessary changes to the care plan from the meeting and IDT meetings to capture resident changes and ensure adequately was provided. He said CR#1 was unpredictable, sometimes re-directable but other times she was not. He said she was capable of ambulating unassisted. He said: on 7/8/2025- He spoke with the nurse about her and the CNA observing her side to be bruised. She was assessed by the nurse. On 7/9/2024- CR#1's x-ray came back negative for left rib, 2 views. On 7/10/2025, CR#1 was found on the floor again and was sent to the ER due to an unwitnessed fall.During an interview with the Interim DON and ADON on 7/15/2025 at 4:01pm they both stated after record review in PCC there were no updates to CR#1's care plan to include added falls nor were there any interventions that were updated on the care plan since 4/17/2024. An interview with the NP on 7/15/2025 at 5:00 PM, she said CR#1 did not have a fall mat because she was ambulatory, and it was more of a risk for her to have a mat. She said the facility staff was good about informing her about incidents. She said she had a history of falls. She said the fall on 7/8/2025 had been reported that CR#1's flank was bruised. She said she was informed and ordered an x-ray. The x-ray was negative on 7/9/2025. She said that was where it got confusing, CR#1 did not have shortness of breath, she also pressed on that area with the bruise, and she did not grimace or gave her any indication she was in pain. She said she could not feel anything was broken on 7/10/2025. She said her PCP also saw her on 7/9/2025 and CR#1 had no indication of any fractures and was ambulatory. If she had broken ribs, she would not have been able to walk. She stated she felt the staff supervised her well and did not see any issues. An interview with the MDS Coordinator on 7/15/2025 at 6:22 PM, she stated a care plan for CR#1 had been completed. She said it was done after her fall on about 7/10/2025. She said she was not sure about what interventions were updated. She said she completed resident care plans upon admission, significant change, and every 90 days. She said the interventions were reviewed quarterly. She stated if a care plan was not updated the facility could not properly provide adequate care for patients. She said CR#1 had no recent falls and therefore prior to last week an update was not warranted. She said she was driving and the interviewed ended. In an interview with the Administrator on 7/15/2025 at 5:39 PM, she stated she had been the Administrator for about 2 weeks. She stated her expectation was for the MDS coordinator to grab her lap top and during meetings when they discuss interventions, she should make updates immediately. She said she spoke with the MDS Coordinator the day after the fall and noticed the care plan did not appear to have been updated or include new interventions. She said they would work on ensuring all updates are completed. She said the MDS Coordinator was responsible for updating the care plans and would make changes during meetings from now on. An Interview with CNA E on 7/30/2025 at 2:00 PM, she said she worked the 6a-6p shift. She said CR#1 was transferred on the 100 hall since returning from the hospital. CNA E stated she was informed the resident needed a 1-2 person assist, broke her ribs, ensure pads were next to the bed and staff must watch her because she would try and get up and walk. She said if there was drastic change in interventions, they got that information from the nurses. She said if something about the care is not in the care plan, then she gets that information from nurses. The only communication regarding a resident and what to do came from the nurse. She stated after CR#1 was fed; she took her to the rest room then laid her down. She stated there were no instructions to increase rounds, but knowing the resident she ensured she peeked in the resident room to make sure she was okay. She stated she did round every two hours; however, she ensured she checked on residents more often than every two hours. She stated she peeked into CR#1's room hourly .A subsequent interview with the MDS Coordinator on 7/30/2025 at 3:15 PM, she stated she had worked at the facility since Jan or [DATE]. She stated when there were significant changes, which required interventions, the updates she immediately entered the changes into the care plan. She stated updates were needed for residents who had a significant change, or falls, for example. She stated updates in care plans were from significant change, falls, IDT meetings, and interviews . An interview with RN D on 7/30/2025 at 3:24 PM, she said she had been employed at the facility for 2 years. She stated if there were interventions not documented in the care plan, the nurses were responsible for informing the incoming shift of issues. She stated all of CR#1's falls should have been documented in the POC/Kardex. She said all falls should be discussed in morning meeting and MDS coordinator should make changes. She stated the Administrator told all management to keep a close eye on CR#1. She said she made it her business to check on the resident herself throughout the shift if the resident was not in the front area by the nursing station.A telephone interview with CNA D on 7/30/2025 at 5:44 PM, she said she worked the 10p-6a shift. She stated she worked last night on A Hall. CNA D stated she was familiar with CR#1. She said she checked on her frequently and she always tried to maneuver herself out of the bed. She stated last night (7/29/25) there were no issues with the resident. She stated she checked on the resident every 30-45 minutes. She stated her last round was at 5:45 AM. CNA D stated the resident was changed, given water and put back in bed. CNA D stated if there were additional interventions for residents that were not on the care plan, the information came from her nurse. A subsequent interview with the Interim DON on 7/30/2025 at 6:15 PM, she stated she would communicate to staff changes in resident behavior and updated interventions during morning stands up with upper management, IDT, then to nursing staff. She stated she would ensure the MDS Coordinator updated the care plans. She said until the care plans were updated, information would verbally be communicated with the CNAs . She said they could not keep her from falling, but staff tried to prevent injuries by having her bed low, extensive supervision and kept her at the nursing station. She said the MDS Coordinator was responsible for updating the care plan.Record review of the MDS Coordinator job description revealed: -MDS Coordinator primary purpose is to coordinate the resident assessment instrument (RAI), process including completion of an accurate and timely Minimum data set (MDS), developing the interdisciplinary plan of care.-Monitor clinical system changes in residents' condition that may affect the MDS process and scheduling and response to changes in residents' condition by coordinating MDS reassessments and re-evaluations of plan of care. Record review of the facility's care plan revision policy, revised on 5/2022, revealed: Policy:The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents within the facility.Guidelines:1. The comprehensive care plan will be reviewed and revised every quarter, when a resident experiences a status change and as deemed necessary.2. Procedure for reviewing and revising the care plan is as follows: a. Upon identification of a change in status, the nurse will notify the MDS Coordinator, the physician, and the resident representative, if applicable.b. The MDS Coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on intervention options.c. The care plan will be updated with the new or modified interventions.d. Staff involved in the care of the resident will report resident response to new or modified interventions. This was determined to be an Immediate Jeopardy (IJ) on 8/1/2025 at 3:30 pm. The Administrator was notified. The Administrator was provided with the IJ and POR templates on 8/1/2025 at 3:40 p.m. The following Plan of Removal submitted by the facility was accepted on 8/2/2025 at 3:35 PM:Immediate Action:Date: 08/02/2025According to the IJ Template, F656 Care Plans. The facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and timeframes to meet CR#1's medical, nursing, and mental and psychosocial needs related to her frequent falls. CR#1's care plan was not updated to reflect the current interventions in place.Plan of RemovalResident#1 is receiving Hospice Care and remains restless, even when monitored at the nursing station. Due to cognitive status and poor safety awareness, fall risk remains high. Interventions include frequent monitoring, incontinence checks, and medication as needed.August 2, 2025-MDS Nurse updated CR# 1's care plan to include appropriate interventions related to her frequent falls, including measurable objectives and time framesResponsible: MDS NurseCompletion Date: August 2, 2025.August 2, 2025 - 30-Day Incident ReviewAction: Regional MDS Nurse completed full review of falls from the past 30 days to ensure all related care plans were properly updated with measurable goals and appropriate interventions.There were not any negative findings.Responsible: Regional MDS NurseCompletion Date: August 2, 2025August 2, 2025 - MDS/Licensed Nurses EducationAction: Regional MDS Nurse provided an in-service education to the facility's MDS nurse on developing a comprehensive person-centered care plan, that includes measurable objectives and time frames to meet the resident's needs. The Regional MDS Nurse will re-educate license nurses on capturing falls in the progress notes as the falls occur. Staff will not provide direct resident care until the training has been completed.Responsible: Regional MDS Nurse/designeeCompletion Date: August 2, 2025August 2, 2025 - Facility Medical Director NotifiedAction: The facility's Medical Director was notified of the F-0656 deficiency. The Medical Director stated that he is very familiar with CR#1 and has had multiple conversations during QAPI meetings regarding the residents falls. He added to continue frequent rounds; review medication(s) with psychiatrists as indicated, and to follow MD orders regarding labs to determine if there is any infection related to the falls. CR#1's Care plan was updated to address the recommendations.Responsible: AdministratorCompletion Date: August 2, 2025August 2, 2025 - Daily Fall Review and Care Plan Update MonitoringAction:o The MDS coordinator will review the 24-hour report daily during the morning meeting with the IDT.o The IDT will discuss the appropriate interventions for residents with falls.o The MDS Coordinator will update the care plan(s) during that meeting. In the absence of the MDS Coordinator, the ADON will update the care plans. o Following the IDT meeting The DON will ensure the care plan is updated appropriately.Completion Date: August 2, 2025Responsible: DON/DesigneeAugust 2, 2025 - Care Plan Revision PolicyAction: The Administrator reviewed the care plan revision policy. Upon review, no changes were noted.Responsible: Administrator/DesigneeCompletion Date: August 2, 2025Monitoring of the POR began on 8/2/2025-8/4/2025:Interviews with the Interim DON, MDS Coordinator, LVN's C, D and E, and RN A between 8/2-8/4/2025 on all shifts revealed they understood the importance of updated person-centered care plans, incident reporting and documenting, reporting to NP, and Responsible party. The MDS Coordinator would be updating care plans in the morning meeting and as needed. Clinical staff stated care plans informed direct care staff about changes, what interventions were needed and proper notification of resident care needs.Record review of in-service documentation revealed the facility completed care plan and incident reporting updates on 8/2/2025.Record review of five resident electronic charts reviewed no issues with care plan updates for these Record review of in-services for care plan and incident reporting was provided by the Interim DON for all nursing staff between 8/2-8/4/2025.Record review of in-service on care planning was completed with the MDS Coordinator by the Regional MDS. It covered the importance of measurable objectives and time frames to meet the resident's needs. Record review of the sign-in sheet for the Regional MDS nurse reflected license nurses were re-educated on capturing falls in the progress notes as the falls occurred.The Administrator was informed the Immediate Jeopardy was removed on 8/4/2025 at 6:45pm. The facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement. 1. The facility failed when Dietary Aide A and Dietary Aide B did not don (put on) hair nets while preparing breakfast in the facility kitchen on 05/20/2025. These failures could place residents at risk of food borne illness and disease. Findings included: During an observation and interview on 5/20/25 at 8:10 AM, Dietary Aide A was observed preparing breakfast prior to donning (putting on) a hair net. Dietary A went and donned a hair net. Dietary Aide A was interviewed and asked why it is important to wear a hair net and she replied, so they (unknown) will not tell the Administrator. An observation and interview on 5/20/25 at 8:15 AM of Dietary Aide B who was working in the kitchen without donning a hair net. Dietary Aide B said she was sorry while donning her hair net at the same time, she said it was important to wear a hair net while in the kitchen for prevention of hair getting into the food and contamination. Observation on 5/20/25 at 8:45 AM of a framed sign hanging on the wall in the dining room that read Must have hair net on to enter kitchen. In an interview on 5/20/25 at 3:36 PM with the Dietary Manager who said Dietary Aide B always had on a hairnet on, I do not know why (Dietary Aide B) did not this time. Dietary Manager said she did not know about Dietary Aide A not having her hairnet on because Dietary Aide A did not tell the Dietary Manager about Dietary Aide A's hairnet not being on while surveyor was in the kitchen. Dietary Manager said Dietary Aide B was honest and said she did not have it on, DM stated she had been here two months, staff get handwashing or hairnet education. If hairnets are not used, hair could get into food and that affects sanitization of food. Interview on 5/20/25 at 4:32 PM with Infection Preventionist (IP)/DON who said, it was not okay to not wear a hairnet, it could get hair and contaminate the food and was gross. Interview on 5/20/25 at 4:43 PM Interview with Administrator, she said Hair nets should be worn, and could lead to infection issues, it was disgusting, and she would start in-services, she said the Dietary Manager was responsible for making sure hairnets were worn. On 5/21/25 at 7:30 AM, an interview with Dietary Manager she said that she was informed about the hair nets, she added the staff knew better, they have been trained and she held in-services again yesterday for wearing hairnets and garbage disposal. During an interview on 5/22/25 at 9:27 AM interview with ADON, He said Hairnets were always to be worn in the kitchen for sanitary reasons. Record review of the facility policy and procedure entitled Employee Sanitation, dated 12/01/11 read in part . Hair restraints, such as hats, hair coverings or nets, caps, and beard/moustache restraints (snoods) or other effective hair restraints are worn to keep hair from contacting food and food-contact surfaces.

Based on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision to prevent and accidents for one (Resident # 1) of 5 residents reviewed for supervision. The facility failed to provide adequate supervision to Resident # 1 to prevent injury of unknown origin (a physical injury where the cause or source is not known, or could not be explained, and raises suspicion of abuse or neglect due to the injury's size, location, or circumstances) which resulted in Resident # 1, who is totally dependent on staff for care, having a mildly displaced fracture of the fourth proximal phalanx (the bone closest to the base of a finger) on 5/7/2025 when a family member visited and noted a swollen finger. Resident # 1 did not leave the facility on an outing and only facility staff provided care to Resident # 1. This deficient practice has the potential to affect all residents in the building by causing resident injuries, such as fractures, falls, and even death due to improper supervision. Findings include: Record review of Resident # 1's face sheet, dated 5/13/2025, revealed a [AGE] year-old male who admitted to the facility on [DATE] (original admission date 9/11/2021) with diagnosies: Toxic Encephalopathy (a condition where brain dysfunction occurs due to exposure to toxic substances), Acute Respiratory Failure with Hypoxia (a condition where the lungs fail to adequately deliver oxygen to the blood), Dementia with Psychotic Disturbance (involves the presence of psychotic features like hallucinations and delusions alongside the cognitive decline of dementia),Chronic Obstructive Pulmonary Disease (a group of lung diseases that cause ongoing inflammation and damage to the airways and lungs), Cerebral Infarction (a condition where blood flow to the brain is interrupted, causing brain tissue damage), Sepsis (a life-threatening medical emergency that occurs when the body's response to an infection harms its own tissues and organs), Mood affective Disorder (mental health conditions characterized by persistent or severe disruptions in emotional state), Muscle Wasting and Atrophy (refers to the decrease in size and weakening of muscle tissue), Record review of Resident # 1's Quarterly MDS , dated 4/15/2025, revealed unclear speech, the resident was rarely/never understood, had severely impaired cognition, no response to resident mood interview questions, behavior not exhibited (physical behaviors, directed towards others, verbal, behavioral symptoms directed to others or other behavioral symptoms not directed towards others, no rejection of care, no wandering, no impairment (upper and lower extremities), mobility device wheelchair (manual or electric), total dependence on all ADL's, total dependence on transfer, always incontinent of both bladder and bowel, medically complexed conditions, and non-traumatic brain dysfunction. Record review of Resident # 1's Care Plan, dated 5/13/2025, revealed: ADL Self Care Deficits, date initiated 3/19/2022: Focus-ADL self-care deficits and is at risk for further decline in ADL functioning and injury. Diagnosis: Dementia CVA. Goal: Resident # 1 will be well dressed, groomed, clean, dignity will be maintained and will have no further decline in ADL functioning or injury over the next 90 day-target date 4/28/2025. Interventions/Tasks-provide extensive assistance of (#1-2- of support persons) for transfers, upper/lower body dressing and bed mobility Mood/Behavior, date initiated 7/28/2022 with target date 4/28/2025: Focus: Resident # 1 has a history of alteration in mood or exhibition of behavioral symptoms: Alzheimer's/Dementia's, Anxiety. Resident # 1 is resistive to care and combative with staff and verbally aggressive at times. Goal: Resident # 1 will be met and will be kept clean, dry, and well-groomed daily within the next review date. Resident # 1 dignity will be preserved, quality of life improved by minimizing the risk of agitation, inappropriate behaviors unmet needs and inappropriate behavioral symptoms will be minimized through the next review period. Goal: Allow resident time to calm down and reapproach later, interact in an empathetic and supportive manner. Communication, date initiated 7/28/2022, Focus: Resident # 1 has impaired communication and is at risk for further declined and injury AEB; Minimal difficulty, Rarely/never understood. Sometimes understands others. Goal with target date 4/28/2025: staff will anticipate and meet needs Resident # 1 is not able to effectively communicate over the next 90 days. Interventions/Tasks: Allow time for resident to digest information-do not rush, anticipate and meet all needs every shift, approach in calm manner using eye contact-call resident by name, and use calm clear voice. Use calm clear voice, use simple/direct communication and repeat as necessary (date initiated 12/6/2022). Safety, date initiated 8/14/2024, Focus: Resident # 1 had an actual fall on 8/14/2024 with no injury r/t /Gait/balance problems. Resident # 1 had an actual fall on 8/14/2024 with no injury r/t. Gait/balance problems. Goal with target date 4/28/2025: Resident # 1 will be free from fall through the review date. Interventions/Tasks: 8/14/2024: head to toe assessment completed, no injury, no signs, or symptoms of pain. NP and DON notified. Left message for representative. Neuro checks in progress. Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Fall facility fall protocol. Record review of Resident # 1's Psychiatry Progress Notes completed by NP B, dated 5/5/2025, revealed [Resident # 1] was dependent for all activities of daily living. [Resident # 1] was seen in the hallway sitting in wheelchair in no apparent distress; awake. Tone: mildly increased tone was noted to right biceps and right forearm muscles specifically, otherwise tone is normal as well in upper and lower body extremities. [Resident # 1] did not have functional ROM in bilateral (pertaining to, involving, or affecting two or both sides) UE or BLE. [Resident # 1] left elbow is limited to about 40 degrees of extension degrees of extension by contracture. His Right elbow can be moved through full ROM, flexion, and extension with passive ROM. All exams were done passive ROM as patient would not follow commands Record review of Resident # 1's Nursing notes, dated 5/7/2025 at 10:55 am, revealed Resident # 1 [ Family Member A ]was in the facility and brought Resident # 1 to the nurse's station and stated that Resident # 1's fourth right finger was swollen, upon observation noted residents finger with swelling and turning outwards, noted during touch, noted with facial grimacing, received new order for Tylenol 325 mg t tabs tid for 7 days and stat Xray, Family Member A stated no I am taking him to the er. Record review of Resident # 1's Nursing notes, dated 5/7/2025 at 6:40 pm revealed The resident returned from a local hospital. Xray findings revealed a mildly displaced fracture of the fourth proximal phalanx with no evidence of dislocation. There is a adjacent soft tissue swelling and joint space narrowing in the interphalangeal (a hinge joint located between two adjacent phalanges, the bones of the fingers) joints. The NP was notified, and no new orders were given. Impression: Mildly displaced fracture of the fourth proximal phalanx. Osteoarthritis of the hand. Record review of Resident #'1's physician's notes signed by NP A, dated 5/8/2025, revealed [Resident # 1] was a [AGE] year-old male with a PMH of CVA, dementia without behavioral disturbances, impulsiveness, hyperlipidemia, HTN, and anxiety. [ Resident # 1 ]is a long-term resident at a NF. Saw patient for ER follow up for mildly displaced fracture of the right fourth proximal phalanx, patient sitting up in long back wheelchair by dining room; alert, eyes open, but not attempting verbalization; keeps eyes contact; no new behavior changes. Current vital signs stable; BP stable, needs total assist with ADL's; limited movements; incontinent; uses wheelchair assistance; occasional resistance to care, frequently redirected by staff each episode, startles easily, incontinent to bowel and bladder. Needs moderate assist with ADL's. Review of Systems: poor historian, denies any complaints; limited verbalization; unable to assess much; reports from staff reports, records, and observation. Musculoskeletal: generalized limitation of range of motion, no paresthesia's, or numbness. No signs of pain noted to right hand. Plan: all above diagnosis reviewed continue current care, medications reviewed and reconciled. Pain management and follow up plan discussed with patient and staff. Assessments:1) Displaced fracture of distal phalanx of right ring finger, subsequent encounter for fracture with routine healing, 2) Unspecified dementia with behavioral disturbance, 3) Personal history of transient ischemic attack and cerebral infarction without residual deficits, and 4) anxiety disorder. Record review of Resident # 1's hospital Radiology report, dated 5/7/2025, revealed Study- 3 views of the right hand. Findings: mildly displaced fracture of the fourth proximal phalanx. No evidence of dislocation. Adjacent soft tissue swelling. Joint Space narrowing of the interphalangeal joints. Impression: 1) Mildly displaced fracture of the fourth proximal thighs and 2) Osteoarthritis of the hand. Record review of Resident # 1's hospital records, dated 5/7/2025, in part revealed [Resident # 1] presented to a local hospital on 5/7/2025 at 12:19 pm. History of Present Illness-chief complaint (including nature, duration, location, onset, progression of symptoms): [AGE] year-old male presents to the ED with [family member] for a chief complaint of right-hand 4th digit pain and swelling. Family Member A states she picked him up from nursing home and asked nursing home if patient had a fall. Patient denies fall but states someone hurt him. Resident told Family Member A someone hit him. Review of Systems- Musculoskeletal: System is negative; positive for Arthralgias (pain in one or more joints); negative for back pain, negative for gait problem, negative for joint swelling; positive for Myalgias(muscle pain or soreness); negative for neck pain. Physical Examination: musculoskeletal -4th digit spiral fracture(a type of bone break that occurs when a twisting force is applied to a long bone, often resulting in a break that winds around the bone). Constitutional-Musculoskeletal upper extremities abnormal: right hand tenderness; right deformity of wrist/hand is noted; right wrist/hand triggering. Imaging-independent interpretation shows Xray mildly displaced fracture. Final diagnosis- right finger fracture 4th digit. Record review of the Nursing Facilities policies and procedures on Abuse, Neglect, and Exploitaion, revised 10/24, read in part The Nursing Facility strictly p prohibits abuse, neglect, exploitation or any mistreatment of residents by anyone at the Facility, including staff, residents, volunteers, visitors, and others. This policy includes 7 key components: Screening, Training Prevention, Identification, Investigation, Protection and Reporting/Response. The Administrator or appointed designee serves at the ANE Prohibition Coordinator overseeing the policy and investigations. Interview with hospital staff on 5/13/2025 at 9:00 am, revealed that Resident # 1 was admitted with a swollen finger on right hand. Resident # 1 was found to have spiral fracture and Resident # 1 was unable to state what happened. She stated that Resident # 1 was transported to the emergency room from the nursing facility with a swollen finger on the right hand. She stated that Resident # 1 was found to have a spiral fracture. Interview with Family Member A on 5/13/2025 at 10:30 am she stated that she visited Resident # 1 at the nursing facility on 5/7/2025 at approximately 10:40 am. She stated that she noticed that Resident # 1's right hand was swollen, and it was green. She stated she asked staff at the nursing facility what happened, and no one could tell her what happened. She stated that she drove Resident # 1 to the hospital. She stated that she was told by the hospital staff that Resident # 1 had a spiral fracture. She stated that the physician at the hospital informed her that the type of injury was consistent with someone twisting the resident's finger. She stated that Resident # 1 was total care, and he needed total assistance from the nursing facility staff. She stated that she's concerned that staff did not observe that her Resident # 1's right hand was swollen, and his middle finger was dislocated. She stated that staff provided ADL's that morning and no one noticed anything. Interview with MA A on 5/13/2025 at 12:58 pm she stated on 05/07/25 she administered medication to Resident # 1. She stated she did not know the time. She stated that prior to administering Resident # 1 his medication he checked Resident #1's blood pressure. She stated that Resident # 1's blood pressure was taken on the left hand. She stated that Resident # 1's right hand was not swollen. MA A stated that she crushed Resident # 1's medication and she administered the medication to Resident # 1. MA stated that Resident # 1 is total care and a 2 person assist. Interview with LVN A on 5/13/2025 at 1:35 pm she stated that Resident #1 was a two-person transfer and total care. She stated she observed Resident # 1 on 5/7/2025 at approximately 6:30 am while making morning rounds. She stated that Resident # 1 was lying in bed and alert, and she did not observe anything wrong with his hands. She stated that she was made aware of Resident # 1's swollen hand when Resident #1's family member mentioned that Resident # 1's hand was swollen on 5/7/2025. She stated she did not know the exact time. She stated that she assessed Resident # 1's right hand. She stated that Resident # 1's hand was swollen. She stated that she did not observe Resident # 1's hand was not discolored or dislocated. She stated that she contacted Resident # 1's NP. She stated that the NP ordered an Xray and Tylenol as needed. She stated that Family Member A stated she did not want to wait for an Xray. She stated Family Member A transported Resident # 1 to the emergency room. She stated that two CNAs assisted with putting Resident # 1 in Family Member A's vehicle. LVN A stated she did not know what how Resident # 1's hand was injured. LVN A stated that Resident # 1's hand possibly was injured while been transferred. She stated that Resident #1 returned from the hospital on 5/7/2025 and he had a splint on his right finger. She stated that Resident # 1 diagnosis was mildly displaced fracture and Osteoarthritis (a degenerative joint disease where the cartilage that cushions the ends of bones in joints wears away over time). Interview with CNA B on 5/13/2025 at 1:57 pm she stated that Resident # 1 is a total care and a 2 person assist. She stated that on 5/7/2025 in the morning she assisted CNA A. She stated that when she arrived Resident # 1 was lying in bed and she assisted CNA A with sitting Resident # 1 up in the bed and transferring Resident # 1 from the bed to the wheelchair. She stated that CNA A was Resident # 1 assigned caregiver. She stated that when she arrived at Resident # 1's room he was dressed and dry. She stated that at the time of the transfer Resident # 1's hand was not swollen. She stated that CNA A rolled Resident # 1 to the dining room in his wheelchair. CNA A stated she was at the nurse's station on 5/7/2025 when Family Member A brought Resident # 1 to the nurse's station and stated that Resident # 1's hand was swollen. CNA B stated that Resident # 1's hand did not hit anything while he was lying in bed. She stated that Resident # 1's hand did not hit anything while being transferred to his wheelchair. CNA B stated that Resident # 1 is total care and a 2 person assist. CNA stated that Resident #1 was compliant with care when she assisted. Interview with CNA A on 5/13/2025 at 2:10 pm she stated she provided care to Resident # 1 on 5/7/2025. CNA A stated that on 5/7/2025 she began her rounds at 6:00 am. She stated that she checked all residents. CNA A stated that once she made her initial rounds she started getting the residents up for breakfast. She stated that on 5/7/2025 she dressed Resident # 1. She stated that she did not change Resident # 1's brief as he was dry. CNA A stated that CNA B assisted with sitting Resident # 1 up in the bed. She stated that CNA B assisted with transferring Resident # 1 to the wheelchair. She stated that she transferred Resident # 1 to the dining area. She stated that Resident # 1's hand was not swollen. CNA A stated she did not know how Resident # 1's hand was injured. She stated while transferring Resident # 1 he did not injure his hand. She denied Resident #'1 hand being caught in the wheelchair wheel while be transported to the dining area. She stated that she was made aware of Resident #1's hand injury when Family Member A brought it to staff attention. She stated that Resident # 1's hand looked normal. She stated that Resident # 1 has arthritis. CNA A stated that she did not shower Resident # 1 as he was bed B and showers were on Tuesday, Thursday, and Saturday. She stated that Resident # 1 was showered on the 5/6/2025 on the second shift. CNA stated that Resident # 1 is total care and a 2 person assist. She stated that Resident # 1 was compliant with care when she assisted on 5/13/2025. Interview with CNA C on 5/13/2025 at 2:30 pm she stated that Resident # 1 is total care. She stated that on 5/7/2025 she did not provide direct care to Resident # 1. She stated that Resident # 1's hand was swollen, and Family Member A wanted to take him to the hospital. She stated that she assisted CNA A with transferring Resident # 1 to the car. She stated that she did not notice anything wrong with his hands. She stated that she worked with Resident # 1 last week. She stated that when transferring Resident # 1 from wheelchair to bed and vice versa he will attempt to grab staff. She stated that Resident # 1 has a strong grip. CNA C stated Resident # 1 is total care and a 2 person assist. She stated Resident # 1 was compliant when she assisted with transferring him to the car. Interview with NP B on 5/13/2025 at 3:00 pm he stated that he is Resident # 1's NP. He stated he was not aware that Resident # 1 was injured. He stated that he was made aware that Resident # 1's was injured on 5/13/2025 while reviewing Resident # 1's chart. NP B stated that nursing facility most likely contacted NP A as NP A is the consulting NP. NP B stated he is not the consulting NP. NP B stated that Resident # 1 is total care, and he has Dementia. He stated that he visited with Resident # 1 on 5/5/2025 and at the time of this visit there were no noted concerns. He stated that Resident # 1's hands were not swollen. NP B stated that Resident # 1's finger fracture most likely caused from him rolling in the bed because Resident # 1 had poor functional ability of the upper extremities. He is very weak in the upper extremities. He stated that he did not have any evidence that Resident # 1 fell. Interview with NP A on 5/13/2025 at 3:10 pm he stated that on 5/7/2025 he was contacted by the nurse at the nursing facility. He stated that the nurse reported that Resident # 1 had swelling to his right hand. He stated that he ordered an Xray and Tylenol as needed for pain. He stated that later the nurse called and stated that Family Member A did not want to have the Xray at the nursing facility and Family Member A was taking Resident # 1 to the emergency room. NP A stated that Resident # 1 has a diagnosis of Dementia, CVA and Arthritis. He stated that Resident # 1 is total care for ADL's and transferring. He stated that he does not know who Resident # 1 injured his hand. He stated that Resident # 1 hand may have been injured during transfer. NP A stated that Resident # 1 was discharged from the emergency room on 5/7/2025 and was diagnosed with mildly displaced fracture of the right fourth proximal phalanx. NP A stated that he completed his weekly wound and follow up ER visit with Resident # 1 on 5/8/2025. He stated that Resident # 1 has a splint on the fourth phalanx. He stated that Resident # 1 fourth phalanx was swollen and little deviated. He stated that Resident # 1 will remain in the splint. He stated that he ordered Tylenol as needed for pain. Interview with DON on 5/13/2025 at 5:16 pm he stated that Resident # 1 is basically total care for the most part and need assistance with everything. He stated that Resident # 1's finger was fractured. He stated that Resident # 1's finger may have gotten fractured as a result of being caught in a wheelchair or bumped into a door. The DON stated he did not know how Resident # 1's finger was injured. He stated that Resident # 1's Xray displayed that Resident # 1 had a displaced fracture. The DON stated that the hospital reported that Resident # 1 had a spiral finger fracture; however, the hospital Xray revealed Resident # 1 had a displaced finger fracture and not a spiral fracture. The DON stated that a spiral fracture is when the circle around the bone is broken. He stated that this would happen if someone twisted the finger. The DON stated that in the past Resident # 1 had a history of combative behavior. The DON stated that Resident # 1's combative behavior has toned down. On 5/13/2025 at 5:30 pm attempted to contact the hospital physician. The hospital physician was not available. In an interview with the Administrator on 5/13/2025 at 6:30 pm she stated she learned of Resident # 1's hand injury on 5/7/2025. She stated on 5/7/2025 Family Member A informed LVN A that Resident # 1's hand was swollen. She stated that LVN A assessed Resident # 1 hand and she contacted NP A. She stated that NP A ordered an Xray of Resident # 1 hand. She stated that Family Member A wanted to take Resident # 1 to the emergency room. She stated that Family Member A took Resident # 1 to the emergency room. She stated that Resident # 1 was a 2-person transfer/lift. The Administrator stated she did not know how Resident # 1 hand was injured. She stated that perhaps when staff was moving or pushing Resident # 1 in the wheelchair his hand got caught in the wheel without staff realizing it. Observation on 5/14/2025 at 1:30 pm revealed Resident # 1 lying in bed. Resident # 1 is non-verbal. Resident # 1 had a splint on his finger.

Based on observation, interview and record review, the facility failed to ensure each residents had the right to be free of abuse for 2 of 9 residents (Resident #2 and Resident #3) reviewed for resident-to-resident abuse. The facility failed to ensure Resident #2 was free from abuse when CR#1 banged Resident #2's head on the floor causing a laceration to the back of his head and requiring 32 staples. The facility failure to ensure residents were free from abuse due to Resident #3 and Resident #4 having an altercation resulting in Resident #3 sustaining a cut to the chin by Resident #4. An Immediate Jeopardy (IJ) was identified on 09/27/2024 at 4:24pm. While the IJ was removed on 09/30/2024 at 2:22pm, the facility remained out of compliance at a scope of Level 2 (E) Although there was IJ for two persons, the potential for more than minimal harm is isolated, the facility continued to monitor the implementation and effectiveness of their corrective systems. These failures could place residents who are dependent on staff for care and supervision at risk for abuse and neglect. Findings Included: Record review of the facility's resident room roster revealed Resident #2 and Resident #3 resided on Hall B (secured unit). Record review of CR#1's face sheet dated 9/25/2024 revealed [AGE] year-old male who was admitted to the facility on [DATE] and discharged [DATE]. His diagnoses included bipolar disorder (episodes of mood swings), schizoaffective disorder (mental health condition), unspecified psychosis (loss of contact with reality), anxiety (mental health disorder that cause fear and worry), essential hypertension (high blood pressure), mood disorder (mental heal disorder that affects emotional state) and insomnia (poor sleeping habits). Record review of CR#1's quarterly Minimum Data Set, dated dated dated [DATE] revealed the resident had a BIMS score of 09 indicating he had cognitive issues. For Behavior, the Resident was coded as having no behaviors, was coded as set up or clean up assistance only for activities of daily living and was continent of bowel and bladder. Record review of CR#1's care plan dated 1/24/2024 revealed: . Focus Resident had episodes of inappropriate behaviors and is at risk for further increased episodes and injury resident yells and curses. Goal: Resident has episodes of appropriate behaviors should be reduced to more than two episodes weekly will be free from injury over the next 90 days. Intervention: Encourage the resident to attend social events. Explain procedures using terms/gesture. Give meds as ordered by the doctor. Monitor behavior and chart and report progress/decline to MD. Observe for warning signs of behavior. Record review of nurse's notes written on 09/23/2024 at 4:20am by LVN K revealed Resident #2 was attacked his roommate CR#1 after they had an argument. The fight ended up in the hallway, Resident #2 fell then CR#1 got on top of him and banged his head on the floor, several times which caused a bad cut on the back of Resident #2's head lots of bleeding, called ambulance, CR#1 got hit on the nose, and has a scratch on his back, notified NP A also left message for Resident #2's family. Record review of Resident #2's face sheet dated 9/25/2024 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included schizoaffective disorder (mental health condition), unspecified psychosis (loss of contact with reality), anxiety (a mental disorder that cause worry and fear), essential hypertension (high blood pressure) and insomnia (inability to sleep). Record review of Resident #2's quarterly Minimum Data Set, dated dated dated [DATE] coded Resident #2 for Cognitive skills for decision making as moderately impaired. For behavior he was coded as delusional and exhibited no behavioral symptoms. For ADL's he was coded as needing supervision and was occasionally incontinent of bowel and bladder. Record review of Resident #2's care plan dated 6/17/2024 revealed: Focus: Resident had episodes of inappropriate behaviors and is at risk for further increased episodes and injury resident wanders throughout the facility, placing gloves on hand and wandering in an out of other resident's room. Took a TV out of another resident room and put it in his room. Goal: Resident has episodes of appropriate behaviors should be reduced to more than two episodes weekly will be free from injury over the next 90 days. Intervention: Encourage the resident to attend social events. Explain procedures using terms/gesture that the resident can understand. Give meds as ordered by the doctor, lab as ordered and report findings to MD. Monitor behavior and chart and report progress/decline to MD. Observe for warning signs of behavior. had impaired cognitive function. Focus: Secure unit: Resident #2 requires secure unit related to cognitive disorder, wandering. Goal: Resident #2's safety will be maintained through appropriate supervision and structured /supportive environment through the review. Intervention: Administered medication as ordered. Behavior control: Utilize techniques such as redirection, distraction and calming. Record review of Nurses Progress Notes dated 9/23/2024 written by LVN K read in part . Resident #2 was attacked by his roommate CR#1 after they had an argument. The fight ended up in the hallway, Resident #2 fell then CR#1 got on top of him and banged his head on the floor, several times which caused a laceration on the back of Resident #2's head and bleeding. 9/23/2024 08:30 written by LVN B read in part . Note Text : resident arrived back to facility via stretcher with EMS x2, resident alert and oriented x1, pleasantly confused, noted ace wrap with gauze to head, assisted resident to bed, resident in sitting position, bp 135/76, pulse 76, c/o discomfort, received new order for Tylenol 650mg bid x7days, assessed back of head and noted laceration in shape of 'Y left side measuring at 6cm and right side measuring at 6.5cm, no active bleeding, no redness noted, 32 staples in place, raised area above laceration, spoke with family and aware of arrival back to facility. 9/23/2024 08:53 Form Summary :Late Entry: by LVN B Form Summary: Change of Condition Identified: laceration to back of head. Vital Signs: BP 148/60 - 9/24/2024 09:54 Position: Sitting l/arm , P 66 - 9/24/2024 09:54 Pulse Type: Regular , R 18.0 - 9/12/2024 00:04, O2 95.0 % - 9/12/2024 00:04 Method: Room Air. What do you think is going on with the resident: altercation with male resident, laceration to back of head with 32 staples in place, new order for Tylenol bid x7days for pain. NP Notified Responsible Party Notified Record review of the hospital report dated 09/23/2024 revealed documentation: Patient comes from nursing home via EMS for head injury. EMS informs us that the patient was assaulted by another patient. The other patient took the patient to the floor and hit his head multiple times on the floor. The patient did not lose consciousness, patient follows command and answer questions appropriately. Patient has laceration to the back of the head with bleeding, pressure wrap applied by EMS. Record review of the hospital event report dated on 09/23/2024 revealed Resident #2 was admitted to the emergency room with a Y shaped 12 cm laceration on the occipital region with minimal bleeding. #50 staples were used to the head. CT of the head was done it showed no acute bleed and no acute fracture. Record review of the Provider's investigation report revealed documentation that CR#1 and Resident #2 altercation were CR#1 banged Resident #2's head on the floor causing a 12 cm laceration to the head back resulting in Resident #2 receiving 32 sutures to the head back was investigated. There were only one CNA on the unit. Observation on 9/25/2024 at 12:20pm revealed Resident #2 in his room, sitting on his bed. He was alert and oriented with some forgetfulness. He was clean and groomed with no offensive odor. He was noted with a laceration to the back of his head with staples. In an interview via interpreter on 9/25/2024 at 12:20pm with Resident #2 he said he did not remember exactly what happened. Resident #2 said he recall CR#1 was in his bed yelling and the next thing his head was hurting. He said he was told that his roommate CR#1 banged his head on the floor. Resident#2 said he and CR#1 had argued before, but CR#1 never hit him. He said he was not really scared of CR#1 but he did not want him to be his roommate again because he did not want a repeat of what happened. He said it was okay for CR#1 to be around but not in his room. He said he did not remember how many staff was working when the incident took place. In an interview with CNA J on 9/25/2024 at 1:25pm she said she was working the 10pm-6am shift on 9/22/2024 on the secure unit when around 4:15am she heard CR#1 yelling, he wanted his roommate out of his room . She said she went to the room and calmed CR#1 down and reminded him that Resident #2 was his roommate. She said when he had calmed down and was back on his side of the room, she left the room. She said, shortly after she left, she heard them yelling and they were on the floor in the hallway and the next thing she saw was CR#1 banging Resident #2's head on the floor and it was bleeding. She said she pulled CR#1 off Resident #2 and put CR #1 in the room and closed the door. She said when she saw the blood coming from his head she called the nurse on her phone, applied pressure to the head until the nurse came and took over. She said 911 was called, physician and family notified, and the resident was, sent to the hospital. Further interview revealed she was the only CNA who was working on the secured unit at the time of the incident. She said 2 aides were schedule to work the unit but there was a call in, and the other aide had to go to another hall. She said it was her first time working the unit. Further interview with CNA J revealed she was trained on abuse/ neglect, managing aggressive residents and reporting abuse and neglect. She said Resident #2 was a very quiet man and he was not aggressive and did not display any behavior issues. Record review of the staff sign in sheet for 09/22/2024 revealed on the 10:00pm to 6:00am only 1 CNA sign in for the shift. Record review of the Facility assessment dated [DATE] read in part . Unit consideration: 200 hall, secure unit: Long term stay requires 2 CNAs all shifts. Night shift is staffed 2 CNAs, Nurses: 2 nurses split 100/200 left and 2 nurses split 200, 300 and 400 halls right. In an interview with CNA L on 9/25/2024 at 4:25pm she said she worked the secure unit and most of the time there were two CNAs on the 200 hall. She said she had never witnessed any abusive behavior on the hall with any resident. She said CR#1 was not physically abusive. She said CR#1 will yell and shout at times but was never physically aggressive toward any resident. She said Resident #2 was not aggressive and had never displayed any aggressive behavior. She said if there were behavior issues, she would defuse the situation. Separate the residents and calm them down. She said she was in-serviced on abuse and neglect. In an interview on 9/25/2024 at 4:40pm with RN A she said she worked with Resident #2 and he was a quiet resident. She said he never displayed any aggressive behavior. She said he never gets mad or gets angry. She said CR#1 yells and screams, he wanders a lot, but he was never physically aggressive to his roommate or any resident. She said she was surprised when she heard there was an altercation between the two residents. She said the CR#1 was in the psych hospital for evaluation. She said Residents #2 was in a room by himself, he did not currently have a roommate. In an interview on 9/25/2024 at 4:45 pm with LVN D she said she worked with both CR#1 and Resident #2. She said she worked with Resident#2 and he never displayed any aggressive behavior. She said the resident was very quiet and spoke mostly Spanish. She said she had never witnessed CR#1 being abusive to any resident. She said CR#1 wanders, will yells and scream but never displayed any aggressive behavior towards any resident. In an interview on 9/26/2024 at 1:00pm with CNA H she said she usually worked on the secure unit., She, said that she had never seen CR#1 physically abusive to anyone. She said he has a behavior of yelling but not physically abusive. She said two staff usually worked the secured unit. She said if a CNA called out then the CNA and the nurses would work the hall. In an interview on 9/27/2024 at 12:20am with LVN C he said he was working the 6:00pm to 6:00am shift on 9/22/2024 the morning when the CR#1 and Resident #2 had the fight. He said he did not actually see what happened but when he went to the unit the resident was on the floor and the nurse was assisting the resident. He said 911 was called and the resident was sent to the hospital. He said usually there would be two aides on the unit, but there was only one aide working the unit that shift. In an interview on 9/27/2024 at 9:34am LVN K revealed she was the nurse in charge of the 6:00pm to 6:00am shift on the secured unit the night the incident took place. She said she was on the unit earlier to calm down a resident who was very agitated and left when he fell asleep. She said when she left the unit the residents were quiet. She said she was on another hall when CNA J called her phone and told her that CR#1 banged Resident #2's head on the floor and it was bleeding. She said she immediately went to the hall, saw the resident on the floor and she assessed the resident, call 911, the family and send the resident to the hospital. She said there was only one aide on the unit that shift. She said when the aide called in on 9/22/2024 she called the on-call staff, but they did not send a replacement. Record review of Resident #3's face sheet dated 9/25/2024 revealed he was a [AGE] year-old male that had been admitted to the facility on [DATE] with diagnoses of unspecified dementia (chronic condition that causes a person to lose the ability to think, learn and remember), diabetes mellitus (disease that result in too much sugar in the blood), essential hypertension(a condition of high blood pressure that is not attributed to another medical condition), unspecified psychosis(a severe mental condition in which thought and emotions are affected), depression(the elevation or lowering of a person's mood), and anxiety disorder(a feeling of worry). Record review of Resident #3's MDS dated [DATE] revealed Section C: BIMS Summary a disease that result score was 02 (which represented severe cognitive impairment). Section E0100- Behavior Z. No delusions or hallucinations. Section E0900 wandering-Presence & frequency was coded 0- behavior not exhibited. Section GG- Functional Abilities and Goals- C. Toileting hygiene was coded as 01- represented dependent (helper does all the effort). D. Sit to stand 04- Supervision or touching assistance (helper provides verbal cues). H0300-Urinary and bowel incontinence was coded as 3-always incontinent. Record review of Resident #3's care plan dated 5/22/2024 revealed: Cognitive impairment: Resident #3 has impaired cognition and is at risk for further decline and injury. Goal: Resident #3 needs will be met, and dignity maintained over the next 90 days. Interventions: Allow time for tasks and responses, explain all procedures. Resident #3 deemed at Risk for Wandering as evidence by: Dementia/Alzheimer, and Resident #3 is ambulatory. Goal: Resident #3 will be able to wander in a safe environment without the occurrence of injury and dignity will be maintained over the next 90 days. Interventions: Maintain resident safety during increased episodes, observe and document resident's location frequently throughout shift, and offer fluids and snacks during increased episodes of wandering. Resident #3 has bowel and bladder incontinence and is at risk for skin break down. Goal: Dry and odor free and no occurrence of skin breakdown will occur over the next 90 days. Intervention: Provide incontinent care after each incontinent episode and prn. Record review of Resident #3's nursing progress note revealed on 9/2/2024 at 8:21 p.m.: CNA called for LVN A stated that resident was hit by another male resident. Resident unable to state what happened. Noted skin tear to forehead and left side of face, noted bruising to left eye and temple, no facial grimacing noted, cleansed, applied Tao. Resident continues to wander hallways and other resident's room, continues to redirect frequently. Notified NP, DON, Administrator, FM aware of incident. Record review of Resident #3's nursing progress note dated 8/10/2024 at 4:41pm: Note Text: CNA reported to nurse this resident #3 went in another male resident's room (Resident 4), and when the other male resident asked this male resident to leave, he began hitting the other male resident. The other male resident then hit him back, and this resident received a small cut to the chin. Residents separated to other areas of unit. Cleansed cut to chin with normal saline, pat dry and apply TAO and band aid. RP, NP, administrator notified of incident. Will continue to monitor. Noted authored by LVN D. Record review of Resident #4's face sheet dated 9/25/2024 revealed he was a [AGE] year-old male that was admitted to the facility on [DATE] with diagnoses of unspecified psychosis a severe mental condition in which thought, and emotions are affected), depression (the elevation or lowering of a person's mood) and benign prostatic hyperplasia (age associated prostate gland enlargement). Record review of Resident #4's quarterly MDS dated [DATE] revealed: Section C0500- BIMS summary score was coded as 7 (which represented severe impairment). Section E0100- Behavior- Z. No delusions or hallucinations Section)-Special treatments coded 0 for Psychological Therapy (by any licensed mental health professional). Record review of nursing progress noted dated 8/10/2014 at 1:18pm. Note Text: Resident was in his restroom when he walked out, he says another resident was standing in his room by his bed. He asked the other resident to get out, then the other resident grabbed his Kleenex off his bed, the resident asked him to put it back, the other resident refused saying no and threw two punches (missing him). The other resident then grabbed this residents' fingers on his left hand and squeezed them together, this was when this resident punched the other resident in the chin. The two parties were separated, and the other resident was escorted out of the room. This resident has no physical injuries at this time and no c/o of pain. Will monitor closely throughout the shift. Note was signed by LVN D. Record review of nursing progress note dated 9/2/2023: Note text: CNA called the nurse stating that she overheard a noise coming from resident #4's room. Resident #4 had become physically aggressive with another resident. Upon observation noted resident sitting in bed, Resident #4 stated that make resident came into his room and he told him to leave and he said no so he punched Resident #3. Resident #4 had no visible signs of injuries. Educated Resident #4 to call for staff instead of being aggressive. Resident understood the education. NP notified, DON, Administrator made aware as well as Resident #4's RP. The notes were signed by LVN A. A telephone interview with FM of Resident #3 on 9/25/24 at 12:03pm revealed that the resident had been in 3 different incidents at the facility. He was reevaluated at local hospital for his medications. She said he had no permanent injuries from the incident, but he had a black eye and bruising. Resident #3 goes in and out of everybody's room and when they want him out, he gets aggressive. He had an incident about two weeks ago and this was the third incident since he had been at the facility (May 2024) and was sent for medication evaluation. He returned around the 20th. He was in another facility before being admitted to the current facility and he was hallucinating and getting very aggressive. The FM stated he was only at a facility for about two weeks before he started breaking mirrors or anything that had his reflection. The FM said he was doing well at first now getting aggressive again. Resident#3 was considered middle to late stage or psychotic dementia diagnosis. The FM said he has anger towards men, and this had been observed. His dementia was causing him to wander and that will not stop, he's been doing that for a while. The FM said his wandering was progressively getting worst. The FM said unfortunately staff must redirect him when he was doing this, and it does not seem like this was being done. The FM stated there was never enough staff when the FM visits. The FM said when CNA was requested to help Resident #3 a few times they were told by unknown CNA that they were the only one on the floor and would get help. Observation and interview with Resident #4 on 9/25/2024 at 12:36pm, revealed he was in his room eating lunch. He was well-dressed in a blue jean shirt and jeans. He stated that he remembered the incident between him and Resident #3. He said that he could not remember the residents name, but a male came in his room, and he asked him to leave. He said he told him no so he whipped his expletive. He said other residents might wander into the room but when he tell them to get out or staff catch them at the door and there were no problems. He said after he asked the resident to leave, he laid in his roommate's bed. He said he told him again and then hit him twice in the face. He said he would never hit a woman, but he will hit a man that comes in his room uninvited. He said he gets along with his roommate well. He said the same resident had been in his room before and he kicked his expletive then, too. An interview with CNA E on 9/25/2024 at 12:54pm, stated she had been employed only a few months. She said Resident #3 wanders a lot. She said when he was awake, he wanders constantly. She said she sometimes placed a chair in the hallway to watch the residents and re-direct the wanderers. She said Resident #3 tries to get into other residents' beds. She said staff must keep a close eye on him. She said there were usually 2 CNA's and 1 nurse on the memory care hall. But sometimes they do not have two because of call-in and no shows. A telephone interview with LVN A on 9/25/2024 at 4:50pm, LVN stated Resident #3 and Resident #4 had an altercation after Resident #3 wandered into Resident #4's room and he asked him to leave. Resident #3 refused and proceeded to lay in his roommates' bed. She said she was the nurse on duty but was not in the unit at the time. She had been called by an unknown CNA after the altercation had been broken up. She said she assessed both residents and documented the bruise to Resident #3's eye. She said she had been employed since 2019 and worked the 6pm-6am shift. She said she worked Halls A (100) and B (200), the right side of B on secure unit. She stated after the incident the DON in-serviced them on Abuse and Neglect. She said wandering residents were redirected with snacks, fluids, and this will usually keep him redirected successfully. Sometimes Resident #3 can become combative and staff were instructed to give him space, offer food which he loves to eat, and this usually distracts him. She said he wanders a lot and staff had to keep a better eye on him. She admitted they were sometimes short-staffed on the secured unit, mostly the 2p-10pm shift. In an interview with the Administrator on 9/27/2024 at 4:15 pm he said CNA J reported that CR#1 and Resident #2 had a resident to resident altercation and CR#1 banged Resident#2's head to the floor. He said he has increased staff by adding an activity assistant, to work in the secured unit. He said incidents have decreased since adding the staff. Record review of the facility's policies and procedures titled Abuse, Neglect and Exploitations dated April 2024 read in part . Policy: The nursing facility strictly opposed abuse, neglect and exploitation or any mistreatment of resident by anyone at the facility including staff, resident, volunteers or visitors and others. The policy contained 7 key components training, screening, prevention, identification, protection, investigation, and reporting/response. Abuse prevention: The facility Administrator or designee serves as the Abuse Prevention Coordinator. Abuse: Any willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. Neglect: The failure of the facility, its employees, service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect may include the failure of the caregiver to provide the necessities of life including protection from harm. The Administrator and DON was notified on 09/27/2024 at 4:24 p.m., an Immediate Jeopardy situation (IJ) was identified due to the above failures. The Administrator was provided the IJ template on 09/27/2024 and a Plan or Removal (POR) was requested. PLAN OF REMOVAL. Immediate Action The SW will complete 100 % safe surveys on residents on the secure unit. The completion date is 9/27/24. The DON/Designee will in-Service all staff on Abuse and neglect policy - Staff absent at the time of in-Service will receive in-service prior to start of their shift. The completion date is 9/27/24. The Administrator held and ad-hoc QAPI meeting on 9/27/24 to address incidents and accidents that occurred in the past 30 days. The charge nurses and resident care specialists will conduct hourly rounds to monitor residents for changes in behavior to prevent resident to resident abuse. The DON/designee will monitor the processes that have been put in place. The abuse prohibition coordinator will ensure that facility staff education and training related to abuse/neglect/exploitation is completed following all allegations of abuse/neglect/exploitation. The Administrator was in-serviced by the RDO on 9/27/24 on the topic's roles and responsibilities of the Abuse Prohibition Coordinator and responding timely to abuse allegations. The policies and procedures were reviewed on 9/27/24 by the Administrator, DON, ADON, and RDO with no changes at this time. The DON and Administrator will ensure that there are always two employees on the secure unit. On 9/28/24 secure unit staff in-serviced on de-escalation techniques, identifying and monitoring residents with agitation and aggression with changes reported to the charge nurse immediately. The in-service was completed by the Senior Director of the Psych hospital]In-Patient Psych. CR#1 and Resident #2 were assessed by the charge nurse prior to their discharges. Skin assessments, pain assessments, SBARs, and incident reports were completed for CR#1 and Resident #2 by the charge nurse. CR#1 was sent out to the Psych hospital In-Patient Psych to be further evaluated and is currently a patient at the In-Patient Psych. Resident #2 was sent to the ER for further evaluation following the incident on 9/23/24 and returned to the facility on [DATE] with new physician orders. CR#1 and Resident #2 care plans have been reviewed by the IDT Team and revised by MDS Coordinator. Monitoring the POR on 09/27/2024: During the survey monitoring, the Administrator was interviewed regarding what he believed was the root cause of the IJ. The Administrator believed that there was a staffing issue. He said he was not aware that the unit was not fully staffed. He said there was a plan in place to monitor this issue, and the staff were in-service on checking on residents every two hours in the general population and every hour on the secure unit. During the survey monitoring, the Director of Nursing (DON) was also interviewed regarding what she believed was the root cause of the IJ. The DON believed there was a staffing issue. The DON planned to ensure that two CNAs were on the secure unit, monitoring was done every hour on the secure unit and every two hours on the other units and as needed. The DON's expectation was for the RN's and LVN's to follow the rules and regulations and be in compliance, be at work on time and take care of the residents. On 09/27/2024 In-Service trainings was initiated by the ADON to licensed nurses. In an interview on 9/28/2024 at 1.56pm with CNA M she said she was in-serviced on abuse/ neglect on 9/27/24 and on 9/28/2024. she was in-serviced on resident-to-resident altercation: Separate residents if there was an altercation, talk to the charge nurse and let them know what was going on and what needed to be done. Monitor the residents and allow them to calm down. Redirect them to do something like an activity. She was also in-serviced on Dignity- respecting the resident as individual and, reporting abuse/neglect to the abuse coordinator. She verbalized understanding of the in-services provided. In an interview on 9/28/2024 at 2:05pm with CNA L she said she was in-serviced on abuse /neglect and calling in. Staff related that neglect was: Was when a person put on the light and needs to be changed and the staff said she would be back and never went back that would be neglect and abuse was when a staff cursing a resident would be verbal abuse and physical abuse was when a staff hit a resident. She verbalized understanding of the in-services provided. In an interview on 9/28/2024 at 2:10pm with MA A he said he was in-serviced on abuse/neglect, different types of abuse such as verbal and physical abuse, neglect -not providing care to resident and reporting of abuse. He said he was also in-serviced on communication and who to call if he could not make it to work. The staff verbalized understanding of the in-service provided. In an interview on 9/28/2024 at 2:39pm with RN C she said she was in-serviced on abuse/neglect, Attendance policy and if she has to call in, she must talk to a live person, and they should call in four hours prior to her shift. Staff were supposed to be at work on time: Delay in patient care and relieving staff. If she calls the on-call person and no one answer to call the Administrator, DON and ADON. Staff verbalized understanding of in-service provided. In an interview on 9/28/2024 at 2:30pm with RN B she said she was in-serviced that morning on Abuse/neglect, how to De-escalate residents when they get agitated. Regarding staff call in- If you have to call in 2 hours prior to when you are schedule to work and let the on call person know. Staff verbalized understanding of in-service provided. In an interview on 9/28/2024 at 3:30pm with CNA E she said she was in-serviced on Abuse/Neglect.: Call in's she said they cannot text have to ensure that they talk to a person. Report on time for work wait for relief to get to the building. She said they were in-serviced on abuse/neglect at least once a month. Staff verbalized understanding of in-services provided. In an interview on 9/28/2024 at 3:40pm with Staffing Coordinator she said she was in serviced on abuse and neglect and staff calling in. She said abuse/neglect be reported to the abuse coordinator. She said the types of abuse were verbal abuse saying unkind thing or cursing, physical abuse hitting touching or handling a resident roughly and neglect was not taking care of residents. She said staff should call in: 4 hours before the start of their shift. If they did not get to the on-call person, they should call the administrator or DON. Staff verbalized understanding of the in-service provided. Interviews were conducted between 9/29/2024-9/30/2024 with CNAs B, C and E, LVNs B and D, RN A were all staff from the morning (6a-6p) shift. They all were able to explain the procedure for call-ins, attendance policy, abuse and neglect, when to let management know if they notice staff were on the schedule but was not at work. Charge Nurses LVN D, RN A and RN B stated they were required to

Based on observation, interview, and record review the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility's assessment tool for 2 of 19 residents (Resident #2 and Resident #3)reviewed for sufficient staff. -The facility failed to ensure adequate supervision was provided for Resident #3's wandering to prevent resident-to resident altercations between Residents #3 and #4 on 8/10/24 and 9/2/2024 in which Resident #3 sustained injuries to his face. -The facility failed to ensure there was sufficient staff on the secured unit overnight shift (10pm-6am) on 9/22/2024 to prevent a resident-to-resident altercation between CR #1 and Resident #2. Resident #2 had to be hospitalized and received 32 staples to the back of his head due to Resident #2 banging his head on the floor. The facility had 1 CNA for 19 residents on the secured unit. An Immediate Jeopardy (IJ) was identified on 09/27/2024 at 4:24 p.m. While the IJ was removed on 9/30/2024 at 2:22 p.m., the facility remained out of compliance at a scope of isolated and a severity level 2 due to the facility's need to monitor the implementation and effectiveness of their corrective systems. These failures could have caused all residents on the secured unit to have injuries, hospitalization s, and pain. Findings Included: Record review of facility's census dated 9/25/2024, revealed there were 19 residents that resided in the secured unit. Record review of facility's resident room roster revealed Resident #2 and Resident #3 resided on Hall B (secured unit). Record review of the facility's nursing schedule revealed CNA B and CNA F were scheduled to work Hall 200 (secured unit) on 9/2/2024 the date of incident between Resident #3 and #4. Further record review of the facility's nursing schedule revealed CNA J, D and H were all on the schedule to work in the secured unit on 9/22/2024 overnight shift (10 p.m.-6 a.m.). CNA J was the only CNA in the secured unit when an altercation occurred between CR#1 and Resident #2. Record review of the incident-by-incident type report provided on 9/27/2024, revealed Residents #3 and Resident #4 had physical altercations on 8/10/2024 and 9/2/2024. Further review of the incident-by-incident type report provided revealed Resident #2 was on the receiving end of physical aggression on 9/23/2024. CR#1 Record review of CR#1's face sheet revealed [AGE] year-old male who was admitted to the facility on [DATE] and discharge 9/24/2024. His diagnoses included bipolar disorder (episodes of mood swings), schizoaffective disorder (mental health condition), unspecified psychosis (loss of contact with reality), anxiety (mental health disorder that cause fear and worry), essential hypertension (high blood pressure), mood disorder(mental heal disorder that affects emotional state) and insomnia(poor sleeping habits). Record review of CR#1's quarterly Minimum Data Set, dated dated dated [DATE] revealed the resident as a BIMS score of 09 indicating he had cognitive issues. For Behavior the Resident was coded as having no behaviors, was coded as set up or clean up assistance only for activities of daily living and was continent of bowel and bladder. Record review of CR#1's care plan dated 1/24/2024 . Focus Resident had episodes of inappropriate behaviors and is at risk for further increased episodes and injury resident yells and curses. Goal: Resident has episodes of appropriate behaviors should be reduced to more than two episodes weekly will be free from injury over the next 90 days. Intervention: Encourage the resident to attend social events. Explain procedures using terms/gesture. Give meds as ordered by the doctor. Monitor behavior and chart and report progress/decline to MD Observe for warning signs of behavior. Record review of nurse's notes written on 09/23/2024 at 4:20am by LVN K revealed Resident #2 was attacked his roommate CR#1 after they had an argument. The fight ended up in the hallway, Resident #2 fell then CR#1 got on top of him and banged his head on the floor, several times which caused a bad cut on the back of Resident #2's head lots of bleeding, called ambulance, CR#1 got hit in the nose, and has a scratch on his back, notified NP A also left message Resident #2's family. Resident #2 Record review of Resident #2 face sheet revealed he was a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included schizoaffective disorder (mental health condition), unspecified psychosis (loss of contact with reality), anxiety (a mental disorder that cause worry and fear), essential hypertension (high blood pressure) and insomnia (inability to sleep). Observation on 9/25/2024 at 12:20pm revealed Resident #2 in his room, sitting on his bed he was alert and oriented with some forgetfulness. He was clean and groomed with no offensive odor. He was noted with a laceration to the back of his head with staples. In an interview via interpreter on 9/25/2024 at 12:20pm with Resident #2 he said he did not remember exactly what happened. Resident #2 said he recall CR#1 was in his bed yelling and the next thing his head was hurting. He said he was told that his roommate CR#1 bang his head on the floor. Resident#2 said he and CR#1 had argued before, but CR#1 in never hit him. He said he was not really scared of CR#1 but he did not want him to be his roommate again because he did not want a repeat of what happen. He said it was okay for CR#1 to be around but not in his room. He said he did not remember how many staff was working when the incident took place. Record review of Resident #2 quarterly Minimum Set dated 7/5/2024 coded Resident #2 for Cognitive skills for decision making as moderately impaired. For behavior he was coded as delusional and exhibited no behavioral symptoms. For ADL's he was coded as needing supervision and was occasionally incontinent of bowel and bladder. Record review of Resident #2's care plan revealed Resident #2 Record review of Resident #2's care plan dated 6/17/2024 revealed: Focus Resident had episodes of inappropriate behaviors and is at risk for further increased episodes and injury resident wanders throughout the facility, placing gloves on hand and wandering in an out of other resident's room. Took a TV out of another resident room and put it in his room. Goal: Resident has episodes of appropriate behaviors should be reduced to more than two episodes weekly will be free from injury over the next 90 days. Intervention: Encourage the resident to attend social events. Explain procedures using terms/gesture that the resident can understand. Give meds as ordered by the doctor, lab as ordered and report findings to MD. Monitor behavior and chart and report progress/decline to MD. Observe for warning signs of behavior. had impaired cognitive function. Focus: Secure unit: Resident #2 requires secure unit related to cognitive disorder, wandering. Goal: Resident #2's safety will be maintained through appropriate supervision and structured /supportive environment through the review. Intervention: Administered medication as ordered. Behavior control: Utilize techniques such as redirection, distraction and calming. Record review of Nurses Progress Notes dated 9/23/2024 read in part . Resident #2 was attacked by his roommate CR#1 after they had an argument. The fight ended up in the hallway, Resident #2 fell then CR#1 got on top of him and banged his head on the floor, several times which caused a laceration on the back of Resident #2's head and bleeding. 9/23/2024 08:30 Nursing Note Note Text: resident arrived back to facility via stretcher with emts x2, resident alert and oriented x1, pleasantly confused, noted ace wrap with gauze to head, assisted resident to bed, resident in sitting position, bp 135/76, pulse 76, c/o discomfort, received new order for Tylenol 650mg bid x7days, assessed back of head and noted laceration in shape of 'Y left side measuring at 6cm and right side measuring at 6.5cm, no active bleeding, no redness noted, 32 staples in place, raised area above laceration, spoke with family and aware of arrival back to facility. 9/23/2024 08:53 Form Summary: Late Entry: Form Summary: Change of Condition Identified: laceration to back of head Vital Signs: BP 148/60 - 9/24/2024 09:54 Position: Sitting l/arm , P 66 - 9/24/2024 09:54 Pulse Type: Regular , R 18.0 - 9/12/2024 00:04, O2 95.0 % - 9/12/2024 00:04 Method: Room Air. What do you think is going on with the resident: altercation with male resident, laceration to back of head with 32 staples in place, new order for Tylenol bid x7days for pain. NP Notified Responsible Party Notified Record review of hospital report dated 09/23/2024 revealed documentation: Patient comes from nursing home via EMS for head injury. EMS informs us that the patient was assaulted by another patient. The other patient took the patient to the floor and hit his head multiple times on the floor. The patient did not lose consciousness, patient follows command and answer questions appropriately. Patient has laceration to the back of the head with bleeding, pressure wrap applied by EMS. Record review of hospital event report dated on 09/23/2024 revealed Resident #2 was admitted to the emergency room with a Y shaped 12 cm laceration on the occipital region with minimal bleeding. #50 staples were used to the head. CT of the head was done it showed no acute bleed and no acute fracture. Resident #3 Record review of Resident #3's face sheet dated 9/25/2024 revealed he was a [AGE] year-old male that had been admitted to the facility on [DATE] with diagnoses of unspecified dementia (chronic condition that causes a person to lose the ability to think, learn and remember), diabetes mellitus (disease that result in too much sugar in the blood), essential hypertension(a condition of high blood pressure that is not attributed to another medical condition), unspecified psychosis(a severe mental condition in which thought and emotions are affected), depression(the elevation or lowering of a person's mood), and anxiety disorder(a feeling of worry). Record review of Resident #3's MDS dated [DATE] revealed Section C: BIMS Summary a disease that result score was 02 (which represented severe cognitive impairment). Section E0100- Behavior Z. No delusions or hallucinations. Section E0900 wandering-Presence & frequency was coded 0- behavior not exhibited. Section GG- Functional Abilities and Goals- C. Toileting hygiene was coded as 01- represented dependent (helper does all the effort). D. Sit to stand 04- Supervision or touching assistance (helper provides verbal cues). H0300-Urinary and bowel incontinence was coded as 3-always incontinent. Record review of Resident #3's care plan initiated dated 5/22/2024 and target date of 10/31/2024 revealed: Cognitive impairment: Resident #3 has impaired cognition and is at risk for further decline and injury. Goal: Resident #3 needs will be met, and dignity maintained over the next 90 days. Interventions: Allow time for tasks and responses, explain all procedures. Resident #3 deemed at Risk for Wandering as evidence by: Dementia/Alzheimer, and Resident #3 is ambulatory. Goal: Resident #8 will be able to wander in a safe environment without the occurrence of injury and dignity will be maintained over the next 90 days. Interventions: Maintain resident safety during increased episodes, observe and document resident's location frequently throughout shift, and offer fluids and snacks during increased episodes of wandering. Resident #3 has bowel and bladder incontinence and is at risk for skin break down. Goal: Dry and odor free and no occurrence of skin breakdown will occur over the next 90 days. Intervention: Provide incontinent care after each incontinent episode and prn. Record review of Resident #3 nursing progress note revealed on 9/2/2024 at 8:21 p.m.: CNA called for LVN A stated that resident was hit by another male resident. Resident unable to state what happened. Noted skin tear to forehead and left side of face, noted bruising to left eye and temple, no facial grimacing noted, cleansed, applied Tao. Resident continues to wander hallways and other resident's room, continues to redirect frequently. Notified NP, DON, Administrator, FM aware of incident. Note authored by LVN B Record review of Resident #3 nursing progress note dated 8/10/2024 at 4:41pm: Note Text: CNA reported to nurse this resident #3 went in another male resident's room(Resident 34), and when the other male resident asked this male resident to leave, he began hitting the other male resident. The other male resident then hit him back, and this resident received a small cut to the chin. Resident's separated to other areas of unit. Cleansed cut to chin with normal saline, pat dry and apply TAO and bandaid. RP, NP, administrator notified of incident. Will continue to monitor. Noted authored by LVN D. Resident #4 Record review of Resident #4's face sheet dated 9/25/2024 revealed he was a [AGE] year-old male that was admitted to the facility on [DATE] with diagnoses of unspecified psychosis a severe mental condition in which thought and emotions are affected), depression (the elevation or lowering of a person's mood)and benign prostatic hyperplasia (age associated prostate gland enlargement). Record review of Resident #4's quarterly MDS dated [DATE] revealed: Section C0500- BIM summary score was coded as 7 (which represented severe impairment). Section E0100- Behavior- Z. No delusions or hallucinations Section O-Special treatments coded 0 for Psychological Therapy (by any licensed mental health professional). Record review of nursing progress noted dated 8/10/2014 at 1:18pm. Note Text: Resident was in his restroom when he walked out, he says another resident was standing in his room by his bed. He asked the other resident to get out, then the other resident grabbed his Kleenex off his bed, the resident asked him to put it back, other resident refused said no and threw two punches (missing him). The other resident then grabbed this residents' fingers on his left hand and squeezed them together, this is when this resident punched the other resident in the chin. The two parties were separated, and the other resident was escorted out of the room. This resident has no physical injuries at this time and no c/o of pain. Will monitor closely throughout the shift. Note was signed by LVN D. Record review of Resident #4's nursing progress note dated 9/2/2023 revealed: Note text: CNA called the nurse stating that she overheard a noise coming from resident #4's room. Resident #4 had become physically aggressive with another resident. Upon observation noted resident sitting in bed, Resident #4 stated that make resident came into his room and he told him to leave and he said no so he punched Resident #3. Resident #4 had no visible signs of injuries. Educated Resident #4 to call for staff instead of being aggressive. Resident understood the education. NP notified, DON, Administrator made aware as well as Resident #4's RP. The note was signed by LVN A. Record review of SBAR summary for Resident #4: Change in condition Identified: Physically aggression initiated 9/2/2024, vitals taken and NP notified, DON and family. SBAR completed by LVN B. A telephone interview with FM of Resident #3 on 9/25/24 at12:03p.m. stated he had been in 3 different incidents at the facility. He was reevaluated at local hospital for his medications. She said he had no permanent injuries from the incident, but he had a black eye and bruising. Resident #3 goes in and out of everybody's room and when they want him out, he gets aggressive. He had an incident about two weeks ago and this was the third incident since he had been at the facility (May, 2024) and was sent for medication evaluation. He returned around the 20th. He was in a facility in a local town before being admitted to his current facility and he was hallucinating and getting very aggressive. FM stated he was only at a facility for about two weeks before he started breaking mirrors or anything that had his reflection. FM said he was doing well at first and now he was getting aggressive again. She said Resident #3 is considered middle to late stage or has a psychotic dementia diagnosis. FM said he has anger towards men, and this had been observed. His dementia caused him to wander and that will not stop he had been doing that for a while. FM said his wandering was progressively getting worst. FM said unfortunately staff must redirect him when he is doing this, and it does not seem like this is being done. FM stated there never seemed to be enough staff working when the FM visited. Observation on 9/25/2024 at12:43pm revealed Resident #3 was in bed asleep. There was a urine odor in his room. He was the only resident that resided in this room. Observation and interview with Resident #4 on 9/25/2024 at 12:36pm, revealed he was in his room eating lunch. He was well-dressed in a blue jean shirt and jeans. He stated that he remembered the incident between him and Resident #3. He said that he could not remember the residents name, but a male came in to his room and he asked him to leave. He said Resident #3 told him no so he whipped his expletive. He said other residents might wander into the room but when he told them to get out or if staff catch them at the door there were no problems. He said after he asked the resident to leave, he laid in his roommate's bed. He said he told him again and then hit him twice in the face. He said he would never hit a woman, but he will hit a man that comes in his room uninvited. He said he get along with his roommate. He said he the same resident had been in his room before and he kicked his expletive then, too . An interview with CNA E on 9/25/2024 at 12:54pm, CNA stated she had been employed only a few months. She said Resident #3 wanders a lot. She said when he is awake, he wanders constantly. She said she sometimes place a chair in the hallway to watch the residents and re-direct the wanderers. She said Resident #3 tries to get into other residents' beds. She said staff must keep a close eye on him. She said there are usually 2 CNA's and 1 nurse on the memory care hall. But sometimes they do not have two because of call-in and no shows. In an interview with CNA J on 9/25/2024 at 1:25pm she said she was working the 10pm-6am shift on the secure unit when around 4:15am she heard CR#1 yelling, he wanted his roommate out of his room. She said she went to the room and calm CR#1 down and remind him that Resident #2 was his roommate. She said when he was calmed down and was back on his side of the room, she left the room. She said, shortly after she left, she heard them yelling and they were on the floor in the hallway and the next thing she saw was CR#1 banging Resident #2's head on the floor and it was bleeding. She said she pulled CR#1 off Resident #2 and put CR #1 in the room and closed the door. She said when she saw the blood coming from his head she called the nurse on her phone, applied pressure to the head until the nurse came and took over. She said 911 was called, physician and family and the resident was, sent to the hospital. Further interview revealed she was the only CNA who was working on the secured unit at the time of the incident. She said 2 aides were schedule to work the unit but there was a call in, and the other aide had to go to another hall. She said it was her first time working the unit. Further interview with CNA J revealed she was trained on abuse/ neglect, managing aggressive residents and reporting abuse and neglect. She said Resident #2 was a very quiet man and he was not aggressive and did not display any behavior issues. She said she had never witnessed CR#1 being aggressive to any resident. A telephone interview with LVN A on 9/25/2024 at 4:50pm, LVN stated Resident #3 and Resident #4 had an altercation after Resident #3 wandered into Resident #4's room and he asked him to leave. Resident #3 refused and proceeded to lay in his roommates' bed. She said she was the nurse on duty but was not in the unit at the time. She had been called by an unknown CNA after the altercation had been broken up. She said she assessed both residents and documented the bruise to Resident #3's eye. She said she had been employed since 2019 and worked the 6pm-6am shift. She said she worked Halls A (100) and B(200), the right side of B or secure unit. She stated after the incident the DON in-serviced them on Abuse and Neglect She said wandering residents are redirected with snacks, fluids, and this will usually keep him redirected successfully. Sometimes Resident #3 can become combative and staff are instructed to give him space, offer food which he loves to eat, and this usually distracts him. She said he wanders a lot and staff had to eye a better eye on him. She admitted they are sometimes short-staffed on the secured unit. Mostly the 2p-10pm shift. A telephone interview with CNA F on 9/26/2024 at 12:11pm, she stated she did work the lock down unit (Hall 200-secured unit). She said had been employed for 2 years. She stated she no longer worked at the facility and did not know anything about the incident with Resident #3 and Resident #4. She said there was never enough staff to work in the secured unit. She said they were always short staffed. The call ended. In interview on 9/26/2024 at 1:38pm with the staffing Coordinator she stated she had been employed for [AGE] years off and on at this facility. She stated the Dementia unit (secured unit) normally staff during the daytime with 2 CNA, and the activity director and evenings were staffed normally with 2 aides and hospitality aide and at night 2 CNAs. She stated that staffing was an issue because staff sometimes call in, but she will usually come in to work or stay over or work a double shift when this happens. She said she would cover the shift herself because she was a CNA. She said on 9/2/2024, she was at work. However, she was not working the floor. She said she had CNA's staffed in the secured unit when Resident #3 and Resident #4 had the altercation. She said sometimes these altercations happens really fast and all they can do is break them up. She said she was not on call when the incident between Residents #1 and #2's altercation occurred on 9/23/2024 and she was not at work or on-call that weekend. She said she was not aware that CNAs did not come to work. She denied knowing which staff did not show up. She said she did not have the schedule on her phone and would have to check. She said Sunday (9/2224) overnight shift had two CNA's and a nurse and that was supposed to be sufficient for the overnight shift. In an interview on 9/26/2024 at 5:18pm with the Administrator, he stated there had been Resident to Resident altercations in the locked unit (2 incidents), he had increased staffing in the secured unit by adding two dedicated activity assistants about 3 months ago to keep the residents on the secured unit busy and to increase staff morale. He stated that the residents were a high elopement risk, and this was the reason Residents #1, 2, 3, and 4 were on the secure unit. They do not have a specialized unit (not dementia unit) just at risk of elopement. He said they had lots of PRN staff that pick and choose shifts. He said staffing was difficult and was indeed a challenge. He said he felt they have made some great strides. He stated that he kept 6 CNAs on each shift for all halls and nurses that came in to help out . He stated staffing is an issue, however they have enough staff to pick up shifts in the event of a call-in. An interview on 9/27/2024 at 3:05 p.m., Asst. Activity B/Transportation she said she had been employed for about 5 months. She said she helped to pass coffee in the dining room, socialize with residents and take them out on cigarette breaks. She said she worked 8am-5pm Monday-Friday. She said she worked the front area (A, C, D) Halls 100, 300 and 400. She said Activity Assistant A worked B Hall 200(secured unit). She said she does not have any CNA duties (like changing residents briefs). She was mostly there to socialize and keep the residents in the secured unit busy doing activities. In a subsequent interview with the Administrator on 9/27/2024 at 3:50 p.m. he was asked if he was aware that there was only 1 CNA on the overnight shift (10pm-6am) working on Hall 200 (secured unit) on night of 9/22/2023 into early morning of 9/23/2024. He stated no one had called to inform him as he was the on-call manager that weekend. He said he later learned that CNA's G and H were both no-call no-shows on the overnight shift. He stated that there were 6 other staff at the facility that could have helped the secured unit. He did not know why the decision was not made to move staff to the secured unit. He said the weekend supervisor should have known to move CNA's back to the secured unit as needed. He stated when they were short-staffed from call-ins the BOM, ADON, and DON have all came in to work shifts. He said it was unfortunate that the resident-to-resident altercation occurred that morning (9/23/24). He said the altercation between Resident #3 and #4 was stopped by staff and they had enough back there. He said Resident #3 did get hit by Resident #4 after wandering into his room. Investigator asked if staff should have been able to prevent the altercation?. He said, if they went to get him after learning he went inside someone else's room. He said, he is just a wanderer. An interview with RN C on 9/29/24 at 2:04pm, she said she had been employed about 1 year. She said she was one of the weekend supervisors. She said most of the residents on the secured unit really need 1-1 care. She said management needed to staff by the residents' acuity does not census in the secured unit to be able to take care of the residents' needs. She said there were too many with aggression in the secured unit and not enough staff to handle them. She said redirecting the residents is a very important skill that required staff to pay very close attention to the residents. She said on weekends they are frequently short. She said they make do. She said she pull CNAs from other halls to go to the secured unit. Sometimes the other halls are short too. She stated she was did not work An interview with CNA B on 9/30/2024 at 2:15pm, revealed her to state she had been employed since 2022. She said she worked Hall B (secured unit) on 9/2/2024 day of incident with Resident #3 and #4's incident. She said Resident #3 wandered a lot and he went into Resident #4's room and CNA F said she saw Resident #4 punching Resident #3. She yelled for her to come to help. She helped Resident #3 back to his room and the nurse assessed him. She said they received in-services for ANE, falls, call-ins, behavior training (how to separate residents, signs of agitation or aggression, changes in their behaviors or moods). She said they were usually staffed well in the secured unit but occasionally someone call in and they do not have enough staff. She stated she was not there when the altercation occurred between An interview with the DON on 9/30/2024 at 4:45pm revealed she had been employed since May 2022. When asked about her expectation for her nursing staff she said, all nurses to be incompliance with state regulations, come to work and do what they were supposed to do. She said resident assessments were done by a corporate team and the facility staff does not do assessments prior to being admitted into the facility. She said nurses were now doing rounding every hour for safety of the residents. She said she was not sure why no one called about the two no-call no- show staff. She said even if there was another CNA back there on 9/23/2024 they cannot stop them from having altercations even if they were standing right there. She said they were adequately staffed. She said she came in to work, ADON and all of management if they need them. The residents were taken care of. Record review of the facility assessment tool dated 8/5/2024 revealed the 200 Hall evening shift (2pm-10pm) was staffed with 2 CNas, a nurse and two medication aides-one split between 100/200(left) and one split between200 right/300/400, 2 nurses split between 100/200(left) 200/300/400 (right). Further review stated 200 Hall secure unit, long-term stay, required two CNas all shifts. Record review of the DON's job description revealed : Summary/Objective In keeping with our organization's goals, the primary purpose of the Director of Nursing is to plan, organize, develop, and direct the overall operation of our Nursing Department. Success in this position is measured by compliance with current federal, state, and local standards, guidelines, and regulations that govern the facility. Additionally, success is measured through patient quality outcomes, staff retention, and staff education/performance. Assist in calculating the number of direct nursing care personnel on duty each shift and determine the staffing needs of the nursing service department necessary to meet the total nursing needs of the residents as well as report such information to ensure that accurate staffing information is achieved and communicated. Monitor absenteeism to ensure that an adequate number of nursing care personnel are on duty at all times. An IJ was identified on 9/27/2024 at 4:24 p.m. The IJ template and Plan of removal were provided to the Administrator via email at 4:28 p.m. The following Plan of Removal was submitted by the facility and was accepted on 9/28/2024 at 10:42 a.m. and indicated the following: Plan of Removal F-725 On 9/27/24 The DON verified the current number of staff on the secure unit to assure sufficient staffing for the evening shift. At least two staff members will be present at all times. The completion date is 9/27/24. The DON reviewed the staffing schedule for the next 7 days to assure staffing is adequate. Ensuring at least two staff members are available on the secure unit. The completion date is 9/27/24. The DON/Designee will In-Service all nursing staff on attendance policy including adhering to the schedule. - Staff absent at the time of In-Service will receive in-service prior to start of their shift. The attendance policy states: Employees are expected to report to work as scheduled, on time and prepared to start work. Employees are also expected to remain at work for their entire work schedule, except for meal and rest periods If employees are unable to report for work on any particular day, or at their scheduled starting time, they must call their direct supervisor. In the event of a call in, the staffing coordinator will notify the DON and Administrator to coordinate a replacement. The charge nurses will make hourly rounds to ensure the safety of the residents and document the findings. The completion date is 9/27/24. The Charge Nurse will notify the Administrator and DON immediately or upon notification when staff is not present for their assigned shift. Monitoring of the plan of removal included the following: Interviews were conducted on 9/29/2024 between 12:07pm-4:34 pm and 9/30/2024 between 9:45 -4:30pm with CNA's B, C, E and LVNs B and D, RN A and RN B from the morning (6a-6p) shift. They were all able to explain the procedure for call-ins, attendance policy, when they should let management know if they notice staff were on the schedule but not at work. Charge Nurses LVN D, RN A and RN B stated they were required to make hourly rounds to check for resident safety. Interviews between 9/29/2024 between 12:07pm-4:34 pm and 9/30/2024 between 9:45 [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure personnel provided basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel for 1 of 19 residents (CR #1) reviewed for CPR. 1. Laundry Aide D failed to call a code blue or express CR #1 experienced a medical emergency when she requested assistance in the locked memory care unit after CR #1 was noted to be unresponsive on [DATE]. This led to a delay of at least three minutes before nursing staff arrived to assess CR #1, who died shortly after arrival to the ER. 2. CNA A initiated CPR with improper chest compressions prior to knowing if CR #1 was full code and prior to checking for a pulse while he was still sitting unresponsive in his wheelchair on [DATE]. 3. Staff failed to immediately retrieve and ensure the crash cart and AED were unlocked and readily accessible after CR #1 was noted to be unresponsive. This led to a delay of approximately ,d+[DATE] minutes before oxygen was administered to CR #1. 4. CPR was initiated on CR #1 when he still had a pulse and nursing staff stated this was appropriate emergency care. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 1:14 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated with the severity level at a potential for more than minimal harm that is not immediate jeopardy because all staff had not been trained on [DATE]. These failures placed residents at risk of experiencing worsening of condition, extended pain, and death from possible delays in the initiation of an emergency response and improper implementation of CPR. Findings include: Record review of CR #1's face sheet dated [DATE] revealed he was an [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with COPD (a group of lung conditions that cause breathing difficulties), vascular dementia (brain damage caused by multiple strokes), diabetes (a group of metabolic diseases that cause persistently high blood sugar levels), psychosis (a mental disorder characterized by a disconnection from reality), gastro-esophageal reflux (a digestive disease in which stomach acid or bile irritates the food pipe lining), metabolic encephalopathy (a group of neurological disorders that cause temporary or permanent brain function disturbances), and essential hypertension (high blood pressure that occurs when there is no identifiable cause). He was discharged to a funeral home after he died on [DATE]. Record review of CR #1's quarterly MDS dated [DATE] revealed he had a BIMS score of 6 (severe cognitive impairment); CR #1 ambulated via walker and wheelchair; CR #1 required supervision or touching assistance from staff for eating and oral hygiene; CR #1 required partial/moderate assistance from staff for toileting hygiene, shower/bathing, dressing, and personal hygiene; and CR #1 was frequently incontinent of bowel and bladder. Record review of CR #1's care plan, revised [DATE] revealed the following care areas: * CR #1/Responsible Party have requested a code status of Full Code. Goals included: CR #1's code status will be maintained/honored. Interventions/Tasks included: If the resident's heart stops, initiate CPR, and call 911 for transfer to the hospital. Inform staff of code status. Monitor for any changes in the resident's code status. Monitor for decline or change of condition and report to physician and responsible party. * CR #1 was at risk for respiratory distress/failure and increased episode of shortness of breath due to diagnosis of COPD. Goals included: CR #1 will be free from any respiratory distress/failure and will have minimal/no further episodes of shortness of breath. Interventions/Tasks included: Allow breaks when performing tasks, do not rush. Minimize stress/anxiety and allow him to verbalize feelings when appropriate. * CR #1 Was an elopement risk/wanderer related to history of attempts to leave the facility unattended, impaired safety awareness, and diagnoses of dementia. Goals included: The resident will not leave the facility unattended. Interventions/Tasks included: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Provide structured activities. The resident's triggers for wandering/eloping are thinking that he wants something from the store. The resident's behaviors are de-escalated by reminding him that staff will assist him with his shopping needs weekly. * CR #1 resided in the Memory Care Unit related to impaired cognition secondary to his diagnosis of dementia, elopement risk, need for controlled environment, need for reduced stimuli, and wandering. Goals included: CR #1's dignity will be maintained, and he will be safe in the memory care secured unit. Interventions/Tasks included: Call resident by name when giving care, involve him in care as much as possible. Keep environment free of possible hazards. Provide activities that accommodate the resident's abilities. * CR #1 required a regular mechanical soft diet with regular thin liquid for nutritional support and was at risk for unplanned weight loss and nutritional complication. Goals included: CR #1 will have adequate nutrition/fluid intake and will be free from unplanned weight loss or other nutritional complication. Interventions/Tasks included: Dietary Manager to monitor/discuss food preferences. Give medications as ordered. Give supplements as ordered by physician. Weigh every month and as needed. Report 5% loss/gain to physician and responsible party. Record review of CR #1's Progress Notes for [DATE] revealed the following: * Effective Date: [DATE] at 1:15 p.m. Type: SBAR Summary. Author: LVN B - Change of Condition Identified: Absence of respirations. Vital Signs: Blood Pressure - ,d+[DATE] ([DATE] at 1:15 p.m.) - Position: Other. Pulse - 0 ([DATE] at 1:15 p.m.) - Pulse Type: unable to determine. Respirations - 0 ([DATE] at 1:15 p.m.). Oxygen - 0% ([DATE] at 1:15 p.m.) - Method: Room Air. What do you think is going on with the resident? Stopped breathing. Physician Notified: [DATE] at 2:10 p.m. Responsible Party Notified: [DATE] at 1:28 p.m. * Effective Date: [DATE] at 1:15 p.m. Type: Nursing Note. Author: LVN B - Housekeeper notified nursing that CNA needed a nurse and that it was an emergency. Upon assessment noted that resident was unresponsive. Noted with no respirations but resident had a pulse. 1:16 p.m. EMS called, and CPR initiated. AED in place. Shock was not advised. 1:18 p.m. supervisor notified. 1:19 p.m. Weekend nursing supervisor arrived and took over CPR. 1:22 p.m. EMS arrived, and RP notified of change of condition. EMS took over CPR. 1:28 p.m. Administrator and DON notified of change of condition. 1:45 p.m. Resident left facility to hospital. 2:02 p.m. received a phone call from ER stating resident had passed away. 2:05 p.m. RP notified of resident's passing. Stated name of funeral home. 2:06 p.m. spoke with hospital letting them know what funeral home the RP was wanting to use. 2:10 p.m. NP and MD notified of resident passing. 2:14 p.m. Spoke with mortuary/funeral home. Record review of CR #1's EMS Report dated [DATE] revealed: . Primary Impression: Cardiac arrest . Signs and Symptoms: Cardiac arrest . Call Received - 1:13 p.m. Dispatched - 1:15 p.m. On Scene - 1:20 p.m. At Patient - 1:22 p.m. Depart Scene - 1:47 p.m. At Destination - 1:48 p.m. Patient Transferred 1:55 p.m. Condition at Destination - Unchanged. End of Event - Expired in ED. Narrative: Dispatched to facility for a cardiac arrest. Arrived to find the patient supine on the floor of the dining room. CPR was being performed by facility staff, AED was attached, staff stated there were no shocks advised, patient was on a nonrebreather attached to O2. Staff member stated that she went to collect the patient's food tray and found him unresponsive. Staff placed patient on the floor, started CPR and applied the AED. Compressions taken over by EMS, placed pads on patient, rhythm showed asystole (flatline, the heart's electrical and mechanical activity completely stopped). Ventilated patient with bag-valve-mask (a basic airway management technique used to provide oxygenation and ventilation to patients in emergency situations) with oxygen. IV access established in the left proximal tibia and secured. Started normal saline drip. Two unsuccessful intubation attempts were performed, a laryngeal mask airway device was placed, continued ventilations with bag-valve-mask. Patient lifted onto the stretcher via a sheet . Moved patient to ambulance. Scene delay due to treatment . No change in patient status while enroute . Vital Signs: Pulse - (1:25 p.m. - blank), (1:29 p.m. - 101), (1:34 p.m. - 101), (1:43 - 127), 1:49 p.m. - 40), 1:54 p.m. - 98) . ECG: 1:25 p.m. - (Artifact (a signal that is not related to the heart's electrical activity), Asystole), 1:34 p.m. - (Ventricular Fibrillation [a life-threatening heart rhythm that results in a rapid, inadequate heartbeat]), 1:43 p.m. (Pulseless Electrical Activity) . Record review of CR #1's hospital records dated [DATE] revealed he was admitted to theER on [DATE] at 1:54 p.m. for non-traumatic cardiac arrest. The document read in part, . Patient arrived by EMS from the facility, active CPR in progress . EMS states patient has been unresponsive 20 minutes during active CPR, unknown downtime. Asystole on monitor entire time . Triage start: [DATE] at 1:54 p.m. Triage stop: [DATE] at 1:54 p.m. [DATE] at 1:57 p.m.: Expired . Observation of the facility's crash cart on [DATE] at 2:50 p.m. revealed it was located between the Administrator's office and the employee breakroom, approximately ,d+[DATE] yards away from the nurse's station. There was an oxygen tank attached to the outside of the crash cart. The crash cart was unlocked. The oxygen tubing and the AED were located inside the drawers of the crash cart. There was a set of two keys on a small keyring hanging on a hook on the back of the crash cart. After locking the crash cart, neither of the two keys unlocked the crash cart. Unidentified staff who were sitting at the nurse's station stated the keys were located on a keyring which hung from a hook on the wall behind the nurse's station. They key behind the nurse's station unlocked the crash cart. In an interview with CNA A on [DATE] at 11:30 a.m., she stated she always worked in the locked memory care unit. She said she usually worked the night shift (10:00 p.m. - 6:00 a.m.), but she moved to the evening shift (2:00 p.m. - 10:00 p.m.) and also picked up additional shifts. She stated CR #1 was alert and could have a conversation. She said he could walk but used a wheelchair. She said when she arrived for her shift on Saturday ([DATE], she worked 6:00 a.m. - 2:00 p.m.) morning, CR #1 was in the shower with a staff from the night shift. She said after CR #1's shower, he went to his room, then he went to the dining room for breakfast, then went back to his room, and then he eventually went back to the dining room for lunch. She said CR #1 ate his lunch with no issues. She said CR #1 ate everything off his lunch tray and he asked her for water after he finished eating. She said CR #1 was on a mechanical soft diet, so he normally had soft meats. She said he required set-up assistance, but he fed himself. She said she only had to watch him to make sure he did not eat too fast. She said she picked up CR #1's lunch tray and gave him water as he requested. She could not recall what time each event occurred that day. CNA A said she left the dining room and went to the hallway (still inside the locked unit) when Housekeeper E said CR #1 was unresponsive. She said she ran back into the dining room and Laundry Aide D, who was in the locked unit closer to the door to the outside, ran to get a nurse. She said CR #1's head was leaned back, and she started CPR. She said CR #1's mouth was open and there was nothing in his mouth. She said she started pressing on CR #1's chest while he was still in his wheelchair. CNA A demonstrated how she pressed on CR #1's chest and it appeared she was pressing underneath his rib cage while she stood in front of him. She said other residents who were nearby kept telling her to keep going (keep doing compressions) because it looked like he was coming back (regaining consciousness). She said while she was doing compressions, CR #1's head and feet started moving. She said when the nurses (LVN B and LVN C) arrived in the dining room, they were just looking around like they did not know what they should do. She said LVN B said they had to determine if CR #1 had a DNR and then asked her if she looked at CR #1's POC. She said she told LVN B she did not have time for that. She said LVN C ran back out to the nurse's station (located outside the locked unit) and looked at CR #1's POC. She said Laundry Aide D told the nurses CR #1's name before they went into the locked unit, so she thought they should have checked his POC before they went in. She said LVN C came back and said CR #1 was full code. She said at that point, she was thinking, Are they going to help me? She said Laundry Aide D told her the nurses were walking and did not react fast when she told them CR #1 needed help. She said more than three minutes, but less than five minutes passed before the nurses arrived in the dining room to assess CR #1. She said one of the nurses ran back out of the unit to get the crash cart and the other said she needed oxygen. She said at the time, CR #1 was still sitting in his wheelchair. CNA A said she kept asking the nurses if they were going to help get CR #1 on the floor, but LVN B said to leave him in his wheelchair because he still had a pulse. She said she thought CR #1 needed CPR, so she ran out of the locked unit to find other CNAs to help get him to the floor. She said when she and the other CNAs (CNA F and CNA G) returned to the unit, they put CR #1 on the floor. She said about three minutes passed from the time LVN C said she needed the crash cart and when returned to the unit with it. She said one of the nurses eventually initiated CPR and the RN (RN Weekend Supervisor) used the AED pads. She said LVN C called 911 and the ambulance and police arrived quickly. She said CR #1 did not cough or choke at all. CNA A said she was certified to do CPR and the Heimlich Maneuver at a class not associated with the facility. She said she was also educated on what to do if a resident was choking at the facility. She said she did not know if CR #1 had a DNR or not, she just acted. She said she did not do any breaths or check his pulse. She said she thought the facility had a mask in the crash cart for the breaths, but the crash cart was locked, and they had to find the key. She said she guessed LVN C had the wrong key when she brought in the crash cart because she was new to the facility. She said the key to the crash cart was located behind nurse station. She said she was told where the key was during training. In an interview with CNA F on [DATE] at 1:10 p.m., she stated she always worked the morning shift (6:00 a.m. - 2:00 p.m.) shift. She said she worked all of the halls, including the locked memory care unit. She stated on Saturday, [DATE], she was doing her last rounds (she could not recall exactly what time it was) when CNA A said she needed help with CR #1 because he was unresponsive. She said when she saw CR #1, his eyes and mouth were wide open. She said CR #1 was not breathing, so she, CNA A and CNA G got him on the floor. She said RN Weekend Supervisor arrived to give CPR. She stated the incident appeared unprofessional because the nurse did not have the key to the crash cart and staff were running back and forth, looking for the key. She said when she arrived in the unit, two nurses, LVN B and LVN C, were there shaking CR #1, trying to get him to respond. She said she thought there was only one crash cart, which was located by the break room and the beauty salon. She said LVN C started CPR and RN Weekend Supervisor took over. She said a few minutes passed after she initially saw CR #1 in his wheelchair and when they started CPR. She said the nurses never tried to get CR #1 to the floor. She said RN Weekend Supervisor said to put the pads on to start shocking CR #1, but the machine said it was not advised to do shock. She said the nurses kept doing CPR until an ambulance arrived. She said if a resident was unresponsive, they should have come with everything they needed, but they did not. She said when she got to CR #1 and saw how he looked, she did not think the nurses moved with urgency. She said the nurses should have gone into the unit prepared or moved with urgency, but there was a lot of confusion. She said she never heard anybody call a code (code blue). She stated she was trained to do CPR and she knew how to start. She said she was pretty sure she had code training at the facility, but she could not recall when. She said when she went to the locked unit, they nurse said CR #1 had a pulse. She said she felt for a pulse, but she did not feel anything there. She said the nurse did not say anything, but that was when they decided to put CR #1 on the floor. She said CR #1 was really stiff and rigid and it was hard to put him on the floor. She said the incident was around 1:00 p.m. because CR #1 ate pretty slow. She said there was no food in CR #1's mouth and he was still warm. In a telephone interview with LVN B on [DATE] at 1:26 p.m., she stated nurses worked 12-hour shifts and she normally worked the 6:00 a.m. - 6:00 p.m. shift. She stated on Saturday, [DATE], she was responsible for D hall, C hall, and the right side of B hall (B hall was the locked memory care unit). She said on that day, she was at the nurse's station charting after lunch when the housekeeper (Laundry Aide D) said they needed a nurse back there in the unit. She said that was all Laundry Aide D said. She said she asked Laundry Aide D what was going on, and she just said they needed a nurse. She said once she got to the dining room, she saw CR #1 laying back in his wheelchair with his mouth and eyes open and he was unresponsive. She said she did her ABC's and saw he was not breathing, but he did have a pulse. She said she asked the other nurse to get the crash cart and AED. She said the other nurse (LVN C) called 911 on her way out of the unit. LVN B said she monitored CR #1's pulse while she waited on the crash cart. She said 1 to 2 minutes passed before the crash cart arrived. She said RN Weekend Supervisor came in and assisted. She said once the crash cart was there, she got the AED out, got O2 on CR #1 and assessed him. She said the AED indicated no shock was advised. She said RN Weekend Supervisor started CPR and then they switched, and she (LVN B) took over. She said the ambulance arrived and the EMS took over CPR. She said shock not advised meant they had to do CPR and there was no shockable heart rhythm. She said there was a CNA on the unit and two additional CNAs came and assisted CR #1 to the floor. She said while the other nurse got the crash cart, the aides assisted CR #1 to the floor. She said they had to get keys for the crash cart because they did not have keys with them. She said someone had to run and get the key. She said the key was now located on the back of the crash cart (the keys located on the back of the crash cart did not open the crash cart). She said on the day of CR #1's incident, the keys were in a drawer at the nurse's station. She said the nurses knew where the keys were located, but she did not know if the CNAs knew because a CNA was running for the crash cart keys and she had to ask where they were. She said a nurse had to help the CNA find them. She said maybe ,d+[DATE] minutes passed from when she initially saw CR #1 and when they started CPR. She said a nurse was back in less than a minute with the keys to the crash cart. She said when she and the other nurse walked in, the aides were just standing there. She said when a resident was unresponsive, you have to immediately get them to the floor. She said in this situation, CR #1 was immediately placed on the floor. She said two aides helped her place CR #1 on the floor. She said she had CR #1's two legs and the aides had his trunk on each side. LVN B said she checked CR #1's radial and carotid pulses and he had a faint pulse. She said they had an AED, and they were waiting on that. She said while the AED was being applied, RN Weekend Supervisor started chest compressions. She said they did not normally do CPR on a person with a pulse, but by the time they reassessed CR #1 on the floor, his pulse was gone. She said she looked for a carotid and radial pulse and there was none at all. She said normally, a code was called but everybody except for a few people were already in the room. She stated she was trained on CPR and codes. She said once the EMS arrived, they took over and got an Ambu bag (bag valve mask which is used to provide respiratory support) out. She said she held the mask while the EMS worked. She said the incident started after lunch around 1:15 p.m. or 1:30 p.m. In a follow-up interview with LVN B on [DATE] at 3:00 p.m., she stated on [DATE], she, RN Weekend Supervisor, and LVN C were at the nurse's station when the housekeeper (Laundry Aide D) came out and said they needed a nurse in the unit. She said when they were almost at the locked unit, the housekeeper said it was CR #1, and then she said it was an emergency when they were almost to the dining room where CR #1 was. She said it was not very long before the nurses got up from the nurse's station after the housekeeper told them they needed a nurse. She said they did not walk very fast because the housekeeper did not say it was an emergency. She said she thought CR #1 fell because he fell a lot. She said RN Weekend Supervisor was still sitting at the nurse's station and did not go inside the unit at that time. She said when they approached CR #1, they saw him sitting in his wheelchair with his head back and his mouth and eyes were open. She said if the housekeeper would have said CR #1 was unresponsive, they would have gone in with the crash cart, and they knew where the key was. She said instead, the aides were running around because they did not know what to do or how to handle the situation. She said LVN C ran and made the call to 911 and all the other staff left her in the dining room alone. She said she kept yelling that she needed oxygen for CR #1. She said CR #1's pulse was a little strong but got fainter. She said maybe ,d+[DATE] minutes maximum passed before the other staff returned to the unit. She said she did not want to dump CR #1 on the floor, and she could not leave him alone. She said when the aides came back in, they helped her lower CR #1 to the floor. She said they waited for the crash cart, but the key was not with it once it arrived. She said CNA G came back and said she could not find the key, so she told her where it was. She said CNA G came back with the key within 30 seconds. She said if there was a faint pulse, she would do CPR, but if it were a deeper pulse, she would not. She said at first, CR #1 had a pulse, so she would not do CPR, but by the time they lowered him to the floor, and she reassessed him, the pulse was faint, and it was time to do CPR. She said she needed the AED and the oxygen tubing from inside the crash cart. She said the oxygen was administered to CR #1 before they got the key to the crash cart because they found tubing somewhere else. She said they started chest compressions before they got the crash cart key. She said LVN C started chest compressions and after a couple of rounds, RN Weekend Supervisor took over for ,d+[DATE] rounds, then she (LVN B) took over. She said maybe ,d+[DATE] minutes passed between the time CR #1 was placed on the floor and when the AED came. She said as soon as they had access, they placed oxygen on CR #1. She said once EMS arrived, they tried to intubate twice, but were unsuccessful. She said EMS only suctioned saliva from CR #1's mouth. She said CR #1's mouth was already stiff, and his color changed while they did CPR. She said CNA A did not tell her she started CPR compressions. She said the nursing staff did everything correct and were not slow to respond. In a telephone interview with Housekeeper E on [DATE] at 1:51 p.m., she stated on Saturday, [DATE], she was in the dining room of the locked unit after lunch, and she had just started to clean it. She said the CNA back there (CNA A) looked at the residents, then she walked out to the hall to get trays from other residents. She said not two minutes later, she looked up and saw CR #1 leaned back in his chair with his mouth and eyes open. She said he was unresponsive and other residents were trying to wake him up. She said she went and told the aide and the aide looked at him and told Laundry Aide D to go get a nurse. She said she helped to get the other residents out of the dining room. She said it took the nurses more than 3 minutes to get to the unit. She said one of the nurses had her phone. She said once the nurses got back there, it was not good because none of them brought the crash cart and then they could not find the key. She said the nurses sent a CNA out to look for the key who did not know where they were. She said there was a visitor inside the dining room who said she did not understand what was going on because of all the confusion. She said CR #1 was still in his wheelchair and was not placed on the floor for more than 5 minutes after the nurses were told about CR #1. She said she heard LVN B say to leave CR #1 in his wheelchair because he had a pulse and was breathing, but his chest was not going up and down. She said two aides placed CR #1 on the floor. In an interview with Laundry Aide D on [DATE] at 2:15 p.m., she stated on Saturday, [DATE], she was delivering clothes in the locked unit. She said she heard something was wrong with CR #1 and the CNA ran back there to the dining room. She said the CNA asked for someone to grab a nurse and she was closer to the door. She said she asked both nurses who were at the nurse's station if someone could come back because CR #1 needed assistance and the aide needed help. She said she could not say exactly how many minutes it took the nurses to go to the unit, but they were behind her. She said she was already back down the hall and in the dining room by the time the nurses came. She said she saw CR #1 laying back in his wheelchair with his mouth open. She said they tried to make sure all the residents were out of the dining room and by that time, the more mobile residents started coming back out of their rooms. She said she closed the door to the dining room so the residents could not see inside. She said she recalled seeing CNAs from every hall run down the hall to help each other get CR #1 of his chair and they laid him flat on the floor. She said RN Weekend Supervisor from C hall heard the commotion and she ran down there to assist. She said she had been trained that if there was an emergency, she was supposed to get help. She said she did not recall being trained to call any codes in an emergency. In an interview with the Administrator and DON on [DATE] at 3:00 p.m., the Administrator said on [DATE], he was at a store across the street from the facility, and he received a call from RN Weekend Supervisor who said CR #1 coded. The Administrator said when he arrived at the facility, EMS had just brought CR #1 out and they were still working on him. The Administrator said the EMS told him they could not give a status report on CR #1 because they were still working on him, but they had not pronounced him dead at that time. The Administrator said he spoke to staff, including CNA A and RN Weekend Supervisor. The Administrator said the staff told him they started CPR immediately. The Administrator said LVN C told him the same story as the other staff, that the laundry aide said they needed a nurse to the unit and the nurses went in there and called 911 on the way in. He said the staff told him CNA A was doing CPR and RN Weekend Supervisor grabbed the crash cart and took it the to unit. The Administrator said that is what he got from the staff who were there. The Administrator said nobody told him CR #1 was in his wheelchair when they started CPR. The DON said it was not appropriate to do CPR while a resident was in a wheelchair. The DON said staff should call a code blue to get assistance when a resident was unresponsive. The DON said staff should check for a pulse, check vital signs, get assistance, and place the resident on the floor. The DON said the first person to respond to the unresponsive resident would check vitals and pulse. The DON said the resident should not be left alone and the staff should document the incident later. The DON said anybody could initiate CPR if they were trained. The Administrator said he did not know what time he was called regarding CR #1 but RN Weekend Supervisor called him. The Administrator said he had a lot going on with his phone, so he could not look through his call log to see what time staff called him. The DON said RN Weekend Supervisor called her on [DATE] regarding CR #1's incident, but she could not look through her phone to provide the time she was called. The DON said the crash cart was usually locked because residents had a tendency to go into it. The DON said the key to the crash cart was at the nurse's station. And all staff knew where key was because they had an in-service regarding the crash cart on [DATE]. The DON said none of the staff told them they had trouble finding the key to the crash cart on [DATE]. In an interview with LVN C on [DATE] at 10:00 a.m., she stated she normally worked the 6:00 a.m. - 6:00 p.m. shift. She said she worked on A hall and half of B hall, but she never cared for CR #1 because he was on the opposite side of B hall. She said on Saturday, [DATE], a housekeeper inside the unit opened the door when she and the other nurse were sitting at the nurse's station. She said the housekeeper said they needed a nurse for CR #1 inside the unit, but she did not say what was wrong. She said she and LVN B both went because the housekeeper had an urgent look on her face. She said they went inside and saw right away that CR #1 was in distress. LVN C said she called 911 before she knew if CR #1 was full code or DNR so EMS could be on the way. She said she then ran to the nurse's station to check CR #1's code status. She said it took her and LVN B about 30 seconds to get to the unit and she observed CR #1 sitting in his wheelchair with his head leaned back. She said CR #1 looked unresponsive and LVN B assessed him while she was on the phone with 911. She said LVN B tried to see if CR #1 had a pulse, and she tried to arouse him, but he looked unresponsive. LVN C said she did not stick around because she wanted to see if CR #1 was full code. She said once she saw CR #1 was full code, she ran back and yelled it out down the hall, but CR #1 was already on the floor out of his wheelchair. She said she told the staff he was full code, then they started CPR. She said someone had already gotten oxygen before that. She said there were a lot of staff back there, including aides from another hall. She said she got the crash cart after she told staff CR #1 was full code. She said she brought the crash cart into the unit, but it was locked. She said the crash cart should be locked because residents could get into it. She said that was her first time having to get the crash cart. She said once the cart was inside the unit, she thought the key was hanging on a keyring on the back of the cart, but they did not need it because they had everything t [TRUNCATED]

Based on observation, interview and record review the facility failed to ensure pain management was provided to residents who required such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 6 residents (Resident #1) of 6 reviewed for pain management in that: -The facility failed to address Resident #1's pain in her left leg and ankle after falls on 1/31/24, 2/8/24 and 4/2/24 and unresolved pain relief from the Tylenol and Tramadol prescribed. This failure could place residents at risk for unnecessary pain, discomfort, and decreased quality of life. Findings included: Resident #1 Record review of Resident #1's face sheet dated 5/2/2024 revealed she was a [AGE] year old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of critical illness myopathy(generalized weakness involving the muscles of the extremities, trunk, and respiration), chronic obstructive pulmonary disease(refers to a group of diseases that cause airflow blockage and breathing-related problems), epilepsy (is a chronic noncommunicable disease of the brain), acute respiratory failure(is often caused by a disease or injury that affects your breathing), asthma, chronic pain syndrome (when pain lasts for 3 to 6 months or more), hypotension (low blood pressure occurs when blood pressure is much lower than normal), hemiplegia and hemiparesis (Hemiplegia refers to a severe or complete loss of strength, whereas hemiparesis refers to a relatively mild loss of strength) following cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting left dominant side, anxiety(a feeling of worry or fear that is strong enough to interfere with one's daily activities), heart failure (a chronic condition in which the heart does not pump blood as well as it should), dependent on renal dialysis (process of removing excess water, solutes and toxins from the blood), end stage renal disease(occurs with chronic kidney disease where you gradually lose kidney function and reaches an advanced state), and unsteadiness on feet, cognitive communication deficit (difficulty with thinking or how someone uses language). Record review of Resident #1's Care plan dated 8/23/23 revealed Resident #1 was indicated for pain: Risk for further episodes of increased pain/discomfort and injury with interventions as allow to verbalize feelings of pain/discomfort, assist with ADL's and comfort measures as indicated, encourage socialization and activity attendance as tolerated, Lyrica cap (pregabalin) as ordered, monitor for effectiveness of pain medication or other intervention-report to MD if ineffective, monitor for side effects of pain medication-report to MD of any noted, observation: pain- observe every shift. If pain present, complete pain flow sheet and treat trying non-pharmacologic interventions prior to medicating if appropriate QS, observe for s/sx of increased pain/discomfort-assess resident for possible causes -give pain medications, treatments, relaxation modalities, etc.- check for relief, tramadol HCL as ordered, utilize 0-10 numbers (0)-represented no pain and 10 meaning the worst pain you have felt) scale to assess pain level. Record review of Resident #1's Quarterly MDS assessment signed on 3/7/24 revealed a cognitive BIMS score of 15 indicating cognition is intact. Resident #1's functional abilities and goals revealed partial/moderate assistance with toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, personal hygiene, sit to stand, chair/bed-to-chair transfer, and supervision or touching assistance for oral hygiene, roll left and right, sit to lying, lying to sitting on side of bed flat on the bed, and lying to sitting on side of bed. Resident #1 was identified for pain, but pain presence was documented at 0. Record review of Resident #1's Physician Orders dated 4/16/24 revealed: Follow up with orthopedic physician re: left ankle x-ray and splint order dated 2/12/24 Observation: Opioid Medication (Side Effects) Document Y if free from side effects and N if side effects are present, Notify MD as needed for presence of side effects. Every shift side effect: Tolerance, increased sensitivity to pain, constipation, nausea, vomiting, dry mouth, sleepiness, dizziness, confusion, depression features, itching, and sweating Observation: Pain- observe every shift. If pain present, complete pain flow sheet and treat trying non-pharmacologic interventions prior to medicating if appropriate. Document in the Patient notes, every shift Acetaminophen Oral Tablet 325 MG (Acetaminophen) Give 2 tablet by mouth two times a day for Pain -Start Date- 10/14/2023 Acetaminophen Oral Tablet 325 MG (Acetaminophen) Give 2 tablet by mouth every 6 hours as needed for general discomfort or pain started on 11/27/23 Lidocaine External Ointment 5 % (Lidocaine) Apply to right arm topically every 8 hours as needed for pain apply thin layer to fistula area (the tunnel that forms under the skin along the drainage tract) before dialysis and prn started 4/13/24 Lyrica Oral Capsule 50 MG (Pregabalin) Give 1 capsule by mouth at bedtime for neuropathic pain . -Start Date- 01/30/2024 Tramadol HCl tablet 50 mg give 50 mg by mouth every 8 hours as needed for pain related to pain, unspecified started on 10/13/23. Voltaren External Gel 1 % (Diclofenac Sodium (Topical)) Apply to affected areas topically every 6 hours as needed for pain started 4/4/24. Record review of Resident #1's progress note dated 1/31/24 at 5:17 am signed by LVN D revealed Resident heard calling out for help from bedroom, found sitting on floor beside bed on entering room. Resident laughs when staff enters room, states that She was bouncing up and down in a dream and woke up sitting there. Neurological assessments initiated, Transfer x 4 assist to bed. Resident denies pain or discomforts, v/s within acceptable parameters, NP notified. Resident s/p surgical procedure to RUE, no resistance in ROM noted, minimal amount of soreness expressed. Record review of Resident #1's progress notes dated 2/1/24 at 8 pm by LVN B revealed Continues on fall follow up for earlier fall. NO c/o pain or discomfort noted or voiced. No visible injuries or bruising noted. Neuro checks WNL. Able to move all extremities WNL. Will continue to monitor. Record review of Resident #1's progress notes dated 2/8/24 at 4:05 am by LVN D revealed Resident heard yelling out, staff enters room to see Resident sitting on the floor beside her bed, holding 2 bags of cookies. Resident states that She had woken up and was trying to fall back to sleep when her body sat on the floor on its own like the last time. Neurological assessments initiated per facility protocol, pain assessment, Resident transferred back to bed x 2 assist while yelling out, just get me up, just get me up. Resident denies pain or discomfort associated with fall. Resident with non-skid proof socks on, educated on importance of wearing skid proof socks for safety and prevention. Resident declines skid proof socks. Call light not in use at time of event. No new orders received from NP. Record review of Resident #1's Nursing Note dated 2/8/24 at 3:15 pm written by LVN B revealed Seen by NP. New order received. X-ray of left ankle. C/O pain to left ankle due to recent fall. Continues on fall follow up. Neuro checks WNL. Will monitor. Record review of Resident #1's Nursing note dated 2/11/24 at 10:23 am by LVN B revealed This author let resident know that X-ray would be here to do her X-ray at 2pm. Resident states she is going to church and this author could not stop her. Educated on importance of getting x-ray. Resident says she will do x-ray today, but will be staying in bed and not taking medications, going to dialysis, meals, etc. NP notified. Record review of Resident #1's Radiology Results dated 2/11/24 at 1:30 pm revealed left ankle, 2 views x-ray completed on 2/11/24 at 1:30 pm revealed left ankle, 2 views. Findings: There is a suspicious oblique non-displaced hairline fracture of the lateral malleolus of the fibula (is a type of ankle fracture that occurs when the fibula fractures just above the ankle joint), which is only visible on the AP images. This finding is suggestive of a low-energy trauma fracture, consistent with the reported history of fall. Impressions: Suspicious oblique non-displaced hairline fracture of the lateral malleolus of the fibula, likely related to the recent fall. Given the subtlety of the finding, clinical correlation is recommended and consideration for further evaluation with advanced imaging, such as MRI, if clinically indicated by persistent pain or functional limitation. Record review of Resident #1's Nursing note dated 2/11/24 at 9:45 pm revealed left ankle x-ray results in, called NP and received new order to send to ER for further evaluation, called RP, no answer, left message to call back, reported to DON and administrator as well of x-ray results and transport to er, called EMS for transport. Record review of Resident #1's February 2024 MAR revealed: Lidocaine External Patch 5 % (Lidocaine) Apply to Left Shoulder topically one time a day For Chronic Pain Syndrome and remove per Schedule -Start Date- 01/09/2024 8:00 am and D/C date 2/8/24 at 5:29 pm revealed: Meds were administered daily. Lyrica Oral Capsule 50 MG (Pregabalin) Give 1 capsule by mouth at bedtime for neuropathic pain. -Start Date- 01/30/2024 8 pm revealed: 2/1-2/22/24 meds were administered, 2/23-2/25/24 meds were not administered with number 8 to check progress note and it stated awaiting from pharmacy, 2/26-2/29/24 meds were administered. Acetaminophen Oral Tablet 325 MG (Acetaminophen) Give 2 tablet by mouth two times a day for Pain -Start Date- 10/14/2023 08:00 am revealed: pain level was NA all days with the exception of 2/16/24 and resident not in facility at 8 am, and 2/2/24, 2/26-2/27/24 at 6 pm and 2/21/24 was 0 at 6 pm. Observation : Pain - Observe every shift. If pain present, complete pain flow sheet and treat trying non-pharmacologic interventions prior to medicating if appropriate. Document in the Progress notes. every shift -Order Date- 11/20/2023 10:11am. Record review revealed the pain level was 0 at 6 am and 6 pm for 2/1-2/29/24. Tramadol HCL Tablet 50 mg give 50 mg by mouth every 8 hours as needed for pain related to pain, unspecified dated 10/13/23 at 10:44 pm PRN administered on 2/6/24 Voltaren External Gel 1 % (Diclofenac Sodium (Topical)) Apply to left ankle topically two times a day for ankle pain for 7 Days -Order Date- 02/09/2024 10:31 am revealed pain level was 0 on 2/1-2/4/24 at 8 am and 8 pm but medication was administered. On 2/5-2/29/24 the facility marked an X and no medication was administered. Acetaminophen Tablet 325 MG Give 2 tablet by mouth every 6 hours as needed for general discomfort or pain -Order Date- 11/27/2023 1:59 pm revealed no PRN medication was administered as observed to be left blank. Voltaren External Gel 1 % (Diclofenac Sodium (Topical)) Apply to neck /shoulder/knees topically every 12 hours as needed for joint pain/neck pain for 30 Days -Order Date- 01/25/2024 2:09 pm revealed no PRN medication was administered . Voltaren External Gel 1% 02/01/24 8:00 am 2/01/24 8:42 pm topically Neck 02/02/24 8:00 am 2/02/24 8:13 pm topically Neck 02/02/24 8:00 pm 2/02/24 7:31 pm topically Neck 02/03/24 8:00 am 2/03/24 7:06 pm topically Neck 02/03/24 8:00 pm 2/04/24 4:23 am topically Neck 02/04/24 8:00 am 2/04/24 8:14 am topically Neck 02/09/24 8:00 pm 2/09/24 7:41 pm topically Abdomen - LUQ 02/10/24 8:00 am 2/10/24 9:38 am topically Abdomen - LUQ 02/10/24 8:00 pm 2/10/24 7:20 pm topically Abdomen - RLQ 02/11/24 8:00 am 2/11/24 7:13 am topically Abdomen - LLQ 02/11/24 8:00 pm 2/11/24 8:25 pm topically Ankle - outer (left) 02/12/24 8:00 am 2/12/24 9:11 am topically Ankle - outer (left) 02/13/24 8:00 am 2/13/24 9:16 am topically Ankle - outer (left) 02/14/24 8:00 am 2/14/24 9:09 am topically Ankle - outer (left) 02/14/24 8:00 pm 2/14/24 7:36 pm topically Ankle - outer (left) 02/15/24 8:00 am 2/15/24 2:57 pm topically Ankle - outer (left) 02/15/24 8:00 pm 2/15/24 8:09 pm topically Ankle - outer (left) 02/16/24 8:00 am 2/16/24 9:52 am topically Ankle Record review of pain assessment dated [DATE] revealed: Pain presence: Ask resident: Have you had pain or hurting anytime in the last 5 days?'' the answer selected was 1. YES. B. Pain Frequency: Ask resident: How much of the time you experienced pain or hurting in the last 5 days? the answer selected was: 1. Almost constantly C. Pain intensity: Numeric rating Scale (0-10) the answer was 05. Verbal descriptor scale was unanswered or not asked. 2A. Describe administration patterns, any side effects and effectiveness- PRN Tramadol and PRN Tylenol Record review of Resident #1's Pain level Summary dated 4/17/24 at 1:13 pm revealed: 2/8/24- Pain level 0 for the day 2/9/24- Pain level 0 for the day 2/10/24- Pain level 0 for the day 2/11/24- Pain level 0 for the day 2/12/24- Pain level 6 at 4:30 am, but for the remainder of the day was 0. 2/13/24- Pain level 3 at 9:16 am, but 0 for the remainder of the day 2/14/24- Pain level 0 for the day 2/15/24- Pain level 3 at 2:57 pm and 5:06 pm and 0 for the rest of the day 2/16/24-3/1/24- Pain level 0 for each day 4/2/24- Pain level 0 for the day 4/3/24-pain level 6 at 11:55 pm 4/4/24- 4/8/24- pain level 0 for each day 4/9/24- pain level 6 at 4:45 am Record review of Resident #1's April 2024 MAR revealed: Acetaminophen Oral Tablet 325 mg give 2 tablet by mouth two times a day for pain start dated 10/14/23 at 8 am. Pain level on 4/1-4/13/24 were NA or 0, 4/14/24 the pain level was X and resident was stated to away from facility without meds and 4/15-4/16/24 was NA. The pain level at 6 pm was NA or 0 on 4/1-4/15/24 with the exception of 4/8/24, 4/12/24 and 4/14/24 where X was notated and the number 2 was listed stating Resident #1 was away from facility without meds. Observation: Pain-observe every shift. If pain present, complete pain flow sheet and treat trying non-pharmacologic interventions prior to medicating if appropriate. Document in the PN s. Every shift order date 11/20/23 at 10:11 am revealed Pain level on 4/1-4/16/24 was 0 at 6 am and 6 pm. Acetaminophen Tablet 325 mg give 2 tablets by mouth every 6 hours as needed for general discomfort or pain order date 11/27/23 at 1:59 pm. Tramadol HCL Tablet 50 mg give 50 mg by mouth every 8 hours as needed for pain related to pain, unspecified order date 10/13/23 at 10:44 pm revealed 4/3/24 pain level 6, 4/9/24 pain level 6, 4/13/24 level 8, 4/14/24 pain level 7 and 4/16/24 pain level 7 and meds were administered . Voltaren External Gel 1% (Diclofenac Sodium (Topical) Apply to affected areas topically every 6 hours as needed for pain order date 4/4/24 at 3:16 pm revealed nothing administered . In an interview and observation on 4/16/24 at 11:25 am with Resident #1 she was observed with a splint on her left lower leg. Resident #1 stated on 4/2/24 she was laying in the bed and leaned up looking for her glasses, she has left side vision (blindness) that started messing with her and she had bad muscle spasms that day. She stated she went to lay down on her pillow and the muscle spasm threw her to the floor. Resident #1 stated she was in the center of the bed when she fell , and her left leg was bruised real bad. Resident #1 stated her left leg was still hurting from the fall on February 8, 2024 . She stated when she fell , her foot went into the wheelchair, and it took 2 people to get it out. Resident #1 stated she has been asking for an appointment to see an orthopedic doctor. She stated a nurse said she set up the appointment, but the appointment got canceled and she did not know how. Resident #1 stated she asked them to set up the appointment again so she can get the splint off and no one has done it. She stated this has been for about 3 weeks. Resident #1 stated the first appointment was back in February 2024 when she had the hairline fracture. Resident #1 stated she fell when she got dizzy and her stomach started bouncing like a basketball and she was laying in the bed and she went to get against the wall and instead of going backwards, her body went to the floor. Observation revealed Resident #1 did not have a fall mat. She stated they have not given her a fall mat . She stated she was in her room when she fell both times and was not sent out 911 when she hit her head. Resident #1 stated the CNA's got her up off the floor and put her back in the bed. She stated it took 4 CNA's both times to help her off the floor. Resident #1 stated the CNA's who assisted her were CNA A, CNA B and CNA D and another CNA (unknown). Resident #1 stated RN A assisted her on 2/8/24, and the second fall was on 4/2/24 and LVN B was the nurse. Resident #1 stated the fall on 4/2/24 her head was against the nightstand, so she does believe that she did hit her head. She stated the CNA's helped to get her off the floor, they were holding her arms trying to help her get up. Resident #1 stated LVN B did not do anything, did not look at her and did not see if she had bruises or anything. She stated she told the nurse she felt like she had bruises when she fell and LVN B stated she told her it was not there, but she did not even check her out. She stated when she fell on [DATE] she blanked out and when she came to her head was on the knob of the nightstand and it was 7:30 am. Resident #1 said she had tenderness on the left temple on the side of her head. She stated that she did have bruises. Resident #1 stated when she screamed, they came and tried to get her off the floor and they had to get the Hoyer lift and put her back in the bed. Resident #1 stated LVN B never came into the room and never checked her out. Resident #1 stated the fall on 1/31/24, she was lying in bed looking at Tv and her stomach started bouncing like a basketball and she called for help and no one ever came over 15 min. She stated she reached for water and went straight to the floor and started screaming again. She stated she tried to reach for the wheelchair to get herself up and she realized her foot was in the wheel. She stated when they tried to get her foot out, it was in between the back wheels of the wheelchair, and it took 2 people (CNA A and CNA B) to get it out. Resident #1 stated she started having real bad pain in her foot on 2/13/24. Resident #1 stated she started having pain in it right after they got her foot out the wheel on 2/8/24 and they did not send her to the hospital or do an x-ray until Sunday, 2/11/24. Resident #1 stated she told RN A and RN A called Resident #1's doctor and her doctor ordered an x-ray and after they did the x-ray on Sunday it came back for a hairline fracture. She stated the nurse sent her out to the hospital on Sunday to get the splint on. She stated RN A did assess her right away and called the NP to get x-rays. Resident #1 stated it took x-ray until Sunday, 2/11/24 to come. Resident #1 stated they started giving her pain medication (Tylenol) prn almost daily beginning 2/8/2024 because her pain level was a 9 . She stated for the first fall on 1/31/24 she did hit her head on the floor and had tenderness on her head. In an interview on 4/17/24 at 3:44 pm with the NP she stated Resident #1 had a fall and they got an x-ray because she had pain . The NP stated it was reported Resident #1 had a fracture. The NP stated Resident #1 went to the ER and they repeated the x-ray, and it said no fracture. The NP stated Resident #1 came back with a splint. She stated there was an x-ray repeated and it was negative. An interview with NP on 5/3/2024 at 12:52pm stated Resident #1 has a long history of neuropathy after therapy she started moving better and had better results. She stated Resident #1 states the resident feels like the Lyrica is not helping, so she will increase. She stated Resident #1 had a fall on 2/8 and she ordered for an x-ray. She said when the results came back with a fracture Resident #1 was sent to the hospital. She stated fractures will cause pain and they do immobilize that is why she has the splint. An interview on 5/5/24 at 12:15pm with Resident#1 revealed she fell on [DATE] and had a splint put on at a local hospital after an x-ray done at the facility came back with results of a hairline fracture to her ankle. An interview on 5/6/2024 at 11:30am with the Local Dialysis Company revealed Resident #1 has dialysis on MWF . She had dialysis on 2/7/24 (Wed) and on 2/9/2024 (Fri). She said on 2/9/24 Resident #1's dialysis was ended early. She said the note read, Patient reason for early treatment termination is that she said she was in so much pain. She also stated Resident #1 said she fell the day before (2/8), and she always complains about her pain and the nursing facility does not do anything about it. An interview on 5/7/24 at 12:13pm with LVN C revealed her to state if a resident has a fall she can tell if they are in pain by grimaces, crying out or holding the part of the body that hurts for nonverbal residents. She said Resident #1 was verbal and did tell her she was in pain often after her falls. She said Resident #1 sometimes say pain medication would not work. She would complain about her back, neck, arm and leg. She stated she always have Resident #1 rate her pain and go back and ask if its effective. An interview with anonymous staff member on 5/8/24 at 12:02pm revealed Resident #1 is labeled as a complainer by most of the nurses and Administration. It was stated Resident #1 often complained about being in pain. An interview with the DON on 5/8/24 at 12:40pm, she stated nurses should not be marking O if a Resident stated they were in pain. She stated Resident #1 complained about generalized pain just recently. Pain was 8/10 recently and she asked if she could give her something. She complained of pain of left foot and x-ray ordered 2/9/24. She said she think her Lidocaine order changed. She stated Resident #1 had a x-ray and a fracture was ruled out. She stated Resident #1 never complained about pain until recently and it is being addressed. An interview with the Administrator on 5/8/24 at 1:58pm revealed him to state Resident #1 pain was assessed she said she had no pain after the fall on 2/8/2024 but a SBAR was done. He said the X-ray was done on 2/11/2024. He reviewed notes in PCC and said she had pain medications in here and her NP was notified. He stated her vitals were being monitored and neuro checks completed. He said there was an order for some gel. He said the gel was an anti-inflammatory and was to be applied to the ankle two times a day. He stated he did not see a note with the order for the gel. He said Resident #1 was being monitored, vitals done and an x-ray was done so he does believe the facility met Resident#1's needs. Record review of the Facility Policy on Nursing Policies and Procedures, Subject: Pain Management Policy revised 6/2019: It is the policy of this facility to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices, related to pain management. Definition Pain- defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (National Institute of Nursing Research, 1994). It is a complex phenomenon that takes into consideration sensory stimulation that has been modified by the individual's pain memory, expectations and emotions. Pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does. [NAME] & [NAME], 1989 Procedures: 1) Upon admission, readmission, quarterly and with significant change in condition, residents will be evaluated for pain. The evaluation will include but is not limited to: a. History of pain and its treatment (including non-pharmacological and pharmacological treatment and whether each treatment has been effective); b. Characteristics of pain, such as: (intensity, pattern, location, frequency and duration) c. Impact of pain on quality of life (e.g., sleeping, functioning, appetite, and mood) d. Factors such as activities, care, or treatment that precipitate or exacerbate pain as well as those that reduce or eliminate the pain e. Additional symptoms associated with pain (e.g., nausea, anxiety) f. Physical and psychosocial issues (physical examination of the site of the pain, movement, or activity that causes the pain, as well as any discussion with resident about any psychological or psychosocial concerns that may be causing or exacerbating the pain) g. Current medical conditions and medications h. The resident's goals for pain management and his or her satisfaction with the current level of pain control. Residents who are cognitively impaired and unable to verbally express pain will be assessed utilizing the recommended pain evaluation which is specific for cognitively impaired residents. The assessment will include interviews with legal representatives/family, if possible, to identify any resident specific behaviors that may indicate the resident is experiencing pain from history. Examples of possible indicators of pain include, but are not limited to the following: Negative verbalizations and vocalizations (e.g., groaning, crying/whimpering, or screaming); Facial expressions (e.g., grimacing, frowning, fright, or clenching of the jaw) 3) Ongoing evaluations of residents for pain will be completed by staff at least 3 times daily and documented as the fifth vital sign on the residents MAR. This evaluation will include verbal responses of level of pain 0-10, verbal descriptors of pain such as slight, moderate or severe and non-verbal descriptors as noted above. 4) Based on the evaluation, the IDT, resident physician and the resident and/or representative, will develop, implement, monitor and revise as necessary interventions to prevent or manage the resident's pain. 5) The comprehensive care plan to manage the resident's pain will include both pharmacological and non- pharmacological interventions based on the resident's goals, levels of pain, type of pain and activity tolerance. 6) Non-pharmacological interventions may include but are not limited to: a. Altering the environment for comfort (such as adjusting room temperature, tightening and smoothing linens, using pressure redistributing mattress and positioning, comfortable seating, and assistive devices) b. Physical modalities, such as ice packs or cold compresses (to reduce swelling and lessen sensation), mid heat (to decrease joint stiffness and increase blood flow to an area), neutral body alignment and repositioning, baths, transcutaneous electrical nerve stimulation (TENS), massage, acupuncture or acupressure, chiropractic or rehabilitation therapy. c. Exercises to address stiffness and prevent contractures as well as restorative nursing programs to maintain joint mobility d. Cognitive/Behavioral interventions (e.g., relaxation techniques, reminiscing, diversions, activities, music therapy, offering spiritual support and comfort, as well as teaching the resident coping techniques and education about pain).

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 one of four residents (Resident #1) reviewed for pressure ulcers. 1. The facility failed to ensure weekly skin assessments were conducted for Resident #1 since he was admitted to the facility. 2. The facility failed to ensure Resident #1 did not have any open pressure ulcers. One open area (sacral) was identified on 02/15/2022. 3. The facility failed to ensure there was documentation in the clinical record of additional skin assessments until 03/13/2022. At that time, five additional opened areas were noted . 4. The facility failed to ensure Resident #1 was provided with individual treatment orders for each pressure sore . An Immediate Jeopardy (IJ) situation was identified on 04/01/2022. While the IJ was removed on 04/05/2022, the facility remained out of compliance at a scope of isolated with potential for more than minimal harm, due to the need to evaluate the effectiveness of the corrective systems. These deficient practices could place residents at risk for pressure sores being unidentified and untreated. Findings include: Record review of the Admission Record for Resident #1 (printed 03/16/2022) revealed an 82- year- old male, who was admitted to the facility on 01/03/2022. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the admission MDS assessment, dated 01/05/22, revealed Resident #1 scored 7 of 15 on the BIMS, which indicated severe cognitive impairment. The resident required extensive assist from one person for bed mobility, transfers, dressing, eating, and personal hygiene. He had upper extremity impairment on one side. At the time of the assessment, Resident #1 exhibited no pressure sores or any other ulcers. Record review of Resident #1's Care Plan dated 02/15/2022 revealed the resident was at risk for developing pressure ulcers as well as worsening of the open area to the sacrum. A second, undated, Care Plan which addressed pressure ulcers revealed staff were to perform weekly skin assessments. Record review of the NN, dated 01/03/2022 (date of admission), revealed Resident #1 had healed scars on the coccyx area, left buttock and right shin . Record review of a Physician SOAP note, dated 02/14/2022, revealed Resident #1 had a sacral wound the nurse reported may need close observation and debridement. The SOAP note had no nurse's signature. Record review of a TO, dated 02/15/2022, revealed Cleanse open area with NS, pat dry. Apply [MEDICATION(S)]. Then place dry dressing. Record review of a NP SOAP note, dated 02/17/2022, for Resident #1 revealed .sacral area decubitus [pressure ulcer] remains non-healing see nursing notes weekly wound care visit notes and weekly recommendations. There was no documentation of any other open areas. Record review of a Physician SOAP note, dated 03/01/2022, revealed .sacral area decubitus [pressure ulcer] remains non-healing see nursing notes weekly wound care visit notes and weekly recommendations. There was no documentation of any other open areas. Record review of a NN, dated 03/10/2022, revealed RN C documented a skin assessment was conducted and a wound culture for the sacral wound was obtained. Record review of a Weekly Wound Observation, dated 03/13/2022 at 12:51 p.m., revealed Resident #1 exhibited six wounds. All six were documented as Wound #1. Wound #1 was located on the left heel. The Weekly Wound Observation dated 03/13/2022 reflected the resident was admitted with the wound. The wound was dry and had necrotic (brown, black, leathery tissue) present. The document reflected the measurements to be 6.0 x 5.4 x 0 cm. Record review of the Admission NN dated 01/03/22 revealed no left heel wound was documented. Wound #2 was located on the left lower leg. The Weekly Wound Observation dated 03/13/2022 reflected the wound was acquired in the facility but reflected no date of onset. The description was reflected as Granulation tissue present (beefy red). The document reflected the measurements to be 8.7 x 5.1 x 0 cm. Wound #3 was located on the right inner knee. The Weekly Wound Observation dated 03/13/2022 reflected the wound was acquired in the facility but reflected no date of onset. The wound was documented as a Stage 2 pressure ulcer. The measurements were 4.7 x 1.7 x 0 cm. Wound #4 was located on the right knee. The Weekly Wound Observation dated 03/13/2022 reflected the wound was acquired at the facility, initially identified on 03/12/2022. The wound was documented as a Stage 4 pressure ulcer. The wound had necrotic tissue present. The wound measurements were 6.1 x 4.2 x 0 cm. Wound #5 was located on the buttocks. The Weekly Wound Observation dated 03/13/2022 reflected the resident was admitted with the wound. The description reflected the wound was a Stage 4 pressure ulcer. The wound had 80% necrotic tissue and was worsening. The wound was malodorous (bad odor). The wound measurements were 10.0 x 8.2 x 0.2 cm. Record review of a NN, dated 02/15/2022, revealed the wound was identified on that date. Wound #6 was located on the right hip. The Weekly Wound Observation dated 03/13/2022 reflected the resident was admitted with the wound. The description reflected the wound was a Stage 4 pressure ulcer. The wound had 90% necrotic tissue and was worsening. The wound measurements were reflected as 5.2 x 4.0 x 0 cm. Record review of the Admission NN dated 01/03/22 revealed no right hip pressure ulcer was documented. Record review of the February 2022 TAR revealed daily treatments were provided for the open area identified on 02/15/2022 (Wound #5) from 02/15/2022 to 02/28/2022. The TAR did not reflect any wound care for Wounds #1, #2, #3, #4 or #6. Record review of the Order Summary Report, dated 03/16/2022, revealed Cleanse open area with NS, pat dry, apply [MEDICATION(S)], then place dry dressing every day shift for wound care. The order was dated 02/15/2022. Record review of the March 2022 TAR revealed daily treatments were provided for the open area identified on 02/15/2022 (Wound #5) from 03/01/2022 to 03/14/2022, when the resident was sent to the hospital. The TAR did not reflect any wound care for Wounds #1, #2, #3, #4 or #6. Record review of the electronic chart for Resident #1 revealed the only Weekly Skin Assessments were dated 03/13/2022. Record review of a NN dated 03/10/2022 revealed a culture swab was obtained from the sacral wound. Interview on 03/16/2022 at 1:20 p.m. with the DON revealed the culture results from 03/10/2022 had not been received. She said she went on 03/14/2022 to assess the resident. She said the wounds were malodorous . She called the physician, and the resident was sent to the hospital on that day. Interview on 03/16/2022 at 2:00 p.m. with the DON revealed each of the six open areas should have had a separate wound care order. The DON said she tried to find out about documentation of Wounds #1, #2, #3, #4 and #6. She said there was a different DON prior to 03/01/2022. She said the nurses should be conducting Weekly Skin assessments and they should be in the computer. Interview via telephone on 03/16/2022 at 3:40 p.m. with RN D revealed she conducted the Weekly Wound Observation for Resident #1 on 03/13/2022. She said the sacral wound had a foul odor and had purulent drainage. She said she cleaned the wounds then she measured and documented six wounds and called NP A. She said NP A gave one order for all six wounds. Interview on 03/17/2022 at 3:05 p.m. with a family member of Resident #1 at the hospital revealed she said the resident was in surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . She said the wounds were horrible . She said the facility had not informed her of the wounds. Interview via telephone with NP A on 03/21/2022 at 11:15 a.m. was unsuccessful. A message with the state surveyor's contact information was left on voicemail. A return call was not received. Record review of the facility's policy Wound Documentation, (revised June 2019,) revealed wounds may be numbered for purposes of documentation. The following was to be documented: location, size and stage, onset date, color, odor, tissue type, tunnelling/undermining, infection, healing (when present), surrounding skin condition, and pain (when present). Record review of the facility's policy physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse was to initial and date the entry on the Treatment Record. This was determined to be an Immediate Jeopardy (IJ) on 04/01/2022 at 5:00 p.m. The Administrator was notified. The Administrator was provided with a copy of the IJ Template on 04/01/2022 at 5:00 p.m. The following Plan of Removal submitted by the facility was accepted on 04/01/2022 at 11:36 p.m.: Resident # 1 was transferred to the hospital on 3/14/22. 100% of resident's skin assessments were completed on 3/22/22 by the DON and 3/28/22 by the regional nurse consultant. Residents with new findings had their physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medical Director was made aware of the identified IJ 4/1/22 by the Administrator. 3/22/22 DON audited 100% of RD Recommendations for the past 60 days to ensure physician notification and implementation was completed. Regional Nurse Consultant reviewed the RD Audits after the IJ was identified to ensure the review on 3/22/22 was completed accurately. 3/31/22 MDS Coordinator reviewed all care-plans on residents with pressure ulcers and at risk for pressure ulcers to ensure interventions for prevention and promotion of healing pressure ulcers were present. Interventions are present on the resident's care-plan on the electronic health record. Regional Nurse Consultant reviewed residents with pressure ulcer's care-plans after the facility was notified of the IJ to ensure interventions were care-planned and in place. AD HOC QAPI was held with Facility Leadership on 3/22/22 after the identification of needed performance improvement plan for skin systems / physician orders. Meeting covered weekly skin assessment documentation, obtaining orders for new skin conditions / dietitian recommendations, completing weekly pressure ulcer assessments, consulting with NP/MD as indicated and completing Braden scales for pressure ulcer risk documentation. Policies and Procedures for Skin Systems and Dietitian Services were brought to the QAPI meeting, no revisions were necessary. Skin Assessment Schedule was confirmed by DON on 3/22/22 to include 100% of residents to have a skin assessment weekly. Skin assessment schedule will be updated with new admissions by nursing leadership prior to the next due assessment. Skin assessment schedules were inputted into PointClickCare by the Regional Nurse Consultant. Regional Nurse Consultant validated that skin assessment schedules were present in PointClickCare after the IJ was identified. 4/1/22 Regional Nurse Consultant initiated Wound Care Assessment and Skills Competency for all licensed nurses (including agency nurses) working at [the facility] and skills competency will be completed prior to working their next assigned shift. Regional Nurse Consultant / Designee (trained nurse manager) will continue the competencies daily until 100% of nurses are checked off. Inservice was initiated 3/23/22 with Licensed Nurses (Scope Specific) by the Director of Nursing and continued daily through 4/1/22. Topics discussed were weekly skin assessment documentation/schedule, obtaining orders for new skin conditions/ dietitian recommendations, completing weekly pressure ulcer assessments, consulting with NP/MD as indicated and completing Braden scales for pressure ulcer risk documentation. Regional Nurse Consultant / Designee (trained nurse manager) will continue the in-services with staff on leave / agency staff prior to working their next shift. Inservice was initiated 3/23/22 with CNAs (Scope Specific) staff by the Director of Nursing and continued daily through 4/1/22. Topics discussed were notification of charge nurse for changes in skin conditions. Completion of shower sheets with skin change notifications to charge nurse. Regional Nurse Consultant / Designee (trained nurse manager) will continue the in-services with staff on leave / agency staff prior to working their next shift. New Wound Care Physician was assigned to the facility by VOHRA [wound care physician group] wound care 3/30/22. Facility will contact wound physician for recommendations / treatment guidance / wound rounding as needed. Wound care rounds will resume the week of 4/4/22. 4/1/22 Regional Nurse Consultant ensured 100% of residents had a current Braden scale for pressure ulcer risk documentation after the IJ was identified. Regional Nurse Consultant / Designee (trained nurse manager) will monitor skin assessment completion in AM meeting. Resident's skin assessment (once weekly) schedule will occur Monday-Friday (Weekly Skin assessment schedules will not occur on the weekends). Audits began 4/1/22 and will occur Monday-Friday x 4 weeks and then randomly. Regional Nurse Consultant / Designee (trained nurse manager) will monitor weekly pressure ulcer assessments for completion weekly. Audits began 4/1/22 and will continue weekly x 4 weeks and then randomly. Audits will occur at bedside. Regional Nurse Consultant / Designee (trained nurse manager) will monitor shower sheet completion and charge nurse notification in AM meeting. Audits initiated 4/1/22 and will occur Monday-Friday x 4 weeks and then randomly. Regional Nurse Consultant / Designee (trained nurse manager) will monitor dietitian recommendations to ensure implementation within 48-72 hours. Audits began 3/22/22 and will occur weekly x 4 weeks and then randomly. Regional Nurse Consultant / Designee (trained nurse manager) will continue the audits until a permanent Director of Nursing is put into place. Findings from reviews will be brought to QAPI and Action Plan will be updated as indicated. Monitoring for the implementation of the POR , initiated on 04/02/2022: Interview on 04/02/2022 at 4:55 p.m. revealed LVN H (6:00 a.m.-6:00 p.m.) had been in-serviced regarding skin assesments, notifications, obtaining treatment orders, and reviewing shower sheets. Interview on 04/02/2022 at 5:02 p.m. revealed CNA I (2:00 p.m.-10:00 p.m.) was in-serviced regarding shower sheets, reporting skin issues, and documentation. Interview on 04/02/2022 at 5:04 p.m. revealed CNA J (2:00 p.m.-10:00 p.m.) was in-serviced regarding shower sheets, reporting skin issues, and documentation. Interview on 04/02/2022 at 5:06 p.m. revealed MA K (2:00 p.m.-10:00 p.m.) was in-serviced regarding shower sheets, reporting skin issues, and documentation. Interview on 04/02/2022 at 5:07 p.m. revealed LVN E (6:00 a.m.-6:00 p.m.) had been in-serviced regarding skin assesments, notifications, obtaining treatment orders, and reviewing shower sheets. Interview on 04/02/2022 at 5:08 p.m. revealed RA L was in-serviced regarding shower sheets, reporting skin issues, and documentation. Interview on 04/02/2022 at 5:10 p.m. revealed CNA M (2:00 p.m.-10:00 p.m.) was in-serviced regarding shower sheets, reporting skin issues, and documentation. Interview on 04/02/2022 at 5:15 p.m. with the Administrator revealed he said he thought there was a system of checks and balances for the skin assessments, but it was not effective, leading to the failure. Interview on 04/02/2022 at 5:27 p.m. with the Regional Nurse revealed she thought the use of agency nurses and lack of monitoring the system led to the failure. Observation on 04/02/2022 at 5:55 p.m. revealed the Regional Nurse provided the in-service to RN F (6:00 p.m.-6:00 a.m.). The Regional Nurse repeated and explained information that the nurse asked for clarification on. Observation on 04/02/2022 at 6:25 p.m. revealed RN F provided wound care for Resident #3. The Regional Nurse demonstrated the elements of the in-service, including measuring, providing description, notifications, and when to obtain a treatment from the physician. RN F was able to return-demonstrate successfully. Interview on 04/02/2022 at 6:40 p.m. with the Administrator revealed a new wound care physician would start on Monday 04/03/2022. Observation on 04/02/2022 at 6:45 p.m. revealed Resident #2 was being propelled in his wheelchair. There was a foam wedge between his knees. Interview on 04/03/2022 at 5:55 a.m. revealed CNA N (10:00 p.m.-6:00 a.m.) was in-serviced regarding shower sheets, reporting skin issues, and documentation. Interview on 04/03/2022 at 5:58 a.m. revealed CNA O (10:00 p.m.-6:00 a.m.) was in-serviced regarding shower sheets, reporting skin issues, and documentation. Interview on 04/03/2022 at 6:17 a.m. revealed CNA P (10:00 p.m.-6:00 a.m.) was in-serviced regarding shower sheets, reporting skin issues, and documentation. Observation on 04/03/2022 at 6:20 a.m. revealed the Regional Nurse provided the in-service to CNA C. CNA C verbalized understanding. Interview on 04/03/2022 at 6:22 a.m. revealed CNA C (6:00 a.m.-2:00 p.m.) was in-serviced regarding shower sheets, reporting skin issues, and documentation. Observation on 04/03/2022 at 7:00 a.m. revealed LVN E provided wound care for Resident #4. The nurse was able to correctly measure the wound. There were no concerns with technique. Interview on 04/03/2022 at 7:30 a.m. revealed CNA R (6:00 a.m.-2:00 p.m.) was in-serviced regarding shower sheets, reporting skin issues, and documentation. Interview on 04/03/2022 at 7:45 a.m. revealed CNA S (6:00 a.m.-2:00 p.m.) was in-serviced regarding shower sheets, reporting skin issues, and documentation. Interview via telephone on 04/04/2022 at 10:48 a.m. with the PCP revealed he said if a resident developed a new pressure sore he or his NP should be informed at least by the next day. He said he was aware of the sacral wound for Resident #1, but not the right hip or right knee. He said the facility had a 'general' wound care order, not just for one wound. He said the resident was sent out because a wound was malodorous. He said generally they (he and his NP) would write the order for the sacral wound. He said it was a 'blanket order.' He then said he would identify each area separately. He said the 'blanket order' was to be used until a doctor or NP could assess. He was unaware that Resident #1 was not being cared for by a Wound Care Physician. He was unaware that only one wound (sacral) was documented as receiving treatment. Interview on 04/05/2022 at 12:34 p.m. via Facetime with Physician G, the Wound Care Physician, revealed she was going to conduct virtual rounds with the staff at that time. Observation on 04/05/2022 at 12:37 p.m. revealed Physician G, assisted by the Regional Nurse, conduct a virtual wound assessment with Resident #5. The resident was assisted to her right side. The resident exhibited an open area on her left hip. She also exhibited excoriation of the right buttock. The Physician gave a separate order for each area. She changed the order for the left ischium to add powdered collagen. LVN E was present. She measured the left hip wound to be 2.5 x 1.0 x 1.0 cm. The Physician gave a new treatment order. All of the open areas were previously documented and were receiving treatments. Observation on 04/05/2022 from 2:00 p.m. to 2:25 p.m. revealed Resident #2 and Resident #3 were in their beds with pillows for positioning and cushioning pressure points. Record review of five residents (Residents #6, #7, #8, #9 and #10) revealed they were all provided skin assessments on 04/01/2022. No new breakdown was discovered. Record review of the dietary recommendation for Resident #10 dated 02/28/2022 revealed she was to receive House Supplement 2.0 Calorie, 90 ml, twice daily. Review of the April 2022 TAR revealed she was receiving the supplement. Record review of the dietary recommendation for Resident #9 dated 03/31/2022 revealed his fluid restriction was to be changed from 1.5 L/day to 1.26 L/day. Review of the April 2022 TAR revealed the recommendation was being followed. Record review of the dietary recommendations for Resident #7 dated 01/26/2022 revealed she was to receive Prostat supplement 30 ml twice daily. Review of the April 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] Record review on 04/02/2022 of the in-service for nurses regarding wound and skin care revealed all nurses present had received the training and return-demonstrated wound care. The Administrator and Regional Nurse were notified the IJ was removed on 04/05/2022 at 2:25 p.m. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview and record review, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 1 of 16 residents reviewed for behavioral health services (Resident #9), in that: The facility did not begin intervention for suicidal threat verbalized by Resident #9 until after surveyor intervention. The facility failed to provide medical and safety intervention for Resident #9 who made a verbalization of suicidal ideation to the facilities' NP on 11/08/2021. This failure could have resulted in serious injury, harm or death for Resident #9. An Immediate Jeopardy (IJ) situation was identified on 11/09/2021. While the IJ was removed on 11/10/2021, the facility remained out of compliance at no actual harm at a scope of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure placed residents with mental/psychological disorders at risk for not receiving appropriate care and interventions related to suicidal ideations. Findings include: A face sheet dated 11/10/2021 revealed that Resident # 9 was a [AGE] year-old female that admitted on [DATE]. Resident #9 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission MDS dated [DATE] indicated that Resident #9 had a BIMS (brief interview of mental status) score of 12 on a scale of 00-15. The score indicated a mild cognitive impairment. The MDS also indicated she had a PHQ-9 (personal health questionnaire designed to identify depression) score of 0. No behaviors were noted on the MDS, which included hallucinations, delusions, physical and verbal aggression, resisting care or wandering. During an interview, observation, and record review on 11/8/2021 at 9:45 am, Resident #9 was lying in bed with all the lights off, no TV on, no radio playing, and the blinds were closed. She said that she had not eaten or drank more than a sip of water in 3 days. When asked why, she said she asked several weeks ago for them to change her [CONDITION(S)] medications because she had become so sensitive to light. It hurt her eyes. She said this had happened to her in the past and they had to taper her off her medications and start again with something new. She said that when she told staff she did not want to take the medications anymore they told her she could take the pills or get a shot. She was unable to recall what staff member exactly told her that she would get a shot. Resident #9 said that had caused her to distrust the staff and she felt they may be trying to slip medicine in her food, and she had not slept much because she was afraid they would give her a shot while she was asleep. Resident #9 did have notable redness around her eyes. Resident #9 said she was just tired of no one at this facility listening to her and taking her concerns seriously. During a review of the current MD orders for the resident the November 2021 MD orders revealed she had orders for [MEDICATION(S)] for [CONDITION(S)] since admission, [MEDICATION(S)] for paranoid [CONDITION(S)] since admission, and was started [MEDICATION(S)] on 10/26/2021 for mood disorder with depressive features. All the orders were for oral medications. No orders for injectable medications were noted. A review of the current (November) MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] During an observation on 11/08/2021 at 12:40pm Resident #9 had eaten none of her lunch meal and drank none of the fluids provided. Staff came in and asked if she was going to eat and she replied that they could take the tray she was not eating it. Staff took the tray. No substitute was offered at this time. On 11/09/2021 at 10:36am an addendum to a complaint was received from CII that stated Resident #9 had complained of suicidal ideations and wanted to go to the hospital, but the facility would not allow her to go. During a record review of nurses notes for Resident #9 on 11/09/2021 at 10:37am, a note written on 11/08/2021 6p-6a shift by RN O wrote First part of the shift CNA reported that Resident refused meal. I went in to talk to Resident, asked why she didn't want to eat? Resident states, I haven't eaten in 3 days because they are putting medicine in my food. Informed Resident that no one is putting anything in her food. That she takes her meds from the Med Aide or Nurse. Educated on the need to eat a balanced diet. That just eating the snacks at HS is not enough. Asked Resident if she was going to start eating her meals? Resident states I don't know. {NP S} called at 7:30, states the Resident called her and told her she hadn't eaten or taken her meds in 3 day because somebody was putting medication in her food. Informed {NP S} I had spoken with med aide and Resident was taking medicine for her. Also informed NP that Resident has taken meds from me the last 3 nights and Resident was eating HS snacks. Will notify day shift and DON of above and the need to monitor meal intake closely. I also asked Resident if she was trying to harm herself by not eating, or if she wanted to harm self at all. Resident says No, I'm not trying to hurt or kill myself. Will continue to monitor. During an interview and observation with Resident #9 on 11/09/2021 at 10:39 am Resident #9 was lying in bed in a dark room. She was alone and staring at the wall. Resident #9 said she told the facility NP last night that she felt like killing herself and she wanted to go to the hospital to get some help. The NP said she would come by today and see me. Resident #9 asked why won't they just send me to get some help? When asked if she was still having thoughts of killing herself, she said yes it does not just stop. When asked if she had a plan to kill herself, she said yes and she was not going to tell what her plan was because she did not want to be stopped. She said one day this place will take her seriously. During an interview on 11/09/2021 at 10:55 am LVN R said she was the nurse for Resident #9. When asked if she was aware of the suicidal thoughts Resident #9 was having, she said yes, she got some information on it in report from the night nurse. When asked what interventions were put in place to protect the resident, she said she did not know. All she knew was that it was written on the 24-hour report that the NP would be here to see her today related to thoughts of wanting to kill herself. When asked how soon the NP would be here, LVN R said she would have to call her and find out specifically because the 24-hour report just said sometime this afternoon. When asked if the resident had anything in her room that could potentially be used to hurt herself, the nurse said she was not sure. When asked if the resident had charging cords, extension cords, anything of that nature LVN R said yes. When asked if Resident #9 could potentially hurt herself with those items LVN R shrugged. When asked what the protocol was in the facility when someone threatened suicide LVN R stated she was unsure, and the Administrator would be able to answer that. During an interview on 11/09/2021 at 11:05 am the Administrator was asked if she was aware of Resident #9's suicidal ideations. The Administrator said no she was not aware. The Administrator was informed that LVN R reported information regarding Resident #9's suicidal ideations were given to her in report this morning and staff was waiting on the NP arrival this afternoon. The Administrator was informed that Resident #9 said she was suicidal and had an active plan that she would not share because she did not want to be stopped as reported by Resident #9. The Administrator began to intervene immediately by placing a staff member in the room with the resident. The Administrator said that the facility protocol for dealing with a resident with suicidal thoughts was for someone to remain with the resident at all times, for any potentially harmful items to be removed from the resident's room, for the nurse to assess the situation, and for the resident to get the help they need. A resident with suicidal ideations could potentially harm or kill themselves if these measures are not taken. During an interview on 11/09/2021 at 11:40 am Resident #9 said she was not going to go with the EMS service to the local ER because she had been down this road before, and they would send her right back to the facility and her problems would still be there. She needed to be directly admitted to a behavioral hospital and she cannot understand why the facility will not just take her to the Behavioral Hospital like they promised. She stated if they would just take me to the behavioral hospital, I would go but this hospital here was no good and they will say she had an [CONDITION(S)] and send her right back here and she will never get better. During an interview on 11/09/2021 at 11:50 am the Admissions Coordinator said the facility van was in route to pick Resident #9 up and take her directly to the behavioral hospital. During an interview on 11/09/2021 at 12:15pm the Admissions Coordinator reported that Resident #9 was on the way to the behavioral hospital. During an interview on 11/09/2021 at 2:42pm RN O said she worked with Resident #9 on 11/08/2021 on the 6p-6a shift as her nurse. RN O stated she received a call from NP S on 11/8/2021 unsure of the time exactly. NP S reported to RN O that Resident #9 called NP S and told her she was not eating or taking her medications because Resident #9 believed the staff was putting medication in her food. NP S also told RN O at this time that Resident #9 mentioned in the conversation that she wanted to kill herself. NP S said she wanted RN O to check on Resident #9. RN O said she had received no information about refusal of medication or meals related to Resident #9. RN O said she went down to the room and asked Resident #9 if she was having thoughts of harming herself and Resident #9 replied no. RN O said she called NP S back and left a message with her that she did not think there was anything to her threat. RN O said that Resident #9 was a quiet resident generally, did most things for herself and slept through the night. RN O said Resident #9 did display some behaviors at times, I don't want to use the word manipulative, but she has some behaviors like saying someone is putting something in her food when they are not. When asked if she displayed any other symptoms or behaviors of concern, RN O stated they put her on an antidepressant mid-October, but other than that she did not see anything concerning about her behavior. RN O stated she checked on Resident #9 periodically throughout the night. RN O stated she notified the DON at 6 am and gave the oncoming nurse LVN R in report the details on NP S calling about Resident #9 saying she wanted to kill herself. When asked why she did not think the threat received by NP S was serious enough to warrant any other intervention she said the information was received over the phone and it was hearsay. RN O said I never heard Resident #9 make a suicidal threat myself. RN O said the facility protocol for handling residents with suicidal ideations was to send them to the ER to be evaluated. RN O said she kept an eye on Resident #9 during the night and does not feel anything else should have been put in place. RN O said she received an in-service this afternoon (11/09/2021) about how to deal with threats of suicide by a resident. She said all threats are to be taken seriously, the staff should stay with the resident, remove all items of potential harm from the room, and notify the administrator, DON, and NP or MD. RN O did not recall the last in-service she received related to the facilities protocol on dealing with a resident with suicidal threats. During an interview on 11/09/2021 at 4:09 pm NP S said that Resident #9 does not normally have behaviors or do anything unusual. NP S said the previous night (11/08/2021) Resident #9 called NP S's cell phone and said she had not eaten in days and was taking her medication on and off. Resident #9 said she felt the staff was poisoning her food with medication and Resident #9 requested to go someplace to fix this problem. NP S asked Resident #9 if she would like to go to the ER and be evaluated and Resident #9 said no. NP S asked if Resident #9 would like the nurse to come down and talk with her, Resident #9 said no. NP S said at that time Resident #9 said well I guess I will have to kill myself. NP S said she did not feel that the resident was making a serious threat. NP S said at that point she called the facility and spoke with RN O and reported to her that Resident #9 was having paranoid behaviors and was refusing to eat and that Resident #9 said she would have to kill herself. NP S asked RN O to check on Resident #9 and make rounds on her. NP S said RN O reported no unusual behavior to her and said Resident #9 was eating out of the snack cart with no problems. NP S stated the next thing she knew the facility was calling her saying Resident #9 was verbalizing suicidal thoughts and she directed them to send her out for help. When asked why she called the facility and reported it to them if she did not feel the resident was making a serious threat, NP S said she called the facility so that they could keep an eye on her and follow their suicidal protocol. If the nurse felt she needed to go, we would transfer or provide one on one care whatever she needed. She said she didn't think big of this. NP S said you know how patients can manipulate situations. NP S said she knew she and the facility must take precautions. NP S stated Resident #9 is under the care of a psych NP that is currently out of the country but is available by email. NP S said she preferred to keep psych medication adjustments done by the psych NP but would adjust them if necessary. NP S stated the last [CONDITION(S)] medication adjustment done was in October when they started Resident #9 on an antidepressant. During an interview on 11/09/2021 at 9:55pm CNA T said he was the CNA assigned to Resident #9 on 11/08/2021 from 10pm to 6am. CNA T said Resident #9 does most things for herself, so other than passing ice water to her we just peeped in on her and make sure she was breathing. CNA T stated he was unaware that Resident #9 had made threats of suicide that night. CNA T said he was not asked to make extra rounds on her or keep a close watch on her. CNA T said he did not notice the nurse make any extra rounds that shift. CNA T said the 3 or 4 times he went into the room to check on Resident #9, she was asleep. CNA T said at around 4:00 am when he made a round, she did wake up briefly but went right back to sleep. CNA T said it was not unusual for Resident #9 to sleep through the night. In a policy titled Suicide Threats dated December 2007 it stated the facilities policy was that . Resident suicide threats shall be taken seriously and addressed appropriately all nursing personnel and other staff involved in caring for the resident shall be informed of the suicide threat and instructed to report changes in the resident's behavior immediately .if the resident remains in the facility, staff will monitor the resident's mood and behavior and update care plans accordingly, until a physician has determined that a risk of suicide does not appear to be present .staff shall document details of the situation objectively in the resident's medical record. The administrator was notified on 11/09/2021 at 12:38 pm that an Immediate Jeopardy situation was identified due to the above failures. The IJ template was provided to the administrator by email on 11/09/21 at 12:50 pm. The facility's Plan of Removal was accepted on 11/09/2021 at 6:00 p.m. and included: Immediate action: *Resident was transferred from the facility on 11/9/21 at 12:05pm to hospital. *On 11/9/21 at 1115 am DON performed 1:1 in service with AM Charge nurse on notifying DON, ADON and ADMIN of residents with suicidal ideations or change of condition. *11/09/21 1120 am DON preformed in service with ALL staff to include everyone that works in facility on proper notification for change of condition or suicidal ideations to include any verbalization of suicidal ideation or attempts to harm self or others as well as AMS (altered mental status), significant change in vital signs and any other issue requiring emergency treatment. Facilities Plan to monitor compliance by *The director of nursing will be responsible for monitoring the daily 24-hour report to ensure that all change of condition has been conveyed to nursing administration. All Licensed Nursing have been in serviced on adding any Change of Condition to the 24hour report including suicidal ideations. If staff unable to be in service they will be in service prior to returning to work. *Social worker/designee has started to interview all residents for potential suicidal ideations and will complete a PHQ-9 (personal health questionnaire designed to identify depression) assessment at least quarterly on each resident. *Will provide information on psych services and/or counsel services during resident council each month. *No staff will be allowed to come back or begin to work until after in-servicing is completed. *Psych service NP to assess any residents with psych issues or requests to see psych services. Resident was transferred from the facility on 11/9/21 at 12:05pm to the hospital. The hospital had a behavioral unit located within the hospital. The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: The DON was interviewed and said she received training on monitoring the 24 hour report daily for changes of condtion and would conveyed all changes to the nursing administration. All licensed nursing had been in serviced on adding any change of condition to the 24hour report including suicidal ideations. NP will be notified and assess any residents with psych issues or any resident that request to see psych services. The social worker designee was interviewed and said she was interviewing all residents for potential suicidal ideations and none had expressed suicidal ideations as of yet. Information on psych services was relayed to the residents during interview Eight residents were interviewed and said they were asked about their mental health and depression and to report any signs or feelings of suicide to the nursing staff immediately and that the facility would get them the help they needed by the DON. Three LVNs were interviewed and said they received training after surveyors' entrance regarding working with residents with suicidal ideation and the facility protocol to keep the suicidal resident safe. Two RNs were interviewed and said they received training after surveyors' entrance regarding working with residents with suicidal ideation and the facility protocol to keep the suicidal resident safe. Six CNAs were interviewed and said they received training after surveyors' entrance regarding working with residents with suicidal ideation and the facility protocol to keep the suicidal resident safe. Five RAs were interviewed and said they received training after surveyors' entrance regarding working with residents with suicidal ideation and the facility protocol to keep the suicidal resident safe. Four administrative staff were interviewed and said they received training after surveyors' entrance regarding working with residents with suicidal ideation and the facility protocol to keep the suicidal resident safe. One laundry worker was interviewed and said they received training after surveyors' entrance regarding working with residents with suicidal ideation and the facility protocol to keep the suicidal resident safe. The Administrator was notified on 11/10/2021 at 8:40 am that the IJ was removed; however the facility remained out of compliance at no actual harm at isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 5 residents (CR #1) reviewed for quality of care. -The facility failed to identify and treat CR#1's ingrown toenail resulting in CR #1 being sent to the hospital being diagnosed with [REDACTED]. The failure could place residents who experience a change in condition at risk of complications from delay in intervention which could result in pain, infection, and hospitalization . Findings include: Record review of the Face Sheet for CR #1 revealed she was [AGE] years of age, and was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of CR #1's MDS assessment dated [DATE] revealed she scored 0 out of 15 on the BIMS indicating severe cognitive impairment. She required maximum assist for transfers. She was assessed as having no skin conditions that required treatments at that time. Record review of CR #1's Care Plan updated 7/29/20 revealed no plan related to skin assessment or skin condition. Record review of CR #1's progress note dated 08/24/20 at 8:34 p.m. written by LVN B revealed the resident exhibited a change of condition. The PN reflected the resident had emesis (vomiting), was not responding to verbal stimuli. The nurse was unable to obtain a blood pressure. 911 was called, and the resident was taken to the ED. The nurse was not available for interview due to no longer being employed by the facility. Record review of CR #1's hospital Clinical Report dated 08/24/20 at 11:54 p.m. revealed a Clinical Impression of Acute mental status change with confusion, [MEDICAL CONDITION] with shock and acute cardiovascular failure and central nervous system failure, Paronychia (nail infection) of the right great toe. Record review of CR #1's hospital History and Physical Note dated 08/25/20 at 10:05 a.m. revealed CR #1 was admitted to the hospital with [REDACTED]. The Note read in part, .She does have a swollen right foot which appears to have originated from the right big toe infection. The Assessment portion of the Note revealed [MEDICAL CONDITION] was most likely from the right foot [MEDICAL CONDITION], and the right foot [MEDICAL CONDITION] was likely from the infected big toe. Record review of CR #1's hospital lab report for the sample collected on 08/24/20 at 9:21 p.m. revealed a WBC level of 17.3 thousand per cubic milliliter, with the reference range of 4.5-11.0 thousand per cubic milliliter. Review of the Blood Culture results collected on 08/24/20 at 10:55 p.m. revealed it was positive for Streptococcus parasanguinis and Coagulase negative staphylococcus (bacteria). The resident was administered IV antibiotics. Record review of CR #1's August 2020 TAR revealed the most recent weekly skin evaluation was conducted on 08/18/20. The entry reflected 'no changes.' There was no documentation to explain what the actual condition was. The next scheduled weekly skin evaluation was scheduled for 08/25/20, the day after the resident was sent to the hospital. In an interview on 09/18/20 at 10:28 a.m., the DON confirmed there was no documentation of the ingrown toenail by the facility. In an interview on 09/18/20 at 1:58 p.m., the NP said when she last observed the resident at the facility, she did not exhibit signs [MEDICAL CONDITION]. She said [MEDICAL CONDITION] was most likely secondary to osteo[DIAGNOSES REDACTED]. In an interview on 09/18/20 at 3:00 p.m., the DON said the Aides were responsible for providing showers. There was not a designated shower aide. In an interview on 09/18/20 at 3:40 p.m., the SW said that CR #1 had been scheduled to be seen by the Podiatrist, but the Podiatry visit had been canceled due to COVID19 restrictions. In an interview on 09/18/20 at 4:30 p.m., RA A said she remembered the day CR #1 was sent to the hospital. She said the resident had emesis, so she informed the nurse. She said she did not see the resident's feet, because the resident had socks on. In an interview on 09/18/20 at 10:28 a.m., the DON was asked for the policy and procedure for assessments. No policy was provided prior to exit.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring and administering of all drugs to meet the needs of one Resident (Resident #5) of seven residents reviewed for pharmacy services in that; -Resident #5 was not administered her prescribed pain medication [MEDICATION NAME] for four days because it was not available in the facility. She experienced increased pain, anxiety and stress due to not taking her medication as prescribed. This failure affected one resident and placed her at risk of increased pain and decreased quality of life and well-being. Findings Include: Record review of Resident#5's admission face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #5's Quarterly MDS assessment dated [DATE] revealed the BIMS score was 6 indicating severely impaired cognitive skills. Further review of the MDS revealed that she required limited assistance from staff for dressing, toilet use and personal hygiene. Resident was continent of bowel and bladder. Further review of the MDS revealed the resident received opioids 7 days a week. Record review of Resident #5's care plan created 9/3/19 and revised on 09/27/2019 revealed Resident is at risk for alteration in comfort and or pain R/T: [MEDICAL CONDITION] Residents specific pain goal is: To have pain relieved resident requires pain scale. (verbal, numeric, pain). Goal: Resident will have pain/discomfort expressed at an acceptable level of pain quarter. Interventions: Administer medications as ordered and monitor for side effects, effectiveness. Resident has: Routine Medications. Assess and treat pain, discomfort as ordered by MD. Notify MD of pain unrelieved by ordered interventions. Assess characteristics of pain (location, duration, quality, [MEDICAL CONDITION], intensity) & document. Ensure MD/family aware of changes in pain presence. Review prn/scheduled pain RX to determine if changes in treatment plan are needed prn. Record review of Resident #5's consolidated physician orders [REDACTED]. Record review of Resident #5's physician's orders [REDACTED].#4 ([MEDICATION NAME]-[MEDICATION NAME]) 300-60mg, one tablet by mouth every 8 hours at 6am, 2pm and 10pm for pain. Record review of the medication administration record for the month of (MONTH) 2019 revealed Resident #5's [MEDICATION NAME] HP ([MEDICATION NAME]-[MEDICATION NAME]) was not given at 6:00 am, 2:00 pm and 10:00 pm from 9/1/19 to 9/4/19. Further review of the medication administration record revealed Resident #5 was administered Tylenol-[MEDICATION NAME] #4 on 9/1/19 at 2pm and 10pm, 9/2/19 at 6am, 2pm and 10pm, 9/3/19 at 6am, 2pm and 10pm, and 9/4/19 at 6am and 2pm. Record review of Resident #5's nurses notes dated 09/04/2019 at 5:26 am read in part: .patient's [MEDICATION NAME] 10-325 mg rx was not delivered as expected at 4am. Pharmacy informed immediately. Received call back from pharmacist with an apology and assured that she would assess the problem and call back. Pharmacist informed that the medication is due to be given to the patient at 6am and needs to be delivered as soon as possible . Record review of Resident #5's nurses notes dated 09/04/2019 at 6:28 am read in part: .received call back from pharmacist, with report that the pharmacy was not able to refill and deliver the patient's [MEDICATION NAME] 10-300 mg d/t the medication being unavailable. She reassured this nurse that the medication would be sent stat to the facility with no charge once it is received and they take responsibility for the delay . In an interview on 9/25/19 at 10:30am with Resident #5, she said she had not received her [MEDICATION NAME] for 4 days at the beginning of this month. She said she suffered from severe pain. She said [MEDICATION NAME] was not available because the facility lost the script. She said they had to get the e-script from the pain management doctor which delayed in getting her medication. She said the NP ordered Tylenol #4 till she received [MEDICATION NAME], but it did not control her pain the same way. In an interview on 9/25/19 at 11:15 am LVN A, she said she worked full time at this facility during the 6am-6pm shift. She said Resident #5 went to see her pain management doctor every month to refill her pain pump and to get the script for the [MEDICATION NAME]. She said Resident #5's appointment envelope got lost and the resident went a few days without her pain medication. She said the NP ordered Tylenol #4 to hold her over until her next pain management appointment. She said the DON in serviced staff to hand all envelopes to her when the resident returned from their appointment. She said after the appointment in September, the envelope went straight to the DON. She said the DON told her she was going to hold on to the script as it needed clarification making sure it was not e-scripted. She said she was off for two days and when she returned to work Resident #5 was in tears due to the pain. She said she did her own investigation and found out that the medication was not ordered. LVN A said she was unable to find the script that was given to the DON. She said she called the doctor and received an e-script. She said that caused delay in getting the resident's pain medication. In an interview on 9/27/19 at 11:20 am the ADON, she looked at September's 2019 MAR and confirmed the [MEDICATION NAME] for Resident #5 was not given from 9/1/19 to 9/4/19 reason noted was awaiting triplicate. She said she had started one month ago at this facility. She said she was still getting to know the residents. In an interview on 9/27/19 at 11:27 am with the MA A, she said as the MA her duty was to remove the label on the med package seven days before the last dose of a resident's medication runs out. She said she would remove the sticker, inform the charge nurse that the resident's medication was about to run out. She said at that point the nurse would call in the order to the pharmacy. She said nurses were in charge of ordering narcotics and follow up. In an interview on 9/27/19 at 1:10pm with the DON, she said [MEDICATION NAME] needed a script and cannot be called in as non-script medications. She said Resident #5's appointment envelope got put in the schredder by mistake and never made it to her nurse. She said she called the pain management doctor and got the e-script. She said after that incident she has in serviced her staff to bring the residents envelope directly to her when the residents return from their appointment. She said she was not aware the resident did not receive her pain medications this month. She said they have a e-kit which nurses can get medications from if there was a delay from the pharmacy. She said it was important for residents to receive their pain medication as prescribed and to stay on their pain regimen. At that point she said they did not have any policy in place as to who to report to if the nurses did not get medications on time when they were ordered. In an interview on 9/27/19 at 1:35pm with the Regional nurse, she said they had a contract with a pharmacy. She said if the pharmacy does not have medications available they would usually send it to the local pharmacy and get it delivered. She said nurses have access to e-kit as back up. She said the nurse should have contacted the doctor to get substitute pain medication to manage Resident #5's pain. Record review of the facility's ordering and receiving medications policy (FAC19 revised 2 11.13.18) read in part: .medications and related products are received from pharmacy on a timely basis. The facility maintains accurate records of medication order and receipt. Reorder medications (seven) days in advance of need to assure an adequate supply is on hand. When reordering medications that requires special processing (such as Schedule II controlled substance, order at least (seven days) in advance of need. The emergency kit is used when the resident needs a medication prior to pharmacy delivery .

Based on observation, interview, and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for two (CR#1 and Resident #2) of six residents reviewed for nutrition in that; -CR#1 sustained a severe weight loss of 17.8 % in 6 months, and was admitted to the hospital with [REDACTED]. -The RD recommendations to add med pass supplement on three different occasions to address CR #1's continued weight loss were not implemented by the facility. - The physician was not notified of CR #1's continued weight loss. -Resident #2 was identified at the facility to exhibit significant weight loss over one month and continued to exhibit weight loss of 5.7 % in one month. -Dietician's recommendations to add a nutritional supplement drink to address weight loss was not implemented by the facility. An IJ was identified on 08/15/19. While the IJ was lowered on 08/19/19, the facility remained out of compliance at a scope of isolated and severity of actual harm that is not immediate jeopardy due to the facility requiring more time to monitor the plan of removal for effectiveness. The failure affected two residents placing them at risk of continued weight loss, dehydration, malnutrition and hospitalization . Findings included: CR# 1 Record review of the Face Sheet for CR#1 revealed a [AGE] year old female admitted to the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. Record review of CR #1's annual MDS assessment dated [DATE] revealed CR#1 had severely impaired decision skills. She required extensive total assistance of one person for bed mobility, transfers, eating and personal hygiene. She was coded as having limitation in range of motion on both her upper and lower extremities. Nutritional section indicated she was 95 pounds and was marked as having weight loss of more than 5%. Under nutritional approaches parental feedings, therapeutic diets, or mechanical altered diets were not checked. The care area assessment summary indicated that nutritional status was triggered to be care planed. Record review of a handwritten Care Plan initiated on 11/6/17 with last update on 04/19/19 problem weight loss unintended but expected due to, but no reason was selected. Goal was to gain 1 to 2 pounds every month until weight was 123 lbs. Approaches included to receive house shakes twice daily, document accurate intake, obtain consult from dietician and follow recommendation promptly, weight weekly until weight is stable and them monthly, offer snacks and substitutes, notify MD of unresolved or declining weight loss. The care plan had not been revised or updated since 4/19/19. Record review of the computerized care plan dated 07/03/19 revealed Nutritional problems. There were no specific interventions related to nutrition or current weight loss. Record review of CR #1's Nutrition Recommendation form dated 03/29/19 revealed the RD recommended Med Pass 2.0 (nutritional supplement), 60 ml to be given twice daily for three weeks, ending on 04/19/19. Record review of the MAR and TAR for (MONTH) 2019 revealed Med Pass 2.0, 60 ml, was given to the resident twice daily from 04/01/19 to 04/30/19. Record review of CR #1's Nutrition Recommendation form dated 04/23/19 revealed the RD recommended Med Pass 60 ml twice daily to promote weight gain and prevent weight loss. Record review of the MAR and TAR for (MONTH) 2019 revealed the Med Pass 2.0 recommendation had not been transcribed. There was no order on the MAR or TAR. Record review of CR #1's RD Progress Note dated 05/27/19 revealed CR #1 exhibited a weight loss of 16.2% in the previous 180 days. The Note reflected the RD recommended Med Pass 2.0 supplement at 90 ml three times daily to help prevent further weight loss. Record review of a Dietician Progress Note dated 06/05/19 revealed CR#1 exhibited a weight loss of 6.6% in the previous month, and 23.4% in the previous six months. Record review of the Nutrition Recommendation Form dated 06/05/19 revealed the RD recommended Med Pass 2.0, 120 ml, to be given three times daily for extra nutritional support. Record review of the MAR and TAR for (MONTH) 2019 revealed Med Pass 2.0 recommendation was not transcribed to the MAR or TAR. Record review of the most recent MDS assessment, dated 06/18/19, revealed CR#1 exhibited severely impaired cognitive skills for daily decision making. The MDS reflected CR#1 required one person physical assist for eating, dressing, and locomotion, but these were marked as activity only occurred once or twice on the look back period. The MDS reflected the resident weighed 85 pounds at that time. CR#1 had exhibited a weight loss of 5% or more in the previous month or loss of 10% or more in the previous six months and assessment was marked as weight loss was not on a physician-prescribed weight-loss regimen. Under nutritional approaches parental feedings, therapeutic diets, or mechanical altered diets were not checked. Record review of the most recent lab reports, dated 07/02/19, revealed a Total Protein level of 5.9 g/dl (normal 6.4-9.8 g/dl), and an [MEDICATION NAME] level of 3.0 g/dl (normal 3.5-5.7 g/dl). Record review of the MAR and TAR for (MONTH) 2019 revealed Med Pass 2.0 was not transcribed to the MAR and TAR to be given to CR#1. Record review of a RD progress note dated 07/23/19 revealed CR #1 exhibited a significant weight loss of 22.6% over the previous six months. The Note reflected the resident was likely to continue weight loss and may be unavoidable due to non-compliance. No new interventions were suggested. Record review of the Nurses' notes from 05/01/19 to 07/10/19 revealed no documentation of CR #1's refusal of Med Pass 2.0 or meals. Record review of a Nurses' notes dated 07/10/19 at 5:34 p.m. revealed the physician ordered all supplements for CR #1 to be discontinued due to 'daily refusals' and non-compliance. The Nurses' notes reflected the discontinued meds were zinc sulfate, multivitamins with minerals, [MEDICATION NAME] sulfate, and vitamin C. The note did not indicate that the MD was also informed that the resident was losing weight. Record review of CR #1's Physician Order Report dated 08/01/19 - 08/12/19 revealed additional [DIAGNOSES REDACTED]. The orders reflected house shakes at 9 am and 5 pm Special Instructions: House shake between meals. The supplement order was dated 06/28/19 and reflected Open Ended. Record review of the (MONTH) 2019 MAR and TAR for CR#1 revealed no documentation of the house shakes being given to the resident. Record review of the (MONTH) 2019 Weekly Weight Tracking sheet revealed CR#1 weighed 78 pounds. Record review of Nurses' notes dated 08/11/19 at 11:50 a.m. revealed CR#1 was sent to the hospital due to a wound on her right great toe. Record review of the hospital Emergency Center Triage Report, dated 08/11/19, revealed CR#1 arrived at the hospital at 12:57 p.m. on that date. The report reflected her weight was 80 pounds. Further review revealed that the resident was very critical with low blood pressure, low hemoglobin, and had a wound to the foot. She was admitted to the ICU with a stage 4 pressure ulcer to the toe, severe dehydration, [MEDICAL CONDITION] and acute [MEDICAL CONDITION] Record review of a hospital Chemistry Lab report dated 08/12/19 at 6:10 a.m. reflected the resident's Protein level was 5.1 g/dl, with the reference range of 6.4 to 8.2 g/dl. CR#1's [MEDICATION NAME] level was reflected as 1.8 g/dl, with the reference range of 3.5 to 4.8 g/dl. She also had a sodium level of 160 mmol/L (high), BUN was 77 mg/dl (high) and [MEDICATION NAME] was 4.4 mg/dl (high). (Low levels of protein and [MEDICATION NAME] could indicate malnutrition) Observation and interview on 08/12/19 at 5:15 p.m. revealed CR#1 was in the hospital ICU. She appeared to be asleep. CR#1 appeared to be very thin. She exhibited contracture of her right leg. She had a Central Line on the left side of her neck. CR#1 awoke and responded to a verbal greeting. She was non-verbal. CR#1's right great toe was discolored black, from the tip to the base of the toe. The nurse said CR#1 [MEDICAL CONDITION]. At that time, CR#1's RP arrived. She said CR#1 was not a candidate for surgery, and that the hospital had discussed hospice care for the resident. Interview on 08/13/19 at 3:50 p.m. the DON was asked if the weight loss for CR #1 care was planned. She said the weight loss should have been care planned and documented in the nurses' notes. She confirmed there was no nutrition care plan in the computer chart. She later presented a paper-chart care plan that was most recently updated in (MONTH) 2019. She said the physician had discontinued all supplements because the resident refused them. She acknowledged the discontinued supplements were the zinc sulfate, multivitamins with minerals, [MEDICATION NAME] sulfate, and vitamin C. She said she had not discussed the option of a feeding tube with CR #1's RP and was not sure if the Social Worker had discussed the option with the RP. She said the option should have been discussed. Record review of the progress notes of all disciplines from 05/01/19 to 08/11/19 revealed no mention of discussion with the RP regarding a feeding tube. Interview via telephone on 08/14/19 at 11:15 a.m. CR #1's RP said she was not informed of the significant weight loss. She said they said the resident didn't eat much when they called her about a fall, but no other information was given. She said nutrition was never discussed with her, and the option of a feeding tube was never presented. She informed the surveyor that CR# 1 was going on Hospice now. Interview on 08/14/19 at 3:15 p.m. the RD she reviewed CR #1 every month. She said CR#1 was on supplements. She said the next step was to consult with the physician. She said she had made recommendations but had not spoken with the physician directly about the resident's weight loss. At that time the RD searched the computer and found no order for Med Pass 2.0. She said she was unaware there was no order or that her recommendations were not followed. Interview on 08/14/19 at 3:40 pm the RNC said that when weight loss was identified, the resident would be initially placed on a fortified meal plan and weighed weekly. The weight loss should be written in the communication log for the physician. She said those should be done as soon as weight loss was identified. Interview on 08/15/19 at 9:42 a.m. MA A said that when she gave CR #1 Med Pass and house shakes, she would drink them. She said the Med Pass 2.0 was discontinued two months ago. She said she would give Med Pass to CR #1 at times if she did not eat her lunch or dinner. Interview on 08/15/19 at 10:40 a.m. LVN B said when a Nutritional Recommendation Form was received, the nurse was supposed to call the NP. If the NP gave an order for [REDACTED]. Interview via telephone on 08/15/19 at 12:00 noon CR #1's Physician said he did not recall the facility telling him about CR#1's significant weight loss. He said he was familiar with CR#1, and she may, or may not have consumed the health shakes if ordered. He said with that amount of weight loss, he should have been notified. He said he would have been involved in any discussion regarding a feeding tube, and there was none. He said he would not have recommended one for this resident. Interview in a meeting on 08/15/19 at 1:00 p.m. with the Administrator, the DON, and the RNC, the Administrator said CR#1's RP had come to the facility and requested medical records. He said she had voiced concerns regarding falls but did not mention weight concerns. During the same meeting, the DON said CR#1 had house shakes with her meals and had 1:1 assist with meals. She said all the resident wanted was coffee and would push the staff hand away. She said that she and the ADON were responsible for reviewing the weights and the dietary recommendations. In the meeting, the RNC said the facility had three Dieticians in one year. When the surveyor asked how the Med Pass 2.0 recommendation could be missed for CR #1, RNC said the facility had been without a DON for a while and it looked like it was never put on the MAR in the computer. She said the other DON had left in mid (MONTH) 2019. Record review of the current DON's personnel file revealed her date of hire was 06/03/19. Resident #2: Record review of the Face Sheet for Resident #2, dated 06/04/19, revealed he was [AGE] years of age, and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of the MDS assessment dated [DATE] revealed a BIMS score of 12, indicative of moderately impaired cognitive skills. The MDS reflected the resident required one person physical assist to eat. The MDS reflected he weighed 247 pounds at that time. Record review of the Nutrition Recommendation Form dated 07/23/19 revealed the Dietician recommended Med Pass 2.0 at 90 ml three times daily for an additional 540 kcal/22.5 g protein per day to supplement. Record review of a physician's telephone order dated 07/26/19 revealed an order for [REDACTED]. Void was scribed on the order. There was no nurse's name on the order. Record review of the Weight Variance Report, dated 08/14/19, revealed Resident #2 weighed 247 pounds on 06/05/19, and 233 pounds on 07/03/19, for a 14 pound/5.7% weight loss in one month. Record review on 08/15/19 of the current physician's orders revealed no order for Med Pass 2.0 for Resident #2. Record Review of the Weight Variance Report, dated 08/15/19, revealed Resident #2 weighed 225.5 pounds on 08/05/19, for an additional 7 pounds/3.2% weight loss in one month. Resident #22 lost 22 lbs since 6/12/2019. Interview with Resident #2 on 08/14/19 at 12:18 p.m. he said he did not like the food at the facility. Record review of the facility policy Nutritional Assessment (Revised (MONTH) 2011) revealed .7. Once current conditions and risk factors for impaired nutrition are assessed and analyzed, individual care plans will be developed that address or minimize, to the extent possible the resident's risks for nutritional complications. Such interventions will be developed within the context of the resident's prognosis and personal preferences . Record review of the facility policy Quality of Care: General Meeting Guidelines and Documentation (no date), located in the Weight Book, revealed in part: . if a significant weight variance was identified, the DON was to notify the Dietician and the Physician for recommendations and orders . The Administrator, the DON, and the RNC were notified of an Immediate Jeopardy (IJ) on 08/15/19 at 3:45 p.m. due to the above referenced failures. A Plan of Removal (POR) was requested at that time. The POR was accepted on 08/16/19 at 2:15 p.m. Interview on 08/15/19 at 2:15 p.m. with the Administrator about the IJ, he said personnel changes during the year may have contributed to the failure. Interview with the DON on 08/17/19 at 8:30 a.m. she said that prior to starting her employment on 06/03/19) with the facility, the DON and ADON were working as floor nurses and could not get to all the orders. She said she became the interim DON on (MONTH) 11th or 12th, and then became the full-time DON. She said the ADON was fairly new as well, and they have not been able to review every chart. She said her, the ADON, and another nurse were going to review all of the current residents' charts. The POR revealed in part: .Resident (CR) #1 is in the hospital and not expected to return to the facility. Resident #2s (sic) physician wrote an order to discontinue the Med Pass 2.0; the RD agreed with this order . . The weight variance report was reviewed by the Regional Nurse Consultant and the Director of Nursing to identify discrepancies in entries. Re-weights were obtained on some entries, and the report corrected and printed again for review. No new concerns were identified; completed 8/15/19 The Regional Nurse Consultant reviewed all Dietary Recommendations for the last three (3) months to validate that Registered Dietician orders were in place and on the medication administration record; completed 8/15/19 . .The Regional Nurse Consultant and the Director of Nursing audited and reconciled the dietary orders with the dietary tickets to validate that the all residents are receiving the correct diet and ordered interventions. Any concerns were corrected immediately; completed 8/15/19 . The Assistant Director of Nursing notified and documented the notification of the physician and the responsible party of any significant weight loss triggering on the weight variance report. No new orders were received; completed 8/15/19 . The Regional Nurse Consultant and the Director of Nursing reviewed residents with weight loss to validate that they had a care plan. A care plan was developed for any resident not having a significant weight loss care plan; completed on 8/15/19 . The Regional Nurse Consultant re-educated the Director of Nursing and the Assistant Director of Nursing on the facility Dietary System on 8/15/19. Included in this education was; obtaining monthly and weekly weights including documentation, timeframes, interpretation of weights, looking for any significant weights loss as defined in the RAI manual, care planning and notification to MD and RP. The Regional Nurse Consultant educated the Nursing Management Team about putting interventions in place following RD protocols immediately upon discovery of significant weight loss and notifying the MD and RD immediately for any weight loss involving residents on an enteral tube feeding . The Director of Nursing and the Regional Nurse Consultant initiated education with nursing staff (nurses and CNAs) regarding reporting to Nursing Management daily, any changes in meal intakes, refusals to eat, and resident's requiring more assistance with meals. On the weekends, this information will be reported to the weekend RN Supervisor's and they will be educated by the Director of Nursing on 8/17/19 on this process. Also included in this education was entering intakes for meals into the Point of Care kiosk. The Assistant Director of Nursing/designee will be responsible for reviewing the kiosk daily, during normal business hours, to validate that meal intakes are being entered correctly and re-educating with any concerns. The weekend RN Supervisor will be responsible for reviewing intakes entered the kiosk over the weekends and reporting any concerns to the Nursing Management person on call . The Director of Nursing/Designee will be responsible to ensuring that weights are obtained between the 1st and the 4th of the month and entered into the EMR system by the 5th of the month. Weekly weights will be taken on Wednesday's by specially trained C.N.A. and reported to the Quality of Care meeting on Thursdays. The Regional Nurse Consultant will provide oversight by attending the Quality of Care meeting by phone or in person; weekly for one (1) month and randomly thereafter to validate policies are being followed and to provide further education. The RD has also committed to coming to these meetings, twice a month. The RD has also committed to exiting with the Nursing Management team after any visit, to discuss concerns and interventions recommended . The Director of Nursing/Designee will print the weight variance report and review for any discrepancies and ask for re-weights as warranted . Residents identified with significant weight loss or concerns who eat food orally will be placed on a Fortified Meal Plan if not already ordered, the first business day after the 5th of the month. If already on a Fortified Meal Plan, then house shakes, or a kitchen ordered snack will be started until the Registered Dieticians (RD) next visit. Residents who exhibit weight loss on an enteral tube will have the RD notified immediately for new orders . It is the policy of the facility that residents with significant weight loss, new enteral tubes, and stage 3 or 4 pressure ulcers be added to the weekly weight log. This log has been completed and will start immediately. This task will be completed by the Director of Nursing and the Assistant Director of Nursing and reviewed and validated weekly by the Regional Nurse Consultant . Weekly weights will be obtained on Tuesday's by a specially trained C.N.A who has been trained by the Assistant Director of Nursing and under the direction of the Assistant Director of Nursing . Weekly weights will be reviewed in the weekly Quality of Care meeting, to be held on Wednesdays by the Interdisciplinary team for effectiveness of interventions and possible need for new interventions. The Physician and RP will be notified of any additional concerns by the Director of Nursing/Designee . The Registered Dietician will exit with the Director of Nursing/Designee and the Administrator and recommendations will be reviewed at that time . Dietary recommendations will be completed within twenty-four (24) hours by the Director of Nursing/Designee .The policies of the facility have not been adequately followed and this is how the deficient practice occurred. The only new policy put in place in response to this deficient practice is the training of the Nursing Management team to review intakes in the kiosk. The timeframes for obtaining monthly and weekly weights, whom to weigh (resident conditions), time frame and reviewing RD recommendations and implementation along with the weekly Quality of Care meeting are all current policies. Following acceptance of the facility's Plan of Removal, the facility was monitored from 08/16/19 to 08/19/19. Record review revealed in-services that had been done for the Licensed Nurses, Medication Aides, and Certified Nurse Aides. Documentation of the following was reviewed: In-services on topics of Meal percentage reporting and how to obtain the report, entering intake %, documentation and notifications, monitoring residents, documenting Med Pass supplement administration, and obtaining weights. Interviews were conducted with a total of 10 Licensed Nurses, Medication Aides, and Certified Nurse Aides from 2 shifts to verify the in-services had been conducted and to validate the staff understanding of the information presented to them. the staff was knowledgeable of the in-serviced received and new procedures. Observations were conducted to verify residents with identified weight loss concerns were being offered the physician-ordered supplements. No issues were found. The Interim Administrator and the RDO were notified that the IJ was lowered on 08/19/19 at 3:38 p.m. However, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated due to the facility needing more time to monitor the plan of correction effectiveness.

Based on observation, interview, and record review, the facility failed to consult with the resident physician when the resident experience a significant change in condition for one two of ten residents (CR # 1 and Resident #3) reviewed for notification of changes. -The facility failed to consult with CR #1 ' s Physician on two different ocassions when the resident had critical lab values. -The facility failed to notify the physician that CR #1 refused urine collection for UA/C&S and failed to follow-up and make additional attempts to obtain the Urinalysis. -CR #1 was transferred to the hospital on [DATE] and was admitted with a fever and [DIAGNOSES REDACTED]. - The facility failed to immediately consult with Resident #3 ' s physician when UA/C&S results indicated the resident had a UTI. An IJ was identified on 01/17/17. While the IJ was removed on 1/20/17 the facility remained out of compliance at a scope of pattern and a severity of actual harm due to facility requiring more time to monitor the plan of removal for effectiveness. This failure affected two residents and placed 54 residents that required lab draws in December 2016 at risk of not being provided with appropriate and timely medical intervention resulting in a decline in their quality of care and quality of life. Findings Included: Record review of CR #1 face sheet revealed a [AGE] year old female admitted to the facility on [DATE] with the following diagnoses; [MEDICAL CONDITION] with Septic Shock, Moderate Protein-Calorie Malnutrition, Diarrhea, Hypo-Osmolality, and [MEDICAL CONDITIONS], Dysphagia, Gastrostomy, [MEDICAL CONDITION] Disease, [MEDICAL CONDITIONS] Fibrillation, Pain, Neonatal Cerebral Depression, and Nausea and Vomiting. She was transferred on 01/01/17 and remains in the hospital. Record review of MDS assessment dated [DATE] revealed that CR #1 had speech impairment, some cognitive deficit and some difficulty making decisions in new situations. Further record review revealed CR #1 required extensive assistance with activities of daily living. She was incontinent of bladder and behaviors of refusing care. Record review of CR #1 ' s care plan date initiated 05/23/16 and revised on 10/31/16 revealed CR #1 was being care planned for dehydration/electrolyte that entailed to monitor for signs and symptoms of dehydration (dry cracked lips, etc.) and report any negative findings to the Physician. Record review of CR #1 Physician orders [REDACTED]. Record review of CR #1 Lab results dated 12/19/16 revealed BUN level- 42(H) with the norm ranging from (7-25), WBC 20.8 (H) and norm (3.8-10.8), and Sodium level 150(H) and the norm (135-146). There was no documentation in the lab section or the resident ' s clinical records that the facility consulted with the physician about these results. Record review of the lab requisition Sheet for 12/19/16 revealed that CR#1 refused the urine collection for the UA/C&S lab. There was no documentation in the residents ' records that the physician was informed or that additional attempts were made to obtain a urine sample. Record review of CR# 1 Nursing Notes revealed in part: -12/19/16 at 6:16 am CNA reported resident were hot during last round of care at approximately 5:45 am. RN-U entered resident room and covers were off of resident body. Resident face was flushed red and forehead was warm to touch. Resident shook her head yes when asked by RN-U if she was hot. RN-U took resident temperature with a reading of 99.5. RN-U reported to oncoming nurse that low grade fever was a new onset and 2 times loose yellow stools were the only concerns during her shift and encouraged oncoming nurse to call the Physician or NP for further orders. Physician was called and [MEDICATION NAME], CBC, CMP and UA ordered. -12/20/16 12:23 pm LVN-G documented resident incontinent of bowel and bladder with watery stool noted times 2 will continue to monitor. There was no documentation that the physician was consulted. Record review of CR #1 ' s physician progress notes [REDACTED]. CR #1 was sent toER on [DATE] due to abdominal distention, pain and abnormal breath sounds. Resident was diagnosed with [REDACTED]. Pneumonia. Resident was placed on ABT times 10 days. On 12/19/16 CBC, CMP and UA was ordered for fever. Resident labs reviewed today and revealed a low Potassium level and increase in WBC. The plan is to continue [MEDICATION NAME] day four of 10 and redraw CBC, CMP in a.m. (12/22/16). Further review of CR #1 ' s labs and clinical record revealed no results for the CBC and CMP ordered on [DATE]. Record review of CR #1 Physician orders [REDACTED].>- dated 12/28/16 CBC CMP in a.m. then every Monday until further notice Record review of lab results dated 12/29/16 revealed the following results: WBC 15.1, Sodium 178 (critical), and BUN 103 (critical). The laboratory called and reported the critical results to LVN-G on 12/29/16 at 7:02 p.m. There was no documentation on the lab result or the clinical file that the physician was informed or consulted about the critical lab results. Record review of Resident # 1 Nursing Notes: - 12/24/16 at 2:24 am of RN-NT documentation reading resident continues to have diarrhea. Further documentation at 11:34 a.m. by LVN-G resident face warm to touch and red with a temperature of 99.3. Tylenol was given and was effective. - 12/24/16 at 11:34 am no s/s of distress .face warm to touch and red, temp of 99.3. Tylenol given .temp down to 97.8 .watery stool x1 this shift - 12/25/16 at 2:57 am RN-NT documenting that resident has been having a low grade temperature of 99.1 and will continue to monitor. -12/26/16 2:53 am resting comfortably, no indication of pain and distress . -12/27/16 7:18 pm continues on ABT, up in a wheelchair this shift, resist care, temp 98.5. -12/29/16 at 2:27 am resting in bed, remains on ABT, continues to have diarrhea, and flushed faced, afebrile at this time. There was no documentation that the physician was consulted at this time. - 12/29/16 at 10:50 am of LVN-G documenting resident is red in face with a low grade temperature of 99.2, will continue to monitor. There was no documentation that the physician was consulted at this time. - 12/30/16 at 5:19 pm pat alert with no adverse reaction to ABT, BP 99/66, heart rate of 100 with a temp of 98.9 - 12/31/16 at 5:07 am no rash, no distress, no physical signs of pain or discomfort . - 01/01/2017 at 10:28 pm of RN-U documenting resident grimacing to touch. [MEDICATION NAME] 50 mg administered via gastrostomy-tube, respirations increased at 32, blood pressure 104/73, heart rate 100, and Oxygen saturation at 95%. A message was left with NP. - 01/01/17 at 11:07 pm of RN-U documenting resident blood pressure 70/54, heart rate 105, respirations 36 and oxygen saturation 97%. The EMS contacted for transport to Hospital. Record review of CR #1 Hospital Admission History and Physical Records dated 01/02/17 revealed that resident was admitted for observation at 0200 from the nursing home. Just prior to admission, resident was noted to have a temperature of 100.6. This is justly significant since her usual temperature is 96. Mucous membranes were dry. Caked intraoral secretions were noted along with poor dental hygiene. Resident labs are significant in that her sodium was 182, chloride 143, BUN 109, and creatinine 2. Resident urine was grossly septic with a large amount of bacteria and white cells. Impression: 1. Severe Dehydration 2. Urosepsis 3. [MEDICAL CONDITION] Record review of CR #1 Hospital Medication Administration Records revealed resident was given a bolus (large dose intravenous) of Sodium Chloride 0.9% a 1000 ml at 999 ml/hr times one on 1/02/17. Further record review of the Medication Administration Record [REDACTED]. Resident was also receiving free water per gastrostomy-tube at 50ml/ hr continuously started on 01/02/17 and Nepro 237 ml every 8 hours. Resident is receiving the antibiotic Meropenem 1000 mg intravenous every 8 hours. Interview on 01/04/17 at 12:40 pm the DON said she was unable to see in the Nursing Notes and Lab Reports that a urinalysis was done for order written on 12/19/16. She said she did see it was documented on the requisition that CR # 1 refused UA on the 12/19/16 and there was no documentation reported to the Physician that CR# 1 refused her UA specimen collection. DON said she just got back from being on vacation. Observation on 01/04/17 at 2:38pm of CR# 1 revealed she was resting in the hospital bed receiving oxygen via nasal cannula at 2 liters. Resident had an indwelling Foley catheter draining clear yellow urine. CR #1 was non-interviewable. Interview with RN-Z on 01/04/17 at 2:45 pm said that CR #1 is no longer receiving continuous intravenous fluids but continues to receive IV antibiotic therapy. Interview on 01/04/17 at 3:15pm with Physician Assistant said CR #1 may be transferred to a LTAC for further IV antibiotic therapy for the next 2 weeks just to make sure she has fully recovered. Interview with the DON on 01/17/17 at 8:55 a.m. she said that CR #1 went to the ER for vomiting, dehydration, and diarrhea and that she did not know what the resident lab results revealed before resident was transferred to the hospital. Interview on 01/17/17 at 9:10 a.m. ADON-MS said she has been working at the nursing facility as an ADON for a year and she was responsible for staffing, incident reports, inputting orders in the computer, in-services the staff, employee information with new hire. ADON-MS said it is the nurse on the Unit that monitors the lab along with the DON. Interview on 01/17/16 at 9:50 a.m. LVN-AA said that when CR #1 first admitted to the facility would refuse care like her baths and lab draws. LVN-AA said you would have to know how to handle CR #1 by backing off and come back at a later time or day. LVN-AA said when a resident refuse lab specimens she would notify the Physician and keep trying. LVN-AA said any abnormal critical lab results she would notify the Physician right away. Interview on 01/17/17 at 9:17 a.m. the DON said that RN-U was terminated from the facility because she sent CR #1 out to the hospital dirty and not notifying the Administration of the transfer. The DON said she did not in-serviced the nursing staff on obtaining lab specimens or the reporting of abnormal or critical lab values to the physician. Interview on 01/17/17 at 9:55 a.m. CNA-YZ said the last time she took care of CR #1, her face was red and resident had diarrhea real bad along with vomiting which was reported to the nurse on the 10pm to 6 am shift. CNA-YZ said CR #1 never refused care with her. In a phone interview on 01/17/17 at 10:05 a.m. RN-U said CR #1 was incontinent and had just finished her antibiotic therapy via gastrostomy-tube. RN-U said CR #1 had been experiencing 2-3 episodes of diarrhea on the night shift but was given to her in report from the day shift and evening shift of no episodes of having diarrhea. RN-U said she could not remember when the diarrhea started. RN-U said the reason why she called EMS to transfer the resident to hospital was because of the increase in respirations. RN-U said she never looked at CR # 1 labs because nothing was being mentioned in the 24-hour report log notebook about critical or abnormal labs. Interview on 01/17/16 at 12:20 pm the NP said she was out of the State from 12/29/16 to 01/03/07 and did not return back to the facility until the 01/09/17. The NP said that was when she saw the critical lab results on CR #1 which was drawn on 12/29/16. NP said then she was informed by staff that CR# 1 had been transferred to the hospital. She said the physician was not notified. Interview on 01/17/17 at 3:25pm LVN-G said she has been working at the facility for about 3 years and did take care of CR # 1. LVN-G said she remembered getting a call from the lab of critical lab results on CR #1. LVN-G said she call the Physician on call number and left a message for the Doctor to call the facility back at his early convenience. LVN-G said she then gave report to the on-coming nurse whose name she was not sure of. LVN-G said she did not document these on the Nursing Notes or the 24-hour report log book. She said she did not talk to the physician of NP. Resident #3: Record review of Resident #3 face sheet revealed an [AGE] year old admitted to the facility on [DATE] with the following diagnoses; [DIAGNOSES REDACTED], Hypertension, Dysphagia, [MEDICAL CONDITIONS] Stage 3 (moderate), Pressure Ulcer of Sacral Region, Pain, and Gastro-[MEDICAL CONDITION] Reflux Disease. Record review of Resident #3 MDS dated [DATE] revealed that resident cognition was severely impaired and required extensive to total assistance with activities of daily living. Record review of Resident #3 ' s UA/C&S results on 12/03/16 revealed a final report of [MEDICATION NAME] (bacteria) in urine sensitivity to [MEDICATION NAME] (antibiotic). There was no documentation that the results were reported to the physician. Further review revealed the NP sign the lab on 12/12/16. Record review of Resident # 3 ' s Physician order [REDACTED]. Record review of facility Lab and Diagnostic Test Results .Clinical Protocol (revised 2012): · A Nurse will review all results; if the staff who first receive or review lab and diagnostic test results cannot follow the remainder of this procedure for reporting and documenting the results and their implications, another nurse in the facility(supervisor, charge nurse, etc.) should follow or coordinate the procedure. · A nurse will identify the urgency of communicating with the Attending Physician, NP, or PA based on physician request. · Facility staff should document information about when, how and to whom the information was provided and the response. Record review of facility Acute Condition Changes .Clinical Protocol Policy (revised 2015) read as follows: · The Nurse shall asses and document/report the following baseline information (vital signs, neurological status, level of consciousness, recent labs, all active diagnoses, and all current medications). The Administrator and DON were notified on 01/17/17 at 4:55 pm of the IJ situation and a POR was requested. The POR was received and after 2 revisions it was accepted on 01/19/17 at 11:35 am. The POR read in part: 1. Notify Medical Director of Immediate Jeopardy status. Completed on 01/17/17 2. Notify VP of Clinical Services of Immediate Jeopardy 3. Resident is currently in hospital, and id due to return to Nursing facility on 01/18/17 4. All residents will have head to toe assessments by licensed nursing staff to identify changes in condition. Assessments started and completed on 01/17/17. This being overseen by DON and or ADON. All findings are documented on Skill Nursing form. Assessment includes vital signs and head to toe assessment. Nurses are using thermometer and blood pressure kit for the vital signs. Notified Physician and responsible party for nay residents identified with a change in condition. 5. Lab audit conducted from [DATE]st, 2016 to current to ensure any critical labs have been identified and MD/NP notified. Audits started January 17th, 2017 and completed on January 18th, 2017. 6. All licensed nurses will be in-serviced on facility ' s policy regarding changes in a residents condition, abnormal labs resulting in change of condition, and change of condition noted during assessment . All licensed nurses will be in-serviced starting on January 17th, 2017 and completed on January 18th, 2017. In-service will include notification and consultation with MD/NP/PA; and include when notification is necessary, the procedure the staff must follow if the MD does not answer, and communication of changes of condition, lab results, and diagnostic results. Any nurses unable to attend in-service by this date will be removed from schedule until in-service has been completed. DON and/or ADON will monitor new hires to ensure that licensed nurses will receive training in the changes in resident ' s condition policy. The facility was monitored from 01/19/17 to 01/20/17 to verify that the plan was implemented. The ADON and 6 nurses from different shifts were interviewed regarding in-service on checking the resident labs to look for any critical or abnormal values and communicating the results to Physician and to document all actions taken and on recognizing changes in condition. Staff was able to report understanding. Interview on 01/19/17 at 12:20pm DON said before, the laboratory would come to the facility and draw resident labs early in the a.m. now they will start coming in the evening to draw resident labs. The DON said before, she would write labs down on each lab draw and print results and give to charge nurses on the unit ton contact the MD/NP. The DON said she has developed a new system in monitoring the resident labs. 1. Print out resident service log lab sheet 2. Place service log lab sheet on the 24 hour report book 3. If lab results are available in the a.m. she will print out and give to charge nurses on the unit. The charge nurse will follow-up with any abnormal/critical labs to the Physician and NP. The DON and ADON will also review labs as well. Records were reviewed to verify the facility completed resident nursing assessments and a review of the labs. Interview on 01/18/17 at 10:45 a.m. the Administrator said the reason he felt that an IJ had occurred was because there was a negative outcome to CR #1 due to the failure of the facility not communicating and documenting critical lab results and change in CR #1 condition. The Administrator said he ensured that the DON was performing her duties as DON by having morning meetings, discussing the 24 hour report log on the residents, using the Standard of Excellence viewing resident outcomes as it relates to each resident such wounds, [MEDICAL CONDITION] medications, weight loss, and falls,etc. Interview on 01/18/17 at 10:55 a.m. the DON said the reason why the Nursing Facility had an IJ was because one person did not document what she had done and did not communicate to the second shift so that a follow-up could be done. The DON said if there was no response from the Physician, the nurse should have notified the DON, ADON, and or the Administrator. The DON she ensured that the nurses were doing their jobs by monitoring the staff, viewing the Medication Administration Record, [REDACTED]. Interview on 01/18/17 at 12:30pm ADON-MS said she tries to help in monitoring the lab draws and results on resident labs especially if the DON was not in the building. ADON-MS said critical lab values should be called to the Physician immediately and given the results. ADON-MS said whenever there was a change in a resident condition, the nurse should use the SBAR assessment tool form and notify the Physician of findings in resident change in condition as well as the resident responsible party. The Administrator and DON were informed on 01/20/17 at 2:05 pm that the IJ was lowered; however the facility remained out of compliance at a pattern level and a severity of actual harm that is not an IJ to resident health or safety due to facility needing more time to train the staff. According to a list provided by the DON, 54 residents had lab tests in the month of December 2016.

Based on observation, interview, and record review the facility failed to ensure each resident was free from neglect for 2 of 10 residents reviewed for abuse and neglect. (CR #1 and Resident #3) -The facility failed to consult with CR #1 ' s Physician on two different ocassions when the resident had critical lab values. -The facility failed to notify the physician that CR #1 refused urine collection for UA/C&S and failed to follow-up and make additional attempts to obtain the Urinalysis. -CR #1 records revealed no nursing assessments when she had a change of condition and experienced watery stools and a low grade fever. -CR #1 was transferred to the hospital on [DATE] and was admitted with a fever and [DIAGNOSES REDACTED]. - The facility failed to immediately consult with Resident #3 ' s physician when UA/C&S results indicated the resident had a UTI. An IJ was identified on 01/17/17. While the IJ was removed on 1/20/17 the facility remained out of compliance at a scope of pattern and a severity of actual harm due to facility requiring more time to monitor the plan of removal for effectiveness. This failure affected two residents and placed 54 residents that required lab draws in December 2016 at risk of not being provided with appropriate and timely medical intervention resulting in a decline in their quality of care and quality of life. Findings Included: Record review of CR #1 face sheet revealed a [AGE] year old female admitted to the facility on [DATE] with the following diagnoses; [MEDICAL CONDITION] with Septic Shock, Moderate Protein-Calorie Malnutrition, Diarrhea, Hypo-Osmolality, and [MEDICAL CONDITIONS], Dysphagia, Gastrostomy, [MEDICAL CONDITION] Disease, [MEDICAL CONDITIONS] Fibrillation, Pain, Neonatal Cerebral Depression, and Nausea and Vomiting. She was transferred on 01/01/17 and remains in the hospital. Record review of MDS assessment dated [DATE] revealed that CR #1 had speech impairment, some cognitive deficit and some difficulty making decisions in new situations. Further record review revealed CR #1 required extensive assistance with activities of daily living. She was incontinent of bladder and behaviors of refusing care. Record review of CR #1 ' s care plan date initiated 05/23/16 and revised on 10/31/16 revealed CR #1 was being care planned for dehydration/electrolyte that entailed to monitor for signs and symptoms of dehydration (dry cracked lips, etc.) and report any negative findings to the Physician. Record review of CR #1 Physician orders dated 12/19/16 STAT CBC, CMP, UA Diagnosis: [REDACTED]. Record review of CR #1 Lab results dated 12/19/16 revealed BUN level- 42(H) with the norm ranging from (7-25), WBC 20.8 (H) and norm (3.8-10.8), and Sodium level 150(H) and the norm (135-146). There was no documentation in the lab section or the resident ' s clinical records that the facility consulted with the physician about these results. Record review of the lab requisition Sheet for 12/19/16 revealed that CR#1 refused the urine collection for the UA/C&S lab. There was no documentation in the residents ' records that the physician was informed or that additional attempts were made to obtain a urine sample. Record review of CR# 1 Nursing Notes revealed in part: -12/19/16 at 6:16 am CNA reported resident were hot during last round of care at approximately 5:45 am. RN-U entered resident room and covers were off of resident body. Resident face was flushed red and forehead was warm to touch. Resident shook her head yes when asked by RN-U if she was hot. RN-U took resident temperature with a reading of 99.5. RN-U reported to oncoming nurse that low grade fever was a new onset and 2 times loose yellow stools were the only concerns during her shift and encouraged oncoming nurse to call the Physician or NP for further orders. Physician was called and [MEDICATION NAME], CBC, CMP and UA ordered. -12/20/16 12:23 pm LVN-G documented resident incontinent of bowel and bladder with watery stool noted times 2 will continue to monitor. There was no documentation that the physician was consulted. Record review of CR #1 ' s physician progress notes [REDACTED]. CR #1 was sent toER on [DATE] due to abdominal distention, pain and abnormal breath sounds. Resident was diagnosed with [REDACTED]. Pneumonia. Resident was placed on ABT times 10 days. On 12/19/16 CBC, CMP and UA was ordered for fever. Resident labs reviewed today and revealed a low Potassium level and increase in WBC. The plan is to continue [MEDICATION NAME] day four of 10 and redraw CBC, CMP in a.m. (12/22/16). Further review of CR #1 ' s labs and clinical record revealed no results for the CBC and CMP ordered on [DATE]. Record review of CR #1 Physician orders revealed: - dated 12/28/16 CBC CMP in a.m. then every Monday until further notice Record review of lab results dated 12/29/16 revealed the following results: WBC 15.1, Sodium 178 (critical), and BUN 103 (critical). The laboratory called and reported the critical results to LVN-G on 12/29/16 at 7:02 p.m. There was no documentation on the lab result or the clinical file that the physician was informed or consulted about the critical lab results. Record review of Resident # 1 Nursing Notes: - 12/24/16 at 2:24 am of RN-NT documentation reading resident continues to have diarrhea. Further documentation at 11:34 a.m. by LVN-G resident face warm to touch and red with a temperature of 99.3. Tylenol was given and was effective. - 12/24/16 at 11:34 am no s/s of distress .face warm to touch and red, temp of 99.3. Tylenol given .temp down to 97.8 .watery stool x1 this shift - 12/25/16 at 2:57 am RN-NT documenting that resident has been having a low grade temperature of 99.1 and will continue to monitor. -12/26/16 2:53 am resting comfortably, no indication of pain and distress . -12/27/16 7:18 pm continues on ABT, up in a wheelchair this shift, resist care, temp 98.5. -12/29/16 at 2:27 am resting in bed, remains on ABT, continues to have diarrhea, and flushed faced, afebrile at this time. There was no documentation that the physician was consulted at this time. - 12/29/16 at 10:50 am of LVN-G documenting resident is red in face with a low grade temperature of 99.2, will continue to monitor. There was no documentation that the physician was consulted at this time. - 12/30/16 at 5:19 pm pat alert with no adverse reaction to ABT, BP 99/66, heart rate of 100 with a temp of 98.9 - 12/31/16 at 5:07 am no rash, no distress, no physical signs of pain or discomfort . - 01/01/2017 at 10:28 pm of RN-U documenting resident grimacing to touch. [MEDICATION NAME] 50 mg administered via gastrostomy-tube, respirations increased at 32, blood pressure 104/73, heart rate 100, and Oxygen saturation at 95%. A message was left with NP. - 01/01/17 at 11:07 pm of RN-U documenting resident blood pressure 70/54, heart rate 105, respirations 36 and oxygen saturation 97%. The EMS contacted for transport to Hospital. Record review of CR #1 Hospital Admission History and Physical Records dated 01/02/17 revealed that resident was admitted for observation at 0200 from the nursing home. Just prior to admission, resident was noted to have a temperature of 100.6. This is justly significant since her usual temperature is 96. Mucous membranes were dry. Caked intraoral secretions were noted along with poor dental hygiene. Resident labs are significant in that her sodium was 182, chloride 143, BUN 109, and creatinine 2. Resident urine was grossly septic with a large amount of bacteria and white cells. Impression: 1. Severe Dehydration 2. Urosepsis 3. [MEDICAL CONDITION] Record review of CR #1 Hospital Medication Administration Records revealed resident was given a bolus (large dose intravenous) of Sodium Chloride 0.9% a 1000 ml at 999 ml/hr times one on 1/02/17. Further record review of the Medication Administration Record [REDACTED]. Resident was also receiving free water per gastrostomy-tube at 50ml/ hr continuously started on 01/02/17 and Nepro 237 ml every 8 hours. Resident is receiving the antibiotic Meropenem 1000 mg intravenous every 8 hours. Record review of facility Complaints and Grievances dated 01/03/17 revealed a complaint about CR #1 from the Hospital to the Administrator reading: CR # 1 arrived to the hospital in poor care. Interview on 01/04/17 at 11:25 a.m. the Social Service Director said she just received the complaint on CR #1 this morning from the Administrator that resident was admitted to the hospital in poor physical appearance. The Social Service Director she will have to in-service the staff once she got more information on the issue. Interview on 01/04/17 at 12:40 pm the DON said she was unable to see in the Nursing Notes and Lab Reports that a urinalysis was done for order written on 12/19/16. She said she did see it was documented on the requisition that CR # 1 refused UA on the 12/19/16 and there was no documentation reported to the Physician that CR# 1 refused her UA specimen collection. DON said she just got back from being on vacation. Observation on 01/04/17 at 2:38pm of CR# 1 revealed she was resting in the hospital bed receiving oxygen via nasal cannula at 2 liters. Resident had an indwelling Foley catheter draining clear yellow urine. CR #1 was non-interviewable. Interview with RN-Z on 01/04/17 at 2:45 pm said that CR #1 is no longer receiving continuous intravenous fluids but continues to receive IV antibiotic therapy. Interview on 01/04/17 at 3:15pm with Physician Assistant said CR #1 may be transferred to a LTAC for further IV antibiotic therapy for the next 2 weeks just to make sure she has fully recovered. Interview with the DON on 01/17/17 at 8:55 a.m. she said that CR #1 went to the ER for vomiting, dehydration, and diarrhea and that she did not know what the resident lab results revealed before resident was transferred to the hospital. Interview on 01/17/17 at 9:10 a.m. ADON-MS said she has been working at the nursing facility as an ADON for a year and she was responsible for staffing, incident reports, inputting orders in the computer, in-services the staff, employee information with new hire. ADON-MS said it is the nurse on the Unit that monitors the lab along with the DON. Interview on 01/17/16 at 9:50 a.m. LVN-AA said that when CR #1 first admitted to the facility would refuse care like her baths and lab draws. LVN-AA said you would have to know how to handle CR #1 by backing off and come back at a later time or day. LVN-AA said when a resident refuse lab specimens she would notify the Physician and keep trying. LVN-AA said any abnormal critical lab results she would notify the Physician right away. Interview on 01/17/17 at 9:17 a.m. the DON said that RN-U was terminated from the facility because she sent CR #1 out to the hospital dirty and not notifying the Administration of the transfer. The DON said she did not in-serviced the nursing staff on obtaining lab specimens or the reporting of abnormal or critical lab values to the physician. Interview on 01/17/17 at 9:55 a.m. CNA-YZ said the last time she took care of CR #1, her face was red and resident had diarrhea real bad along with vomiting which was reported to the nurse on the 10pm to 6 am shift. CNA-YZ said CR #1 never refused care with her. In a phone interview on 01/17/17 at 10:05 a.m. RN-U said CR #1 was incontinent and had just finished her antibiotic therapy via gastrostomy-tube. RN-U said CR #1 had been experiencing 2-3 episodes of diarrhea on the night shift but was given to her in report from the day shift and evening shift of no episodes of having diarrhea. RN-U said she could not remember when the diarrhea started. RN-U said the reason why she called EMS to transfer the resident to hospital was because of the increase in respirations. RN-U said she never looked at CR # 1 labs because nothing was being mentioned in the 24-hour report log notebook about critical or abnormal labs. Interview on 01/17/16 at 12:20 pm the NP said she was out of the State from 12/29/16 to 01/03/07 and did not return back to the facility until the 01/09/17. The NP said that was when she saw the critical lab results on CR #1 which was drawn on 12/29/16. NP said then she was informed by staff that CR# 1 had been transferred to the hospital. She said the physician was not notified. Interview on 01/17/17 at 3:25pm LVN-G said she has been working at the facility for about 3 years and did take care of CR # 1. LVN-G said she remembered getting a call from the lab of critical lab results on CR #1. LVN-G said she call the Physician on call number and left a message for the Doctor to call the facility back at his early convenience. LVN-G said she then gave report to the on-coming nurse whose name she was not sure of. LVN-G said she did not document these on the Nursing Notes or the 24-hour report log book. She said she did not talk to the physician of NP. Resident #3: Record review of Resident #3 face sheet revealed an [AGE] year old admitted to the facility on [DATE] with the following diagnoses; [DIAGNOSES REDACTED], Hypertension, Dysphagia, [MEDICAL CONDITIONS] Stage 3 (moderate), Pressure Ulcer of Sacral Region, Pain, and Gastro-[MEDICAL CONDITION] Reflux Disease. Record review of Resident #3 MDS dated [DATE] revealed that resident cognition was severely impaired and required extensive to total assistance with activities of daily living. Record review of Resident #3 ' s UA/C&S results on 12/03/16 revealed a final report of [MEDICATION NAME] (bacteria) in urine sensitivity to [MEDICATION NAME] (antibiotic). There was no documentation that the results were reported to the physician. Further review revealed the NP sign the lab on 12/12/16. Record review of Resident # 3 ' s Physician order dated 12/12/16 revealed to [MEDICATION NAME] twice a day times 5 days diagnosis; Urinary Tract Infection. Record review of the facility policy titled Abuse prohibition revised in 2016 revealed in part: .the health care center will ensure a safe environment for residents by prohibiting physical and mental abuse .neglect and misappropriation of resident property .neglect- includes but is not limited to failure to provide goods and services necessary to avoid harm . Record review of facility Acute Condition Changes---Clinical Protocol Policy (revised 2015) read as follows: · The Nurse shall asses and document/report the following baseline information (vital signs, neurological status, level of consciousness, recent labs, all active diagnoses, and all current medications). The Administrator and DON were notified on 01/17/17 at 4:55 pm of the IJ situation and a POR was requested. The POR was received and after 2 revisions it was accepted on 01/19/17 at 11:35 am. The POR read in part: 1. Notify Medical Director of Immediate Jeopardy status. Completed on 01/17/17 2. Notify VP of Clinical Services of Immediate Jeopardy 3. Resident is currently in hospital, and id due to return to Nursing facility on 01/18/17 4. All residents will have head to toe assessments by licensed nursing staff to identify changes in condition. Assessments started and completed on 01/17/17. This being overseen by DON and or ADON. All findings are documented on Skill Nursing form. Assessment includes vital signs and head to toe assessment. Nurses are using thermometer and blood pressure kit for the vital signs. Notified Physician and responsible party for nay residents identified with a change in condition. 5. Lab audit conducted from [DATE]st, 2016 to current to ensure any critical labs have been identified and MD/NP notified. Audits started January 17th, 2017 and completed on January 18th, 2017. 6. All licensed nurses will be in-serviced on facility ' s policy regarding changes in a residents condition, abnormal labs resulting in change of condition, and change of condition noted during assessment . All licensed nurses will be in-serviced starting on January 17th, 2017 and completed on January 18th, 2017. In-service will include notification and consultation with MD/NP/PA; and include when notification is necessary, the procedure the staff must follow if the MD does not answer, and communication of changes of condition, lab results, and diagnostic results. Any nurses unable to attend in-service by this date will be removed from schedule until in-service has been completed. DON and/or ADON will monitor new hires to ensure that licensed nurses will receive training in the changes in resident ' s condition policy. The facility was monitored from 01/19/17 to 01/20/17 to verify that the plan was implemented. The ADON and 6 nurses from different shifts were interviewed regarding in-service on checking the resident labs to look for any critical or abnormal values and communicating the results to Physician and to document all actions taken and on recognizing changes in condition. Staff was able to report understanding. Interview on 01/19/17 at 12:20pm DON said before, the laboratory would come to the facility and draw resident labs early in the a.m. now they will start coming in the evening to draw resident labs. The DON said before, she would write labs down on each lab draw and print results and give to charge nurses on the unit ton contact the MD/NP. The DON said she has developed a new system in monitoring the resident labs. 1. Print out resident service log lab sheet 2. Place service log lab sheet on the 24 hour report book 3. If lab results are available in the a.m. she will print out and give to charge nurses on the unit. The charge nurse will follow-up with any abnormal/critical labs to the Physician and NP. The DON and ADON will also review labs as well. Records were reviewed to verify the facility completed resident nursing assessments and a review of the labs. Interview on 01/18/17 at 10:45 a.m. the Administrator said the reason he felt that an IJ had occurred was because there was a negative outcome to CR #1 due to the failure of the facility not communicating and documenting critical lab results and change in CR #1 condition. The Administrator said he ensured that the DON was performing her duties as DON by having morning meetings, discussing the 24 hour report log on the residents, using the Standard of Excellence viewing resident outcomes as it relates to each resident such wounds, [MEDICAL CONDITION] medications, weight loss, and falls,etc. Interview on 01/18/17 at 10:55 a.m. the DON said the reason why the Nursing Facility had an IJ was because one person did not document what she had done and did not communicate to the second shift so that a follow-up could be done. The DON said if there was no response from the Physician, the nurse should have notified the DON, ADON, and or the Administrator. The DON she ensured that the nurses were doing their jobs by monitoring the staff, viewing the Medication Administration Record, [REDACTED]. Interview on 01/18/17 at 12:30pm ADON-MS said she tries to help in monitoring the lab draws and results on resident labs especially if the DON was not in the building. ADON-MS said critical lab values should be called to the Physician immediately and given the results. ADON-MS said whenever there was a change in a resident condition, the nurse should use the SBAR assessment tool form and notify the Physician of findings in resident change in condition as well as the resident responsible party. The Administrator and DON were informed on 01/20/17 at 2:05 pm that the IJ was lowered; however the facility remained out of compliance at a pattern level and a severity of actual harm that is not an IJ to resident health or safety due to facility needing more time to train the staff. According to a list provided by the DON, 54 residents had lab tests in the month of December 2016.

Based on observation, interview and record review the facility failed to pomptly notify the ordering physician, physician assistant, or nurse practitioner of laboratory results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's order [REDACTED]. (CR #1 and Resident #3) -The facility failed to consult with CR #1 ' s Physician on two different ocassions when the resident had critical lab values. -CR #1 was transferred to the hospital on [DATE] and was admitted with a fever and [DIAGNOSES REDACTED]. - The facility failed to immediately consult with Resident #3 ' s physician when UA/C&S results indicated the resident had a UTI. An IJ was identified on 01/17/17. While the IJ was removed on 1/20/17 the facility remained out of compliance at a scope of pattern and a severity of actual harm due to facility requiring more time to monitor the plan of removal for effectiveness. This failure affected two residents and placed 54 residents that required lab draws in December 2016 at risk of not being provided with appropriate and timely medical intervention resulting in a decline in their quality of care and quality of life. Findings Included: Record review of CR #1 face sheet revealed a [AGE] year old female admitted to the facility on [DATE] with the following diagnoses; [MEDICAL CONDITION] with Septic Shock, Moderate Protein-Calorie Malnutrition, Diarrhea, Hypo-Osmolality, and [MEDICAL CONDITIONS], Dysphagia, Gastrostomy, [MEDICAL CONDITION] Disease, [MEDICAL CONDITIONS] Fibrillation, Pain, Neonatal Cerebral Depression, and Nausea and Vomiting. She was transferred on 01/01/17 and remains in the hospital. Record review of MDS assessment dated [DATE] revealed that CR #1 had speech impairment, some cognitive deficit and some difficulty making decisions in new situations. Further record review revealed CR #1 required extensive assistance with activities of daily living. She was incontinent of bladder and behaviors of refusing care. Record review of CR #1 ' s care plan date initiated 05/23/16 and revised on 10/31/16 revealed CR #1 was being care planned for dehydration/electrolyte that entailed to monitor for signs and symptoms of dehydration (dry cracked lips, etc.) and report any negative findings to the Physician. Record review of CR #1 Physician orders [REDACTED]. Record review of CR #1 Lab results dated 12/19/16 revealed BUN level- 42(H) with the norm ranging from (7-25), WBC 20.8 (H) and norm (3.8-10.8), and Sodium level 150(H) and the norm (135-146). There was no documentation in the lab section or the resident ' s clinical records that the facility consulted with the physician about these results. Record review of the lab requisition Sheet for 12/19/16 revealed that CR#1 refused the urine collection for the UA/C&S lab. There was no documentation in the residents ' records that the physician was informed or that additional attempts were made to obtain a urine sample. Record review of CR# 1 Nursing Notes revealed in part: -12/19/16 at 6:16 am CNA reported resident were hot during last round of care at approximately 5:45 am. RN-U entered resident room and covers were off of resident body. Resident face was flushed red and forehead was warm to touch. Resident shook her head yes when asked by RN-U if she was hot. RN-U took resident temperature with a reading of 99.5. RN-U reported to oncoming nurse that low grade fever was a new onset and 2 times loose yellow stools were the only concerns during her shift and encouraged oncoming nurse to call the Physician or NP for further orders. Physician was called and [MEDICATION NAME], CBC, CMP and UA ordered. -12/20/16 12:23 pm LVN-G documented resident incontinent of bowel and bladder with watery stool noted times 2 will continue to monitor. There was no documentation that the physician was consulted. Record review of CR #1 ' s physician progress notes [REDACTED]. CR #1 was sent toER on [DATE] due to abdominal distention, pain and abnormal breath sounds. Resident was diagnosed with [REDACTED]. Pneumonia. Resident was placed on ABT times 10 days. On 12/19/16 CBC, CMP and UA was ordered for fever. Resident labs reviewed today and revealed a low Potassium level and increase in WBC. The plan is to continue [MEDICATION NAME] day four of 10 and redraw CBC, CMP in a.m. (12/22/16). Further review of CR #1 ' s labs and clinical record revealed no results for the CBC and CMP ordered on [DATE]. Record review of CR #1 Physician orders [REDACTED].>- dated 12/28/16 CBC CMP in a.m. then every Monday until further notice Record review of lab results dated 12/29/16 revealed the following results: WBC 15.1, Sodium 178 (critical), and BUN 103 (critical). The laboratory called and reported the critical results to LVN-G on 12/29/16 at 7:02 p.m. There was no documentation on the lab result or the clinical file that the physician was informed or consulted about the critical lab results. Record review of Resident # 1 Nursing Notes: - 12/24/16 at 2:24 am of RN-NT documentation reading resident continues to have diarrhea. Further documentation at 11:34 a.m. by LVN-G resident face warm to touch and red with a temperature of 99.3. Tylenol was given and was effective. - 12/24/16 at 11:34 am no s/s of distress .face warm to touch and red, temp of 99.3. Tylenol given .temp down to 97.8 .watery stool x1 this shift - 12/25/16 at 2:57 am RN-NT documenting that resident has been having a low grade temperature of 99.1 and will continue to monitor. -12/26/16 2:53 am resting comfortably, no indication of pain and distress . -12/27/16 7:18 pm continues on ABT, up in a wheelchair this shift, resist care, temp 98.5. -12/29/16 at 2:27 am resting in bed, remains on ABT, continues to have diarrhea, and flushed faced, afebrile at this time. There was no documentation that the physician was consulted at this time. - 12/29/16 at 10:50 am of LVN-G documenting resident is red in face with a low grade temperature of 99.2, will continue to monitor. There was no documentation that the physician was consulted at this time. - 12/30/16 at 5:19 pm pat alert with no adverse reaction to ABT, BP 99/66, heart rate of 100 with a temp of 98.9 - 12/31/16 at 5:07 am no rash, no distress, no physical signs of pain or discomfort . - 01/01/2017 at 10:28 pm of RN-U documenting resident grimacing to touch. [MEDICATION NAME] 50 mg administered via gastrostomy-tube, respirations increased at 32, blood pressure 104/73, heart rate 100, and Oxygen saturation at 95%. A message was left with NP. - 01/01/17 at 11:07 pm of RN-U documenting resident blood pressure 70/54, heart rate 105, respirations 36 and oxygen saturation 97%. The EMS contacted for transport to Hospital. Record review of CR #1 Hospital Admission History and Physical Records dated 01/02/17 revealed that resident was admitted for observation at 0200 from the nursing home. Just prior to admission, resident was noted to have a temperature of 100.6. This is justly significant since her usual temperature is 96. Mucous membranes were dry. Caked intraoral secretions were noted along with poor dental hygiene. Resident labs are significant in that her sodium was 182, chloride 143, BUN 109, and creatinine 2. Resident urine was grossly septic with a large amount of bacteria and white cells. Impression: 1. Severe Dehydration 2. Urosepsis 3. [MEDICAL CONDITION] Record review of CR #1 Hospital Medication Administration Records revealed resident was given a bolus (large dose intravenous) of Sodium Chloride 0.9% a 1000 ml at 999 ml/hr times one on 1/02/17. Further record review of the Medication Administration Record [REDACTED]. Resident was also receiving free water per gastrostomy-tube at 50ml/ hr continuously started on 01/02/17 and Nepro 237 ml every 8 hours. Resident is receiving the antibiotic Meropenem 1000 mg intravenous every 8 hours. Interview on 01/04/17 at 12:40 pm the DON said she was unable to see in the Nursing Notes and Lab Reports that a urinalysis was done for order written on 12/19/16. She said she did see it was documented on the requisition that CR # 1 refused UA on the 12/19/16 and there was no documentation reported to the Physician that CR# 1 refused her UA specimen collection. DON said she just got back from being on vacation. Observation on 01/04/17 at 2:38pm of CR# 1 revealed she was resting in the hospital bed receiving oxygen via nasal cannula at 2 liters. Resident had an indwelling Foley catheter draining clear yellow urine. CR #1 was non-interviewable. Interview with RN-Z on 01/04/17 at 2:45 pm said that CR #1 is no longer receiving continuous intravenous fluids but continues to receive IV antibiotic therapy. Interview on 01/04/17 at 3:15pm with Physician Assistant said CR #1 may be transferred to a LTAC for further IV antibiotic therapy for the next 2 weeks just to make sure she has fully recovered. Interview with the DON on 01/17/17 at 8:55 a.m. she said that CR #1 went to the ER for vomiting, dehydration, and diarrhea and that she did not know what the resident lab results revealed before resident was transferred to the hospital. Interview on 01/17/17 at 9:10 a.m. ADON-MS said she has been working at the nursing facility as an ADON for a year and she was responsible for staffing, incident reports, inputting orders in the computer, in-services the staff, employee information with new hire. ADON-MS said it is the nurse on the Unit that monitors the lab along with the DON. Interview on 01/17/16 at 9:50 a.m. LVN-AA said that when CR #1 first admitted to the facility would refuse care like her baths and lab draws. LVN-AA said you would have to know how to handle CR #1 by backing off and come back at a later time or day. LVN-AA said when a resident refuse lab specimens she would notify the Physician and keep trying. LVN-AA said any abnormal critical lab results she would notify the Physician right away. Interview on 01/17/17 at 9:17 a.m. the DON said that RN-U was terminated from the facility because she sent CR #1 out to the hospital dirty and not notifying the Administration of the transfer. The DON said she did not in-serviced the nursing staff on obtaining lab specimens or the reporting of abnormal or critical lab values to the physician. Interview on 01/17/17 at 9:55 a.m. CNA-YZ said the last time she took care of CR #1, her face was red and resident had diarrhea real bad along with vomiting which was reported to the nurse on the 10pm to 6 am shift. CNA-YZ said CR #1 never refused care with her. In a phone interview on 01/17/17 at 10:05 a.m. RN-U said CR #1 was incontinent and had just finished her antibiotic therapy via gastrostomy-tube. RN-U said CR #1 had been experiencing 2-3 episodes of diarrhea on the night shift but was given to her in report from the day shift and evening shift of no episodes of having diarrhea. RN-U said she could not remember when the diarrhea started. RN-U said the reason why she called EMS to transfer the resident to hospital was because of the increase in respirations. RN-U said she never looked at CR # 1 labs because nothing was being mentioned in the 24-hour report log notebook about critical or abnormal labs. Interview on 01/17/16 at 12:20 pm the NP said she was out of the State from 12/29/16 to 01/03/07 and did not return back to the facility until the 01/09/17. The NP said that was when she saw the critical lab results on CR #1 which was drawn on 12/29/16. NP said then she was informed by staff that CR# 1 had been transferred to the hospital. She said the physician was not notified. Interview on 01/17/17 at 3:25pm LVN-G said she has been working at the facility for about 3 years and did take care of CR # 1. LVN-G said she remembered getting a call from the lab of critical lab results on CR #1. LVN-G said she call the Physician on call number and left a message for the Doctor to call the facility back at his early convenience. LVN-G said she then gave report to the on-coming nurse whose name she was not sure of. LVN-G said she did not document these on the Nursing Notes or the 24-hour report log book. She said she did not talk to the physician of NP. Resident #3: Record review of Resident #3 face sheet revealed an [AGE] year old admitted to the facility on [DATE] with the following diagnoses; [DIAGNOSES REDACTED], Hypertension, Dysphagia, [MEDICAL CONDITIONS] Stage 3 (moderate), Pressure Ulcer of Sacral Region, Pain, and Gastro-[MEDICAL CONDITION] Reflux Disease. Record review of Resident #3 MDS dated [DATE] revealed that resident cognition was severely impaired and required extensive to total assistance with activities of daily living. Record review of Resident #3 ' s UA/C&S results on 12/03/16 revealed a final report of [MEDICATION NAME] (bacteria) in urine sensitivity to [MEDICATION NAME] (antibiotic). There was no documentation that the results were reported to the physician. Further review revealed the NP sign the lab on 12/12/16. Record review of Resident # 3 ' s Physician order [REDACTED]. Record review of facility Lab and Diagnostic Test Results .Clinical Protocol (revised 2012): · A Nurse will review all results; if the staff who first receive or review lab and diagnostic test results cannot follow the remainder of this procedure for reporting and documenting the results and their implications, another nurse in the facility(supervisor, charge nurse, etc.) should follow or coordinate the procedure. · A nurse will identify the urgency of communicating with the Attending Physician, NP, or PA based on physician request. · Facility staff should document information about when, how and to whom the information was provided and the response. Record review of facility Acute Condition Changes .Clinical Protocol Policy (revised 2015) read as follows: · The Nurse shall asses and document/report the following baseline information (vital signs, neurological status, level of consciousness, recent labs, all active diagnoses, and all current medications). The Administrator and DON were notified on 01/17/17 at 4:55 pm of the IJ situation and a POR was requested. The POR was received and after 2 revisions it was accepted on 01/19/17 at 11:35 am. The POR read in part: 1. Notify Medical Director of Immediate Jeopardy status. Completed on 01/17/17 2. Notify VP of Clinical Services of Immediate Jeopardy 3. Resident is currently in hospital, and id due to return to Nursing facility on 01/18/17 4. All residents will have head to toe assessments by licensed nursing staff to identify changes in condition. Assessments started and completed on 01/17/17. This being overseen by DON and or ADON. All findings are documented on Skill Nursing form. Assessment includes vital signs and head to toe assessment. Nurses are using thermometer and blood pressure kit for the vital signs. Notified Physician and responsible party for nay residents identified with a change in condition. 5. Lab audit conducted from [DATE]st, 2016 to current to ensure any critical labs have been identified and MD/NP notified. Audits started January 17th, 2017 and completed on January 18th, 2017. 6. All licensed nurses will be in-serviced on facility ' s policy regarding changes in a residents condition, abnormal labs resulting in change of condition, and change of condition noted during assessment . All licensed nurses will be in-serviced starting on January 17th, 2017 and completed on January 18th, 2017. In-service will include notification and consultation with MD/NP/PA; and include when notification is necessary, the procedure the staff must follow if the MD does not answer, and communication of changes of condition, lab results, and diagnostic results. Any nurses unable to attend in-service by this date will be removed from schedule until in-service has been completed. DON and/or ADON will monitor new hires to ensure that licensed nurses will receive training in the changes in resident ' s condition policy. The facility was monitored from 01/19/17 to 01/20/17 to verify that the plan was implemented. The ADON and 6 nurses from different shifts were interviewed regarding in-service on checking the resident labs to look for any critical or abnormal values and communicating the results to Physician and to document all actions taken and on recognizing changes in condition. Staff was able to report understanding. Interview on 01/19/17 at 12:20pm DON said before, the laboratory would come to the facility and draw resident labs early in the a.m. now they will start coming in the evening to draw resident labs. The DON said before, she would write labs down on each lab draw and print results and give to charge nurses on the unit ton contact the MD/NP. The DON said she has developed a new system in monitoring the resident labs. 1. Print out resident service log lab sheet 2. Place service log lab sheet on the 24 hour report book 3. If lab results are available in the a.m. she will print out and give to charge nurses on the unit. The charge nurse will follow-up with any abnormal/critical labs to the Physician and NP. The DON and ADON will also review labs as well. Records were reviewed to verify the facility completed resident nursing assessments and a review of the labs. Interview on 01/18/17 at 10:45 a.m. the Administrator said the reason he felt that an IJ had occurred was because there was a negative outcome to CR #1 due to the failure of the facility not communicating and documenting critical lab results and change in CR #1 condition. The Administrator said he ensured that the DON was performing her duties as DON by having morning meetings, discussing the 24 hour report log on the residents, using the Standard of Excellence viewing resident outcomes as it relates to each resident such wounds, [MEDICAL CONDITION] medications, weight loss, and falls,etc. Interview on 01/18/17 at 10:55 a.m. the DON said the reason why the Nursing Facility had an IJ was because one person did not document what she had done and did not communicate to the second shift so that a follow-up could be done. The DON said if there was no response from the Physician, the nurse should have notified the DON, ADON, and or the Administrator. The DON she would ensure that the nurses were doing their jobs by monitoring the staff, viewing the Medication Administration Record, [REDACTED]. Interview on 01/18/17 at 12:30pm ADON-MS said she tries to help in monitoring the lab draws and results on resident labs especially if the DON was not in the building. ADON-MS said critical lab values should be called to the Physician immediately and given the results. ADON-MS said whenever there was a change in a resident condition, the nurse should use the SBAR assessment tool form and notify the Physician of findings in resident change in condition as well as the resident responsible party. The Administrator and DON were informed on 01/20/17 at 2:05 pm that the IJ was lowered; however the facility remained out of compliance at a pattern level and a severity of actual harm that is not an IJ to resident health or safety due to facility needing more time to train the staff. According to a list provided by the DON, 54 residents had lab tests in the month of December 2016.

Based on observation, interview and record review, the Administrator and DON failed to administer the facility in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 4 of 10 residents reviewed for quality of care. (CR #1 and Resident # 3) The Administrator failed: - to implement the facility abuse and neglect prohibition policy. --supervise the DON to ensure that nursing staff was trained in recognizing and reporting changes in condition for residents with critical and abnormal lab values. -The DON failed to: -train and supervise the nursing staff to ensure they were providing care to include accurate documentation and assessments in following up and communicating with the Physician on critical, abnormal lab results, and collecting specimens as ordered by the Physician. - train and supervise the nursing staff to ensure they were able to recognize and report changes in condition after receiving critical lab results. An IJ was identified on 01/17/17. While the IJ was removed on 1/20/17 the facility remained out of compliance at a scope of pattern and a severity of actual harm due to facility requiring more time to monitor the plan of removal for effectiveness. This failure affected two residents and placed 54 residents that required lab draws in December at risk of not being provided with appropriate and timely medical intervention resulting in a decline in health and quality of care and life. Findings include: Interview on 01/18/17 at 10:45 a.m. the Administrator said the reason he felt that an IJ had occurred was because there was a negative outcome to CR #1 due to the failure of the facility not communicating and documenting critical lab results and change in CR #1 condition. The Administrator said he ensured that the DON was performing her duties as DON by having morning meetings, discussing the 24 hour report log on the residents, using the Standard of Excellence viewing resident outcomes as it relates to each resident such wounds, [MEDICAL CONDITION] medications, weight loss, and falls,etc. Interview on 01/18/17 at 10:55 a.m. the DON said the reason why the Nursing Facility had an IJ was because one person did not document what she had done and did not communicate to the second shift so that a follow-up could be done. The DON said if there was no response from the Physician, the nurse should have notified the DON, ADON, and or the Administrator. The DON said she ensured that the nurses were doing their jobs by monitoring the staff, viewing the Medication Administration Record, [REDACTED]. Record review of CR #1 face sheet revealed a [AGE] year old female admitted to the facility on [DATE] with the following diagnoses; [MEDICAL CONDITION] with Septic Shock, Moderate Protein-Calorie Malnutrition, Diarrhea, Hypo-Osmolality, and [MEDICAL CONDITIONS], Dysphagia, Gastrostomy, [MEDICAL CONDITION] Disease, [MEDICAL CONDITIONS] Fibrillation, Pain, Neonatal Cerebral Depression, and Nausea and Vomiting. Record review of CR #1 Lab results dated 12/19/16 revealed BUN level- 42(H) with the norm ranging from (7-25), CBC 20.8 (H) and norm (3.8-10.8), and Sodium level 150(H) and the norm (135-146). There was no documentation that the facility consulted with the physician about these results. Record review of the lab requisition Sheet for 12/19/17 revealed that CR#1 refused the urine collection for the UA/C&S lab. There was no documentation in the residents ' records that the physician was informed. Record review of CR# 1 Nursing Notes revealed in part: -12/19/16 CNA reported resident was hot during last round of care at approximately 0545. RN-U entered resident room and covers were off of resident body. Resident face was flushed red and forehead was warm to touch. Resident shook her head yes when asked by RN-U if she was hot. RN-U took resident temperature with a reading of 99.5. RN-U reported to oncoming nurse that low grade fever was a new onset and 2 times loose yellow stools were the only concerns during her shift and encouraged oncoming nurse to call the Physician or NP for further orders. Physician was called and [MEDICATION NAME], CBC, CMP and UA ordered. -12/20/16 12:23 pm LVN-G documented resident incontinent of bowel and bladder with watery stool noted times 2 will continue to monitor. There was no documentation that the physician was consulted. Record review of CR #1 Physician orders [REDACTED].>- dated 12/28/16 CBC CMP in a.m. then every Monday until further notice - dated 01/09/17 repeat CBC and CMP in a.m. Record review dated 12/29/16 revealed the following results: WBC 15.1, Sodium 178 (critical), and BUN 103 (critical). The laboratory called and reported the critical results to LVN-G on 12/29/16 at 7:02 p.m. There was no documentation on the lab result or the clinical file that the physician was informed or consulted about the critical lab results. There was no notation of UA lab results for the month of December 2016 for CR #1. Record review of Resident # 1 Nursing Notes: · 12/24/16 at 2:24 am of RN-NT documentation reading resident continues to have diarrhea. Further documentation at 11:34 a.m. by LVN-G resident face warm to touch and red with a temperature of 99.3. Tylenol was given and was effective. · 12/25/16 at 2:57 am RN-NT documenting that resident has been having a low grade temperature of 99.1 and will continue to monitor. · 12/29/16 at 2:27 am of RN-T documenting resident continues to have diarrhea and flushed face, will continue to monitor. · 12/29/16 at 10:50 am of LVN-G documenting resident is red in face with a low grade temperature of 99.2, will continue to monitor. · 01/01/2017 at 10:28 pm of RN-U documenting resident grimacing to touch. [MEDICATION NAME] 50 mg administered via gastrostomy-tube, respirations increased at 32, blood pressure 104/73, heart rate 100, and Oxygen saturation at 95%. A message was left with NP. · 01/01/17 at 11:07 pm of RN-U documenting resident blood pressure 70/54, heart rate 105, respirations 36 and oxygen saturation 97%. The EMS contacted for transport to Hospital. Record review of CR #1 Hospital Admission History and Physical Records dated 01/02/17 revealed that resident was admitted for observation at 0200 from the nursing home. Just prior to admission, resident was noted to have a temperature of 100.6. This is justly significant since her usual temperature is 96. Mucous membranes were dry. Caked intraoral secretions were noted along with poor dental hygiene. Resident labs are significant in that her sodium was 182, chloride 143, BUN 109, and creatinine 2. Resident urine was grossly septic with a large amount of bacteria and white cells. Impression: 1. Severe Dehydration 2. Urosepsis 3. [MEDICAL CONDITION] Record review of facility Complaints and Grievances dated 01/03/17 revealed a complaint about CR #1 from the Hospital to the Administrator reading: CR # 1 arrived to the hospital in poor care. Interview on 01/04/17 at 12:40 pm the DON said she was unable to see in the Nursing Notes and Lab Reports that a urinalysis was done for order written on 12/19/16. She said she did see it was documented on the requisition that CR # 1 refused UA on the 12/19/16 and there was no documentation reported to the Physician that CR# 1 refused her UA specimen collection. DON said she just got back from being on vacation. Interview on 01/17/16 at 9:50 a.m. LVN-AA said that when CR #1 first admitted to the facility would refuse care like her baths and lab draws. LVN-AA said you would have to know how to handle CR #1 by backing off and come back at a later time or day. LVN-AA said when a resident refuse lab specimens she would notify the Physician and keep trying. LVN-AA said any abnormal critical lab results she would notify the Physician right away. Interview on 01/17/17 at 9:17 a.m. the DON said that RN-U was terminated from the facility because she sent CR #1 out to the hospital dirty and not notifying the Administration of the transfer. The DON said she did not in-serviced the nursing staff on obtaining lab specimens or the reporting of abnormal or critical lab values to the physician. Interview on 01/17/17 at 10:05 a.m. RN-U said CR #1 was incontinent and had just finished her antibiotic therapy via gastrostomy-tube. RN-U said CR #1 had been experiencing 2-3 episodes of diarrhea on the night shift but was given to her in report from the day shift and evening shift of no episodes of having diarrhea. RN-U said she could not remember when the diarrhea started. RN-U said the reason why she called EMS to transfer the resident to hospital was because of the increase in respirations. RN-U said she never looked at CR # 1 labs because nothing was being mentioned in the 24-hour report log notebook about critical or abnormal labs. Interview on 01/17/16 at 12:20 pm the NP said she was out of the State from 12/29/16 to 01/03/07 and did not return back to the facility until the 01/09/17. The NP said that was when she saw the critical lab results on CR #1 which was drawn on 12/29/16. NP said then she was informed by staff that CR# 1 had been transferred to the hospital. She said the physician was not notified. Interview on 01/17/17 at 3:25pm LVN-G said she has been working at the facility for about 3 years and did take care of CR # 1. LVN-G said she remembered getting a call from the lab of critical lab results on CR #1. LVN-G said she call the Physician on call number and left a message for the Doctor to call the facility back at his early convenience. LVN-G said she then gave report to the on-coming nurse who name she was not sure of. LVN-G said she did not document these on the Nursing Notes or the 24-hour report log book. She said she did not talk to the physician of NP. Resident #3: Record review of Resident #3 face sheet revealed an [AGE] year old admitted to the facility on [DATE] with the following diagnoses; [DIAGNOSES REDACTED], Hypertension, Dysphagia, [MEDICAL CONDITIONS] Stage 3 (moderate), Pressure Ulcer of Sacral Region, Pain, and Gastro-[MEDICAL CONDITION] Reflux Disease. Record review of Resident #3 ' s UA/C&S collected on 12/03/16 revealed a final report of [MEDICATION NAME] (bacteria) in urine sensitivity to [MEDICATION NAME] (antibiotic). There was no documentation that the results were reported to the physician. Further review revealed the NP sign the lab on 12/12/16. Record review of Resident # 3 ' s Physician order [REDACTED]. The Administrator and DON were notified on 01/17/17 at 4:55 pm of the IJ situation and a POR was requested. The POR was received and after 2 revisions it was accepted on 01/19/17 at 11:35 am. The POR read in part: 1. Notify Medical Director of Immediate Jeopardy status. Completed on 01/17/17 2. Notify VP of Clinical Services of Immediate Jeopardy 3. Resident is currently in hospital, and id due to return to Nursing facility on 07/18/17 4. All residents will have head to toe assessments by licensed nursing staff to identify changes in condition. Assessments started and completed on 01/17/17. This being overseen by DON and or ADON. All findings are documented on Skill Nursing form. Assessment includes vital signs and head to toe assessment. Nurses are using thermometer and blood pressure kit for the vital signs. Notified Physician and responsible party for nay residents identified with a change in condition. 5. Lab audit conducted from [DATE]st, 2016 to current to ensure any critical labs have been identified and MD/NP notified. Audits started January 17th, 2017 and completed on January 18th, 2017. 6. All licensed nurses will be in-serviced on facility ' s policy regarding changes in a residents condition, abnormal labs resulting in change of condition, and change of condition noted during assessment . All licensed nurses will be in-serviced starting on January 17th, 2017 and completed on January 18th, 2017. In-service will include notification and consultation with MD/NP/PA; and include when notification is necessary, the procedure the staff must follow if the MD does not answer, and communication of changes of condition, lab results, and diagnostic results. Any nurses unable to attend in-service by this date will be removed from schedule until in-service has been completed. DON and/or ADON will monitor new hires to ensure that licensed nurses will receive training in the changes in resident ' s condition policy. The facility was monitored from 01/19/17 to 01/20/17 to verify that the plan was implemented. The ADON and 6 nurses from different shifts were interviewed regarding in-service on checking the resident labs to look for any critical or abnormal values and communicating the results to Physician and to document all actions taken and on recognizing changes in condition. Staff was able to report understanding. Interview on 01/19/17 at 12:20pm DON said before, the laboratory would come to the facility and draw resident labs early in the a.m. now they will start coming in the evening to draw resident labs. The DON said before, she would write labs down on each lab draw and print results and give to charge nurses on the unit ton contact the MD/NP. The DON said she has developed a new system in monitoring the resident labs. 1. Print out resident service log lab sheet 2. Place service log lab sheet on the 24 hour report book 3. If lab results are available in the a.m. she will print out and give to charge nurses on the unit. The charge nurse will follow-up with any abnormal/critical labs to the Physician and NP. The DON and ADON will also review labs as well. Records were reviewed to verify the facility completed resident nursing assessments and a review of the labs. The Administrator and DON were informed on 01/20/17 at 2:05 pm that the IJ was lowered; however the facility remained out of compliance at a pattern level and a severity of actual harm that is not an IJ to resident health or safety due to facility needing more time to train the staff. According to a list provided by the DON, 54 residents had lab tests in the month of December.