Every finding on record at Park Manor of Cypress Station

Based on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's nursing, mental and psychosocial needs for 1 of 9 residents (Resident #2) reviewed for comprehensive care plans in that: Resident #2's care plan for physical behaviors was not implemented when he physically abused Resident #3 on 8/8/25 and physically abused Resident #1 on 9/26/25. Resident #2's care plan intervention was to analyze the circumstances and triggers after incidents of physical behaviors. Nursing staff were unaware of circumstances and triggers that could cause Resident #2 to physically abuse other residents. These failures placed residents at risk of not having their behavioral needs met, which could lead to abuse and emotional distress. The findings included:Record review of Resident #2's admission Record generated on 3/19/26 revealed he was readmitted to the facility on [DATE] with diagnoses of encephalopathy, aphasia, hemiplegia and hemiparesis following cerebral infarction, bipolar disorder and anxiety disorder. He was [AGE] years of age. Record review of Resident #2's care plan dated 8/26/24 revealed he had a potential to demonstrate physical behaviors related to becoming agitated and combative with others as evidenced by alleged physical aggression on 12/16/24, 8/8/25 and 9/26/25 toward other residents. Interventions included psych consult for evaluation and treatment, analysis of key times, places, circumstances, triggers and what de-escalates behavior, provide physical and verbal cues to alleviate anxiety, give the resident as many choices as possible about care and activities. Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed he was usually understood and could usually understand others. He had a BIMS of 9, indicating he had moderate cognitive impairment. He required supervision for transferring from chair/bed-to-chair and walking 10 feet. He used a wheelchair and could propel himself 50 feet independently.Record review of Resident #2's Progress Note dated 8/8/25 read, Resident was reported to have suddenly slapped with his hand, another resident on the right side of the other resident's face. Resident was trying to get by the other resident on the hallway. Both residents separated immediately.Facility started an abuse investigation. Record review of a Provider Investigation Report dated 8/12/25 revealed on 8/8/25, the receptionist reported that Resident #2 slapped Resident #3 in the face after having words. The document noted the Administrator interviewed the alleged perpetrator and he said he hit Resident #3 because he did not like what he said. When interviewing (Resident #3), he said they both had words and (Resident #2) just hit him in the face. The report did not indicate that there was an analysis of circumstances or triggers of the incident. In a telephone interview on 3/18/26 at 3:15pm, when asked about the incident between Resident #2 and Resident #3, the Former Receptionist said Resident #3 was sitting in a spot along the wall where he normally sat. She said Resident #2 wanted to sit in the same spot. She said they had a brief altercation when they started arguing, then Resident #2 stood up, leaned in and hit Resident #3 with a closed fist. Record review of Resident #2's Progress Note dated 9/26/25 at 3:53pm read, Resident was witnessed to have suddenly got out of his wheelchair and walked up to another resident. Resident suddenly with his fist, hit the other resident on the face. Resident states, 'He is always messing with me, I got upset and hit him to put a stopto (sic) it.'. An officer arrived, interviewed resident and transferred resident to (local county).Record review of a Provider Investigation Report dated 9/30/25 revealed on 9/26/25 at 12:00pm, the Activity Director stated Resident #2 punched Resident #1. The document noted the Administrator interviewed the alleged perpetrator and he said he hit Resident #1 because he was always messing with him. The Administrator interviewed Resident #1 who said he was on his phone and did not tell him anything. The report did not indicate that there was an analysis of circumstances or triggers of the incident. Record review of Resident #2's Progress Note dated 11/10/25 at 11:31am revealed Resident #2 was readmitted to the facility from the county jail. In an interview on 3/18/26 at 12:20pm Resident #1 said on the day of the physical altercation a few months ago, he was sitting outside and said a phrase that prompted a task on his phone into his headset. He said Resident #2 thought he was talking to him. He said Resident #2 stood up from his wheelchair, walked a distance across the patio, then started swinging at him causing him excruciating pain. He said he felt helpless because he could not defend himself. He said he had limited mobility in his arms and hands. He said a few weeks ago, Resident #2 was moved to his hall and he did not like it. He said now Resident #2 sat outside of his room and looked in. He said he would do everything he could to defend himself. In an interview on 3/18/26 at 2:00pm, the Activity Director said on the day of the incident between Resident #1 and Resident #2, they were sitting outside on the patio. Resident #1 was seated on one side of the patio and Resident #2 was seated on the other side of the patio. She said she heard Resident #1 activate a task on his phone, then Resident #2 stood up from his wheelchair, walked over to Resident #1, then started swinging at him. She said it was a pretty exaggerated punch. In an interview on 3/18/26 at 4:55pm, CNA A said Resident #2 moved to her hall assignment in the last few weeks. She said she was not aware of past aggressive incidents regarding Resident #2, and further stated that Resident #2 had no signs of physical or verbal aggression. In an interview on 3/19/26 at 10:25am, the DON said Resident #2 did not have any behaviors on a daily basis. She said she did not identify triggers after the past physical abuse incidents. In an interview on 3/19/26 at 11:46am, LVN E said Resident #2 stayed to himself and did not bother anyone. She said she was aware that he had a history of physical abuse. She said she was not aware of any triggers or circumstances that would cause Resident #2 to become physically abusive toward others. In an interview on 3/19/26 at 2:00pm CNA T said Resident #2 was a good guy and minded his own business. She said she was aware that he had a history of physical abuse. She said she was not aware of any triggers or circumstances that would cause Resident #2 to become physically abusive toward others. In an interview on 3/19/26 at 4:56pm, the Social Worker said the MDS Nurse was responsible for writing the residents' care plans. She said Resident #2 was quiet. She said Resident #2 had not done anything to indicate he would hurt someone. She said they provide supervision to prevent abuse from occurring. In an interview on 3/19/26 at 5:05pm, the MDS nurse said she wrote the resident's care plan when they were admitted . She said if she noticed something or heard something new was going on with a resident in their daily morning meetings, she would add it to the care plan. She said Resident #2 was combative at times and became agitated easily. She said they did in-services with the staff to ensure they were aware of his behaviors. In an interview on 3/20/26 at 5:00pm, the Administrator said after Resident #2's physical abuse incidents, he did not assess to determine the circumstances or triggers that would cause the behavior. When asked what he thought his trigger could be, he said when the other person is talking noise. He said he could not say that they educate the nursing staff specifically on triggers. He stated Resident #2 had no behaviors and had been fine since he returned from jail. Record review of In-Service Training Reports revealed the following: - An In-service training report dated 11/11/25 for nursing staff conducted by the Administrator read, (Resident #2) will be encouraged to participate in more activities and we will increase monitoring when he's around (Resident #1) and (Resident #3). - An in-service training reported dated 12/15/25 for administration and DON conducted by RN R read, Resident to Resident Altercation and Interventions. move to another hall.behavior specific care plans. trigger identification (loud noises, a lot of people around). Record review of the facility policy regarding Care Plans-Comprehensive dated December 2009 read, An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. each resident's comprehensive care plan is designed to: incorporate identified problem areas; incorporate risk factors associated with identified problems.The Care Planning/Interdisciplinary Team is responsible for the periodic review and updated of care plans. when the desired outcome is not met.at least quarterly.

Based on observations, interviews, and record review, the facility failed to ensure each resident was free from abuse for 1 of 9 residents (Resident #1) reviewed for abuse. Resident #2 was physically abusive to Resident #1 on 9/26/25 when he punched him with a closed fist in the face.These failures placed residents, who resided in the facility, at risk of abuse, pain and emotional distress. The findings included:Resident #2Record review of Resident #2's admission Record generated on 3/19/26 revealed he was readmitted to the facility on [DATE] with diagnoses of encephalopathy (a syndrome of brain dysfunction caused by toxins, infections, metabolic imbalances, or trauma, leading to altered mental status, confusion, and cognitive deficits), aphasia (inability or impaired ability to understand or produce speech, as a result of brain disease or damage), hemiplegia (a severe neurological condition causing paralysis on one side of the body) and hemiparesis (partial weakness or reduced mobility on one side of the body caused by nervous system damage) following cerebral infarction (a type of ischemic stroke caused by blocked blood flow to the brain), bipolar disorder a chronic mental health condition characterized by intense mood shifts between extreme highs, including mania/hypomania and lows, including depression), and anxiety disorder (mental health conditions characterized by excessive, persistent, and uncontrollable worry or fear that interferes with daily life, work, or relationships). He was [AGE] years of age. Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed he was usually understood and could usually understand others. He had a BIMS of 9, indicating he had moderate cognitive impairment. He required supervision for transferring from chair/bed-to-chair and walking 10 feet. He used a wheelchair and could propel himself 50 feet independently. He had behavioral symptoms not directed at others 1 to 3 days of 7 days. Record review of Resident #2's care plan dated 8/26/24 stated Resident #2 had a potential to demonstrate physical behaviors related to becoming agitated and combative with others as evidenced by alleged physical aggression on 12/16/24, 8/8/25 and 9/26/25 toward other residents. Interventions included psych consult for evaluation and treatment, analysis of key times, places, circumstances, triggers and what de-escalates behavior, provide physical and verbal cues to alleviate anxiety, give the resident as many choices as possible about care and activities. Record review of Resident #2's care plan dated 8/28/24 revealed he had a behavior problem related to rummaging through other resident's rooms. Interventions included, administer medications as ordered. anticipate and meet the resident's needs. intervene as necessary to protect the rights and safety of others. Record review of Resident #2's Progress Note dated 9/26/25 at 3:53pm read, Resident was witnessed to have suddenly got out of his wheelchair and walked up to another resident. Resident suddenly with his fist, hit the other resident on the face. Resident states, 'He is always messing with me, I got upset and hit him to put a stopto (sic) it.'. An officer arrived, interviewed resident and transferred resident to (local county).Record review of Resident #2's Progress Note dated 11/10/25 at 11:31am revealed Resident #2 was readmitted to the facility from the county jail. Resident #1 Record review of Resident #1's admission Record generated on 3/19/26 revealed he was admitted to the facility on [DATE] with diagnoses of quadriplegia (paralysis of all four limbs), epilepsy (a chronic neurological disorder characterized by recurrent, unprovoked seizures caused by abnormal electrical activity in the brain), bipolar disorder and major depressive disorder (a serious mental health condition characterized by persistent sadness, low mood, and loss of interest in activities for at least two weeks). He was [AGE] years of age. Record review of Resident #1's care plan revised dated 2/14/22 revealed he had a potential to demonstrate verbally abusive behaviors related to yelling, cursing, and being disrespectful to staff and yelling/cursing at his roommate. Interventions included, Analyze (sic) of key times, places, circumstances, triggers and what de-escalates behavior and document. assess and anticipate resident's needs. give the resident as many choices as possible about care and activities. Record review of Resident #1's annual MDS assessment dated [DATE] revealed he had a BIMS of 15, indicating he had no cognitive impairment. He had verbal behaviors directed toward others that occurred 4-6 days of 7 days. He had upper and lower extremity functional limitations on both sides of his body. He was dependent on staff for personal hygiene and transfers and used a motorized wheelchair independently. Record review of a Provider Investigation Report dated 9/30/25 revealed on 9/26/25 at 12:00pm, the Activity Director stated Resident #2 punched Resident #1. The document noted the Administrator interviewed the alleged perpetrator (Resident #2) and he said he hit Resident #1 because he was always messing with him. The Administrator interviewed Resident #1 who stated he was on his phone and did not tell him anything. Record review of Resident #1's Progress Note dated 9/26/25 at 3:53pm read, Another Resident was witnessed to have suddenly got out of his wheelchair and walked up to this resident. The other resident suddenly with his fist, hit this resident on the left side of the face . head to toe assessment completed (sic) no discolorations, skin tears, redness, swelling or open areas noted. Resident states that his left side of the face is hurting and pain to the touch .Record review of Resident #1's Patient Visit Information from a local hospital dated 9/26/25 revealed he was seen for an alleged assault and had patient discharge instructions for a facial bruise. In an interview on 3/18/26 at 2:00pm, the Activity Director said on the day of the incident between Resident #1 and Resident #2, they were sitting outside on the patio. Resident #1 was seated on one side of the patio and Resident #2 was seated on the other side of the patio. She said she heard Resident #1 activate a task on his phone, then Resident #2 stood up from his wheelchair, walked over to Resident #1, then started swinging at him. She said it was a pretty exaggerated punch. In an interview on 3/18/26 at 12:20pm Resident #1 said on the day of the physical altercation a few months ago, he was sitting outside and said a phrase that prompted a task on his phone into his headset. He said Resident #2 thought he was talking to him. He said Resident #2 stood up from his wheelchair, walked a distance across the patio, then started swinging at him causing him excruciating pain. He said he felt helpless because he could not defend himself. He said he had limited mobility in his arms and hands. In an interview on 3/19/26 at 1:30pm, the Administrator stated after Resident #2 readmitted to the facility, they made sure Resident #1 and Resident #2 were not in the same area at the same time. He said Resident #1 did not have any issues with Resident #2 returning to the facility, and there were no incidents since September 2025. In an observation on 3/19/26 at 3:40pm, Resident #2 was seated in a wheelchair in his room eating a snack. Surveyor attempted to interview Resident #2 and was unsuccessful. Record review of In-Service Training Reports revealed the following: - An In-service training report dated 11/11/25 for nursing staff conducted by the Administrator read, (Resident #2) will be encouraged to participate in more activities and we will increase monitoring when he's around (Resident #1) and (Resident #3). - An in-service training reported dated 12/15/25 for administration and DON conducted by RN R read, Resident to Resident Altercation and Interventions. move to another hall.behavior specific care plans. trigger identification (loud noises, a lot of people around). Record review of the facility's policy regarding Abuse Prevention Program dated August 2006 read, Our residents have the right to be free from abuse, neglect. comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of our residents. Our abuse prevention program provides policies and procedures that govern, as a minimum. Identification of occurrences and patterns of potential mistreatment/abuse. the implementation of changes to prevent future occurrences of abuse.

Based on observations, interviews and record reviews, the facility failed to implement written policies and procedures that prohibit and prevent abuse for 2 of 9 residents (Residents #1 and #2) reviewed for abuse. The facility failed to implement written policies regarding prevention of abuse when Resident #2 was physically abusive to Resident #1 on 9/26/25 when he punched him with a closed fist in the face. The facility failed to implement written policies regarding abuse prevention and protection when Resident #2 was moved to a new room on 3/11/26 placing Resident #1 and Resident #2 in close proximity to each other after Resident #2 assaulted Resident #1 on 9/26/25.This failure placed residents at risk of abuse, mental anguish and fearfulness. The findings included: Record review of the facility's policy regarding Abuse Prevention Program dated August 2006 read, Our residents have the right to be free from abuse, neglect. comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of our residents. Our abuse prevention program provides policies and procedures that govern, as a minimum. Identification of occurrences and patterns of potential mistreatment/abuse. the implementation of changes to prevent future occurrences of abuse. Resident #2Record review of Resident #2's admission Record generated on 3/19/26 revealed he was readmitted to the facility on [DATE] with diagnoses of encephalopathy (a syndrome of brain dysfunction caused by toxins, infections, metabolic imbalances, or trauma, leading to altered mental status, confusion, and cognitive deficits), aphasia (inability or impaired ability to understand or produce speech, as a result of brain disease or damage), hemiplegia (a severe neurological condition causing paralysis on one side of the body) and hemiparesis (partial weakness or reduced mobility on one side of the body caused by nervous system damage) following cerebral infarction (a type of ischemic stroke caused by blocked blood flow to the brain), bipolar disorder a chronic mental health condition characterized by intense mood shifts between extreme highs, including mania/hypomania and lows, including depression), and anxiety disorder (mental health conditions characterized by excessive, persistent, and uncontrollable worry or fear that interferes with daily life, work, or relationships). He was [AGE] years of age. Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed he was usually understood and could usually understand others. He had a BIMS of 9, indicating he had moderate cognitive impairment. He required supervision for transferring from chair/bed-to-chair and walking 10 feet. He used a wheelchair and could propel himself 50 feet independently. He had behavioral symptoms not directed at others 1 to 3 days of 7 days. Record review of Resident #2's care plan dated 8/26/24 stated Resident #2 had a potential to demonstrate physical behaviors related to becoming agitated and combative with others as evidenced by alleged physical aggression on 12/16/24, 8/8/25 and 9/26/25 toward other residents. Interventions included psych consult for evaluation and treatment, analysis of key times, places, circumstances, triggers and what de-escalates behavior, provide physical and verbal cues to alleviate anxiety, give the resident as many choices as possible about care and activities. Record review of Resident #2's care plan dated 8/28/24 revealed he had a behavior problem related to rummaging through other resident's rooms. Interventions included, administer medications as ordered. anticipate and meet the resident's needs. intervene as necessary to protect the rights and safety of others. Record review of Resident #2's Progress Note dated 9/26/25 at 3:53pm read, Resident was witnessed to have suddenly got out of his wheelchair and walked up to another resident. Resident suddenly with his fist, hit the other resident on the face. Resident states, 'He is always messing with me, I got upset and hit him to put a stopto (sic) it.'. An officer arrived, interviewed resident and transferred resident to (local county).Record review of Resident #2's Progress Note dated 11/10/25 at 11:31am revealed Resident #2 was readmitted to the facility from the county jail. Record review of Resident #2's Progress Note dated 3/11/26 at 8:44pm revealed Resident #2 was moved to a new room. Resident #1 Record review of Resident #1's admission Record generated on 3/19/26 revealed he was admitted to the facility on [DATE] with diagnoses of quadriplegia (paralysis of all four limbs), epilepsy (a chronic neurological disorder characterized by recurrent, unprovoked seizures caused by abnormal electrical activity in the brain), bipolar disorder and major depressive disorder (a serious mental health condition characterized by persistent sadness, low mood, and loss of interest in activities for at least two weeks). He was [AGE] years of age. Record review of Resident #1's care plan revised dated 2/14/22 revealed he had a potential to demonstrate verbally abusive behaviors related to yelling, cursing, and being disrespectful to staff and yelling/cursing at his roommate. Interventions included, Analyze (sic) of key times, places, circumstances, triggers and what de-escalates behavior and document. assess and anticipate resident's needs. give the resident as many choices as possible about care and activities. Record review of Resident #1's annual MDS assessment dated [DATE] revealed he had a BIMS of 15, indicating he had no cognitive impairment. He had verbal behaviors directed toward others that occurred 4-6 days of 7 days. He had upper and lower extremity functional limitations on both sides of his body. He was dependent on staff for personal hygiene and transfers and used a motorized wheelchair independently. Record review of a Provider Investigation Report dated 9/30/25 revealed on 9/26/25 at 12:00pm, the Activity Director stated Resident #2 punched Resident #1. The document noted the Administrator interviewed the alleged perpetrator and he said he hit Resident #1 because he was always messing with him. The Administrator interviewed Resident #1 who stated he was on his phone and did not tell him anything. Record review of Resident #1's Progress Note dated 9/26/25 at 3:53pm read, Another Resident was witnessed to have suddenly got out of his wheelchair and walked up to this resident. The other resident suddenly with his fist, hit this resident on the left side of the face . head to toe assessment completed (sic) no discolorations, skin tears, redness, swelling or open areas noted. Resident states that his left side of the face is hurting and pain to the touch .Record review of Resident #1's Patient Visit Information from a local hospital dated 9/26/25 revealed he was seen for an alleged assault and had patient discharge instructions for a facial bruise. In an interview on 3/18/26 at 2:00pm, the Activity Director said on the day of the incident between Resident #1 and Resident #2, they were sitting outside on the patio. Resident #1 was seated on one side of the patio and Resident #2 was seated on the other side of the patio. She said she heard Resident #1 activate a task on his phone, then Resident #2 stood up from his wheelchair, walked over to Resident #1, then started swinging at him. She said it was a pretty exaggerated punch. In an interview on 3/18/26 at 12:20pm Resident #1 said on the day of the physical altercation a few months ago, he was sitting outside and said a phrase that prompted a task on his phone into his headset. He said Resident #2 thought he was talking to him. He said Resident #2 stood up from his wheelchair, walked a distance across the patio, then started swinging at him causing him excruciating pain. He said he felt helpless because he could not defend himself. He said he had limited mobility in his arms and hands. He said a few weeks ago, Resident #2 was moved to his hall and he did not like it. He said now Resident #2 sat outside of his room and looked in. He said he would do everything he could to defend himself. In an interview on 3/19/26 at 10:25am, the DON stated they were monitoring Resident #1 and Resident #2 in the hallway and common areas. She said they made sure they were not in the same hallway. She said they spoke to Resident #1 before Resident #2 returned to the facility and Resident #1 said he did not have any issues with Resident #2. When informed that the residents were residing in the same hall, she said Resident #2 was at the end of the hallway and reiterated Resident #1 did not have issues with Resident #2. In an interview on 3/19/26 at 1:30pm, the Administrator stated after Resident #2 readmitted to the facility, they made sure Resident #1 and Resident #2 were not in the same area at the same time. He said Resident #1 did not have any issues with Resident #2 returning to the facility, and there were no incidents since September 2025 He said they moved Resident #2 recently to the back of the hallway where Resident #1 resided because they were making room for new admissions. He said Resident #1 did not have an issue with Resident #2 moving to his hall because they did not interact. In an observation on 3/19/26 at 3:40pm, the surveyor walked past Resident #1's room to approach Resident #2's room. Resident #2's room was four doors down and across the hallway from Resident #1, and Resident #2's room was at the end of a hallway that dead-ended into an emergency exit door. Resident #2 was seated in a wheelchair in his room eating a snack. Surveyor attempted to interview Resident #2 and was unsuccessful. In an interview on 3/20/26 at 4:40pm, Resident #1 said the facility staff did not speak to him when Resident #2 was moved to his hallway. He said he did not speak to Resident #2 unless Resident #2 stopped by his room then Resident #1 would ask Resident #2 to go somewhere else. Record review of In-Service Training Reports revealed the following: - An In-service training report dated 11/11/25 for nursing staff conducted by the Administrator read, (Resident #2) will be encouraged to participate in more activities and we will increase monitoring when he's around (Resident #1) and (Resident #3). - An in-service training reported dated 12/15/25 for administration and DON conducted by RN R read, Resident to Resident Altercation and Interventions. move to another hall.behavior specific care plans. trigger identification (loud noises, a lot of people around).

Based on interview and record review, the facility failed to ensure each resident received adequate supervision for 3 of 4 residents (CR #1, Resident#2, and Resident #3) reviewed for accidents and supervision. -CR #1 walked out of the facility unattended with a wander guard (device designed to prevent wandering in elderly) and was missing for approximately 1 hour and 9 minutes on 07/20/2024 and was located nearby an apartment complex. -The facility failed to ensure that Resident#2 had orders in place to monitor placement and functioning of a wanderguard from 07/23/2023-06/10/2025. -The facility failed to ensure that Resident#3 had orders in place to monitor placement and functioning of a wanderguard from 03/24/2025-06/10/2025. An Immediate Jeopardy (IJ) was identified on 06/11/2025. The IJ template was provided to the facility on [DATE] 5:43 PM. While the IJ was removed on 06/13/2025, the facility remained out of compliance scoped at pattern with no actual harm and potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems. These failures could place all residents at risk of harm due to elopement. Findings Include: Resident CR#1 Record review of CR #1's face sheet revealed she was an [AGE] year-old female admitted to the facility on [DATE] with a primary diagnoses of anemia (condition where there are not enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues) Alzheimer's (a brain disorder that slowly destroys memory and thinking skills), and dementia (memory loss and difficulties with thinking, problem-solving, or language), and discharged from the facility, 06/09/2025. Record review of CR#1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 4 to indicate she had severe cognitive impairment with a wander/elopement alarm for daily use. Record review of CR#1's undated care plan revealed: Focus: an elopement risk/wanderer AEB impaired safety awareness exit seeking. 07/20/2024 elopement resident was placed on Q 15 min checks until seen by psych(psychiatric) Date Initiated: 03/07/2024 Revision on: 07/26/2024. Goal: Safety will be maintained through the review date. Interventions: Check for wander guard proper functioning daily. Check for wanderguard placement every shift. Focus: CR#1 is at risk for falls. Goal: CR#1 to be free from falls through the next review date, which is targeted for 07/24/2025. Interventions: CR#1 last fall was on, 03/22/2025 with no injury. The facility staff is to be sure CR#1's call light is within reach for the resident to use for assistance as needed. Record review of CR#1's Progress Notes dated 07/20/2024 at 9:59 PM signed by the LVN D read in part, .At about 8:30pm, resident was found wheeling herself back to her room. Resident's wanderguard was assessed and it was in good condition and functioning properly .At about 8:45pm, CNA came to writer, who was on 100 hall and notified writer that resident was neither in her bed in in her bathroom .Writer, CNA, CNA Coordinator and CMA (300/400 hall) immediately went into the room on all four halls before continuing the search around the premises and as far as the gas stations to the left and right of the facility. Writer returned and notified on-call staff, DON, Administrator and Resident's family. Resident was escorted into the building at about 9:59pm in her wheelchair by two emergency response staff, the Administrator and resident's daughter .Resident was fitted with a new wanderguard, which is functioning appropriately . Resident #2 Record review of Resident #2's face sheet revealed she was an [AGE] year-old female admitted to the facility on [DATE] with a primary diagnosis of Alzheimer's (a brain disorder that slowly destroys memory and thinking skills. Record review of Resident #2's admission MDS assessment dated [DATE] and quarterly MDS assessment dated [DATE] revealed she had a wander/elopement alarm for daily use and the resident does not require any assistive devices or staff assistance and has the ability to walk on their own, according to the MDS assessment. Record review of Resident #2's undated care plan revealed: Focus: an elopement risk/wanderer r/t (related to) wanders in facility exit seeking. Date Initiated: 03/22/2023 Revision on: 07/23/2024. Goal: Safety will be maintained through the review date. Interventions: Check for wander guard proper functioning daily. Check for wanderguard placement every shift. Focus: Resident #2 is at risk for fall with impaired mobility and fluctuation in cognition. Goal: Resident #2 will be free of falls the review date of, 07/16/2025. Interventions: Resident #2 has been free of falls since, 04/17/2023.wanderi Record review of Resident #2's Progress Notes dated 03/26/2025 at 9:28 a.m. signed by the Social Worker read in part, .Resident exit seeks at times, has a wander guard . Record review of Resident #2's Progress Notes dated 11/19/2024 at 12:49 p.m. signed by the Social Worker read in part, .Resident exit seeks at times, has a wander guard . Record review of Resident #2's electronic medical records physician orders reflected that orders to check the residents wanderguard functioning and placement daily each shift started 3/21/2023 and ended 07/27/2023. Record review of Resident #2's electronic medical records physician orders reflected that orders to check the residents wanderguard functioning and placement daily each shift started 06/10/2025. Resident #3 Record review of Resident #3's face sheet revealed he was a [AGE] year-old male admitted to the facility on [DATE] with a primary diagnosis of Cerebral Infraction (stroke) with secondary diagnosis of schizophrenia(a mental disorder that involves a range of problems with thinking, behavior and emotion) and cognitive communication deficit (results from impaired functioning of cognitive processes, including attention, memory, perception, insight, judgment, organization, orientation, and language). Record review of Resident #3's quarterly MDS assessment dated [DATE] revealed he was severely impaired for cognitive skills for daily decision making, and he had a wander/elopement alarm for daily use and and the resident does require assistive device with a manual wheelchair as they are unable to walk on their own, according to the MDS assessment. Record review of Resident #3's undated care plan revealed: Focus: an elopement risk/wanderer r/t exit seeking. Date Initiated: 03/24/2025 target date: 09/06/2025. Goal: Safety will be maintained through the review date. Interventions: Check for wander guard proper functioning daily. Check for wanderguard placement every shift. Record review of Resident #3's electronic medical records physician orders reflected orders to have a wanderguard on at all times started 03/24/2025. Record review of Resident #3's electronic medical records physician orders reflected that orders to check the residents wanderguard functioning and placement daily each shift started 06/10/2025. In an interview on 06/10/2025 at 12:10 p.m., the Administrator who stated he started at the facility in September of 2022 and the DON who stated she started at the facility in 2020. Both said that any resident that was high risk of elopement or exit seeking upon admission or anytime during the stay at the facility have interventions of a wanderguard to prevent elopement. Both said that residents with a wanderguard orders to monitor the function and placement of the guard every shift and it is documented on the MAR. Both said that CR #1 was able to elope from the facility while wearing a wanderguard. Both said that CR #1 was last seen at 8:30 p.m. inside the facility, then at 8:45 p.m. a visitor (name unknown) saw CR#1 outside of the facility and returned to the facility at 9:59 p.m. by a mobile response team. Both said that there was a concern identified that CR#1's wander guard did not alert staff that she eloped from the facility, and there was a facility investigation, report filed with State Survey Agency (SSA), a Quality Assurance and Performance Improvement (QAPI) was held in August of 2024, and Performance Improvement Plan (PIP) initiated July of 2024 to address concerns by ensuring all residents with an active wanderguard had daily monitoring for placement and functioning. The following policies were requested, Incident and accidents, Elopement/Wandering, and Wanderguard. In an interview on 06/10/2025 at 1:22 p.m., the DON a request was made for a policy wander guard placement and function testing. Interview on 06/10/2025 at 1:45 p.m. with MA A, who said that she started at the facility in December of 2024. She said while working on 07/20/2024 a visitor (name unknown) reported to her at 8:45pm that she saw an unknown resident that fit the description of CR#1 walking down the street. She said that she told CNA B to initiate the facility elopement code, and she proceeded to search for resident outside on facility grounds and in the community by car but was unsuccessful in locating CR#1. She said that she was notified that the resident was located by law enforcement sometime after 9pm and returned to the facility. She said that she did not hear the door alarm sound to indicate that CR#1's wander guard functioned to alert staff of the elopement. Interview on 06/10/2025 at 1:57 p.m., with CNA B, who said she started at the facility in October of 2022, and she is also the staffing coordinator. She said that on 07/20/2025 she worked the floor, and right before 9 p.m. a visitor (name unknown) saw unknown resident that fit the description of CR #1 walking down the street and reported to MA A. She said that facility elopement code was initiated when she reported it to LVN D the unit manager and LVN E the assigned nurse, and MA A started search for CR #1 outside of the facility immediately. She said that when CR #1 was not located inside of the facility the search was expanded by car to the community by MA A, CNA B, LVN D, MA F, CNA G, and herself. She said that CR #1 was located by a mobile response team sometime after 9 pm and returned to the facility before 10pm. She said that she did not hear a door alarm to sound to indicate that CR #1's wander guard functioned to alert staff of the elopement. Record review on 06/10/2025 of a facility provided list of current residents with a wanderguard that included Resident#2 and Resident #3. Observation on 06/10/2025 at 2:30 p.m., the DON tested the wanderguard of Resident #3 for placement and functioning using a facility device while Resident #3 was seated in his wheel chair in the main dining room, and by physically taking Resident #3 to the door located at the main entrance of facility, and it was observed to be in place and functioning. Resident #3 was not interviewable. Observation on 06/10/2025 at 2:45 p.m., Unit Manager/RN to test the wanderguard of Resident #2 for placement and functioning using a facility device at the bedside, and it was observed to be in place and functioning. Resident #2 asked the Unit Manager/RN when the wanderguard would be removed because she had for a long time. Unit Manager/RN said the wanderguard was still needed for safety. In an interview on 06/10/2025 at 3:37 p.m., CNA G said that she started at the facility in 2018. She said that she was working the on 07/20/2024 when CR#1 eloped from the facility. She said that she last saw CR#1 in the lobby at 8:30pm. She said that facility elopement code was initiated, and she assisted in the search of the resident off the facility grounds. She said that the CR#1 was located by law enforcement, but she was unsure of the time she was found or when she returned to the facility. She said that she did not hear a door alarm to sound to indicate that CR#1's wander guard functioned to alert staff of the elopement. In an interview on 06/11/2025 at 8:05 a.m., Resident #2 at the besides, said that she had a bracelet on her ankle to tell staff if she leaves the building. She said that she did not need the bracelet, and she had it for a long time. She said that staff checks every day with the box to make sure it works, and she did not take it off. In an effort to complete a phone interview on 06/11/2025 at 9:24 a.m., with former employee, LVN E, a message was left. In an effort to complete a phone interview on 06/11/2025 at 9:25 a.m. with former employee, MA F, the number was disconnected. In a phone interview on 06/11/2025 at 9:26 a.m. with the Medical Director, who said he participated in a QAPI to address concerns of an elopement in August of 2024, but he could not recall the residents name involved. He said that the resident was able to elope from the facility while wearing a wanderguard. He said that a plan was developed to train staff on the elopement process, monitor resident at high risk for elopement with a wanderguard with monitoring for placement and testing the function of the wanderguard each shift. He said that staff should follow their elopement process and monitor residents to prevent elopements, if not there is risk that residents can elope, and there is always the potential for harm with each elopement. In an interview on 06/11/2025 at 10:20 a.m. with LVN D, who said that she last worked at the facility in October of 2024 as a Unit Manager. She said that she worked on 07/20/2025 when CR#1 eloped. She said that a medication aide (MA A) was told by a visitator (name unknown) at 8:45pm that a resident that fit the description of CR#1 was seen walking down the street. She said that she was notified by the staffing coordinator (CNA B), that a medication aide (MA A) had started to search outside immediately, and the facility elopement code was initiated with a search inside the facility and outside the facility for 30 minutes. She said that when CR#1 was not located the search was expanded by car to the community by two medication aides (MA A and MA F), staffing coordinator (CNA B), the assigned CNA (CNA G), and herself. She said that CR#1 was located by a mobile response team sometime after 9pm and returned to the facility at 9:50pm. She said that she did not hear a door alarm to sound to indicate that CR#1's wander guard functioned to alert staff of the elopement. She said that CR#1's wander guard was tested prior to the elopement an upon returning to the facility and it was functioning but still replaced. She said that residents that are high risk for elopement must have orders in place to test for functioning and ensure placement every shift. She said that there is a policy and procedure in place to prevent elopement, if not followed the risk is elopement, and there can be harm with every elopement. Record review on 06/11/2025 at 12 pm of document titled QAPI and dated 08/15/2025 read in part, . Problem: Elopement risks Goal: Ensure all residents with wonder guards are monitored closely and all preventative measures are being followed. Root Cause: Staff aren't monitoring them close enough. Action Items: Ensure staff are doing daily checks of functionality of the wander guards. Person Responsible: Administrator/designee Follow up date: 7/18/2024. Date Resolved or reevaluated: ongoing Reviewed in QAPI: Monthly . Record review on 06/11/2025 at 12:05 pm of document titled PIP and dated 07/22/2024 read in part, .Focus Area: Resident Elopement Prevention Revie date: Random and PRN Background: A recent elopement incident involving a resident has highlighted the need for enhanced protocols and safe guards to prevent unauthorized departures. This PIP aims to address the gaps and reinforced safety measures, particularly with residents who wear wander guards. Goals: Prevent further residents elopement incidents. Ensure proper functioning and regular testing of wander guard devices. Reinforce staff awareness regarding high risk residents. Enhanced elopement risk assessment and response protocols. Action plan: Ensure all wander guard devices are tested for proper function and alarm response. Log results Conduct standardized elopement risk assessments upon admission, quarterly, and with any change in condition. Residents identified as elopement risks will have checks every 2 hours. Provide inservice on elopement protocols Record review on 06/11/2025 at 12:10 p.m. of document titled Wanderguard Functionality from 07/20/2024-09/30/2024 to indicated that wanderguards was checked for functioning and placement daily, but the document did not provide information as to which residents was assessed. In an interview on 06/11/2025 at 1:00 p.m. the DON, who said there was only two residents during the PIP that was at risk for elopement with a wanderguard, CR#1 and Resident #2. She said that CR#1 and Resident #2 would have been the only residents apart of the daily audit to test placement and functioning of wanderguards, and the nurses would have documented that the guards were placed and functioning on the MAR. She said that she documented the residents involved with the PIP in a written statement, she provided a copy, and the record was reviewed. She agreed to email the document with the MAR for each resident 07/20/2024-09/30/2024 as evidence that that task was completed as part of the PIP. She agreed to email the following policies Incident and accidents, Elopement/Wandering, and Wanderguard. In an interview and observation on 06/11/2025 at 2:15 p.m., with LVN H, who said that she started in January 2025 at the facility, and she works the 400 hall from 6:00am-2:00pm. She said that residents are assessed for elopement at admission, readmission, and quarterly for elopement. She said that residents at high risk for elopement or with exit seeking behavior have orders for a wander guard. She said that residents with a wanderguard have orders for a nurse to check placement and function each shift, and the task is documented on MAR. She said that if a task is not documented it did not happen, and if there are no orders there is no way to document on the MAR. She said that if there is no monitoring for placement and functioning of a wanderguard a resident could elope if the wanderguard is taken off or it does not work. She said that the risk to a resident would be elopement, and there was a chance for harm for any elopement. She said that there were two residents on 400 hall with a wanderguard to include Resident#2. She was observed to check Resident#2's electronic medical records and confirmed there were no orders in place until 06/10/2025 to check placement and functioning of the wanderguard. She said that she thought Resident#2 had orders, she checked daily, and thought she documented on the MAR. She said that Resident#2 had a wanderguard since she started working at the facility. In an interview and observation on 06/11/2025 at 2:20pm with RN I, who said that she started in March 2025 at the facility, and she works the 400 hall from 2:00pm-10:00pm. She said that residents are assessed for elopement at admission, readmission, and quarterly for elopement. She said that residents at high risk for elopement or with exit seeking behavior have orders for a wander guard. She said that residents with a wanderguard have orders for a nurse to check placement and function each shift, and the task is documented on MAR. She said that if a task is not documented it did not happen, and if there are no orders there is no way to document on the MAR. She said that if there is no monitoring for placement and functioning of a wanderguard a resident could elope if the wanderguard is taken off or it does not work. She said that the risk to a resident would be elopement, and there was a chance for harm for any elopement. She said that there were two residents on 400 hall with a wanderguard to include Resident#2. She was observed to check Resident#2's electronic medical records and confirmed there were no orders in place until 06/10/2025 to check placement and functioning of the wanderguard. She said that she thought Resident#2 had orders, she checked daily, and thought she documented on the MAR. She said that Resident#2 had a wanderguard since she started working at the facility. In an interview and observation on 06/11/2025 at 2:25 p.m. LVN J, said that she started at the facility in March 2025, and she works the 200 and 100 hall from 6:00am -2:00pm. She said that residents are assessed for elopement at admission, readmission, and quarterly for elopement. She said that residents at high risk for elopement or with exit seeking behavior have orders for a wander guard. She said that residents with a wanderguard have orders for a nurse to check placement and function each shift, and the task is documented on MAR. She said that if a task is not documented it did not happen, and if there are no orders there is no way to document on the MAR. She said that if there is no monitoring for placement and functioning of a wanderguard a resident could elope if the wanderguard is taken off or it does not work. She said that the risk to a resident would be elopement, and there was a chance for harm for any elopement. She said that there was one resident on 200 hall with a wanderguard, Resident #3. She was observed to check Resident#3's electronic medical records and confirmed there were no orders in place until 06/10/2025 to check placement and functioning of the wanderguard. She said that she thought Resident#3 had orders, she checked daily, and thought she documented on the MAR. She said that Resident#3 had a wanderguard since March or April of 2025. In an interview and observation on 06/11/2025 at 2:30pm with RN K, who said that she started at the facility 11 years ago, and she works the 200 and 100 hall from 2:00pm. She said that residents are assessed for elopement at admission, readmission, and quarterly for elopement. She said that residents at high risk for elopement or with exit seeking behavior have orders for a wander guard. She said that residents with a wanderguard have orders for a nurse to check placement and function each shift, and the task is documented on MAR. She said that if a task is not documented it did not happen, and if there are no orders there is no way to document on the MAR. She said that if there is no monitoring for placement and functioning of a wanderguard a resident could elope if the wanderguard is taken off or it does not work. She said that the risk to a resident would be elopement, and there was a chance for harm for any elopement. She said that there was one resident on 200 hall with a wanderguard, Resident #3. She was observed to check Resident#3's electronic medical records and confirmed there were no orders in place until 06/10/2025 to check placement and functioning of the wanderguard. She said that she thought Resident#3 had orders, she checked daily, and thought she documented on the MAR. She said that Resident#3 had a wanderguard since March of 2025. In an interview on 06/11/2025 at 3:20 pm with the DON, who said residents are assessed for elopement at admission, readmission, and quarterly for elopement. She said that residents at high risk for elopement or with exit seeking behavior have orders for a wander guard. She said that residents with a wanderguard have orders for a nurse to check placement and function each shift, and the task is documented on MAR. She said that if a task is not documented it did not happen, and if there are no orders there is no way to document on the MAR. She said that if there is no monitoring for placement and functioning of a wanderguard a resident could elope if the wanderguard is taken off or it does not work. She said that the risk to a resident would be elopement, and there was a chance for harm for any elopement. She said that Resident#2 did not have a wanderguard during the time of the QAPI and PIP. She said that Resident#2's order was discontinued because she was no longer exit seeking, and the order was received on 06/10/2025 when Resident#2 started showing behaviors of exit seeking. She did not provided answer when asked why Resident#3's orders started on 6/10/2025, when he has had a wanderguard since March of 2025. In an interview on 06/11/2025 at 3:30 p.m., the Administrator, who said residents are assessed for elopement at admission, readmission, and quarterly for elopement. He said that residents at high risk for elopement or with exit seeking behavior have orders for a wander guard. He said that residents with a wanderguard have orders for a nurse to check placement and function each shift, and the task is documented on MAR. He said that if a task is not documented it did not happen, and if there are no orders there is no way to document on the MAR. He said that if there is no monitoring for placement and functioning of a wanderguard a resident could elope if the wanderguard is taken off or it does not work. He said that the risk to a resident would be elopement, and there was a chance for harm for any elopement. He said that Resident #2 and Resident #3 had a wanderguard, both should have orders to check placement and function each shift, and both have had the guards in place for some time. He said that he did not know for how long Resident #2 had the guard, it was in place when CR#1 eloped last year, and Resident #2 should have been a part of the PIP to ensure monitoring for placement and functioning. He said that it would not be a true statement that Resident #2 only got the guard on 06/10/2025. He said that he did not know why the DON would say that Resident #2 only got the guard on 6/10/2025 and that was concerning for him to know. Requested the following policies were requested, Incident and accidents, Elopement/Wandering, and Wanderguard. The policies for Incident and Accidents, Elopement/Wandering, and Wanderguard on 06/10/2025 at 12:10 p.m., and on 06/11/2025 at 1:00pm and 3:30pm, and were not received prior to exit. A policy for testing wanderguards for placement and functioning on 06/11/2025 at 1:22 p.m. and was not received prior to exit. Record review of policy titled, Wandering Unsafe Resident, with a revised date of December 2008 read in part, The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement . Safety Interventions 4. Interventions to try to maintain safety will be included in the residents are plan. This was determined to be an Immediate Jeopardy (IJ) on 06/11/2025. The Administrator was notified on 06/11/2025. The IJ template was provided to the facility on [DATE] at 5:43pm. In an interview on 06/12/2025 at 9:49 a.m. the CO-Medical Director, who said that he was notified about the IJ being called, and he had been included on the POR. He said that all treatments and care should have orders, should be documented, and standard. The following Plan of Removal (POR) submitted by the facility was accepted on 06/12/2025 at 1:14 p.m. The plan of removal reflected the following: Facility Name: Date: June 12th, 2025 Plan of Removal F 689 Accidents/Hazards Facility submits the following Plan of Removal for the alleged failure to ensure the resident environment remained free of accidents, and hazards each resident received adequate supervision to prevent accidents for CR #1, Resident #2, and Resident #3. What corrective actions have been implemented for the identified residents? A. Resident CR#1 discharged from facility on 6/09/2025. B. On 6/11/2025, Resident #2 medical record was reviewed by the Clinical Services Director to ensure Wanderguard orders were in place, with instructions to verify proper placement every shift and ensure proper functioning daily. Care plans reviewed for residents with Wanderguards and updated if indicated. Wanderguard devices are in place and have been verified to be functioning correctly by the DON on 6/11/2025. C. On 6/11/2025, Resident #3 medical record was reviewed by the Clinical Services Director to ensure Wanderguard orders were in place, with instructions to verify proper placement every shift and ensure proper functioning daily. Care plans reviewed for residents with Wanderguards and updated if indicated. Wanderguard devices are in place and have been verified to be functioning correctly by the DON on 6/11/2025. D. On 6/11/2025 at 06:31 pm the Administrator notified the Medical Director of alleged deficient practice. E. On 6/11/2025 the DON/Nurse Managers completed a 100% elopement risk assessment of all residents residing in the facility for risk of elopement, and no new residents were identified to be at risk. F. On 6/11/2025 DON/Nurse Managers audited the residents' orders that require a Wanderguard, no concerns were identified. G. On 6/11/2025 the DON/Nurse Managers and Administrator were in-serviced on the Elopement Policy by the Regional [NAME] President of Operations and the Clinical Services Director. H. On 6/11/2025 the license nurses were trained on testing the Wanderguard device. I. On 6/11/2025 the DON received a written warning on the Elopement Policy by the Administrator. J. The Clinical Services Director reviewed facility Elopement Policy on 6/11/2025 no revisions were deemed necessary. How were other residents at risk to be affected by this deficient practice identified? A. Residents that are at risk for elopement have the potential to be affected by the alleged deficient practice. What does the facility need to change immediately to keep residents safe and ensure it does not happen again? A. An in-service was initiated on 6/11/2025 by the Corporate Clinical Service Director, DON, and Nurse Managers with the licensed nursing staff on the Elopement Policy and obtaining orders for residents that requires a Wanderguard. Licensed nurses will not be allowed to return to work until they receive this in-service. Completion date 6/11/2025. B. An in-service was initiated on 6/11/2025 by the Nurse Managers and the Administrator with the facility frontline staff on the residents that requires a Wanderguard and obtaining orders. Completion date 6/11/2025. C. Newly hired nurses will be in-serviced by the DON/designee on the Elopement Policy and obtaining orders for residents that require a Wanderguard. Licensed nurses will not be allowed to work until they receive this in-service. Completion date 6/11/2025. D. Newly hired frontline staff will be in-serviced by the DON/designee on the residents that requires a Wanderguard. They will not be allowed to work until they receive this in-service. Completion date 6/11/2025. E. New Admissions and Readmissions Elopement Assessment and Risk Management will be reviewed daily in the morning meeting to identify residents at risk for elopement and ensure adequate supervision in place, monitoring of Wanderguard placement and proper functionality. The Charge Nurse will monitor the placement and functionality of the Wanderguard devices daily and document on the resident's MAR. The DON/designee will monitor the placement and functionality of the devices 3x week X 6 weeks and review will be documented on an audit report form. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 6/11/2025 with the Medical Director. The Medical Director has reviewed and agrees with this plan. The Plan of Removal was confirmed for the IJ by mon[TRUNCATED]

Based on observations, interviews, and record reviews the facility failed to ensure that it was free of a medication error rate of below 5 percent (%) or greater. The facility had a medication error rate of 22%, based on 8 out of 37 opportunities, which involved 3 of 6 residents (Resident #72, Resident # 23 and Resident #506) and 2 of 3 staff (MA B and LVN M) reviewed for medication administration errors. MA B administered Calcium Carbonate(used as an antacid to relieve heartburn, acid indigestion and upset stomach), Diphenoxylate/atropine 2.5 mg, and Dicyclomine 40 mg (drug used to treat irritable bowel syndrome) more than 2 hours and 45 minutes after the scheduled time to Resident #72 on 6/10/25. MA B failed to administer Lisinopril (used to treat high blood pressure), Cetirizine HCL (used to treat allergy symptoms like runny nose sneezing, itchy eyes and hives), Lidocaine external (medication use to local anesthetic for pain), Buspirone (medication use to treat anxiety disorders) as ordered by the Physician to Resident #23 on 6/10/25. LVN M failed to administer Clopidogrel ( Plavix is an antiplatelet drug you can take to prevent blood clots) to Resident #23 as ordered by the physician. These failures could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. The findings included: Record review of Resident #72's face sheet, dated 6/10/25, revealed Resident #72 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses lymphedema(a condition where swelling occurs, usually in the arms or leg, due to a problem with the lymphatic), cachexia ( wasting syndrome), adult failure to thrive, irritable bowel syndrome with diarrhea, cellulitis(bacterial skin) unspecified, muscle weakness (generalized), major depressive disorder, single episode, moderate, adjustment disorder with mixed anxiety and depressed mood, irritable bowel syndrome, unspecified, other malaise, acute embolism and thrombosis (sudden blood clot) of unspecified deep veins of left lower extremity, rhabdomyolysis (muscles break down, releasing harmful substances into your bloodstream), dehydration, fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with delayed healing cellulitis of left lower limb. Record review of Resident #72s quarterly MDS, dated [DATE], revealed Resident #72 had a BIMS score of 14 which indicated no cognitive impairment. Resident #72 was dependent of staff for all ADLs. Record review of Resident#72's physician orders revealed the following: - Order date was 7/18/23: Diphenoxylate-Atropine Tablet 2.5-0.025 MG *Controlled Drug*=Give 1 tablet by mouth before meals for IBS AND Give 1 tablet by mouth every 12 hours as needed for IBS - Order date was 5/6/24: Tums Oral Tablet Chewable 500 MG (Calcium Carbonate (Antacid) Give 1 tablet by mouth before meals and at bedtime for indigestion. - Order date was 3/12/25: Dicyclomine HCl Tablet 20 MG Give 2 tablet by mouth before meals and at bedtime related to IRRITABLE BOWEL SYNDROME. Record review of the MAR and time schedule dated 6/10/25 reflected the following medications were initialed as given to Resident #72: Diphenoxylate-Atropine Tablet 2.5-0.025 MG *Controlled Drug* Give 1 tablet by mouth before meals for IBS (Scheduled time on MAR was 7:00 am, 11:00 am, 4:00 pm). MA B initialed on MAR for Diphenoxylate-Atropine Tablet 2.5-0.025 as given at 7:00 AM Tums Oral Tablet Chewable 500 MG (Calcium Carbonate (Antacid) Give 1 tablet by mouth before meals and at bedtime for indigestion (Scheduled time on MAR was 06:30 am, 11:30 am, 16:30 pm and 20:00). MA B initialed on MAR for Tums Oral Tablet Chewable 500 MG as given at 6:30 AM Dicyclomine HCl Tablet 20 MG, Give 2 tablets by mouth before meals and at bedtime related to IRRITABLE BOWEL SYNDROME, (Scheduled time on MAR was 06:30 am, 11:30 am, 16:30 pm and 20:00). MA B initialed on MAR for MA B initialed on MAR for Dicyclomine HCl Tablet 20 MG as given at 6:30 AM. Observation on 6/10/25 at 10:55AM, during medication pass with MA B, Resident #72 was lying in bed he said I normally get my med Dicyclomine and most medication before 7AM, they mess up med all the time MA B picked up blister packet and punched of Diphenoxylate-Atropine Tablet 2.5-0.025 MG and Dicyclomine HCl Tablet 20 MG, with other medications in the medication cup and administered to Resident #72 by mouth. MA B administered Tums Oral Tablet Chewable 500 MG to Resident #72. Interview with MA B on 6/10/25 at 10:55 AM, she said the meal tray was served for breakfast between 7:00 AM to 7:15 AM. 2.Record review of Resident 23's face sheet, dated 6/10/25, revealed Resident #23 was a [AGE] year old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses osteoarthritis,( degenerative joint disease in which the tissues in the joint break down over time) ) anemia, ( low number of red blood cell in the blood ) unsteadiness on feet lack of coordination, , cellulitis of unspecified part of limb, muscle wasting and atrophy, not elsewhere classified, unspecified site(m, constipation, unspecified, pain in unspecified joint, other lack of coordination, essential (primary) hypertension, covid-19, chronic obstructive pulmonary disease, unspecified, major depressive disorder, recurrent severe without psychotic features , difficulty in walking, not elsewhere classified, muscle weakness (generalized), type 2 diabetes mellitus (high glucose in the blood) with diabetic retinopathy ( eye condition that can cause vision loss or blindness due to damage to the retina caused by diabetes) without macular edema, other abnormalities of gait and mobility, insomnia due to other mental disorder, major depressive disorder, recurrent, moderate, type 2 diabetes mellitus with hyperglycemia, type 2 diabetes mellitus with diabetic polyneuropathy(peripheral nerves throughout weakness are damaged or not working properly, body mass index adult, epigastric pain, other malaise, other chronic pain, urinary tract infection, site not specified, hydroureter, type 2 diabetes mellitus without complications, peripheral vascular disease,, anxiety disorder, Alzheimer's disease( a brain disorder that slowly destroys memory and eventually, the ability to carry out simple tasks) with late onset, primary insomnia, acute bronchitis, unspecified, chronic obstructive pulmonary disease with (acute) lower respiratory infection, polyneuropathy, unspecified, morbid (severe) obesity due to excess calories, chronic systolic (congestive) heart failure,, cataract (white opacity of the eye) extraction status, eye, dysphagia( difficulty swallowing), other sequelae of cerebral infarction (stroke), heart failure, history of falling, atherosclerotic heart disease ( fatty materials like build up inside your arteries). Record review of Resident#23's quarterly MDS, dated [DATE], revealed Resident #23 had a BIMS score of 15, signifying no cognitive impairment. Resident #23 was dependent of staff for all ADLs. Record review of Resident#23's physician orders revealed the following: Order date 3/28/25: Lisinopril Oral Tablet 10 MG (Lisinopril) Give 1 tablet by mouth one time a day (morning) Hypertension Hold for BP 105/60 Order date 5/8/25: for Zyrtec Allergy Oral Capsule (Cetirizine HCl) Give 5 mg by mouth one time a day for Nasal congestion. Order date5/12/25: Buspirone HCl Oral Tablet 10 MG (Buspirone HCl) Give 1 tablet by mouth one time a day for anxiety. Order date 5/10/25: Lidocaine External Patch 5 % (Lidocaine) Apply to Right Knee topically one time a day for pain remove patch at 8 pm. Record review of the June 2025 MAR indicated on 6/10/25 the following medications was initialed as given: Lisinopril Oral Tablet 10 MG (Lisinopril) Give 1 tablet by mouth one time a day (morning) Zyrtec Allergy Oral Capsule (Cetirizine HCl) Give 5 mg by mouth one time a day. (morning) Buspirone HCl Oral Tablet 10 MG (Buspirone HCl) Give 1 tablet by mouth one time a day. (Morning) Lidocaine External Patch 5 % (Lidocaine) Apply to Right Knee topically one time a day for pain remove patch at 8 pm. (morning) Observation of the medication pass on 6/10/25 at 11:05 AM, MA B entered Resident #23's room, the resident was lying in bed, she checked the blood pressure ( was BP 127/65) she picked up a blister packet and punched out: - Buspirone Oral Tablet 7.5 mg. - Cetirizine (HCl) 10mg - Lisinopril tab 5 mg po and punched with other medication in medicine cup. The blister packet had Lisinopril tab 5 mg Give 2 tablets =10 mg. MA B at 11:08 AM was about to administered Resident #23's medications when surveyor stopped MA B and she added another Lisinopril tab 5 mg MA B stated it should be 10mg ,2 tablets and thank you very much. - MA B did not administer Lidocaine External Patch 5 % to Right Knee. Interview with MA B on 6/12/25 at 11:22 AM, she said not giving the medications as ordered was an oversight and she did not check the medication dosage and she would be very careful, she did not realize that Buspirone HCl Oral Tablet was 10 MG not 7.5mg on the blister, the ZyrTEC Allergy Oral Capsule (Cetirizine HCl) Give 5 mg by mouth one time a day for Nasal congestion, and Lisinopril Oral Tablet 5 MG (Lisinopril) was poured 1 tablet by mouth one time a day. Interview with MA B on 6/12/25 at 11:45 AM, regarding lidocaine 5% not given as ordered by the doctor. She said she did not give it to the resident because she always refused and was asked why she initialed the medication as given with no documentation MA B said she was sorry and was shown the blister packet of Buspirone HCl Oral Tablet 7.5 mg and Cetirizine 10 mg bottle in the medication cart for 100 hall, MA B said she was very sorry and would be more careful, she said not giving the medication as ordered could lead to resident not getting well, because it would not be effective. Record review of Resident #506's face sheet, dated 6/11/25, revealed Resident #506 was admitted to the facility on [DATE].Diagnoses included, disorders of brain, hyperlipidemia ( high fat in the blood), essential (primary) hypertension( high blood pressure) (, malignant neoplasm of parietal lobe, chronic kidney disease, stage 3( kidneys are damaged and can't filter blood as well as they should), combined forms of age-related cataract(lens of your becomes cloudy) , bilateral, chronic obstructive pulmonary disease (the airways and air sacs in your lungs get damaged) , unspecified, occlusion and stenosis ( narrowing)of right carotid artery, occlusion and stenosis of right middle cerebral artery, hemiplegia(weakness), unspecified affecting left nondominated side and gastrostomy tube( is a surgically place device used to give direct access to your stomach for nutrition, fluid and medications). Record review of Resident #506's physician orders obtained, revealed the following: Order date 6/10/25: Plavix Oral Tablet 75 MG (Clopidogrel Bisulfate) 1 tablet via G-Tube one time a day for hyperlipidemia. Observation on 6/11/25 at 9:25 AM, during medication pass with LVN M, Resident #506 was lying in bed. LVN M picked up a blister packet of Clopidogrel 75 mg 1 tablet crushed and diluted with 20cc of water in medication cup, she then checked Resident #506's GT for placement, flushed with 30cc of water before and administered Clopidogrel 75 mg. LVN M did not stir or rinse the medication cup. LVN M had a lot of residue of Clopidogrel in the medication cup and after medication administration, she discarded the medication cup. The nurse surveyor picked up the medication cup and showed her the residual and proceeded to show the DON who said that is a lot of medication in the medicine cup Interview with LVN M on 6/11/25 at 9:45 AM, said if medication was not given in totality resident would not get required effects of the medication. During an interview on 6/12/25 at 1:55 PM, the ADM, DON, regional nurse and regional ADM said the risk of not getting the medication as ordered by the doctor and in a timely manner could lead to not be effective and his expectation was zero medication error rate. The DON said not giving medication as ordered by the doctor could cause more health issues and potent of the medication in the blood and she would be in-servicing the staff. In an interview on 6/13/22 at 1:27 PM, the DON stated the staff were supposed to administered medications per the physician orders and the facility policy. She stated she was not aware that the medications was being administered late. After being informed on the time the medications was administered and the scheduled time, she stated the medications was administered late. Review of the facility policy revised 2012 and titled administering medications reflected, Medications shall be administered in a safe and timely manner, and as prescribed 3. Medications must be administered in accordance with the orders, including any required time frame. 4. Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).

Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 3 residents (Resident #9 and Resident #90) reviewed for incontinent care. -The facility failed to ensure CNA A cleaned Resident #9 properly during incontinent care on 6/10/25. -The facility failed to ensure CNA G cleaned Resident # 90's indwelling Foley catheter properly and followed proper hand hygiene during incontinent care on 6/11/25. -Resident #90 did not have a STATLOCK to secure the Foley catheter. These failures could place residents at risk for pain, infection, injury, and hospitalization. Finding included: Record review of a face sheet print date of 6/12/25 reflected, Resident #9 was a [AGE] year old female admitted [DATE]. Resident #9's diagnoses included abnormalities of gait and mobility, lack of coordination, weakness, acute kidney failure, osteoarthritis (a common joint condition that occurs when the cartilage that cushions the ends of bones gradually wears down), other lack of coordination, pain in right knee, pain in right ankle and joints of right foot, muscle wasting and atrophy, multiple sites unsteadiness on feet, pain in left knee, repeated falls, hypo-osmolality and hyponatremia, benign neoplasm of meninges ( tumor arising from the membranes covering the brain and spinal cord), hypothyroidism ( a condition where the thyroid gland doesn't produce enough thyroid hormones to regulate metabolism and energy use), muscle weakness (generalized), other abnormalities of gait and mobility, cognitive communication deficit, muscle wasting and atrophy, covid-19, dysphagia, oral phase, other chronic allergic conjunctivitis, major depressive disorder, recurrent, moderate, Alzheimer's disease with late onset, dementia( progressive neurodegenerative disorder that primarily affects memory, thinking and behavior) psychotic disturbance ( a person is having trouble distinguishing between what is real and what is not) and acute cystitis( inflammation of the bladder without hematuria ( blood in the urine). Record review of Resident #9's quarterly MDS dated [DATE] reflected a BIMS of 7 which indicated the residents cognition was severely impaired. Record review of section H (Bowel and Bladder) in the MDS reflected incontinent of bowel and bladder. Record review of Resident #9's care plan dated 4/30/25 indicated she had an ADL Self Care Performance Deficit and required assistance with all ADLs. Observation of incontinent care on 06/10/25 at 11:36 AM, done by CNA A , revealed Resident #9 was lying in the bed on her back, CNA A unfastened the brief , using the wet wipes, she did not separate the labia to clean, resident had large bowel movement, CNA A used the same wet wipe to clean the groin, and did not clean around resident buttocks and changed gloves. Attempted interview with CNA A on 6/10/25, unable she left for the day. On 6/11/25 at 5:30 PM and on 6/13/25 at 1:33 PM via telephone and there was no response. 2.Record review of Resident #90's face sheet printed 06/12/25, indicated Resident #90 was admitted on [DATE]. Resident #90's diagnoses included the following: essential (primary) hypertension (high blood pressure), gastro-esophageal reflux disease (gastric reflux) without esophagitis, acute kidney failure (sudden kidney failure), acute posthemorrhagic anemia, melena( blood in the stool), other asthma ( chronic lung condition causes the airways inflamed and narrow, making it difficult to breathe), chronic obstructive pulmonary disease (a common lung disease causing restriction of airflow and breathing problems), other symptoms and signs involving cognitive functions and awareness, muscle weakness (generalized, cognitive communication deficit, gastrointestinal hemorrhage, elevated white blood cell count, benign prostatic hyperplasia (enlarge prostrate)without lower urinary tract symptoms, obstructive and reflux uropathy, unspecified, hypertensive heart disease without heart failure, other symptoms and signs involving appearance and behavior acute (illness that develops quickly) and chronic (lasting for a long time) respiratory failure with hypoxia (lack of oxygen to sustain bodily functions), neuromuscular (affecting the nerves controlling the muscles) dysfunction of the bladder, sepsis (infection in the blood). Record review of Resident #90's admission MDS assessment dated [DATE], Section C (Cognitive Patterns) reflected a BIMS score of 5 which indicated severe impairment in thinking. Section H (Bladder and Bowel) reflected resident had an indwelling catheter. Resident #90's functional status revealed he was independent with supervision of staff with bed mobility, transfer, and toilet use. Further review revealed Resident #90 had an indwelling Foley catheter. Record review of Resident #90's physician order dated from May 2025 read in part . change Foley catheter with 18 inch catheter and 10cc bulb on the 1st of each month dated 3/23 . keep catheter from kinks and drainage bag lower than bladder at all times dated 4/29/25. Observation on 6/11/25 at 2:32 p.m. of indwelling catheter and incontinent care for Resident #90 performed by CNA J, Resident #90 was sitting on the wheelchair with catheter bag hung on the side of the wheelchair. CNA J washed her hands, donned a gown and transferred the resident to bed and removed the residents pants. Resident #90's indwelling catheter was not secured to the thigh to prevent pulling. CNA J used wet wipes cleaned visible part of the catheter tubing about ½ inch of catheter, she did not clean the catheter in a circular motion from the insertion site. Interview on 06/11/25 at 2:52 PM, CNA J said she was very nervous, during the care, she said the nurses was responsible for ensuring that a statlock /secure strap was attached to the Foley. She said she had an in-service a month ago on indwelling Foley. Interview on 06/11/25 at 3:00 PM, LVN H said it was the responsibility of the nurse to assess residents that had a Foley catheter to ensure that a Statlock was in place every shift to prevent the Foley catheter from being pulled out. LVN H said it placed the resident at risk for pain, bleeding, and infections. LVN H said she was Resident #90's nurse. Interview on 06/11/25 at 6:05 PM, the DON said residents with an indwelling Foley catheter should have a statlock/secure strap in place to prevent pulling the Foley tubing out. The DON said it was the nurses that were supposed to ensure that this device was in place. The DON said the nurses should be assessing the resident at least once a shift. The DON said if the residents Foley tubing is dislodged with the bulb still inflated, the incident could cause the resident discomfort as well as more discomfort in inserting a new Foley catheter and catheter should be cleaned in a circular motion and 4 inches away from insertion site. The DON said it ultimately fell on her to ensure that the nurses were carrying out this task and the CNAs were trained to open labia and clean to prevent infection. Record review of the facility policy for Catheter Care Urinary dated 3/31/2016 revealed: For the female: Use a washcloth with warm water and soap to cleanse around the meatus. Cleanse the glans using circular strokes from the meatus outward. Change the position of the washcloth with each cleansing stroke. With a clean washcloth, rinse with warm water using the above technique. Return foreskin to normal position. 16. Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 of 6 residents (Resident #72 and Resident #23) reviewed for drug administration in that: - Resident #72's medication Calcium Carbonate(used as an antacid to relieve heartburn, acid indigestion and upset stomach) was provided 2 hours and 45 minutes late on 06/10/2025. - Resident#72's medication Diphenoxylate/atropine 2.5 mg (to treat severe diarrhea) was provided 2 hours and 45 minutes late on 06/10/2025. - Resident #72's medication Dicyclomine 40 mg (drug used to treat irritable bowel syndrome) was provided 2 hours 45 minutes late on 06/10/2025. - Resident #23's Lisinopril (used alone or together with other medicines to treat high blood pressure) not given as ordered on 6/10/25. The nurse surveyor had to intervened. This deficient practice could affect residents who receive medication and place them at risk for not receiving a therapeutic effect. The findings were: Record review of Resident #72'S face sheet, dated 6/10/25, revealed Resident #72 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses lymphedema( a condition where swelling occurs, usually in the arms or leg, due to a problem with the lymphatic), cachexia ( wasting syndrome), adult failure to thrive, irritable bowel syndrome with diarrhea, cellulitis( bacterial skin) unspecified, muscle weakness (generalized), major depressive disorder, single episode, moderate, adjustment disorder with mixed anxiety and depressed mood, irritable bowel syndrome, unspecified, other malaise, acute embolism and thrombosis ( sudden blood clot) of unspecified deep veins of left lower extremity, rhabdomyolysis ( muscles break down, releasing harmful substances into your bloodstream), dehydration, fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with delayed healing(s, cellulitis of left lower limb. Record review of Resident #72'S quarterly MDS, dated [DATE], revealed Resident #72 had a BIMS score of 14, signifying moderate cognitive impairment. Record review of Resident#72's physician orders obtained, revealed the following: Order date was 7/18/23: Diphenoxylate-Atropine Tablet 2.5-0.025 MG *Controlled Drug*=Give 1 tablet by mouth before meals for IBS AND Give 1 tablet by mouth every 12 hours as needed for IBS. Order date was 5/6/24: Tums Oral Tablet Chewable 500 MG (Calcium Carbonate (Antacid) Give 1 tablet by mouth before meals and at bedtime for indigestion. Order date was 3/12/25: Dicyclomine HCl Tablet 20 MG Give 2 tablet by mouth before meals and at bedtime related to IRRITABLE BOWEL SYNDROME. Record review of the MAR on 6/10/25 reflected the following medications was initialed as given: Diphenoxylate-Atropine Tablet 2.5-0.025 MG *Controlled Drug* Give 1 tablet by mouth before meals for IBS (Scheduled time on MAR was 7:00 am, 11:00 am, 4:00 pm). Tums Oral Tablet Chewable 500 MG (Calcium Carbonate (Antacid)) Give 1 tablet by mouth before meals and at bedtime for indigestion (Scheduled time on MAR was 06:30 am, 11:30 am, 4:30 p.m. and 8:00 p.m.). Dicyclomine HCl Tablet 20 MG Dicyclomine HCl Tablet 20 MG Give 2 tablet by mouth before meals and at bedtime related to IRRITABLE BOWEL SYNDROME, (Scheduled time on MAR was 06:30 am, 11:30 am, 4:30 pm and 8:00 p.m.). Observation of medication pass on 6/10/25 at 10:55 AM, MA B, Resident #72 was lying in bed he said I normally get my med Dicyclomine and most medication before 7AM, they mess up med all the time Interview with MA B on 6/10/25 at 10:55 AM, she said the meal tray was served for breakfast between 7:00 AM to 7:15 AM. Interview with Resident #72 on 6/12/25 at 11:10 AM, he said regarding his medication he had complained to Nurse T about not getting his medication in a timely manner, he was supposed to take some of his medication before breakfast to help his stomach and it has been going on for 2 months and he wish they keep his medication schedule time. Interview with LVN T on 6/12/25 at 11:22 AM, regarding Resident #72's, concerns about medication timing, she said, Resident #72 spoke to him about 2 months ago about then MA who no longer works for the facility and MA did apologize to Resident #72 and he had not complained anymore. The MA then started passing medication on 100 hall because of Resident #72. 2.Record review of Resident 23's face sheet, dated 6/10/25, revealed Resident #23 was a [AGE] year old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses osteoarthritis (degenerative joint disease in which the tissues in the joint break down over time) ) anemia, ( low number of red blood cell in the blood) unsteadiness on feet lack of coordination, cellulitis of unspecified part of limb, muscle wasting and atrophy, not elsewhere classified, unspecified site(m, constipation, unspecified, pain in unspecified joint, other lack of coordination, essential (primary) hypertension, covid-19, chronic obstructive pulmonary disease, unspecified, major depressive disorder, recurrent severe without psychotic features, difficulty in walking, not elsewhere classified, muscle weakness (generalized), type 2 diabetes mellitus (high glucose in the blood) with diabetic retinopathy (eye condition that can cause vision loss or blindness due to damage to the retina caused by diabetes) without macular edema, other abnormalities of gait and mobility, insomnia due to other mental disorder, major depressive disorder, recurrent, moderate, type 2 diabetes mellitus with hyperglycemia, type 2 diabetes mellitus with diabetic polyneuropathy(peripheral nerves throughout weakness are damaged or not working properly, body mass index adult, epigastric pain, other malaise, other chronic pain, urinary tract infection, site not specified, hydroureter, type 2 diabetes mellitus without complications, peripheral vascular disease,, anxiety disorder, Alzheimer's disease( a brain disorder that slowly destroys memory and eventually, the ability to carry out simple tasks) with late onset, primary insomnia, acute bronchitis, unspecified, chronic obstructive pulmonary disease with (acute) lower respiratory infection, polyneuropathy, unspecified, morbid (severe) obesity due to excess calories, chronic systolic (congestive) heart failure,, cataract (white opacity of the eye) extraction status, eye, dysphagia( difficulty swallowing), other sequelae of cerebral infarction (stroke), heart failure, history of falling, atherosclerotic heart disease ( fatty materials like build up inside your arteries). Record review of Resident#23'S quarterly MDS, dated [DATE], revealed Resident #23 had a BIMS score of 15, signifying no cognitive impairment. Record review of Resident #23's physician orders revealed the following: Order date 3/28/25: Lisinopril Oral Tablet 10 MG (Lisinopril) Give 1 tablet by mouth one time a day (morning) Hypertension Hold for BP 105/60 Observation on 6/10/25 at 11:05 AM, during medication pass with MA B, Resident #23 was lying in bed, she checked Resident #23's blood pressure (BP127/65) she picked up a blister packet of Lisinopril tabs 5 mg and punched with other medication in medicine cup. The blister packet had Lisinopril tab 5 mg Give 2 tablets =10 mg. MA B at 11:08 AM was about to administer Resident #23's medications when surveyor stopped MA B and she added another Lisinopril tab 5 mg MA B stated it should be 10mg , 2 tablets and thank you very much During an interview on 6/12/25 at 12:30 PM., MA B when asked what training did she have to ensure the right time was given the right medication, MA B stated, she said she started working for the facility about two weeks ago and she always start her medication pass on 200 hall and then 100 hall. MA B said she had training before she started working in the facility but was overshadowed when she started work with facility. MA B stated the rights of medication administration include the right resident, right dose, right documentation, right route, and right time. When asked why it was important to ensure the right resident was given the right medication at the right time MA B stated, Because if it's the wrong person, you could harm them if they don't need it. MA B said she would start her medication pass on 100 hall because Resident #72 had medication due before breakfast. During an interview on 6/12/25 at 1:55 PM, the DON stated, we have the [medication administration] competency that's done upon hire and we do it annually as a refresher and we also do it as needed. Corporate will come in and they'll do an observation, and they'll make recommendations. It's a lot of [as needed] from time to time. The DON stated the facility's consulting pharmacist will also visit to do cart audits and medication administration observations. The DON stated the facility also conducted random medication cart checks weekly and these audits included checking if medication was given at the right time. When asked what sort of negative effects could occur to the resident if a medication was given at the wrong time, the DON stated, Depending on the medication, itself, it can have an effect where it's running into another medication that it shouldn't be given near and if you're not going an appropriate amount of time you can give something too close together. You can get sedations; you can get all sorts of outcomes by not following when the medication is supposed to be given. Record review of the facility's Administering Medications policy dated December 2012 read in part, . Medications shall be administered in a safe and timely manner, and as prescribed .

Based on observation, interview, and record review the facility failed to ensure residents were free of any significant medication errors for 1 of 6 residents (Resident #506) reviewed for significant medication errors. LVN M failed to administer Clopidogrel (Plavix is an antiplatelet drug you can take to prevent blood clots) to Resident #23 as ordered by the physician. This failure could result in increased side effects and hospitalization. Findings include: Record review of Resident #506's face sheet, dated 6/11/25, revealed Resident #506 was admitted to the facility on [DATE]. Diagnoses included, disorders of brain, hyperlipidemia ( high fat in the blood), essential (primary) hypertension( high blood pressure) (, malignant neoplasm of parietal lobe, chronic kidney disease, stage 3( kidneys are damaged and can't filter blood as well as they should), combined forms of age-related cataract(lens of your becomes cloudy) , bilateral, chronic obstructive pulmonary disease (the airways and air sacs in your lungs get damaged) , unspecified, occlusion and stenosis ( narrowing)of right carotid artery, occlusion and stenosis of right middle cerebral artery, hemiplegia(weakness), unspecified affecting left nondominated side and gastrostomy tube( is a surgically place device used to give direct access to your stomach for nutrition, fluid and medications). Record review of Resident #506's physician orders revealed the following: Order date 6/10/25: Plavix Oral Tablet 75 MG (Clopidogrel Bisulfate) 1 tablet via G-Tube one time a day for hyperlipidemia. Observation on 6/11/25 at 9:25 AM, during medication pass with LVN M, Resident #506 was lying in bed. LVN M picked up a blister packet of Clopidogrel 75 mg 1 tablet crushed and diluted with 20cc of water in medication cup, she then checked Resident #506's GT for placement, flushed with 30cc of water before and administered Clopidogrel 75 mg. LVN M did not stir or rinse the medication cup. LVN M had lot of residue of Clopidogrel in the medication cup and after medication administration, she discarded medication cup. The nurse surveyor picked up medication cup and show her the residual and proceeded to show the DON who said that is a lot of medication in the medicine cup Interview with LVN M on 6/11/25 at 9:45 AM, she said if medication was not given in totality resident would not get required effects of the medication. During an interview on 6/12/25 at 1:55 PM, with the ADM, DON, regional nurse, and regional ADM on. The ADM said the risk of not getting the medication as ordered by the doctor and in a timely manner could lead to not be effective and his expectation was zero medication error rate. The DON said not giving medication as ordered by the doctor could cause more health issues and potent of the medication in the blood and she would be in-servicing the staff. Review of the facility policy revised 2012 and titled administering medications reflected, Medications shall be administered in a safe and timely manner, and as prescribed 3. Medications must be administered in accordance with the orders, including any required time frame. 4. Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).

Based on observation, interview, and record review the facility failed to properly store, label, and/or secure medications and biologicals for 1 of 3 medication carts (400 hall medication cart) and 1 of 1 medication storage room reviewed for drug storage. 1. The facility failed to ensure medications that required a prescription were labeled with the appropriate information including open date in the medication room in the refrigerator. 2. 400-hall medication cart had medication open not dated. These failures could place residents at risk of not receiving the appropriate medications and not reaching the intended therapeutic dose and possible exacerbation of health conditions. Findings include: Observation on 06/11/25 at 12:50 PM with LVN M, in the Medication room refrigerator revealed the following: 1. Haloperidol 2mg/ml Quantity 30mls open not dated 2.Gabapentin solution 250/5ml Quantity 84 mls open with no date Interview with LVN M on 6/11/25 at 12:50 PM, she said any elixir open should have an open date on it for its potency. Observation of the medication cart on 400 hall on 6/11/25 at 12:55 PM reflected: Gabapentin ( used to help manage seizures and nerve pain) Solution 250/5ml and quantity 473 ml. Had give 10mls per GTube TID, the bottle had labeled Refrigerate 3 times on it after opening, there was no open date. Interview on 6/12/25 at 10:00 AM, LVN H said she did not administer the medication and she did not see the label and if the medication is not stored as ordered by the pharmacist it could lose the effectiveness. During an interview on 06/12/2025 at 1:55 PM, the DON and ADM, stated all liquid medication opened should have an open label on it and follow pharmacist recommendations. The DON stated the nurses was responsible for ensuring the proper labeling and storage of the medications. Record review of the facility policy on Medication Storage revised April of 2007 reflected in part: .The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner .The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed .

Based on observation, interview, and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 2 of 2 residents (Resident #9 and Resident #90) and 2 of 2 staff (CNA A and CNA J) reviewed for incontinent care and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #71) of 28 residents reviewed for infection control. The facility failed to ensure CNA A washed or sanitized her hands after doffing (taking off) dirty gloves after providing incontinent care on 6/10/25 for Resident #9. The facility failed to ensure CNA J washed or sanitized her hands after doffing (taking off) dirty gloves after providing incontinent care on 6/11/25 for Resident #90. This deficient practice placed residents at risk for cross contamination and the spread of infection. Finding included: Record review of Resident #9's face sheet print date of 6/12/25 reflected a [AGE] year old female with a date of admission of 2/20/20. Resident #9's diagnoses included abnormalities of gait and mobility, lack of coordination, weakness, acute kidney failure, osteoarthritis (a common joint condition that occurs when the cartilage that cushions the ends of bones gradually wears down), other lack of coordination, pain in right knee, pain in right ankle and joints of right foot, muscle wasting and atrophy, multiple sites unsteadiness on feet, pain in left knee, repeated falls, hypo-osmolality and hyponatremia, benign neoplasm of meninges ( tumor arising from the membranes covering the brain and spinal cord), hypothyroidism ( a condition where the thyroid gland doesn't produce enough thyroid hormones to regulate metabolism and energy use), muscle weakness (generalized), other abnormalities of gait and mobility, cognitive communication deficit, muscle wasting and atrophy, covid-19, dysphagia, oral phase, other chronic allergic conjunctivitis, major depressive disorder, recurrent, moderate, Alzheimer's disease with late onset, dementia( progressive neurodegenerative disorder that primarily affects memory, thinking and behavior) psychotic disturbance ( a person is having trouble distinguishing between what is real and what is not) and acute cystitis( inflammation of the bladder without hematuria ( blood in the urine). Record review of Resident #9's quarterly MDS dated [DATE] reflected a BIMS of 7 which indicated resident cognition was severely impaired. Record review of section H (Bowel and Bladder) in the MDS reflected incontinent of bowel and bladder. Record review of Resident #9's care plan dated 4/30/25 indicated an ADL Self Care Performance Deficit, and required assistance with all ADLs. Observation of incontinent care on 06/10/25 at 11:36 AM, done by CNA A , Resident #9 was lying in the bed on her back, CNA A unfastened the residents brief , using the wet wipes, she did not open/separate labia to clean, resident had large bowel movement, CNA A used the same wet wipe to clean the groin, she changed gloves, did not wash hands or use hand sanitizer. Resident draw sheet was soiled, CNA A doffed soiled gloves without washing hands, opened door went to parked housekeeping cart on the hallway and grabbed trash bag, and then went to the clean linen room and picked up clean draw sheet, and came back to Resident #9 room, resident had another bowel movement, , CNA A cleaned BM several times without washing hands doffed gloves and donned another pair of clean gloves to pick up clean brief and place it resident and fasten. Unable to interview CNA A on 6/10/25 because she left for home, called twice on 6/11/25 at 5:30 PM and on 6/13/25 at 1:33 PM there were no response, the DON said CNA A worked PRN. The DON did not provide CNA A's personnel file as requested. Record review of Resident #90's face sheet dated 06/12/25 revealed an [AGE] year old male who was admitted on [DATE]. diagnoses included the following: essential (primary) hypertension (high blood pressure), gastro-esophageal reflux disease (gastric reflux) without esophagitis, acute kidney failure (sudden kidney failure), acute posthemorrhagic anemia, melena( blood in the stool), other asthma ( chronic lung condition causes the airways inflamed and narrow, making it difficult to breathe), chronic obstructive pulmonary disease (a common lung disease causing restriction of airflow and breathing problems), other symptoms and signs involving cognitive functions and awareness, muscle weakness (generalized, cognitive communication deficit, gastrointestinal hemorrhage, elevated white blood cell count, benign prostatic hyperplasia (enlarge prostrate)without lower urinary tract symptoms, obstructive and reflux uropathy, unspecified, hypertensive heart disease without heart failure, other symptoms and signs involving appearance and behavior acute (illness that develops quickly) and chronic (lasting for a long time) respiratory failure with hypoxia (lack of oxygen to sustain bodily functions), neuromuscular (affecting the nerves controlling the muscles) dysfunction of the bladder, sepsis (infection in the blood). Record review of Resident #90's admission MDS assessment dated [DATE], Section C (Cognitive Patterns) reflected a BIMS score 5 which indicated severe cognitive impairment. Section H (Bladder and Bowel) reflected resident had an indwelling catheter. Resident #90's functional status revealed he was independent with supervision of staff with bed mobility, transfer, and toilet use. Record review of Resident #90's physician order dated from May 2025 read in part . change Foley catheter with 18 inch catheter and 10cc bulb on the 1st of each month dated 3/23 . keep catheter from kinks and drainage bag lower than bladder at all times dated 4/29/25. Record review of the facility antibiotic stewardship dated 3/28/25 to 4/1/25 revealed resident was treated with Ciprofloxacin for urinary tract infection. (Ciprofloxacin is prescribed for the treatment of various bacterial infections) Observation on 6/11/25 at 2:32 p.m. of indwelling catheter and incontinent care for Resident #90 performed by CNA G, Resident #90 was sitting on the w/chair with catheter bag hung on the side of the wheelchair. CNA washed her hands, donned gown and transferred the resident to bed, donned clean gloves, picked up wet wipe packet and placed on Rsident #90's bed, while cleaning Resident #90's F/C with the wet wipes, it fell on the floor, CNA J picked wet wipes off the floor and throw it in the trash can without changing gloves, then picked up a clean brief to put on Resident #90, while repositioning the resident the brief fell on the floor, CNA picked it up and placed on the resident and fastened. In an interview with CNA J on 6/11/25 at 2:50 PM, she said during F/C and incontinent care , she said she was nervous, she had in-service a month ago on 300 hall, she said she forgot to change her gloves and it could lead to cross contamination and infection. Interview on 06/11/25 at 6:05 PM, the DON said the nurse should have sanitized her hands in between each glove changes. She stated not doing so could result in spread of germs and the facility's policy for staff to wash or sanitize hands when going from a dirty to clean surface. She stated staff had been in-serviced on infection control and hand hygiene. She stated if hand hygiene or sanitizing was not performed when going from a dirty to clean surface, it could cause an infection. Record review of the facility's Skills Checklist-Treatment dated 02/19/2025 revealed CNA J demonstrated competency in handwashing. Review of facility policy, titled Hand Hygiene revised 12/2023 revealed Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: Before donning [putting on] sterile gloves after removing gloves .

Based on observation, interview, and record review, the facility failed to store, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen. -The facility did not ensure plates in the kitchen were free of debris. These failures could place residents at risk of cross-contamination and foodborne illness. Findings include: Observation on 5/8/2024 at 11:43 AM revealed all foods were at an appropriate temperature. Two divided plates were observed under the steam table, on a shelf, with a small black substance on them, and one of the divided plates also had a metallic substance on it. The plates were on the top of two stacks of plates which were to be used for serving meals. Photographs were taken. Interview on 5/8/2024 at 11:53 PM with the DM, she said the black debris and metallic substance on two divided plates on the steam table was not appropriate. The DM said the staff should ensure cleanliness while working, and prior to serving any meals. The DM said the reason staff should ensure there was never any debris or other substances on a plate which would be used to serve residents was to avoid cross contamination or bacteria. The DM said the staff should check the plates or other dining items before placing any food on the plates. The DM said the plates were checked after being washed, and so she believed the black debris and metallic substance on the two divided plates came from either the steam table or when foil was taken off a dish coming out of the oven. The DM said the two divided plates were not acceptable for serving food to residents. The DM pulled two stacks of divided plates from the steam table area and took them to the dish washing area to be rewashed and sanitized after the black debris and metallic substance were identified during the survey process. Interview on 5/9/2024 at 11:03 AM with the Admin, he said he expected the kitchen to be cleaned at all times, and any spills or other messes to be cleaned immediately. The Admin said the substances on the two divided plates which were observed on 5/8/2024 during the survey should not have been on the steam table. The Admin said he expected that the plates should be cleaned prior to serving. The Admin said the dietary department was contracted, but the facility was moving to an in-house dietary department in the summer of 2024. The Admin said the staff do not go into the kitchen, but he did and he typically did not have any concerns with the sanitary conditions in the kitchen. Record review of the facility's Ware Washing policy dated 9/2017 revealed a policy statement which read All dishware, and utensils will be cleaned and sanitized after each use. Record review of the facility's Manual Ware Washing policy dated 9/2017 revealed a policy statement which read All cookware, dishware, and service ware that is not processed through the dish machine will be manually washed and sanitized.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 of 8 residents (Residents #12) reviewed for pharmacy services. -The facility failed to dispose of Resident #12's Rivastigmine's patches appropriately. These failures could result in increased side effects and hospitalization . Findings include: Record review of Resident #12's face sheet dated 5/9/24 revealed a [AGE] year-old female who readmitted on [DATE]. Her diagnosis included Alzheimer's disease, cognitive communication deficit, major depressive disorder, anxiety, psychotic disorder, and other reduced mobility. Record review of Resident #12's annual MDS assessment dated [DATE] revealed a BIMS score of 9 out of 15 which indicated moderate cognitive impairment. She required assistance from staff for ADL care. Record review of Resident #12's care plan dated 5/8/24 revealed she had impaired cognitive function/impaired thought processes related to dementia. Her interventions were to administer medications as ordered. Record review of Resident #12's Physician orders revealed an order for Rivastigmine patch 9.5 mg/24 hr apply 1 one time a day for dementia, order date 5/4/24. In an Observation and Interview on 5/7/24 at 8:31 a.m. of Resident #12's room with the Wound Care Nurse revealed there were three light brown patches on the floor with Rivastigmine printed on them. Two patches were undated, and one patch was dated 4/27/24. The Wound Care Nurse placed the patches in a Ziploc bag and said they were for Resident #12's behaviors. Interview on 5/7/24 at 11:04 a.m. the Wound Care Nurse said Rivastigmine patches should be disposed of in the sharps container (a puncture-resistant, leak proof container designed to safely dispose of sharp objects that could potentially cause injury or spread infection). Interview on 5/7/24 at 1:11 p.m. the DON stated patches should be disposed of in the trash. She said they should not be on the floor because it was not a good presentation and did not belong on the floor. She said the patch was not a narcotic and was unsure if it still contained medication. Interview on 5/7/24 at 1:27 p.m. the Administrator said patches should be disposed of in the trash can because of infection control. He said he did not know why the patches were on the floor and nurses were responsible for ensuring they were in the trash. Record review of the facility's Administering Medications policy dated December 2012 read in part, . Medications shall be administered in a safe and timely manner, and as prescribed .

Based on observation, interview, and record review the facility failed to ensure residents were free of any significant medication errors for 1 of 8 residents (Resident #32) reviewed for significant medication errors. -MA N attempted to administer Eliquis 5 mg (a blood thinner) to Resident #32 instead of Eliquis 2.5 mg according to Physician orders. Surveyor intervened. This failure could result in increased side effects and hospitalization . Findings include: Record review of Resident #32's face sheet dated 5/9/24 revealed a [AGE] year-old male who readmitted on [DATE]. His diagnosis included Alzheimer's disease, heart failure, peripheral vascular disease (a common condition in which narrowed arteries reduce blood flow to the arms or legs), and cognitive communication deficit. Record review of Resident #32's quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15 which indicated intact cognition. He required supervision or touching assistance with ADL care. Record review of Resident #32's care plan dated 1/23/24 revealed he was on anticoagulant therapy related to peripheral vascular disease. His interventions were to administer medication as ordered. Record review of Resident #32's Physician Orders revealed an order for Apixaban 2.5 mg give 1 tablet two times a day for prophylactic, order date 5/8/24. Record review of Resident #32's MAR for May 2024 revealed Apixaban 2.5 mg 1 tablet by mouth two times a day for prophylactic was scheduled for 8:00 a.m. and 4:00 p.m. In an Observation and Interview on 5/8/24 at 8:33 a.m. of Resident #32's morning medication pass with MA N revealed she prepared Eliquis (Apixaban) 5 mg (whole tablet), Midodrine 10 mg, and Pantoprazole 40 mg for Resident #32. She locked the medication cart and entered the resident's room. As she prepared to administer the medication to Resident #32 this Surveyor intervened. This Surveyor asked MA N to retrieve the Eliquis (Apixaban) blister pack from the cart. MA N retrieved Eliquis 5 mg (whole tablet) again. She said Oh and then said she did not have Eliquis 2.5 mg on the cart. MA N cut the 5 mg pill in half. MA N said she previously asked another nurse about cutting the pill but then said she would ask the DON. MA N asked the DON for Eliquis 2.5 mg and the DON said she would retrieve it from the emergency pharmacy kit. MA N said when she passed medications she verified the medication name, strength, and resident's name to the system. She said she thought she saw 5 mg on the MAR and was used to the resident receiving the 5 mg. She said Eliquis was a blood thinner and if he received more than prescribed his blood would be thinner than normal and he could die. Interview on 5/9/24 at 11:51 a.m. the DON said it was important for nursing staff to follow physician orders and verify the right medication, dose, time, and protocol for medication pass. She said Eliquis was for DVT (deep vein thrombosis, a condition in which the blood clots form in veins located deep inside the body) and Resident #32 was previously on 5 mg, but it was changed to 2.5 mg twice per day because he was bleeding. She said if he received more Eliquis than prescribed he could have bleeding and bruises. She said the Unit Manager, DON, charge nurse, and the person passing the medication was responsible for accuracy. Record review of the facility's Administering Medications policy dated December 2012 read in part, . Medications shall be administered in a safe and timely manner, and as prescribed .7. The individual administering the medication must check the label to verify the right resident, right medication, right dosage, right time and right method of administration before giving the medication .

Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #74) of 6 residents viewed for infection control. -CNA R did not wear appropriate PPE when providing care to Resident #74 during incontinence care. This failure could place residents and staff at risk for cross-contamination, spread of infection and could potentially affect all others in the building. Findings include: Record review of Resident #74's undated face sheet revealed she was a [AGE] year-old female admitted on [DATE] with an original admitted [DATE]. She had diagnoses of osteomyelitis (bone infection) of right tibia and fibula (lower leg bones), infection following a procedure, non-ST elevation myocardial infarction (heart attack), chronic obstructive pulmonary disease (group of lung diseases that block airflow and make it difficult to breathe), infection and inflammatory reaction due to internal left knee prosthesis (infection and inflammation due to left knee replacement), and sepsis (infection through the body). Record review of Resident #74's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15 which indicated normal cognition. The resident had impairment on both sides of her upper extremities and impairment on one side of her lower extremities. She required substantial/max assist with toileting hygiene, lower body dressing, putting on/taking off footwear, and personal hygiene. She required partial/moderate assistance with showers/baths. She had an indwelling catheter (tube into bladder to drain urine) and was always incontinent of bowel. The MDS had diagnoses listed as acute osteomyelitis (bone infection) of right tibia and fibula (bones of lower leg), infection following a procedure, infection and inflammation due to internal left knee prosthesis. The MDS revealed she had recent knee replacement surgery, had a surgical wound, and was receiving surgical wound care. Record review of Resident #74's care plan dated 12/7/23, revealed a Focus: Resident has a foley catheter (tube into bladder to drain urine) (Initiated: 12/8/23, Revised: 12/8/23). Goal: Resident will be/refrain free from catheter-related trauma through review date (Initiated: 12/8/23, Target: 7/14/24). Interventions: Catheter: Change catheter as indicated. Focus: Resident has potential impairment to skin integrity r/t surgical wound to the LT knee (Initiated: 1/12/24, Revised: 4/4/24). Goal: Will be free from injury through the review date (Initiated: 1/12/24, Target: 7/14/24). Interventions: Observe skin injury for abnormalities, failure to heal, s/sx of infection, maceration (skin breakdown from liquid), etc. and report to MD. Focus: Resident will utilize enhanced Barrier Precautions-at risk for infection r/t Indwelling Medical Device, Wounds (Initiated: 4/9/24, Revised: 4/9/24). Goal: Resident will reduce risk of infection through next review (Initiated: 4/9/24, Target: 7/14/24). Interventions: Sanitize hands before entering and leaving the resident's room. Wear gloves and gown during high-contact care activities for resident with indwelling medical devices, wounds and colonized or infection with a CDC targeted MDRO. Record review of Resident #74's Physician's Progress Notes revealed a note from 4/29/24 that was signed by NP A on 5/2/24 at 1:54pm that read, A [AGE] year-old female with medical history of .left knee prosthetic infection. Status post a left knee revision on 3/20/24 with prosthetic reimplantation complicated with MRSA and now on IV antibiotics .Surgical incisions healing well . Record review of Resident #74's Progress Notes revealed a note on 5/8/24 at 11:41pm by Charge Nurse J that read, Resident has PICC line to right upper arm in place without any s/sx of infection. Vancomycin 500mg is on hold. Resident received meropenem 500mg day 37/42 for osteomyelitis [bone infection]. Foley catheter [tube into bladder to drain urine] care was perform in place . Record review of Resident #74's Physician Orders revealed the following orders from MD A: -FC: Foley Catheter 16 FR 10 cc bulb to bedside drainage, Diagnosis: Neurogenic bladder (lack of bladder control) with urinary retention. Ordered on 4/2/24 at 10:00pm. -PICC to Right arm: Flush each lumen (opening to the PICC line) with 10ml of NS Q shift. Ordered on 4/4/24 at 6:00am. -Monitor surgical site Right tibia and fibula (lower leg bones) .Ordered on 4/3/24 at 2:00pm. -Meropenem Intravenous Solution Reconstituted 500mg, 500mg IV Q12hr. Ordered on 4/3/24 at 3:00pm. In an Observation on 5/7/24 at 7:10am, Resident #74 had an Enhanced Barrier Precautions sign taped to her door with a cart full of PPE outside of her door. The resident was asleep in bed and had a foley bag hanging on the bed. In an Observation and Interview on 5/8/24 at 9:28am, CNA R was observed providing incontinence care and personal care to Resident #74 with gloves on but no gown. CNA R said EBP meant staff have to wear PPE if the resident had a line, foley (line into bladder to drain urine), or wound and they were providing care for the resident. She said the resident had a line for antibiotics and had a foley (line into bladder to drain urine). She said she forgot to wear the PPE and she could get contaminated from the resident or contaminate the resident herself. Interview with the DON on 5/8/24 at 10:37am, she said she expected staff to wear gown and gloves when providing resident care to resident's on EBP. She said it was to prevent contamination from staff to the resident and from the resident to the staff. She said CNA R should have been wearing a gown and she would perform a 1-1 in-service with her. Record review of the facility's policy and procedure on Enhanced Barrier Precautions (effective 4/1/24) read in part: This policy outlines the guidelines and procedures to implement enhanced barrier precautions to prevent the spread of infectious diseases among residents and staff. Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities .EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing. EBP are indicated for resident with any of the following: Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply. Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, Device care or use: central line [deeper, longer IV], urinary catheter [tube into bladder to drain urine], feeding tube [tube into stomach for nutrition], tracheostomy/ventilator [hole in throat for oxygen], Wound care: any skin opening requiring a dressing. Wounds generally include chronic wounds, not shorter-lasting wounds, such as skin breaks or skin tears covered with an adhesive bandage (e.g., Band-Aid) or similar dressing. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers [lack of circulation]. Indwelling medical device examples include central lines [deeper, longer IV], urinary catheters [tube into bladder to drain urine], feeding tubes [tube into stomach for nutrition], and tracheostomies [tube into throat for oxygen]. A peripheral intravenous line (not a peripherally inserted central catheter) is not considered an indwelling medical device for the purpose of EBP .Facilities have discretion on how to communicate to staff which residents require the use of EBP. CMS supports facilities in using creative (e.g., subtle) ways to alert staff when EBP use is necessary to help maintain a home-like environment, as long as staff are aware of which residents require the use of EBP prior to providing high-contact care activities .

Based on observations, interviews, and record review, the facility failed to be equipped to allow residents to call for staff through a communication system which relays the call directly to a centralized staff work area for 1 of 6 residents (Resident #18) reviewed for call lights. -The facility failed to ensure Resident #18's call button by her bed was working. This failure could place residents at risk of injury, pain, and hospitalization . The findings include: Record review of Resident #18's undated face sheet revealed she was a [AGE] year-old female admitted on [DATE] with an original admitted [DATE]. She had diagnoses of cerebral infarction due to occlusion/stenosis of left middle cerebral artery (stroke due to an artery in the brain being clogged), type 2 diabetes (body does not produce insulin or resists it), aphasia (trouble speaking), scabies (contagious, intensely itchy skin condition caused by a tiny, burrowing mite), vascular dementia (problems with reasoning, planning, judgment, memory caused by brain damage from impaired blood flow to brain), repeated falls, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis and numbness after a stroke on the right side), and dysphagia (trouble swallowing). Record review of Resident #18's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 2 out of 15, which indicated severely impaired cognition. She had impairment on one side of her upper and lower extremities and used a wheelchair. According to the MDS the resident was substantial/max assist with toileting hygiene, showers/baths, lower body dressing, and personal hygiene. She was always incontinent of bowel and bladder. The assessment revealed she had open lesions other than ulcers, rashes, or cuts, and was on isolation for active infectious disease. Record review of Resident #18's care plan dated 12/15/22, revealed a Focus: Resident is at risk for falls r/t impaired mobility (Initiated: 1/16/23, Revised: 1/18/23). Goal: Resident will be free of falls through the review date (Initiated: 1/16/23, Target: 6/27/24). Interventions: 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. Focus: Resident has rash (to the back) r/t Dx of scabies (contagious, intensely itchy skin condition caused by a tiny, burrowing mite), isolation in place (Initiated: 4/24/24, Revised: 4/24/24). Goal: Will have no s/sx of infection of the rash through the review date (Initiated: 4/24/24, Target: 6/27/24). Interventions: Avoid scratching and keep hands and body parts from excessive moisture. Observe skin rashes for increased spread or signs of infection. Seek medical attention if skin becomes bloody or infected. Focus: The resident has an ADL self-care performance deficit r/t impaired mobility (Initiated: 12/29/22, Revised: 12/29/22). Goal: Resident will be cleaned, well-groomed, appropriately dressed and weight maintained through next review date (Initiated: 12/29/22, Target: 6/27/24). Interventions: Toilet Use: The resident requires extensive assist x 1 staff participation to use toilet. Bed Mobility: The resident requires extensive assist x 1 staff participation to reposition and turn in bed. Focus: Resident requires isolation due to contact isolation for scabies (contagious, intensely itchy skin condition caused by a tiny, burrowing mite) (Initiated: 4/24/24, Revised: 4/24/24). Goal: Resident will not have any psychosocial concerns and will no longer require isolation within the next 90 days (Initiated: 4/24/24, Target: 6/27/24). Interventions: Assure isolation is time limited. Follow facility isolation policy. Provide for in room visits and activities. Record review of Resident #18's Physician Orders revealed the following orders from MD A: -Contact Isolation Precautions for Scabies (contagious, intensely itchy skin condition caused by a tiny, burrowing mite), every shift for 17 days. Ordered on 4/25/24 at 9:33am. In an Observation of Resident #18 on 5/7/24 at 6:54am, she had a contact isolation sign on her door. She was asleep in bed. Her call light was clipped to her bed and when the button was pushed the light on the wall did not come on and neither did the light outside the door. In an Observation and interview with Resident #18 on 5/8/24 at 9:10am, the call light was still not working. The resident was confused and not able to say how she reached staff if she needed help. Interview with CNA M on 5/8/24 at 9:15am, she said Resident #18 used her call button when she needed to reach staff. She was not aware the call light was not working and said she last checked on her after breakfast and she was fine at that time and did not need anything. The CNA said she checked on residents at least every 2hrs. She also said that leadership checked call bells every day. Interview with LVN L on 5/8/24 at 9:18am, she said Resident #18 calls staff with her call bell. LVN L did not know her call bell was not working. She said she gave her ice at about 7:45am and the resident was ok at that time. She said staff check the call bells daily when they go in at the beginning of the day. She said she was going to put in a request for maintenance to come fix it. LVN L said if the resident did not have a working call bell, lots of things could happen to the resident, including a fall. Interview with the DON on 5/8/24 at 10:50am, she said leadership checked call bells every morning during Angel Rounds. She said they did not check every room but would pick a few call bells randomly to try. She said no one had checked Resident #18's in the last few days. She said if the resident did not have a working call bell the resident could fall, but the resident was total care so she should be checked on at least every 2hrs. Record review of the facility's policy and procedure on Answering the Call Light (revised March 2012) read in part: The purpose of this procedure is to respond to the resident's requests and needs .Demonstrate the use of the call light. Ask the resident to return the demonstration so that you will be sure that the resident can operate the system .Be sure that the call light is plugged in at all times. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. Some residents may not be able to use their call light. Be sure you check these residents frequently. Report all defective call lights to the Nurse Supervisor promptly .

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program for 1 of 8 residents (Resident #12) reviewed for pests, in that: -Resident #12 had one medium sized roach and approximately five small black ants crawling in bed with her. This failure could place residents at risk of residing in an environment with pests. Findings included: Record review of Resident #12's face sheet dated 5/9/24 revealed a [AGE] year-old female who readmitted on [DATE]. Her diagnosis included Alzheimer's disease, cognitive communication deficit, major depressive disorder, anxiety, psychotic disorder, and other reduced mobility. Record review of Resident #12's annual MDS assessment dated [DATE] revealed a BIMS score of 9 out of 15 which indicated moderate cognitive impairment. She required assistance from staff for ADL care. Observation and Interview on 5/7/24 at 8:31 a.m. of Resident #12 revealed she was lying in bed. Resident #12 did not respond to this Surveyor's greeting. There was one roach crawling on the bed sheet near the head of the bed. This Surveyor left the room to alert staff. The Wound Care Nurse returned to the room with this Surveyor and observed approximately five small black ants crawling on the resident's bed sheet. The roach was no longer on the bed but was observed crawling down the call light toward the floor. The Wound Care Nurse stepped on the roach and said the bugs on the bed looked like ants. The Wound Care Nurse said she would notify a CNA to change the bedding and provide care for Resident #12. In an Observation and Interview on 5/7/24 at 8:40 a.m. of Resident #12 in bed revealed small black ants crawling on the sheet. CNA L said the bug looked like an ant and she would wash the resident's bottom to make sure she was clean. Interview on 5/7/24 at 1:11 p.m. the DON said Resident #12 may have had a night snack in her room. She said bugs should not be present in the room or the facility because it was unsanitary, and the resident could get bitten. She said staff conducted room rounds daily and as needed to ensure there were no pests or food crumbs. She said all staff were responsible to report if pests were seen. Interview on 5/7/24 at 1:27 p.m. the Administrator said the facility had a little problem with sugar ants and sometimes the residents left sweets out. He said there was no problem with roaches. He said pest control treated the facility monthly and in an emergency. He said the exterminator treated Resident #12's room (today) and said the bugs were sugar ants. He said it was important that the facility stayed free of pests because he did not want the resident to be bitten or susceptible to infection. He said staff were responsible for checking for pests and sweets that were left out. Record review of the facility's pest control invoice dated 5/7/24 revealed the facility received an emergency service to treat little black ants. Record review of the facility's Pest Control policy dated May 2008 read in part, Our facility shall maintain an effective pest control program . 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents .

Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 11 residents (Resident #1) reviewed for quality of care in that: -The facility failed to transfer Resident #1 to the hospital in a timely manner when resident had an unwitnessed fall on 09/11/2023 at 4:23 a.m. and sustained a head injury. Resident #1 was receiving Eliquis (blood thinner). Resident #1 was not transferred to the hospital until after 8:00 a.m. Resident #1 is scheduled to have surgery on 9/14/23 due to brain bleed. - The facility failed to call 911 services to transport Resident #1 to a higher level of care instead, used their non-emergency transportation to send resident to the hospital. -The NF delayed in calling the physician and sending Resident #6 to a higher level of care to be evaluated when Resident #6 had an unwitnessed fall with head injury on 08/19/2023. -The NF delayed sending CR #7 to a higher level of care when CR #7 had an unwitnessed fall on 08/19/2023 at 6:28am. CR #7 was not sent to the hospital until 12:20pm where it was discovered that CR #7 had a fractured C1 & C2 (neck region). An Immediate Jeopardy (IJ) was identified on 09/14/2023. While the IJ was removed on 09/17/2023, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not IJ due to the facility continuing to monitor the implementation and effectiveness of their corrective systems. This failure could place residents that sustain a fall with head injuries on blood thinners at risk for delayed treatment that could lead to severe injury, intracranial hemorrhage and/or death. Findings Record review of Resident #1 face sheet revealed a [AGE] year-old male admitted to the NF on 12/09/2022. Resident #1 diagnoses included the following: hemiplegia (paralysis that affects one side of the body) & hemiparesis (weakness) following cerebral infarction (disrupted blood to the brain), congestive heart failure (heart does not pump blood as well as it should), atrial fibrillation (irregular heartbeat), cognitive communication deficit (impairment in an individual's mental capacity), muscle weakness, hyperlipidemia (elevated cholesterol), and hypertension (high blood pressure). Record review of Resident #1's MDS dated [DATE] revealed that resident had a BIMS score of 11(signifying mild mental impairment). Further review revealed that resident required limited assistance with bed mobility, transfer, and personal hygiene. Further review revealed that resident required supervision with dressing, eating, and toilet use. Record review of Resident #1s' Physician Orders revealed the following orders: -aspirin oral tablet 325mg give 1 tablet by mouth every 6 hours as needed for pain, order date 08/04/2023, -Eliquis oral tablet 2.5mg give 1 tablet by mouth two times a day for atrial fibrillation, order date 02/17/2023. Record review of Resident #1's MAR for the month of September 2023 revealed the resident was receiving the medication aspirin and Eliquis as ordered by the physician. Record review of Resident #1's Care Plan revealed that resident was care planned for falls dated 02/24/2023 with an intervention to determine possible causative factors and implement interventions. Further review revealed that Resident #1 was care planned for anticoagulant therapy dated 01/31/2023 with interventions that included administer medication as ordered, labs as ordered, reporting abnormal lab results, and report skin abnormalities. Record review of Resident #1's Nursing Progress Notes revealed the following: -dated 09/11/2023 documented by RN A at 5:50 am the following: .Called NF transportation for patient pick up time within 1 to 1.5 hour arrival . -dated 09/11/2023 documented by Unit Manager at 6:28a.m. .This writer making rounds, observed resident sitting in his wheelchair on the side of his bed. Noted with raised area above left eye. Resident verbal and able to express needs at this time. EMS in route for transport to ER. -documented by LVN D on 09/11/2023 at 8:08 am: .Resident left facility via EMS regular transportation with family member .swelling noted left .and skin tear to right knee .resident alert and responsive . LVN D documentation did not specify what he meant when he documented left. Record review of Resident #1's hospital records dated 09/11/2023 [AGE] year-old admitted to the emergency department form NF for fall on Eliquis. Patient reports that he was standing up whenever he slipped on his socks and fell , hitting his head. Did not lose consciousness. Complaining of neck pain and right shoulder pain. Brought to the emergency department via EMS. No interventions prior to arrival. C-collar placed on arrival to the emergency department .CT (computerized x- ray) of the head without contrast was done with the following: Intra orbital (foreign object inside of a space caused by a trauma) hemorrhage (bleeding) in the left orbit with periorbital tissue swelling and mild proptosis .mildly depressed left medial orbital wall fracture .bilateral nasal bone fracture with overlying soft tissue swelling. Further review revealed that severe spinal stenosis secondary to DISH (Diffuse idiopathic skeletal hyperostosis-condition affecting the spine). Plan is tentatively for OR (Operating Room) tomorrow. Interview on 09/13/2023 at 12:55 p.m., RN A said he worked on 09/10/2023 the 6pm-6am shift and was Resident #1's nurse. RN A said he found Resident #1 on the floor in his room at the foot of his bed laying on his right side. RN A said the time was around 4am-5am. RN A said Resident #1 told him that he was trying to transfer himself from his wheelchair to his bed. RN A said he did range of motion on Resident #1 and that he could move his extremities without complaints of pain. RN A said he initiated neuro checks. RN A said Resident #1 told him that he had hit his head. RN A said he did not see any signs of injury such as a knot on the head or any bleeding. RN A said resident was placed back in his wheelchair with the assistance of a CNA who name he could not remember. RN A said he called the family of Resident #1 as well as the doctor who gave the order to send resident to the hospital. RN A said regular transportation was called to transport resident to the hospital instead of 911 services because Resident #1's vital signs was stable, there was no bleeding, and resident was conscious. Further interview with RN A said he was not aware that Resident #1 was receiving the blood thinner Eliquis twice a day. RN A said if a resident experienced a fall with a head injury and receiving blood thinners they should be transported to the hospital immediately for further evaluation because resident could be bleeding internally. Interview on 09/13/2023 at 1:40 p.m., family member of Resident #1 said resident was still at the hospital experiencing bleeding from the brain and that the hospital said they were going to have to do surgery on the neck to relieve some pressure. The family member said Resident #1 was scheduled to have surgery on 09/14/2023 to relieve the pressure. The family member said the NF called her a little after 5:00 a.m. informing her that Resident #1 had fallen. The family member said she made it to the NF around 5:40 a.m. and that Resident #1 was complaining of pain to the right side of his neck and back, and left side of his head. The family member said Resident #1 left side of face was swelling extending to the forehead near the left eye. The family member said there was no sense of urgency to transport Resident #1 to the hospital. The family member said she went to let a male nurse know Resident #1 had swelling to his head. The family member said when the male nurse looked at Resident #1, he admitted resident had swelling to his head and told her that help was on the way. The family member said she then went to the nurse station and spoke to a female nurse asking when Resident #1 was going to be transported to the hospital. The family member said the female nurse told her that she had called transportation and was told that that they were in route to the NF. The family member said it was after 8:00 a.m. when Resident #1 left the NF on the way to the hospital. Interview on 09/13/2023 at 2:02 p.m., the Unit Manager said she worked at the NF from 8am-5pm and had been working at the NF for [AGE] years. The Unit Manager said on 09/11/2023 she arrived at the NF around 7:45 a.m. and began making rounds on the Hallways. The Unit Manager said she saw Resident #1's family member at the nurse station asking when the ambulance was coming to take resident to the hospital because he had experienced a fall in his room. The Unit Manager said when she arrived at Resident #1's room, resident was sitting in his room in his wheelchair. The Unit Manager said Resident #1 was not able to tell her what had happened to him. The Unit Manager said she learned that Resident #1 had fallen on the 10pm-6am shift. The Unit Manager said the nurse on the night shift (10pm-6am) had already given report to the oncoming nurse LVN D who was working the morning shift. The Unit Manger said in the event of an emergency the Nursing staff would call 911 services and not the NF transportation System (non-emergency). An attempted interview and observation on 09/14/2023 at 10:31a.m. with Resident #1 was unsuccessful due to hospital staff informing the surveyor that Resident #1 was in surgery. Interview on 09/14/2023 at 1:17 p.m., the DON said according to the Nursing Progress Notes, Resident #1 was in his wheelchair and tried to transfer on his own to his bed fell and hit his head. The DON said resident was transferred to the hospital and resident family member was with him. The DON said she soke with RN A who said Resident #1 was yelling for help. The DON said when RN A arrived at Resident #1's room, resident was on the floor reporting that he had hit his head. The DON said RN A assessed Resident #1 and done ROM on resident along with offering the resident something for pain. The DON said based on the Nursing documentation, Resident #1 was not in any pain. The DON said she learned later from the hospital that Resident #1 CT scan of the head was positive for hemorrhage. The DON said she informed the Administrator of the hospital findings, and the Administrator called the incident in to the state. The DON said the NF initiated in-service with the staff on fall precautions and abuse and neglect based on the NF policy. The DON said she was aware that Resident #1 was on a blood thinner and was transported to the hospital via the NF transportation. The DON said it was a case by case (pending on the resident (s) level of consciousness, vital signs, pain, distress, etc.) that determined if a resident is sent out by normal transportation or 911 services. The DON said the NF transportation could take up to 1- 2 hours to transport a resident to the hospital. The DON said she was aware that it took the NF almost 4 hours to send resident to higher level of care. The DON said she could not say if the course of action taken regarding Resident #1's unwitnessed fall with a head injury receiving blood thinners was the right course of action and again that it was a case-by-case situation. The surveyor asked the DON what was the NF policy regarding a resident on blood thinners experiencing a fall with head injuries? The DON said she did not know what the NF policy was on falls with head injuries in relation to residents taking anticoagulants/blood thinners and would have to go read it. Further interview with the DON said the NF did not have a policy regarding falls as it relates to blood thinners. Interview on 09/15/2023 at 12:22 p.m., LVN D said she worked the morning shift full time. LVN D said RN A gave her report on 09/11/2023 at 6:30 a.m. LVN D said RN A reported that Resident #1 had fallen in his room. LVN D said she asked RN A if he had called 911 services and RN A said no. LVN D said when she assessed Resident #1, the resident's left eye was swollen, and he had a skin tear to his right knee. LVN D said Resident #1 could not tell her exactly what had happened just that he had fallen on the floor. Resident #6 Record review of Resident #6 face sheet revealed an [AGE] year-old male admitted to the NF on 05/01/2019 with the following diagnoses that included: nontraumatic subarachnoid hemorrhage (bleeding between the brain and the tissue covering the brain-08/25/2023), cerebral infarction (disruption of blood flow to the brain, Parkinson's Disease (disorder that effects movement), contracture (shortening and hardening of the muscles), history of falling, heart failure, hypertension (high blood pressure), hypotension (low blood pressure), dementia (impairment of the brain causing memory loss and judgement), and metabolic encephalopathy (disorder of the brain caused by a chemical imbalance in the blood). Record review of Resident #6's MDS dated [DATE] revealed that resident had a BIMS score of 2 indicating that resident cognition level was severely impaired. Further review revealed that Resident #6 required extensive assistance with bed mobility, transfer, dressing, eating, and total assistance with toileting and personal hygiene. Record review of Resident #6's Care Plan dated 02/24/2023, revealed that resident was being care planned for falls related to poor balance dated 07/04/2023 with an intervention that included keep resident on visible area for close monitor. Record review of Resident #6's Nursing Progress Notes dated 08/19/2023 documented by LVN M at 5:21p.m., revealed in part: .Resident observed on the floor at the top of the 200 hallway. He is observed face down on the floor, in front of his wheelchair. He was assessed for injuries and pain, then assisted back into his wheelchair x 3 staff. He is noted with a small amount of running, bright red blood coming out of his nose, nose pinched together for a few seconds, bleeding stopped, no visible injuries noted. Family member arrived shortly afterward and were informed of the incident and requested an ice pack to apply to his nose. A few minutes later, family member requested would like for resident be transported to the hospital to have a CT SCAN. Regular EMS phoned to transport resident to hospital .5:53pm regular transportation here to transport resident to the hospital per family request . Record review of Resident #6 hospital records dated 08/19/2023 indicated that a CT of the head was done with the following impression: right frontal contusion (injured skin or tissue where blood vessels have burst suddenly) .small volume subarachnoid hemorrhage . Record review of the NF investigation report dated 09/11/2023revealed that Resident #6's CT scan at the hospital showed that resident had a displaced fracture in the right frontal calvarium (skull) with extension into the right orbital (bony space that contains the eyeball) roof. Interview on 09/19/2023 at 1:27 p.m., the RP of Resident #6 said she did not receive a call from the NF regarding resident fall. The RP said when she arrived at the NF, resident had redness, bruising, and swelling to the side of his eye, could not remember which eye it was. The RP said she had to request that Resident #6 be sent out to the hospital. The RP said it took the NF about 30 minutes to transport resident to the hospital. Interview on 09/19/2023 at 2:32 p.m., LVN M said she worked at the NF on weekends part time 6am-6pm shift. LVM M said on 08/19/2023 she was called by RN N telling her that Resident #6 was on the floor and that resident had been placed back in his wheelchair. LVN M said when she saw resident, he was sitting in his wheelchair with blood on the side of his nose as well as on the outside of his nose. LVN M said she pinched resident nostrils and cleaned it with a wet towel and the bleeding stopped. LVN M said she assessed resident for injuries and initiated neuro checks on resident. LVN M said she called the RP and the doctor. LVN M said the RP wanted to send resident out to the hospital. LVN M told the surveyor what all took place around Resident #6 fall on 08/19/2023 was documented in the nurse's notes. LVN M said the last time she received in-service on falls was last week but could not remember the last time she received in- services on unwitnessed falls. Interview on 09/19/2023 at 7:17 p.m., RN N said he observed Resident #6 on hall 200 near his room in the hallway close to the nurse station. RN N said resident was sitting in his wheelchair bleeding from his nostrils with LVN and a CNA standing around resident. RN N said he was trying to stop the bleeding coming from resident nostrils which he was able to stop the bleeding. RN N said Resident #6 was not complaining of pain, but his words were not clear, and that resident spoke in allow tone. RN N said he did not notify the doctor. RN N said he assumed that the primary care nurse called the doctor and the RP. Resident CR #7 Record review of CR #7's face sheet revealed a [AGE] year-old female admitted to the NF on 12/08/2021 diagnoses that included the following: Alzheimer's Disease, nontraumatic subarachnoid hemorrhage from right middle cerebral artery, encephalopathy (brain disease that alters the brain function), dementia (loss of memory and judgement), insomnia (difficulty falling asleep), hypertension (high blood pressure), atrial fibrillation (irregular heartbeat), rheumatoid arthritis(Disorder affecting many joints including the hands and feet), and muscle weakness. Record review of CR #7's x-ray of the spine cervical 2-3 views dated 02/27/2023 impression revealed: mild arthritis and loss of the normal cervical lordosis (condition that pushes the neck further forward than it should be or usually is). Record review of CR #7's MDS dated [DATE] revealed that CR #7 had BIMS score of 5 indicating that CR #7's cognition was severely impaired. Further review revealed that CR #7 required supervision with bed mobility, transfer, eating, and toilet use. Further review revealed that CR #7 required limited assistance with dressing and personal hygiene. Record review of CR #7's Care Plan dated 12/15/2021 and revised 08/28/2023 revealed that resident was being care planned for falls and having an actual fall on 08/19/2023 and revised 08/28/2023 with an intervention that included the following: observe/document/report to MD as needed for s/sx (signs and symptoms): pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation. Further record of CR #7's Care Plan did not reveal that CR #7 was being care planned for or loss of the normal cervical lordosis. Record review of CR #7's Nursing Progress Notes revealed in part: Documented by LVN G on 08/19/2023 at 6:28am .Resident noted lying on floor with blanket and pillow. When asked why she was on the floor, resident replied I am tired and want to sleep here .Resident educated to sleep in bed and not on floor. Resident assisted from floor to bed via staff .Resident resting quietly . Documented by LVN O on 08/19/2023 at 10:24 a.m., revealed in part: .Resident reported to this nurse that she fell on the floor during 10pm-6am shift. Resident is complaining of neck pain, bruises also noted on the left elbow. Resident also reported biting her tongue. NP in the building and notified . At 10:34 a.m. New order for X-ray left elbow, radius and humerus, left shoulder. X-ray called with the x-ray order . Documented by the DON dated 08/19/2023 at 10:52am revealed in part: .Resident was found sleep on the floor next to her bed .now she is complaining of pain .The NP at the facility give new order for place C-collar (cervical/neck brace) send to hospital for fall and c/o neck pain do not move pt/or stand . Documented by LVN O on 09/18/2023 at 12:20pm revealed in part: 911 call placed, EMS and transferred resident to the hospital .C collar in place . Record review of the NF Investigation report dated 08/19/2023 revealed that CR #7 was observed laying on floor, complained of pain, sent to the hospital and MRI revealed that that CR #7 had mildly displaced acute fractures of the anterior arch of C1 and C2. Interview on 09/14/2023 at 10:54 a.m., the hospital staff RNZZ said CR #7 was admitted to the hospital with a cervical fracture on 08/19/2023. RN ZZ said CR #7 was transferred to SICU and later to hospice services. RN ZZ said CR #7 passed away on 08/29/2023. Interview on 09/14/2023 at 12:20 p.m., the Administrator said CR #7 had a fall and was sent to the hospital. The Administrator said it was discovered at the hospital that CR #7 had a neck fracture. The Administrator said while CR #7 was at the hospital she developed pneumonia as well. The Administrator said CR #7 had been placed on in-patient hospice. Interview on 09/18/2023 at 11:23 a.m., LVN G said she worked on 08/19/2023 on the 10pm-6am shift. LVN G said when she arrived at work, CR #7 was sitting in her wheelchair at the front entrance and did not agree to go to bed until 3:00 a.m. LVN G said she made rounds on the residents around 5:00 a.m. and that CR #7 was resting in bed. LVN G said she made her last rounds on the residents at 6:00 a.m., and when she arrived at CR #7's room, CR #7 was on the floor on the left side of her bed wrapped in a blanket with a pillow resting under her head. LVN G said CR #7 said she wanted to lay on the floor. LVN G said she told CR #7 no and that she needed to get back in the bed. LVN G said she checked CR #7 for range of motion with no complaints of discomfort. LVN G said she called for help and that. LVN H with the assistance of the CNA, CR #7 was put back in bed. LVN G said she had been working at the NF for 3 years but practicing as a nurse for 7 months. LVN G said when a resident with confusion was found on the floor and no one know what happened, the course of action to take was to do range of motion assessing for pain. LVN G said she did not do a complete head to toe skin assessment before placing CR #7 back in bed. LVN G said she had been in- serviced on falls and that it was okay to move a resident with an unwitnessed fall after assessing their range of motion. LVN G said it was okay to move a resident that was conscious but not a resident that was unconscious. LVN G said she was not aware of the NF policy on un-witnessed falls. LVN G said she was just trying to keep CR #7 comfortable. LVN G said it was not normal behavior for CR #7 to lay on the floor. Interview on 09/18/2023 at 12:55 p.m., LVN O said she worked the weekend shift 6am-10pm and was the nurse that relieved LVN G on 08/19/2023. LVN O said she had received in report from LVN G letting her know that CR #7 was found on the floor with no injuries and that LVN G had initiated neuro checks. LVN O said when she arrived at CR #7 room, CR #7 was in bed and denied pain. LVN O said she continued the neuro checks per facility protocol and that when she returned to CR #7 room again, CR #7 was complaining of elbow pain. LVN O said she could not remember which elbow it was but noticed a little red bruise to the elbow. LVN O said at this time (could not remember the time), the NP was at the NF. LVN O said later, CR #7 started to complain of pain to her neck. LVN O said the NP assessed CR #7 asking resident to turn her neck, but CR #7 was unable to turn her neck. LVN O said the NP gave orders to place a C collar on resident neck and send to the hospital. Further interview on 09/18/2023 at 12:55 p.m., LVN O said she had been in- serviced on falls to check the resident status of orientation, if confused do not move the resident because resident may have injured themselves. LVN O said resident would be sent to the hospital for further evaluation. Interview on 09/18/2023 at 1:35 p.m., LVN H said she worked the night shift 10pm- 6am full time. LVN H said when CR #7 was found on floor in her room with pillow under head, she assisted LVN G along with the CNA in placing CR #7 back in bed. LVN H said CR #7 did not complain of pain. LVN G said the doctor and RP needed to be notified immediately about a fall witnessed or unwitnessed. Interview on 09/19/2023 at 11:10 a.m., CNA Q said she worked the 10pm-6am shift and was the CAN for CR #7. CNA Q said she was coming up the hallway around 5:45am-6:00am making her last rounds on the resident when she saw the nurse in CR #7 room. CNA Q said when she arrived at CR #7's room, CR #7 was on the floor with her bed in the. CNA Q said CR #7 was asked where she was going but CR #7 could not say. CNA Q said resident was not complaining of pain. CNA Q said right after she assisted with placing CR #7 back in bed, CR #7 began to complain of pain saying that her neck hurt. Record review of the NF Policy on Falls revised September 2012 revealed in part: .The physician will identify medical conditions affecting fall risk and the risk for significant complications of falls ( .increased risk of bleeding in someone taking an anticoagulant) . Record review of the NF Policy on Anticoagulation revised April 2007 revealed in part: The staff and physician will identify and address potential complications in individuals receiving anticoagulation; for example, someone with a fall risk . The Administrator and DON was notified on 09/14/2023 at 1:56 p.m., an Immediate Jeopardy situation (IJ) was identified due to the above failure. The Administrator was provided the IJ template on 09/14/2023 at 1:56 P.M. and a Plan or Removal (POR) was requested. The facility POR was accepted on 09/15/2023 at 10:14a.m. and indicated: PLAN OF REMOVAL F684 Name of facility: Park Manor Cypress Station Date: 09/14/2023 Immediate Action Impact Statement: On 9/14/23 an abbreviated survey was initiated at Park Manor of Cypress Station at 420 Lantern Bend Dr, Houston, Texas 77090. On 9/14/23 the facility was provided notification that the Survey Agency has determined that the conditions at the center constitute Immediate Jeopardy to resident health due to failure to ensure that resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and resident choice. How were other residents at risk to be affected by this deficient practice identified? The facility completed an audit to address all falls in residents on blood thinners in the last 30 days to ensure the residents received treatment and care in accordance with professional standard of practice. All residents on blood thinners that had a fall have the potential to be affected by this deficient practice, no other residents were identified as being affected. What corrective actions have been implemented for the identified resident? Resident with deficient practice was discharged to hospital on 9/11/2023. Nurse on duty received 1:1 in-service on falls in residents receiving anticoagulant medications. What corrective actions were taken? 1. The following actions were initiated immediately on 9/14/23 a. On 9/14/23 an audit was completed by CSD (Clinical Services Director) and/or designee to identify all residents on anticoagulants who had a fall in the last 30 days to ensure these residents received treatment and care in accordance with professional standard of practice. No residents were identified to be affected by deficient practice. b. Director of Nursing was educated on 9/14/23 by Clinical Services Director on process of care for residents on anticoagulants when experience a fall with head injury are sent to a higher level of care for further evaluation via 911 based on resident assessment by licensed nurse. a) Initiated in-services on 9/14/23 with licensed nurses by Director of Nursing /Designee to send residents that are on anticoagulant medications and sustain a head injury to a higher level of care for further evaluation care via 911 based on resident assessment by licensed nurse. Completed by 9/15/2023. Staff unable to come to receive education will not be allowed to provide direct care until training is completed. 2. How will the system be monitored to ensure compliance? b) The Director of Nurses/Administrator will review falls in morning meeting starting on 9/15/23 and ongoing to ensure falls on residents taking anticoagulant medications are appropriately addressed. Any identified concerns will be addressed immediately, and additional training will be provided as needed. c) The weekend supervisor and/or designee was in-serviced on 9/14/23 by Director of Nursing/ Designee on identifying all residents experiencing falls on Saturdays and Sundays and ensure that any resident on anticoagulant medication that experiences a fall with head injury are sent to a higher level of care via 911 based on resident assessment by licensed nurse. d) Newly hired staff and PRN staff will be educated by the Director of Nursing/Designee on residents taking blood thinners that sustain a head injury are sent to a higher level of care for further evaluation care via 911 based on resident assessment by licensed nurse. Completed by 9/15/2023. Staff unable to come to receive education will not be allowed to provide direct care until training is completed. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 9/14/23 with the Medical Director. The Medical Director has reviewed and agrees with this plan that includes the Fall Policy updated with residents on anticoagulant medications will be send via 911 transport based on license nurse assessment. The surveyor confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following: Interview on 09/15/2023 at 12:11 p.m., LVN C who worked the morning shift 6am-2p.m. said she received in-service on falls with head injuries. LVN C said if a resident had a fall with head injuries, she was to call 911 to transport resident to the hospital to be further evaluated. Interview on 09/15/2023 at 12:14 p.m., LVN B who worked the morning shift 6am-p.m. said she had been in-serviced on the following: fall precautions and the new protocol that if resident had a fall with head injuries and on blood thinners, the resident had to be sent to a higher level of care to be further evaluated. LVN B said if the resident denied pain after the fall to continue doing neuro checks per NF protocol. LVN B said if the resident began to show a change in condition with the neuro checks, she was to call the physician and the RP. Interview on 09/15/2023 at 12:22 p.m., LVN D said she worked the morning shift 6am-2pl time. LVN D said she had been in-serviced on that when a resident experience a fall with head injuries and on blood thinners, she had to send resident to the hospital via 911 services. Interview on 09/15/2023 at 4:52 p.m., LVN E said she worked the 2pm-10pm shift full time Monday through Friday. LVN E said she had been in-serviced on falls. LVN E said if a resident fell with head injuries and was taking blood thinners, that resident had to be sent to the hospital via 911 services. Interview on 09/15/2023 at 4:55 p.m., RN F said she worked the 2pm-10pm shift full time. RN F said she had been in-serviced on falls. RN F said if a resident had fallen and hit their head and was taking blood thinners, the resident had to be transported to the hospital via 911 services for further evaluation. Interview on 09/15/2023 at 10:30 p.m., LVN G said she worked the 10pm-6am shift full time. LVN G said she had received in-service on fall precautions, falls with head injuries. LVN G said she was in-serviced to check and see if the resident was on any blood thinners, notify the physician, and RP and send the resident to the hospital via 911 services. Interview on 09/15/2023 at 10:44 p.m., RN A said he had been in-serviced on falls. RN A [NAME] [TRUNCATED]

Based on interview and record review the facility failed to ensure residents have the right to be free from neglect for 3 of 11 residents (Resident #1, Resident # 6, and CR #7) reviewed for neglect in that: -The facility system for obtaining medical care for un-witnessed falls was not effective in protecting the health & safety of residents as follows: -The facility failed to transfer Resident #1 to the hospital immediately when resident had an unwitnessed fall on 09/11/2023 at 4:23 a.m. sustaining a head injury. Resident #1 was receiving the medication Eliquis (blood thinner) and was not transferred to the hospital until 8:00 a.m. Resident #1 is scheduled for surgery on 9/14/23 due to brain bleed. -The NF delayed in calling the physician and sending Resident #6 to a higher level of care to be evaluated when Resident #6 had an unwitnessed fall with head injury on 08/19/2023. -The NF delayed sending CR #7 to a higher level of care when CR #7 had an unwitnessed fall on 08/19/2023 at 6:28am. CR #7 was not sent to the hospital until 12:20pm where it was discovered that CR #7 had a fractured C1 & C2 (neck region). An IJ was identified on 09/21/2023. While the IJ was removed on 09/25/2023, the facility remained out of compliance at a scope of a pattern that is not IJ due to the facility continuing to monitor the implementation and effectiveness of their corrective systems This failure place residents who have unwitnessed falls at risk of increase injury, pain, and death. Findings: Record review of Resident #1 face sheet revealed a 64year old male admitted to the NF on 12/09/2022. Resident #1 diagnoses included the following: hemiplegia (paralysis that affects one side of the body) & hemiparesis (weakness) following cerebral infarction (disrupted blood to the brain), congestive heart failure (when the heart does not pump blood adequately), atrial fibrillation (irregular heartbeat), cognitive communication deficit (impairment in an individual's mental capacity), muscle weakness, hyperlipidemia (elevated cholesterol), and hypertension (high blood pressure). Record review of Resident #1's MDS dated [DATE] revealed that resident had a BIMS score of 11(signifying mild mental impairment). Further review revealed that resident required limited assistance with bed mobility, transfer, and personal hygiene. Further review revealed that resident required supervision with dressing, eating, and toilet use. Record review of Resident #1s' Physician Orders revealed the following orders: -aspirin oral tablet 325mg give 1 tablet by mouth every 6 hours as needed for pain, order date 08/04/2023, -Eliquis oral tablet 2.5mg give 1 tablet by mouth two times a day for atrial fibrillation, order date 02/17/2023. Record review of Resident #1's MAR dated September 2023 revealed that the NF was administering the medication aspirin and Eliquis as ordered by the physician. Record review of Resident #1's Nursing Progress Notes revealed the following: -dated 09/11/2023 documented by RN A at 5:50am the following: .Called NF transportation for patient pick up time within 1 to 1.5 hour arrival . -documented by LVN D on 09/11/2023 at 8:08am: .Resident left facility via EMS regular transportation with family member .swelling noted left .and skin tear to right knee .resident alert and responsive . Record review of Resident #1's hospital records dated 09/11/2023 revealed that a CT (computerized x- ray) of the head without contrast was done with the following: Intra orbital (foreign object inside of a space caused by a trauma) hemorrhage (bleeding) in the left orbit with periorbital tissue swelling and mild proptosis .mildly depressed left medial orbital wall fracture .bilateral nasal bone fracture with overlying soft tissue swelling. Interview on 09/13/2023 at 12:55 p.m., RN A said he worked on 09/10/2023 the 6pm-6am shift and was Resident #1's nurse. RN A said he found Resident #1 on the floor in his room at the foot of his bed laying on his right side. RN A said the time was around 4am-5am. RN A said Resident #1 told him that he was trying to transfer himself from his wheelchair to his bed. RN A said Resident #1 told him that he had hit his head. RN A said he did not see any signs of injury such as a knot on the head or any bleeding. RN A said resident was placed back in his wheelchair with the assistance of a CNA who name he could not remember. RN A said he called the family of Resident #1 as well as the doctor who gave the order to send resident to the hospital. RN A said regular transportation was call to transport resident to the hospital instead of 911 services because Resident #1 vital signs was stable, there was no bleeding, and resident was conscious. Further interview with RN A said he was not aware that Resident #1 was receiving the blood thinner Eliquis twice a day. RN A said if a resident experienced a fall with a head injury and receiving blood thinners should be transported to the hospital immediately for further evaluation because resident could be bleeding internally. Interview on 09/13/2023 at 1:40 p.m., family member of Resident #1 said resident was still at the hospital experiencing bleeding from the brain. The family member said Resident #1 was scheduled to have surgery on 09/14/2023 to relieve the pressure. The family member said the NF called her a little after 5:00 a.m. informing her that Resident #1 had fallen. The family member said she made it to the NF around 5:40 a.m. and that Resident #1 was complaining of pain to the right side of his neck and back, and left side of his head. The family member said Resident #1 left side of face was swelling extending from the forehead near the left eye. The family member said there was no sense of urgency to transport Resident #1 to the hospital. The family member said she went to let a male nurse know Resident #1 had swelling to his head. The family member said when the male nurse looked at Resident #1, he admitted resident had swelling to his head and told her that help was on the way. The family member said she then went to the nurse station and spoke to a female nurse asking when Resident #1 was going to be transported to the hospital. The family member said the female nurse told her that she had called transportation and was told that that they were in route to the NF. The family member said it was after 8:00am when Resident #1 left the NF on the way to the hospital. Interview on 09/13/2023 at 2:02 p.m., the Unit Manager said she worked at the NF from 8am-5pm. The Unit Manager said on 09/11/2023 she arrived at the NF around 7:45am and began making rounds on the Hallways. The Unit Manager said she saw Resident #1 family member at the nurse station asking when the ambulance was coming to take resident to the hospital because he had experienced a fall in his room. The Unit Manager said when she arrived at Resident #1's room, resident was sitting in his room in his wheelchair. The Unit Manager said Resident #1 was not able to tell her what had happen to him. The Unit Manager said she learned that Resident #1 had fallen on the 10pm-6am. The Unit Manager said the nurse on the night shift (10pm-6am) had already given report to the oncoming LVN D who was working the morning shift. The Unit Manger said in the event of an emergency the Nursing staff would call 911 services and not the NF transportation System (non-emergency). Interview on 09/14/2023 at 1:17 p.m., the DON said according to the Nursing Progress Notes, Resident #1 was in his wheelchair and tried to transfer on his own to his bed fell and hit his head. The DON said resident was transferred to the hospital and resident family member was with him. The DON said she spoke with RN A who said Resident #1 was yelling for help. The DON said when RN A arrived at Resident #1's room, resident was on the floor reporting that he had hit his head. The DON said RN A assessed Resident #1 and done ROM on resident along with offering the resident something for pain. The DON said based on the Nursing documentation, Resident #1 was not in any pain. The DON said she learned later from the hospital that Resident #1 CT scan of the head was positive for hemorrhage (bleeding). The DON said she informed the Administrator of the hospital findings, and the Administrator called the incident in to the state. The DON said the NF initiated in-service with the staff on fall precautions, abuse, and neglect based on the NF policy. The DON said she was aware that Resident #1 was on a blood thinner and was transported to the hospital via the NF transportation. The DON said it was a case by case (pending on the resident (s) level of consciousness, vital signs, pain, distress, etc.) that determined if a resident is sent out by normal transportation or 911 services. The DON said the NF transportation could take up to 1- 2 hours to transport a resident to the hospital. The DON said she was aware that it took the NF almost 4 hours to send resident to higher level of care. The DON said she could not say if the course of action taken regarding Resident #1's unwitnessed fall with a head injury receiving blood thinners was right or wrong course of action and again that it was a case-by-case situation. The surveyor asked the DON what was the NF policy regarding a resident on blood thinners experiencing a fall with head injuries? The DON said she did not know what the NF policy was on falls with head injuries in relation to residents taking anticoagulants/blood thinners and would have to go read it. Further interview with the DON said the NF did not have a policy regarding falls as it relates to blood thinners. The DON was asked for the NF Policy on Abuse and Neglect. The NF provided the surveyor a Policy on Abuse Investigation and Report. Interview on 09/15/2023 at 12:22 p.m., LVN D said she worked the morning shift full time. LVN D said RN A gave her report on 09/11/2023 at 6:30 a.m. LVN D said RN A reported that Resident #1 had fallen in his room. LVN D said she asked RN A if he had called 911 services and RN A said no. LVN D said when she assessed Resident #1, resident left eye was swollen and he had a skin tear to his right knee. LVN D said Resident #1 could not tell her exactly what had happened just that he had fallen on the floor. Resident #6 Record review of Resident #6 face sheet revealed an [AGE] year-old male admitted to the NF on 05/01/2019 with the following diagnoses that included: nontraumatic subarachnoid hemorrhage (bleeding between the brain and the tissue covering the brain-08/25/2023), cerebral infarction (disruption of blood flow to the brain, Parkinson's Disease (disorder that effects movement), contracture (shortening and hardening of the muscles), history of falling, heart failure, hypertension (high blood pressure), hypotension (low blood pressure), dementia (impairment of the brain causing memory loss and judgement), and metabolic encephalopathy (disorder of the brain caused by a chemical imbalance in the blood). Record review of Resident #6's MDS dated [DATE] revealed that resident had a BIMS score of 2 indicating that resident cognition level was severely impaired. Further review revealed that Resident #6 required extensive assistance with bed mobility, transfer, dressing, eating, and total assistance with toileting and personal hygiene. Record review of Resident #6's Care Plan dated 02/24/2023, revealed that resident was being care planned for falls related to poor balance dated 07/04/2023 with an intervention that included keep resident on visible area for close monitor. Record review of Resident #6's Nursing Progress Notes dated 08/19/2023 documented by LVN M at 5:21p.m., revealed in part: .Resident observed on the floor at the top of the 200 hallway. He is observed face down on the floor, in front of his wheelchair. He was assessed for injuries and pain, then assisted back into his wheelchair x 3 staff. He is noted with a small amount of running, bright red blood coming out of his nose, nose pinched together for a few seconds, bleeding stopped, no visible injuries noted. Family member arrived shortly afterward and were informed of the incident and requested an ice pack to apply to his nose. A few minutes later, family member requested would like for resident be transported to the hospital to have a CT SCAN. Regular EMS phoned to transport resident to hospital .5:53pm regular transportation here to transport resident to the hospital per family request . Record review of Resident #6 hospital records dated 08/19/2023 indicated that a CT of the head was done with the following impression: right frontal contusion (injured skin or tissue where blood vessels have burst suddenly) .small volume subarachnoid hemorrhage . Record review of the NF investigation report dated 09/11/2023revealed that Resident #6's CT scan at the hospital showed that resident had a displaced fracture in the right frontal calvarium (skull) with extension into the right orbital (bony space that contains the eyeball) roof. Interview on 09/19/2023 at 1:27 p.m., the RP of Resident #6 said she did not receive a call from the NF regarding resident fall. The RP said when she arrived at the NF, resident had redness, bruising, and swelling to the side of his eye, could not remember which eye it was. The RP said she had to request that Resident #6 be sent out to the hospital. The RP said it took the NF about 30 minutes to transport resident to the hospital. Interview on 09/19/2023 at 2:32 p.m., LVN M said she worked at the NF on weekends part time 6am-6pm shift. LVM M said on 08/19/2023 she was called by RN N telling her that Resident #6 was on the floor and that resident had been placed back in his wheelchair. LVN M said when she saw resident, he was sitting in his wheelchair with blood on the side of his nose as well as on the outside of his nose. LVN M said she pinched resident nostrils and cleaned it with a wet towel and the bleeding stopped. LVN M said she assessed resident for injuries and initiated neuro checks on resident. LVN M said she called the RP and the doctor. LVN M said the RP wanted to send resident out to the hospital. LVN M told the surveyor what all took place around Resident #6 fall on 08/19/2023 was documented in the nurse's notes. LVN M said the last time she received in-service on falls was last week but could not remember the last time she received in- services on unwitnessed falls. Interview on 09/19/2023 at 7:17 p.m., RN N said he observed Resident #6 on hall 200 near his room in the hallway close to the nurse station. RN N said resident was sitting in his wheelchair bleeding from his nostrils with LVN and a CNA standing around resident. RN N said he was trying to stop the bleeding coming from resident nostrils which he was able to stop the bleeding. RN N said Resident #6 was not complaining of pain, but his words were not clear, and that resident spoke in allow tone. RN N said he did not notify the doctor. RN N said he assumed that the primary care nurse called the doctor and the RP. Resident CR #7 Record review of CR #7's face sheet revealed a [AGE] year-old female admitted to the NF on 12/08/2021 diagnoses that included the following: Alzheimer's Disease, nontraumatic subarachnoid hemorrhage from right middle cerebral artery, encephalopathy (brain disease that alters the brain function), dementia (loss of memory and judgement), insomnia (difficulty falling asleep), hypertension (high blood pressure), atrial fibrillation (irregular heartbeat), rheumatoid arthritis(Disorder affecting many joints including the hands and feet), and muscle weakness. Record review of CR #7's x-ray of the spine cervical 2-3 views dated 02/27/2023 impression revealed: mild arthritis and loss of the normal cervical lordosis (condition that pushes the neck further forward than it should be or usually is). Record review of CR #7's MDS dated [DATE] revealed that CR #7 had BIMS score of 5 indicating that CR #7's cognition was severely impaired. Further review revealed that CR #7 required supervision with bed mobility, transfer, eating, and toilet use. Further review revealed that CR #7 required limited assistance with dressing and personal hygiene. Record review of CR #7's Care Plan dated 12/15/2021 and revised 08/28/2023 revealed that resident was being care planned for falls and having an actual fall on 08/19/2023 and revised 08/28/2023 with an intervention that included the following: observe/document/report to MD as needed for s/sx (signs and symptoms): pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation. Further record of CR #7's Care Plan did not reveal that CR #7 was being care planned for or loss of the normal cervical lordosis. Record review of CR #7's Nursing Progress Notes revealed in part: Documented by LVN G on 08/19/2023 at 6:28am .Resident noted lying on floor with blanket and pillow. When asked why she was on the floor, resident replied I am tired and want to sleep here .Resident educated to sleep in bed and not on floor. Resident assisted from floor to bed via staff .Resident resting quietly . Documented by LVN O on 08/19/2023 at 10:24 a.m., revealed in part: .Resident reported to this nurse that she fell on the floor during 10pm-6am shift. Resident is complaining of neck pain, bruises also noted on the left elbow. Resident also reported biting her tongue. NP in the building and notified . At 10:34 a.m. New order for X-ray left elbow, radius and humerus, left shoulder. X-ray called with the x-ray order . Documented by the DON dated 08/19/2023 at 10:52am revealed in part: .Resident was found sleep on the floor next to her bed .now she is complaining of pain .The NP at the facility give new order for place C-collar (cervical/neck brace) send to hospital for fall and c/o neck pain do not move pt/or stand . Documented by LVN O on 09/18/2023 at 12:20pm revealed in part: 911 call placed, EMS and transferred resident to the hospital .C collar in place . Record review of the NF Investigation report dated 08/19/2023 revealed that CR #7 was observed laying on floor, complained of pain, sent to the hospital and MRI revealed that that CR #7 had mildly displaced acute fractures of the anterior arch of C1 and C2. Interview on 09/14/2023 at 10:54 a.m., the hospital staff RNZZ said CR #7 was admitted to the hospital with a cervical fracture on 08/19/2023. RN ZZ said CR #7 was transferred to SICU and later to hospice services. RN ZZ said CR #7 passed away on 08/29/2023. Interview on 09/14/2023 at 12:20 p.m., the Administrator said CR #7 had a fall and was sent to the hospital. The Administrator said it was discovered at the hospital that CR #7 had a neck fracture. The Administrator said while CR #7 was at the hospital she developed pneumonia as well. The Administrator said CR #7 had been placed on in-patient hospice. Interview on 09/18/2023 at 11:23 a.m., LVN G said she worked on 08/19/2023 on the 10pm-6am shift. LVN G said when she arrived at work, CR #7 was sitting in her wheelchair at the front entrance and did not agree to go to bed until 3:00 a.m. LVN G said she made rounds on the residents around 5:00 a.m. and that CR #7 was resting in bed. LVN G said she made her last rounds on the residents at 6:00 a.m., and when she arrived at CR #7's room, CR #7 was on the floor on the left side of her bed wrapped in a blanket with a pillow resting under her head. LVN G said CR #7 said she wanted to lay on the floor. LVN G said she told CR #7 no and that she needed to get back in the bed. LVN G said she checked CR #7 for range of motion with no complaints of discomfort. LVN G said she called for help and that. LVN H with the assistance of the CNA, CR #7 was put back in bed. LVN G said she had been working at the NF for 3 years but practicing as a nurse for 7 months. LVN G said when a resident with confusion was found on the floor and no one know what happened, the course of action to take was to do range of motion assessing for pain. LVN G said she did not do a complete head to toe skin assessment before placing CR #7 back in bed. LVN G said she had been in- serviced on falls and that it was okay to move a resident with an unwitnessed fall after assessing their range of motion. LVN G said it was okay to move a resident that was conscious but not a resident that was unconscious. LVN G said she was not aware of the NF policy on un-witnessed falls. LVN G said she was just trying to keep CR #7 comfortable. LVN G said it was not normal behavior for CR #7 to lay on the floor. Interview on 09/18/2023 at 12:55 p.m., LVN O said she worked the weekend shift 6am-10pm and was the nurse that relieved LVN G on 08/19/2023. LVN O said she had received in report from LVN G letting her know that CR #7 was found on the floor with no injuries and that LVN G had initiated neuro checks. LVN O said when she arrived at CR #7 room, CR #7 was in bed and denied pain. LVN O said she continued the neuro checks per facility protocol and that when she returned to CR #7 room again, CR #7 was complaining of elbow pain. LVN O said she could not remember which elbow it was but noticed a little red bruise to the elbow. LVN O said at this time (could not remember the time), the NP was at the NF. LVN O said later, CR #7 started to complain of pain to her neck. LVN O said the NP assessed CR #7 asking resident to turn her neck, but CR #7 was unable to turn her neck. LVN O said the NP gave orders to place a C collar on resident neck and send to the hospital. Further interview on 09/18/2023 at 12:55 p.m., LVN O said she had been in- serviced on falls to check the resident status of orientation, if confused do not move the resident because resident may have injured themselves. LVN O said resident would be sent to the hospital for further evaluation. Interview on 09/18/2023 at 1:35 p.m., LVN H said she worked the night shift 10pm- 6am full time. LVN H said when CR #7 was found on floor in her room with pillow under head, she assisted LVN G along with the CNA in placing CR #7 back in bed. LVN H said CR #7 did not complain of pain. LVN G said the doctor and RP needed to be notified immediately about a fall witnessed or unwitnessed. Interview on 09/19/2023 at 11:10 a.m., CNA Q said she worked the 10pm-6am shift and was the CAN for CR #7. CNA Q said she was coming up the hallway around 5:45am-6:00am making her last rounds on the resident when she saw the nurse in CR #7 room. CNA Q said when she arrived at CR #7's room, CR #7 was on the floor with her bed in the. CNA Q said CR #7 was asked where she was going but CR #7 could not say. CNA Q said resident was not complaining of pain. CNA Q said right after she assisted with placing CR #7 back in bed, CR #7 began to complain of pain saying that her neck hurt. Record revie of the NF Policy on Anticoagulant-Clinical Protocol revised April 2007 revealed in part: .The staff and physician will identify and address potential complications in individuals reveiving anticoagulation . Record review of the NF Policy on Falls revised September 2012 revealed in part: .The physician will identify medical conditions affecting fall risk and the risk for significant complications of falls (for example, increase fracture risk in someone with osteoporosis or increase risk of bleeding in someone taking an anticoagulant). The Administrator was notified on 09/21/00 at 3:04 p.m., an Immediate Jeopardy situation (IJ) was identified due to the above failure. The Administrator was provided the IJ template on 09/21/202300 at 3:04 PM and a Plan or Removal (POR) was requested. The facility POR was accepted on 09/24/202300 at 3:00p.m. and indicated: PLAN OF REMOVAL F600 Name of facility: Park Manor Cypress Station Date: 09/21/2023 Immediate Action Impact Statement: On 9/21/23 the state surveyor entered to continue an abbreviated survey at Park Manor of Cypress Station at 420 Lantern Bend Dr, Houston, Texas 77090. On 9/21/23 the facility was provided notification that the Survey Agency has determined that the conditions at the center constitute Immediate Jeopardy to resident health due to failure of the to ensure each resident was free from neglect. How were other residents at risk to be affected by this deficient practice identified? The facility completed an audit to address all unwitnessed falls in residents with head injury in the last 30 days to ensure the residents received treatment and care in accordance with professional standard of practice. All residents with unwitnessed falls have the potential to be affected by this deficient practice, no other residents were identified as being affected. Audit completed on 9/21/2023 by Director of Nursing. What corrective actions have been implemented for the identified resident? Resident CR # 7 was discharged to hospital on 8/19/2023. Resident #6 readmitted to facility and is in stable condition. Resident #1 readmitted to facility on 9/19/2023 in stable condition and had care plan updated with the fall preventions interventions. Nurses on duty for the above residents received 1:1 in-service by Director of Nursing on unwitnessed fall protocol that included the assessment of resident and following the Care Path Fall Tool attached. CNAs were in-serviced by Director of Nursing on fall protocol that included not to move a resident post fall and to immediately notify the license nurse to assess resident. What corrective actions were taken? 3. The following actions were initiated immediately on 9/21/23 c. On 9/21/23 an audit was completed by the Director of Nursing and/or designee to identify all unwitnessed falls in the last 30 days to ensure these residents received treatment and care in accordance with professional standard of practice. No residents were identified to be affected by deficient practice. d. Director of Nursing was educated on 9/21/23 by Clinical Services Director on signs and symptoms of neglect, reporting neglect, Abuse Coordinator and protocol an unwitnessed fall with/or suspected major/serious injuries are sent to a higher level of care for further evaluation via 911 based on resident assessment by licensed nurse using the Care Path Fall Tool attached. e. Initiated in-services on 9/21/23 with licensed nurses by Director of Nursing /Designee on signs and symptoms of neglect, reporting neglect, Abuse Coordinator, and protocol on unwitnessed fall with major/serious injury will be sent to a higher level of care for further evaluation via 911 based on resident assessment by licensed nurse using the Care Path Fall Tool attached. Completed by 9/22/2023. Staff unable to come to receive education will not be allowed to provide direct care until in-service is completed on signs and symptoms of neglect, reporting neglect, Abuse Coordinator, and protocol on unwitnessed fall with major/serious injury will be sent to a higher level of care for further evaluation via 911 based on resident assessment by licensed nurse using the Care Path Fall Tool attached. Nursing staff was in-serviced on fall interventions on 9/22/2023 by Director of Nursing. Fall interventions are entered for each resident in their care plan that is easily accessible to nurses via PCC care plan tab and for CNAs under Kardex in their POC documentation tool for each resident. Nursing staff was in-serviced on these tools on 9/22/2023 by Director of Nursing. 4. How will the system be monitored to ensure compliance? a. The Director of Nurses/Administrator will review falls in morning meeting starting on 9/22/23 and ongoing to ensure no neglect occurred on unwitnessed falls with/or suspected major/serious injury. Any identified concerns will be addressed immediately, and additional training will be provided as needed. b. The weekend supervisor and/or designee was in-serviced on 9/21/23 by Director of Nursing/ Designee on signs and symptoms of neglect, reporting neglect, Abuse Coordinator, and protocol on unwitnessed fall with major/serious injury will be sent to a higher level of care for further evaluation via 911 based on resident assessment by licensed nurse using the Care Path Fall Tool attached. The Weekend Manager will monitor compliance during Saturdays and Sundays and ensure no neglect occurred on unwitnessed falls with/or suspected major/serious injury. c. Newly hired staff and PRN staff will be educated by the Director of Nursing/Designee on signs and symptoms of neglect, reporting neglect, Abuse Coordinator, and protocol on unwitnessed fall with major/serious injury will be sent to a higher level of care for further evaluation via 911 based on resident assessment by licensed nurse using the Care Path Fall Tool attached. Completed by 9/22/2023. Staff unable to come to receive education will not be allowed to provide direct care until training is completed on signs and symptoms of neglect, reporting neglect, Abuse Coordinator, and protocol on unwitnessed fall with major/serious injury will be sent to a higher level of care for further evaluation via 911 based on resident assessment by licensed nurse using the Care Path Fall Tool attached. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 9/21/23 with the Medical Director. The Medical Director has reviewed and agrees with this plan that includes the Fall Policy updated on neglect policy and fall protocol including unwitnessed falls with/or without injuries. Unwitnessed falls be sent to a higher level of care for further evaluation via 911 based on resident assessment by licensed nurse using the Care Path Fall Tool attached. The surveyor confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following: Interview on 09/24/2023 at 11:36am RN P said she worked the 6am-6pm shift and had been in-serviced on abuse and neglect, falls unwitnessed or witnessed and the resident on anticoagulants that experienced injury especially head injury to send resident out to the hospital via 911 services. Interview on 09/24/2023 at 11:42am LVN RR said she worked at the NF PRN on the 6am- 2pm shift. LVN RR said she had been in-serviced on abuse and neglect, falls assessing residents with witnessed and un-witnessed falls. LVN RR said after assessing the resident and there are complaints of pain do not move the resident, check to see if the resident is on any blood thinners, send to the hospital via 911 for further evaluation, notifying the doctor and the RP. Interview on 09/24/2023 at 11:50am LVN R said she worked at the NF full time 8am-5pm. LVN RR said she had been in-serviced on falls witnessed and unwitnessed to do a head-to-toe assessing for pain or any injuries. LVN R said if the resident hit their head neuro checks had to be initiated per facility protocol. LVN RR said she was in-serviced to check to see if the resident was on any blood thinners and prepare to send the resident to the hospital 911. LVN RR said if an injury is suspected, do not move the resident, and send to hospital 911 for further evaluation being sure to notify the doctor and RP and document all actions taken. Interview on 09/24/23 at 12:00pm CNA S said she worked at the NF full time on the weekends 6am-10pm and had been in-serviced on falls. CNA S said if a resident had fall that was witnessed or un-witnessed do not move the resident and get the nurse right away to assess the resident. Interview on 09/24/2023 at 12:05pm CNA V said she worked the 6am-2pm shift and had been in-serviced on abuse and neglect, falls, not to move the resident but alert the nurse so that the resident could be assessed for any injuries. Interview on 09/24/2023 at 12:08pm CNA K said she worked the 6am-2pm shift on certain days and the 2pm-10pm shift on certain days. CNA K said she had been in-serviced on abuse and neglect, falls, and the prevention of falls (keeping the resident call light in reach). CNA K said if a resi [TRUNCATED]

Based on interview and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accident for 2 of 11 residents (Resident #6 and CR #7) reviewed for accidents in that: -The facility failed to implement Resident #6 care plan to monitor resident to prevent fall from wheelchair developing a right frontal contusion and displaced fracture of the right frontal calvarium (section of the skull). -The facility failed to take proper precautions when CR #7 who x-ray results revealed loss of normal cervical lordosis (improper alignment of the neck) experienced an unwitnessed fall. CR #7 had a fractured C1 & C2 (neck region). An IJ was identified on 09/21/2023. While the IJ was removed on 09/25/2023, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not IJ due to the facility continuing to monitor the implementation and effectiveness of their corrective systems. This failure could place other residents in the NF with unwitnessed falls with injuries at risk for unwanted hospitalization and death. Findings: Resident #6 Record review of Resident #6 face sheet revealed an 86year old male admitted to the NF on 05/01/2019 with the following diagnoses that included: nontraumatic subarachnoid hemorrhage (bleeding between the brain and the tissue covering the brain-08/25/2023), cerebral infarction (disruption of blood flow to the brain, Parkinson's Disease (disorder that effects movement), contracture (shortening and hardening of the muscles), history of falling, heart failure, hypertension (high blood pressure), hypotension (low blood pressure), dementia (impairment of the brain causing memory loss and judgement), and metabolic encephalopathy (disorder of the brain caused by a chemical imbalance in the blood). Record review of Resident #6 MDS dated [DATE] revealed that resident had a BIMS score of 2 indicating that resident cognition level was severely impaired. Further review revealed that Resident #6 required extensive assistance with bed mobility, transfer, dressing, eating, and total assistance with toileting and personal hygiene. Record review of Resident #6 Care Plan revealed that resident was being care planned for falls related to poor balance dated 07/04/2023 with an intervention that included keep resident on visible area for close monitor. Record review of Resident #6 Nursing Progress Notes dated 08/19/2023 documented by LVN M at 5:21pm revealed in part: .Resident observed on the floor at the top of the 200 hallway. He is observed face down on the floor, in front of his wheelchair. He was assessed for injuries and pain, then assisted back into his wheelchair x 3 staff. He is noted with a small amount of running, bright red blood coming out of his nose, nose pinched together for a few seconds, bleeding stopped, no visible injuries noted. Family member arrived shortly afterward and were informed of the incident and requested an ice pack to apply to his nose. A few minutes later, family member requested would like for resident be transported to the hospital to have a CT SCAN. Regular EMS phoned to transport resident to hospital .5:53pm regular transportation here to transport resident to the hospital per family request . Record review of Resident #6 hospital records dated 08/19/2023 that a CT of the head was done with the following impression: right frontal contusion (injured skin or tissue where blood vessels have burst suddenly) .small volume subarachnoid hemorrhage . Record review of the NF investigation report revealed that Resident #6 CT scan at the hospital showed that resident had a displaced fracture in the right frontal calvarium (skull) with extension into the right orbital (bony space that contains the eyeball) roof. Interview on 09/19/2023 at 1:27pm RP of Resident #6 said she did not receive a call from the NF regarding resident fall. The RP said when she arrived at the NF, resident had redness, bruising, and swelling to the side of his eye, could not remember which eye it was. The RP said she had to request that Resident #6 be sent out to the hospital. The RP said it took the NF about 30 minutes to transport resident to the hospital. Interview on 09/19/2023 at 2:32pm LVN M said she worked at the NF on weekends part time 6am-6pm shift. LVM M said on 08/19/2023 she was called by RN N telling her that Resident #6 was on the floor and that resident had been placed back in his wheelchair. LVN M said when she saw resident, he was sitting in his wheelchair with blood on the side of his nose as well as on the outside of his nose. LVN M said she pinched resident nostrils and cleaned it with a wet towel and the bleeding stopped. LVN M said she assessed resident for injuries and initiated neuro checks on resident. LVN M said she called the RP and the doctor. LVN M said the RP wanted to send resident out to the hospital. LVN M told the surveyor what all took place around Resident #6 fall on 08/19/2023 was documented in the nurse's notes. LVN M said the last time she received in-service on falls was last week but could not remember the last time she received in- services on unwitnessed falls. Interview on 09/19/2023 at 7:17pm RN N said he observed Resident #6 on hall 200 near his room in the hallway close to the nurse station. RN N said resident was sitting in his wheelchair bleeding from his nostrils with LVN and a CNA standing around resident. RN N said he was trying to stop the bleeding coming from resident nostrils which he was able to stop the bleeding. RN N said Resident #6 was not complaining of pain, but his words were not clear, and that resident spoke in allow tone. RN N said he did not notify the doctor. RN N said he assumed that the primary care nurse called the doctor and the RP. Resident CR #7 Record review of CR #7 face sheet revealed a 73year old female admitted to the NF on 12/08/2021 diagnoses that included the following: Alzheimer's Disease, nontraumatic subarachnoid hemorrhage from right middle cerebral artery, encephalopathy (brain disease that alters the brain function), dementia (loss of memory and judgement), insomnia (difficulty falling asleep), hypertension (high blood pressure), atrial fibrillation (irregular heart beat), rheumatoid arthritis (disorder affecting many joints including the hands and feet), and muscle weakness. Record review of CR #7's x-ray of the spine cervical 2-3 views dated 02/27/2023 impression revealed: mild arthritis and loss of the normal cervical lordosis (condition that pushes the neck further forward than it should be or usually is). Record review of CR #7's MDS dated [DATE] revealed that CR #7 had BIMS score of 5 indicating that CR #7 cognition was severely impaired. Further review revealed that CR #7 required supervision with bed mobility, transfer, eating, and toilet use. Further review revealed that CR #7 required limited assistance with dressing and personal hygiene. Record review of CR #7 Care Plan dated 12/15/2021 and revised 08/28/2023 revealed that resident was being care planned for falls and having an actual fall on 08/19/2023 and revised 08/28/2023 with an intervention that included the following: observe/document/report to MD as needed for s/sx (signs and symptoms): pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation. Further record of CR #7's Care Plan did not reveal that CR #7 was being care planned for or loss of the normal cervical lordosis. Record review of CR #7's Nursing Progress Notes revealed in part: Documented by LVN G on 08/19/2023 at 6:28am .Resident noted lying on floor with blanket and pillow. When sked why she was on the floor, resident replied I am tired and want to sleep here .Resident educated to sleep in bed and not on floor. Resident assisted from floor to bed via staff .Resident resting quietly . Documented by LVN O on 08/19/2023 at 10:24am revealed in part: .Resident reported to this nurse that she fell on the floor during 10pm-6am shift. Resident is complaining of neck pain, bruises also noted on the left elbow. Resident also reported biting her tongue. NP in the building and notified . At 10:34am New order for X-ray left elbow, radius, and humerus, left shoulder. X-ray called with the x-ray order . Documented by the DON dated 08/19/2023 at 10:52am revealed in part: .Resident was found sleep on the floor next to her bed .now she is complaining of pain .The NP at the facility give new order for place C-collar (cervical/neck brace) send to hospital for fall and c/o neck pain do not move pt/or stand . Documented by LVN O on 09/18/2023 at 12:20pm revealed in part: 911 call placed, EMS and transferred resident to the hospital .C collar in place . Record review of the NF Investigation report dated 08/19/2023 revealed that CR #7 was observed laying on floor, complained of pain, sent to the hospital and MRI revealed that that CR #7 had mildly displaced acute fractures of the anterior arch of C1 and C2. Interview on 09/14/2023 at 10:54am the hospital staff RN-ZZ said CR #7 was admitted to the hospital with a cervical fracture on 08/19/2023. RN ZZ said CR #7 was transferred to SICU and later to hospice services. RN ZZ said CR #7 passed away on 08/29/2023. Interview on 09/14/2023 at 12:20pm Administrator said CR #7 had a fall and was sent to the hospital. The Administrator said it was discovered at the hospital that CR #7 had a neck fracture. The Administrator said while CR #7 was at the hospital she developed pneumonia as well. The Administrator said CR #7 had been placed on in-patient hospice Interview on 09/18/2023 at 11:23am LVN G said she worked on 08/19/2023 on the 10pm-6am shift. LVN G said when she arrived at work, CR #7 was sitting in her wheelchair at the front entrance and did not agree to go to bed until 3:00am. LVN G said she made rounds on the residents around 5:00am and that CR #7 was resting in bed. LVN G said she made her last rounds on the residents at 6:00am and went she arrived at CR #7's room, CR #7 was on the floor on the left side of her bed wrapped in a blanket with a pillow resting under her head. LVN G said CR #7 said she wanted to lay on the floor. LVN G said she told CR #7 no and that she needed to get back in the bed. LVN G said she checked CR #7 for range of motion with no complaints of discomfort. LVN G said she called for help and that LVN H with the assistance of the CNA, CR #7 was put back in bed. LVN G said she had been working at the NF for 3 years but practicing as a nurse for 7 months. LVN G said when a resident with confusion was found on the floor and no one know what happened, the course of action to take was to do range of motion assessing for pain. LVN G said she did not do a complete head to toe skin assessment before placing CR #7 back in bed. LVN G said she had been in- serviced on falls and that it was okay to move a resident with an unwitnessed fall after assessing their range of motion. LVN G said it was okay to move a resident that was conscious but not a resident that was unconscious. LVN G said she was not aware of the NF policy on un-witnessed falls. LVN G said she was just trying to keep CR #7 comfortable. LVN G said it was not normal behavior for CR #7 to lay on the floor. Interview on 09/18/2023 at 12:55pm LVN O said she worked the weekend shift 6am-10pm and was the nurse that relieved LVN G on 08/19/2023. LVN O said she had received in report from LVN G letting her know that CR #7 was found on the floor with no injuries and that LVN G had initiated neuro checks. LVN O said when she arrived at CR #7 room, CR #7 was in bed and denied pain. LVN O said she continued the neuro checks per facility protocol and that when she returned to CR #7 room again, CR #7 was complaining of elbow pain. LVN O said she could not remember which elbow it was but noticed a little red bruise to the elbow. LVN O said at this time (could not remember the time), the NP was at the NF. LVN O said later, CR #7 started to complain of pain to her neck. LVN O said the NP assessed CR #7 asking resident to turn her neck, but CR #7 was unable to turn her neck. LVN O said the NP gave orders to place a C collar on resident neck and send to the hospital. Further interview on 09/18/2023 at 12:55pm with LVN O said she had been in- serviced on falls to check the resident status of orientation, if confused do not move the resident because resident may have injured themselves. LVN O said resident would be sent to the hospital for further evaluation. Interview on 09/18/2023 at 1:35pm LVN H said she worked the night shift 10pm- 6am full time. LVN H said when CR #7 was found on floor in her room with pillow under head, she assisted LVN G along with the CNA in placing CR #7 back in bed. LVN H said CR #7 did not complain of pain. LVN G said the doctor and RP needed to be notified immediately about a fall witnessed or unwitnessed. Interview on 09/19/2023 at 11:10am CNA Q said she worked the 10pm-6am shift and was the CAN for CR #7. CNA Q said she was coming up the hallway around 5:45am-6:00am making her last rounds on the resident when she saw the nurse in CR #7 room. CNA Q said when she arrived at CR #7's room, CR #7 was on the floor with her bed in the. CNA Q said CR #7 was asked where she was going but CR #7 could not say. CNA Q said resident was not complaining of pain. CNA Q said right after she assisted with placing CR #7 back in bed, CR #7 began to complain of pain saying that her neck hurt. Record review of the NF Policy on Quality of Care: Safety and Supervision of Residents revised December 2007 revealed in part: .Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .Resident supervision is a core component of the systems approach to safety . The * Administrator was notified on 09/21/00 at 3:04 p.m., an Immediate Jeopardy situation (IJ) was identified due to the above failure. The *Administrator was provided the IJ template on 09/21/23 at 3:04 PM and a Plan or Removal (POR) was requested. The facility POR was accepted on 09/23/20 at 3:00 PM and indicated: PLAN OF REMOVAL F689 Name of facility: Park Manor Cypress Station Date: 09/23/2023 Immediate Action Impact Statement: On 9/21/23 the state surveyor entered to continue an abbreviated survey at Park Manor of Cypress Station at 420 Lantern Bend Dr, Houston, Texas 77090. On 9/21/23 the facility was provided notification that the Survey Agency has determined that the conditions at the center constitute Immediate Jeopardy to resident health due to failure of the facility of developing and implementing a system ensuring that all nursing staff are in-serviced/trained on the importance of sending a resident to a higher level of care that experience an unwitnessed fall with head injuries via 911. How were other residents at risk to be affected by this deficient practice identified? The facility completed an audit to address all unwitnessed falls in residents with head injury in the last 30 days to ensure the residents received treatment and care in accordance with professional standard of practice. All residents with unwitnessed falls have the potential to be affected by this deficient practice, no other residents were identified as being affected. Audit completed on 9/21/2023 by Director of Nursing. What corrective actions have been implemented for the identified resident? Resident CR # 7 was discharged to hospital on 8/19/2023. Resident #6 readmitted to facility and is in stable condition. Resident's care plan was updated with fall incident and interventions to prevent further falls. Staff were educated on resident's updated plan of care for fall. Nurses on duty for the above residents received 1:1 in-service by Director of Nursing on unwitnessed fall protocol that included the assessment of resident and following the Care Path Fall Tool attached. CNAs were in-serviced by Director of Nursing on fall protocol that included not to move a resident post fall and to immediately notify the license nurse to assess resident. What corrective actions were taken? 5. The following actions were initiated immediately on 9/21/23. f. On 9/21/23 an audit was completed by the Director of Nursing and/or designee to identify all unwitnessed falls in the last 30 days to ensure these residents received treatment and care in accordance with professional standard of practice. No residents were identified to be affected by deficient practice. Residents with falls in the last 30 days had their care plan for fall reviewed for interventions and effectiveness by Director of Nursing/designee on 9/21/2023. g. Director of Nursing was educated on 9/21/23 by Clinical Services Director on the protocol of unwitnessed fall with major/serious injury being sent to a higher level of care for further evaluation via 911 based on resident assessment by licensed nurse using the Care Path Fall Tool attached. h. Initiated in-services on 9/21/23 with licensed nurses by Director of Nursing /Designee on protocol of unwitnessed fall with major/serious injury will be sent to a higher level of care for further evaluation via 911 based on resident assessment by licensed nurse using the Care Path Fall Tool attached. Completed by 9/22/2023. Staff unable to come to receive education will not be allowed to provide direct care until in-service is completed on protocol of unwitnessed fall with major/serious injury will be sent to a higher level of care for further evaluation via 911 based on resident assessment by licensed nurse using the Care Path Fall Tool attached. 6. How will the system be monitored to ensure compliance? a. The Director of Nurses/Administrator will review falls in morning meeting starting on 9/22/23 and ongoing to ensure unwitnessed falls with/or suspected major/serious injury are appropriately addressed. Any identified concerns will be addressed immediately, and additional training will be provided as needed. b. The weekend supervisor and/or designee was in-serviced on 9/21/23 by Director of Nursing/ Designee on identifying all residents experiencing falls on Saturdays and Sundays to ensure that any resident that experiences an unwitnessed fall with major/serious injury will be sent to a higher level of care for further evaluation via 911 based on resident assessment by licensed nurse using the Care Path Fall Tool attached. c. Newly hired staff and PRN staff will be educated by the Director of Nursing/Designee to send residents that experience an unwitnessed fall with/or suspected major/serious injury to a higher level of care for further evaluation care via 911 based on resident assessment by licensed nurse using the Care Path Fall Tool. Completed by 9/22/2023. Staff unable to come to receive education will not be allowed to provide direct care until training is completed on protocol for unwitnessed falls with/or suspected major/serious injury. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 9/21/23 with the Medical Director. The Medical Director has reviewed and agrees with this plan that includes the Fall Policy updated on neglect policy and fall protocol including unwitnessed falls with/or without injuries. Unwitnessed falls will be sent to a higher level of care for further evaluation via 911 based on resident assessment by licensed nurse using the Care Path Fall Tool attached. The surveyor confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following: Interview on 09/24/2023 at 11:36am RN P said she worked the 6am-6pm shift and had been in-serviced on abuse and neglect, falls unwitnessed or witnessed and the resident on anticoagulants that experienced injury especially head injury to send resident out to the hospital via 911 services. Interview on 09/24/2023 at 11:42am LVN RR said she worked at the NF PRN on the 6am- 2pm shift. LVN RR said she had been in-serviced on abuse and neglect, falls assessing residents with witnessed and un-witnessed falls. LVN RR said after assessing the resident and there are complaints of pain do not move the resident, check to see if the resident is on any blood thinners, send to the hospital via 911 for further evaluation, notifying the doctor and the RP. Interview on 09/24/2023 at 11:50am LVN R said she worked at the NF full time 8am-5pm. LVN RR said she had been in-serviced on falls witnessed and unwitnessed to do a head-to-toe assessing for pain or any injuries. LVN R said if the resident hit their head neuro checks had to be initiated per facility protocol. LVN RR said she was in-serviced to check to see if the resident was on any blood thinners and prepare to send the resident to the hospital 911. LVN RR said if an injury is suspected, do not move the resident, and send to hospital 911 for further evaluation being sure to notify the doctor and RP and document all actions taken. Interview on 09/24/23 at 12:00pm CNA S said she worked at the NF full time on the weekends 6am-10pm and had been in-serviced on falls. CNA S said if a resident had fall that was witnessed or un-witnessed do not move the resident and get the nurse right away to assess the resident. Interview on 09/24/2023 at 12:05pm CNA V said she worked the 6am-2pm shift and had been in-serviced on abuse and neglect, falls, not to move the resident but alert the nurse so that the resident could be assessed for any injuries. Interview on 09/24/2023 at 12:08pm CNA K said she worked the 6am-2pm shift on certain days and the 2pm-10pm shift on certain days. CNA K said she had been in-serviced on abuse and neglect, falls, and the prevention of falls (keeping the resident call light in reach). CNA K said if a resident had a fall, she was not to move the resident instead stay with the resident and call for the nurse. CNA K said she had also been in-serviced on going into the computer to look at the resident POC to see what interventions had been put in place to care for the resident needs and follow the interventions. Interview on 09/24/2023 at 12:17pm CNA U said she worked the 6am-2pm and had been in- serviced on that when a resident fall to stay with the resident and call the nurse. CNA U said she had also been in-serviced on abuse and neglect. Interview on 09/24/2023 at 1:05pm CNA X said she worked the 2pm-10pm shift. CNA X said she had been in-serviced on falls and fall risk, keeping the resident's bed in low position, call lights in reach, fall matts on the floor at the bed side. CNA X said if she witnessed a fall or unwitnessed a fall, she was not to move the resident but stay with the resident and call the nurse right away. Interview on 09/24/2023 at 1:33pm CNA I said she worked various shifts pending where the staffing needs were. CNA I said she had been in-serviced on falls witnessed and unwitnessed not to move the resident, stay with the resident and alert the nurse. CNA I said she was also in-serviced that if she was not familiar with the resident care needs, she could look at the resident POC in the computer. Interview on 09/24/2023 at 8:10pm RN A (worked 6pm-6am) said he had been further in- service on falls to assess the resident for injuries and if so, do not to move the resident and call 911 to send the resident out to the hospital right away to be evaluated. Interview on 09/24/2023 at 8:20pm RN F said she worked the 2pm-10pm shift and had been in-serviced on abuse and neglect as well as falls. RN F said she had been further in-serviced on falls that if there were injuries or suspected injuries to not move the resident and call 911 to have resident sent out to the hospital 911. Interview on 09/24/2023 at 8:27pm CNA Y via phone said she worked the 10pm-6am shift and had been in-serviced on abuse and neglect and falls to not move the resident and call the nurse. Interview on 09/25/2023 at 10:30am LPN Z said she worked the 6am-2pm shift and sometimes the 2pm-10pm shift. LPN Z said she had been in-serviced on falls witnessed and un- witnessed. LPN Z said she had also been in-service on how to look on the computer to review the resident (s) plan of care and their interventions. LPN Z said if a resident had a fall, she would assess the resident for injuries, review the resident medications to see if they were on any blood thinners; LPN Z said if the resident had injuries or suspected injuries, she was in- serviced not to move the resident, call 911 to have resident transported to the hospital right away for further evaluation. LPN Z said she had also been in-serviced on abuse and neglect. Interview on 09/25/2023 at 10:36am LVN C said she had been further in-serviced on falls witnessed or unwitnessed assess range of motion. LVN c said if the resident complained of pain, do not move the resident, and arrange to have resident sent to the hospital via 911. Interview on 09/25/2023 at 10:42pm CNA AA said she worked the 6am-2pm shift and that she had received in-service on residents falling and to not leave the resident alone and call the nurse. CNA AA said she had also received in-services on abuse and neglect. Interview on 09/25/2023 at 10:47am CNA CC said she worked the 6am-2pm shift and had been in-serviced on abuse and neglect, falls witnessed and unwitnessed to not move the resident but stay with the resident and call the nurse. Interview on 09/25/2023 at 10:54am CNA DD said she worked the 6am-2pm shift and that she had been in-serviced on fall preventions, keeping the bed in the low locked position with the call light in reach. CNA DD said she had also been in-serviced that if a resident fell , to stay with the resident, don't move the resident and call the nurse. Interview on 09/25/2023 at 11:16am via phone LVN BB said she worked the 6pm-6am shift. LVN BB said she had been in-serviced on falls witnessed and un-witnessed. LVN BB said if the resident had fallen and was alert and oriented able to tell what happened and hit his head, she would not move the resident, checked to see if the resident was on any blood thinners, initiate neuro checks, call the physician and the RP, and prepare to send the resident to the hospital via 911. LVN BB said she had also been in-serviced on abuse and neglect and who to report it to which was the Administrator. Interview on 09/25/2023 at 11:30am CNA FF via phone said she worked the 10pm-6am shift. CNA FF she had been in-serviced on abuse and neglect and to report to the Administrator. CNA FF said she was in-serviced on falls when a resident had a fall to not move the resident and call foe the nurse. CNA FF said she had been in-serviced on fall preventions by keeping the resident bed in a low position with call light in reach. On 09/25/2023 at 12:26 p.m., the Administrator, Clinical Service Director was informed that the IJ was removed, however, the facility remained out of compliance at a scope of a isolated and severity of actual harm that is not IJ as the facility was continuing to monitor the implementation and effectiveness of their plan of removal.

Based on observation, interview and record review, the facility failed to provide food that was palatable, and at a safe and appetizing temperature for 3 of 5 residents reviewed for food temperature. The facility failed to provide food that was palatable for 3 of 4 (R#2 #3,#4) residents served (Regular,) at 2 of the 3 meals observed. The facility failed to have sufficient staff to deliver meals to the resident rooms in the required time frame. These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss. The findings included: Electronic Record Review of Resident #2 face sheet dated 7.27.21, revealed an [AGE] year-old admitted to the facility on [DATE] with a primary diagnosis revealed unspecified dementia (unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. Record Review of Resident #2 Annual MDS dated 8.4.23 (BIMS -11) revealed a BIMS (Moderately Impaired Cognition) score of 11. Record Review of Resident #4 face sheet reveal she was admitted [DATE] and readmitted [DATE]. Record Review of Annual MDS dated 8.2.23 revealed a BIM score of 15 (Cognitive Intactness). Record Review of Resident #3 face sheet dated 5.31.22 Record Review of Resident #3's Annual MDS dated 6.9.23 revealed BIM Score of 5 (Severe Cognitive Impairment). Observations revealed the facility's mealtime posting, which is visible on the nurse's station located in the entrance areas for all visitors and residents to see, Breakfast at 7am; Lunch at 12:00PM and Dinner at 5PM. There are 4 resident hallway living areas. The postings in each hallway, 100, 200, 300 and 400 revealed, Mealtimes, Breakfast at 7:10am, Lunch at 12:10pm, and Dinner at 5:10PM. Observation on 9/13/2023 at 12:24 p.m., the Dining Tray delivered to conference room for staff. The menu was meat loaf, potatoes and gravy and carrots. The meat loaf's temp was taken using the Investigator's temperature gauge and it was 70 degrees, potatoes were a little warm and cooked carrots were cool to the taste. Observation on 9/14/23 at 7:10AM,. some residents were seated in the dining area, while staff was entering with other residents. At 7:25am, an intercom message for all staff to assist with residents in the dining room. At this time, a kitchen employee emerged from the kitchen area with the tray stands with trays. The DON was assisting with placing trays on the tables where residents were seated. There were another staff person doing the same. Observation on 9/14/23 at 7:30AM, observed trays on the 100-resident hallway corridor. The administrator along with another employee were passing the trays out to the rooms. Observation and interview on 9/14/23 At 7:50AM, Resident #3 was not eating her Oatmeal, Eggs & Toast. She stated the entire meal was cold and she could not eat it. She stated the Kitchen area is nasty. Stated by time you send your plate back to the kitchen when the staff return its almost the next feeding schedule. She stated sometimes she just has to accept what she gets since this facility is her only option. Observation on 9/14/23 at 7:57AM, this surveyor observed trays still on the cart in the 400- hallway corridor to be passed out. The Administrator arrived and began passing trays to residents who were in their room waiting for their breakfast meal. Observation and interview on 9/14/23 at 8:00AM, Resident #4 lifted the cover from the top of her plate. She had just received her tray. Resident #4 was served Grits and Coffee, this surveyor observed both, the grits and coffee, to be cold, which was confirmed by the resident. Resident #4 put a piece of butter on the grits, and it did not melt. This surveyor felt the outside of the coffee cup and it was not warm. Resident #4 said, this is the norm most times, but there is nothing you can do. The resident stated complaining does not help and complaints just goes on death ears. Observation on 9/14/23 at 12:00PM of the kitchen area, the dietary manager was asked to test the food on the serving table. The initial test revealed the following: Lasagna 192.9 degrees Green beans 181 degrees Puree green beans 145 degrees Mash potatoes 120 degrees Gravy 134 degrees Potato salad 44.4 degrees Puree bread 92.7 The dietary manager was asked to ensure the gravy was at the correct temperature along with the lasagna and green beans. The second test revealed the following: Lasagna at 145 Green Beans 145 Mash Potatoes at 130 Puree at 140 (green Beans) The dietary manager was asked a third time to address the food temperature for the Mashed Potatoes, which she did, and the final temperature was 150 degrees. The Dietary Manager revealed if the food on the stream table was at least 135 degree it was acceptable. She was asked to produce the dining/nutrition policy. The noon meal was served in the dining room at approximately 12:44PM. Observation and interview on 9/14/23 at 12:46PM, the Dietary Manager delivered the test tray as requested, the tray had Lasagna, drinks and salad was served. Green Beans were not on the tray and when asked, the dietary manager indicated the green beans was for residents with a special diet. The dietary manager was asked to observe as this surveyor tested the temperature of the lasagna with thermometer. this surveyor asked the dietary manager what the results of the food temperature revealed, and she responded, 100 degrees. The dietary manager reiterated the food on the steam table is supposed to be at least 135. She further stated it (Lasagna) drops temps when you cut into it. This surveyor asked if each resident should have food that is warm like everyone else. She stated she don't know anything about that, she just knows that food temperature drops when it is cut and leave the serving line. She states the dining room is fed first and then the residents in their room are fed. When asked if she feels it is right for the people in their rooms to receive often cold food, she refused to answer. Dietary Manager stated she did not know what the policy said about the food temperature. Observation on 9/17/2023 at 12:10PM, this surveyor observed dining room residents' meal beginning to be served. There are 4 hallways with residents who eat in their rooms. The 300-hallway had the first cart of trays delivered at 12:37PM. 100-hallway had the tray cart delivered at 12:40pm. The 400-hallway tray cart was delivered at 1:00PM. Lastly, the 200-hallway tray cart was delivered at 1:05PM. The cart is placed in the front of the hallway for staff to take plates off and deliver it to the resident's room. Observation on 9/18/23 at 12:40PM, 100 Resident Hall trays delivered 12:38PM; 400 Resident Hall trays delivered at 12: 40PM; 300 Resident Hall trays delivered 12:42PM; 200 Resident Hall trays delivered at 12:51pm. Observation revealed the facility's mealtime posting, which is visible on the nurse's station located in the entrance areas for all visitors and residents to see, Breakfast at 7am; Lunch at 12:00PM and Dinner at 5PM. There are 4 resident hallway living areas. The postings in each hallway, 100, 200, 300 and 400 revealed, Mealtimes, Breakfast at 7:10am, Lunch at 12:10pm, and Dinner at 5:10PM. Interview on 9/13/2023 at 10:50AM, Resident #2- Stated he has been at the facility for 2 years. Resident states she has complained about her Food. She says her cold food is served warm and warm food is served cold. She states she does not eat in the dining area. She said the staff leaves the tray at the end of the hallway and by time they serve me the food it is not at an adequate temperature. She states the workers are not wearing, gloves or hairnets. Resident #2 states in the morning her coffee is cold, and they don't give her sugar or cream, the grits are cold and there is no butter. She says she has made several unsuccessful attempts to call ombudsman office. She's left messages and no one responds. Interview on 9/14/23 at 1:05 PM, the DON stated that there have been complaints/grievances from residents regarding the temperature of the food. She stated the residents who eat in their rooms are fed after the dining room residents. She stated all the residents should have food that has an adequate temperature. She stated if a resident's food is not warm enough, they can ask staff (CNA) to return their plate to kitchen, then the food is warmed up by microwave and brought back to them. The DON was unable to say how long this process would take. Interview on 9/17/2023 at 1:18 PM, CNA A stated she has been working here at the facility for almost a year. She states she is a staffing coordinator, and she coordinates the CNA's schedule for supervision in each hallway. She states there are times when residents complain about their food not being warm enough. She states that whenever a tray is delivered to A room and the patient or resident does not like the food temperature then the staff returned the tray immediately and having warmed up and take him back to the patient for their approval. She states missus manner is sometimes difficult however she is a resident and staff will accommodate her. She states miss manner refuses showers which is documented by the CNA's. Interview on 9/18/2023 at 11:15AM, the Dietary Manager stated the residents eat 7:00am, 12:00pm and 5:00pm. She stated there are schedules posted in the hallways for the residents who eat in their rooms. Those posted times are 7:10am. 12:10pm and 5:10pm. She stated she and the Administrator was discussing the issues regarding trays getting residents who are eating in their rooms. She states there is a feeding time of 1 1/2hours for all residents. When asked for the documentation in policy, she stated there is no documentation or policy to support the feeding timeline. Interview on 9/18/2023 at 11:32AM, the Dietary District Manager, stated he is contracted through the facility. Therefore, he nor the dietary manager is directly employed by the facility. Dietary District Manager stated the contracted He states the dietary department is contracted through his company. Dietary District Manager states the times for resident feeding are 7am, 12, and 5pm. States the facility in conjunction with the healthcare services group agree on the time; however, the ultimate decision for the feeding schedule is up to the facility. Dietary District Manager stated Dietary is ready at the posted times but must wait for facility staff members assigned to specific hallways to come into the dining areas to assist with placing trays on the table. Some of the staff are also required to feed the residents. He states if there is a waiting period it's because there isn't enough staff in the dining area, which is based on facility management and not dietary services. Interview on 9/18/2023 at 12:52PM, CNA J said she works 400-hall. She stated sometimes she gets complaints from residents because food is cold. She stated the afternoon trays are typically delivered between 1:00pm -1:15pm. Record Review revealed of the Resident Nutrition Services policy (Revised 9/2017). According to the policy, #5 states, To minimize the risk of foodborne illness, the time that potentially hazardous foods remain in the danger zone (41F to 135F) will be kept to a minimum. Foods that are left without a source of heat (for hot foods) or refrigeration (for cold foods) longer than 2 hours will be discarded.

Based on interview, and record review, the facility failed to provide pain management consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 8 residents (Resident #3) reviewed for pain management, in that: Resident #3 had a fall and complained of pain which was not effectively monitored or managed. She was not provided pain medications for 2 days and X-ray results indicated a fractured rib. This failure could affect all residents who require pain management. Findings include: Resident #3 Record review of Resident #3's face sheet dated 2/27/20 revealed a [AGE] year-old female admitted to the facility on [DATE] and discharged on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #3's pain assessment dated [DATE] revealed no pain was indicated. Record review of Resident #3's admission MDS dated [DATE] revealed a BI[CONDITION] score of 8 indicating moderate cognitive impairment. She required limited assistance of one staff for ADLs and extensive assistance of one staff for toileting. She was coded as using a wheelchair and walker for ambulation. She was not coded as having pain. She had a recent fall prior to admission. Record review of Resident #3's care plan dated 1/15/20 revealed she was at risk for falls. The goal was she would be free of falls. Interventions including anticipating and meeting her needs and ensuring the call light was within reach. Record review of Resident #3's Nursing Note dated 1/20/2020 at 10:57am revealed Nurse informed by Therapy Director that resident was on floor. Nurse entered room, res sitting on floor with SLP sitting in room. Nurse asked res what happened, res stated I was trying to open my blinds, but I didn't lock my wheels. Nurse assessed res, no injuries noted. Neuro's in place, NP notified, DON notified, RP number not working. Record review of Resident #3's Nursing Note dated 1/20/2020 revealed Resident stated she had a fall in her private bathroom, she did not fall against anything, she just hit the floor. Complained of pain to her left flank, Physician notified, ordered x rays to left pelvis and lumbar spine. Mobile X Ray called and reported to complete x rays ordered. Record review of Resident #3's physician order [REDACTED]. Record review of Resident #3's radiology report dated 1/20/20 revealed No acute fracture or dislocation. There was a handwritten note that the physician was notified on 1/22/20. Record review of Resident #3's fall investigation worksheet dated 1/20/20 revealed she had an unwitnessed fall around 4pm in her bathroom. She required supervision, did not call for help, and did not use an assistive device. The physician and family were notified. Pain was not indicated. The summary revealed Due to investigation details it was found that the resident was attempting to self-ambulate into the bathroom, legs became weak and resident sat on the floor. Resident able to make needs known, resident interviewed and verbalized, I was walking to the bathroom and my legs gave out and I sat on the floor. Resident immediately assessed, no injuries noted, c/o pain to left side. MD notified received order for x-ray to lumbar. X-ray negative. Neuro checks initiated. Educated resident to call for assistance when needed, resident verbalized understanding. Facility will continue to monitor for safety needs at this time. Record review of Resident #3's care plan revealed both of her actual falls on 1/20/20 were care planned and indicated there was no injuries. Interventions included monitoring for pain. Record review of Resident #3's speech therapy daily treatment note dated 1/21/20 revealed Patient was seen for skilled speech therapy services to improve cognitive communication deficits. Patient was alert but complaining of pain on left side. Record review of Resident #3's daily skilled nurse's note dated 1/21/20 revealed her pain was rated as a 5 from 1/20/20 at 4pm. Record review of Resident #3's physician orders [REDACTED]. Record review of Resident #3's MAR indicated [REDACTED]. Record review of Resident #3's speech therapy daily treatment note dated 1/22/20 revealed Patient stated that she was feeling pain on her left side but had recently received first dose of pain medication. Record review of Resident #3's daily skilled nurse's note dated 1/22/20 revealed her pain was rated as a 5 from 1/20/20 at 4pm. Record review of Resident #3's speech therapy daily treatment note dated [DATE] revealed Patient was alert but complaining of pain on left side of hip. Record review of Resident #3's radiology report dated [DATE] revealed There is an acute-appearing [MEDICAL CONDITION] 8th rib posteriorly. There was a handwritten note that the physician was notified on 1/24/20 by LVN #S. Record review of Resident #3's daily skilled nurse's note dated 1/24/20 revealed her pain was rated as a 0 at 1:15pm. Record review of the facility's provider investigation report dated 1/24/20 revealed Resident #3 had an unwitnessed fall on 1/20/20. An x-ray was ordered and came back negative. After complaints of pain another x-ray was ordered on [DATE] which showed a fractured rib. No treatment was provided. [MEDICATION NAME] was ordered for pain management. Record review of Resident #3's MAR indicated [REDACTED]. At 11:45 am her pain was rated as a 5 and [MEDICATION NAME] was administered. Record review of Resident #3's daily skilled nurse's note dated 1/25/20 revealed her pain was rated as a 0 at 8:22am. Record review of Resident #3's MAR indicated [REDACTED]. Record review of Resident #3's physician orders [REDACTED]. Record review of Resident #3's MAR indicated [REDACTED]. Record review of Resident #3's physician orders [REDACTED]. Record review of Resident #3's MAR indicated [REDACTED]. Record review of Resident #3's TAR dated January 2020 revealed on [DATE] she had no documented pain and the second shift did not record her pain. Record review of Resident #3's TAR dated January 2020 revealed on 1/28/20 her pain was recorded as a 5 on the first two shifts. Record review of Resident #3's MAR indicated [REDACTED]. Record review of Resident #3's TAR dated January 2020 revealed on 1/29/30 she had no documented pain and the second shift did not record her pain. Record review of Resident #3's TAR dated January 2020 revealed she had no documented pain and the second shift did not record her pain. Record review of Resident #3's MAR indicated [REDACTED]. During an interview on 2/27/20 at 12:55pm, LVN #S said Resident #3 had two falls on 1/20/20. She said the first fall happened on her shift when she slid out of her wheelchair. She said Resident #3 did not complain of pain. She said the second fall happened on the night shift in her restroom. She said she believed Resident #3 hit her rib on the sink. She said whenever Resident #3 complained of pain she contacted the doctor and got an order for [REDACTED].>During a follow-up interview on 2/27/20 at 1:40 pm, when asked if there were any new orders following the identification of the fracture, LVN #S said she did not believe so. When asked if Resident #3 was sent out to the hospital she said she did not believe so. During an interview on 2/27/20 at 2:00 pm, Corporate Nurse said Resident #3 never pointed out where the pain was, so they guessed and did the hip x-ray. She said Resident #3 did not complain of pain, but when in therapy was noted to have pain to that area so another X-ray was ordered. During an interview on 2/27/20 at 2:12pm the Unit Manager said daily skilled nurse's notes should have pain for the day of the note. During an interview on 2/27/20 at 5:18 pm, the Speech Therapist said she saw Resident #3 for a couple of weeks for cognitive communication. She said on 1/21/20 Resident #3 complained of pain to left side. She said, I documented and reported to the nurse. She said she was unable to recall which nurse she informed of Resident #3's pain. When asked when she informed the nurse of Resident #3's pain, she said at least the 21st and 23rd. She said the nurse said she would follow through. During an interview on 2/28/20 at 1:55 pm, when asked what her expectations were for residents who complain of pain the DON said the resident should be assessed and asked if they want pain medication. If the resident refused the medications it should be documented. She said the physician should also be made aware. Record review of the facility's pain management policy dated April 2009 revealed Assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain.

Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choice for 1 of 8 residents (Resident #5) reviewed for quality of care. The facility staff (RN #1) failed to seek prompt medical intervention when Resident #5 continued to complain of shortness of breath and shaking after a breathing treatment. Resident # 5 called 911 and was transferred to hospital where she was diagnosed with [REDACTED]. The facility failed to monitor Resident #5's oxygen saturation after being readmitted from the hospital with a new order for continuous oxygen. The facility failed to ensure Resident #5 received oxygen per the physician's orders [REDACTED]. The facility failed to have evidence indicating monitoring of Resident #5's oxygen saturation was implemented every shift per the physician's orders [REDACTED].>These failures could affect any resident with a change in condition. Resident #5 Record review of Resident #5's face sheet dated [DATE] revealed a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #5's significant change in status MDS dated [DATE] revealed a BI[CONDITION] score of 10 indicating moderate cognitive impairment. She required limited to extensive assistance of 1 to 2 staff for ADLs. She used a wheelchair for ambulation. Shortness of breath was not coded, but she was coded as being on oxygen therapy. Record review of Resident #5's undated care plan revealed Resident #1 has a behavior problem related to calling 911. The only intervention was anticipate and meet the resident's needs. Further review revealed she had oxygen therapy related to shortness of breath. Interventions included observing for signs and symptoms of respiratory distress and report to the physician as needed and administering oxygen per the physician order. During an interview on [DATE] at 2:16 pm LVN B said she was responsible for the 400 hallway. She described Resident #5 as really anxious. She said Resident #5 sometimes complained of pain or shortness of breath and was recently put on continuous oxygen. Record review of Resident #5's physician order [REDACTED]. Record review of Resident #5's respiratory TAR dated revealed on [DATE] a [MEDICATION NAME]-[MEDICATION NAME] Solution XXX,[DATE].5 (3) MG/3ML was administered and signed off at 6:48 pm. Documented respirations were 20. Record review of Resident #5's Nursing Note dated [DATE] revealed Resident complaint of shortness of breath, nurse performed an assessment , lung sounds clear all lobes, oxygen saturation at 96% room air and no episode of anxiety noted. Resident insisted on a breathing treatment, nurse provided as needed breathing treatment, saturation improved to 100% RA, Resident continued to complain of shortness of breath and shaking. The note was signed by RN #A at 7:14 PM. Record review of Resident #5's Nursing Note dated [DATE] revealed Resident called 911, E[CONDITION] transportation at facility, resident insisted on going to the hospital, Resident is her own RP. The note was signed by RN #A at 7:54 PM. During an interview on [DATE] at 2:32 pm, RN #A said he was a PRN nurse at the facility. He said on [DATE] Resident #5 was complaining of shortness of breath and shaking. He said her oxygen saturation was around 98% and her lungs were clear. She requested a breathing treatment, so he administered it. He said, She's always quick to call 911 and called 911 herself who showed up ,[DATE] minutes after the breathing treatment. When asked why 911 or the physician were not called after symptoms were still present he said Resident #5 had no signs of being short of breath or respiratory distress. He said The shaking to me wasn't evidence of shortness of breath, to me it was a show. She wasn't cold. The shakiness to me didn't make any sense. When asked if the physician was contacted he said, I believe I left a message that the patient was transferred to the hospital but he Never received a call back. When asked when an SBAR should be completed, he said In the event of an incident. When asked if he completed an SBAR he said, I don't remember. When asked if he took vitals before and after the treatment he said he believed he documented them in the nurse's note. Record review of Resident #5's clinical chart revealed there was no SBAR for the incident on [DATE]. Record review of Resident #5's hospital records revealed she was admitted [DATE] from the emergency department and discharged [DATE] back to the facility. It revealed she had acute [MEDICAL CONDITION] with hypoxic and hypercapnia (inadequate Oxygen supply to body tissues and hypercapnia (buildup of carbon [MEDICATION NAME] in the bloodstream) that was compensated, treated for [REDACTED]. During an interview on [DATE] at 1:33pm, the DON said in the case of changes in a resident's respiratory condition the nurse should do an assessment which included checking the vital signs, administering any PRN orders for oxygen, and calling the resident's physician immediately. She said before and after administering a breathing treatment the nurse should check and document the respirations, pulse, lungs, and oxygen saturation. She said if the resident was still in distress, the doctor or 911 should be called. During an interview on [DATE] at 1:34 pm, the Unit Manager said she was responsible for halls 100 and 200 but had been managing all the halls for one month. She said if a resident was having trouble breathing they should be assessed, their oxygen saturation should be checked, and the physician should be contacted. She said Resident #5 had a history of [REDACTED]. Record review of Resident #5's E[CONDITION] report dated [DATE] revealed they arrived on the scene at 7:39 pm. She was breathing rapidly. Her blood pressure was ,[DATE], pulse was [AGE], respiratory rate was 26, and oxygen saturation was [AGE]%. She was transferred to the emergency room . During an interview on [DATE] at 12:35 pm, Resident #5's family member said she was breathing funny on [DATE] and called another family member. Resident #5 requested that the family member call 911, because facility staff refused to call for her. She said Resident #5 complained of shortness of breath several times prior and facility staff always tell her she had to call 911 herself. Record review of Resident #5's consolidated physician orders [REDACTED]. - oxygen at 3L/minute via nasal cannula continuously ordered dated [DATE] - oxygen at 2L/minute via nasal cannula continuously ordered dated [DATE] -O2 saturations every shift and as needed ordered [DATE] Record review of Resident #5's respiratory TAR dated [DATE] revealed oxygen was administered continuously 3L/minute via nasal canula from [DATE] - [DATE] and 2L/minute starting [DATE]. There were check marks which meant administered but the actual volume was not being documented. Record review of Resident #5's Nursing Note dated [DATE] revealed Skilled nurse arrived to patient's room at or around 11:20am. Upon arrival patient was sitting up in wheelchair at bedside with oxygen in place at 2 liters. Skilled nurse voiced to patient that I was coming to check her blood sugar. Skilled nurse noted patient had her head down and did not respond. Skilled nurse stayed with patient and yelled for house sup as she rushed to patients to assist. Skilled nurse noted patient cool, clammy and very diaphoretic. Skilled nurse performed fingerstick and blood sugar was 170, blood pressure was ,[DATE], R 12 and O2 sat were [AGE]% with 2 liters nasal cannula and T-96.6. Skilled nurse was assisted by several staff members to transfer patient to a flat surface and during transport patient stopped breathing and patient had no rise or fall to chest and no pulse found. At 11:23am, CPR was initiated, and AED was applied to patient's chest and staff cleared as instructed by AED to analyze for shock and no shock was advised and E[CONDITION] called and notified CPR in progress. Family was also notified at or around 11:25am. At 11:27am E[CONDITION] and (fire department) arrived to facility and took over progression of patient emergent care and departed facility at or around 11:40am. Skilled nurse notified medical transport team of all events. Skilled nurse called (physician) at 11:42am and notified DON at or around 11;45am. Administrator notified by facility secretary. Resident returned to the facility the same day . Record review of Resident #5's respiratory TAR dated February 2020 received on [DATE] revealed oxygen saturation missing for the following dates: - ,[DATE] - evening and night shifts - ,[DATE] - night shift - ,[DATE] - evening and night shifts - ,[DATE] - evening shift - ,[DATE] - evening shift - ,[DATE] - evening shift - ,[DATE] - evening shift - ,[DATE] - evening shift - ,[DATE] - evening shift - ,[DATE] - evening shift - ,[DATE] - evening shift - ,[DATE] - evening shift - ,[DATE] - evening shift - ,[DATE] - evening shift - ,[DATE] - evening shift Further review revealed her oxygen saturation ran between ,[DATE]. During an interview on [DATE] at 12:53 pm LVN D said the respiratory therapists are responsible for getting O2 sat and documenting them on the respiratory TAR. During an interview on [DATE] at 1:40 pm, the Corporate Nurse said nurses were responsible for documenting O2 sat every shift for residents who require continuous oxygen. She said the respiratory therapists have their own case load they monitor which was extra monitoring. During an interview on [DATE] at 1:45 pm, the Respiratory Director said when residents were admitted to the facility that required respiratory services she would be alerted by the admissions department and she would ensure the resident had the necessary supplies. She said she was responsible for checking on the respiratory residents, their O2 sat, and documenting the actual volume on the respiratory TAR when she was in the facility. She said nurses were responsible for documenting O2 sat if respiratory was not in the facility. Observation and interview on [DATE] at 12:53pm revealed Resident #5 sitting in her wheelchair with oxygen on 4L. LVN D was sitting behind the nurse's station. When asked for Resident #5's orders for oxygen she began searching in the computer. She said Resident #5's oxygen order was 2L. She said the respiratory therapists were responsible for getting O2 sat and documenting them on the respiratory TAR. She said that it was wrong but would check with the Respiratory Director who had just walked passed Resident #5's room. She returned and said she confirmed with the Respiratory Director that the order is for 2L/minute. She reduced the oxygen from 4L to 2L. During an interview on [DATE] at 1:45 pm, the Respiratory Director said she usually arrived around 8 am and started rounding around that time. She said she checked the levels of residents on oxygen once a day during her rounds and as needed. When asked who was responsible for ensuring the oxygen was on the correct level, she said everyone was responsible. When asked what time she saw Resident #5 she said she went into her room around 9 am and she was in bed with oxygen on in bed 2L. She said she asked Resident #5 if she needed a breathing treatment and she declined. Record review of the facility's policy regarding change in condition dated [DATE] revealed Our facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition. Further review revealed the charge nurse was responsible for informing the attending physician/on-call physician when there was a significant change in condition and a comprehensive assessment would be completed.

Based on observation, interview and record review, the facility failed to develop and/or 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 3 of 20 Residents (CR #93, #88, and #41) reviewed for comprehensive care plans, in that: CR #93's fall prevention interventions were not person centered to include close monitoring and supervision . CR #93 had a fall 10 days after his admission to the facility and sustained a head injury requiring sutures and re- fractured his hip requiring surgical revision of hip replacement. Resident #88's care plan did not include interventions for his grooming and personal hygiene . Resident #41 care plan did not include interventions for her significant weight loss. These failures affected one former resident and two current residents , placing them at risk of their needs not being met, and decline in health. Findings include: CR #93 Record review of CR #93's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. disturbance, [MEDICAL CONDITION], hypertension, gastro-[MEDICAL CONDITION] reflux disease (GERD), muscle weakness, abnormalities of gait and mobility, and lack of coordination. Record review of CR #93's Fall Risk assessment dated [DATE] revealed he was a moderate fall risk. Record review of CR #93's admission MDS dated [DATE] revealed Brief Interview of Mental Status (BIMS) score of 7 indicating severe cognitive impairment. Further review of the MDS revealed resident needed extensive assistance by one person for transferring and he needed limited assistance ambulating on and off unit with the assist of one person. Resident used mobility devices of wheel chair and walker. CR#93's MDS revealed he had a fall before admission resulting in serious injury and had a fall since admission with no injuries. Record review of CR #93's care plan dated 9/18/19 revealed he had an actual fall with minor injury, cognitive impairment, unsteady gait. His interventions included: check range of motion, check vital signs. Take blood pressure lying, sitting, standing X1 in first 24 hour, continue interventions on the at-risk plan, for no apparent acute, determine and address causative factor of the fall, neuro checks as indicated, observe/document/report to MD as needed for signs/symptoms: pain bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation, pharmacy consult to evaluate medications, post fall intervention, determine possible causative factors and implement proper interventions, physical therapy/occupational therapy consult for strength and mobility. Further review of CR#93's care plan dated 9/18/19 revealed no intervention indicating CR#93 required close supervision and monitoring to prevent subsequent falls. Record review of CR #93's assessments revealed his Fall Risk Assessment, Pain Assessment in Advanced Dementia, and Falls Investigation worksheet completed on 9/18/19 were all struck out for incorrect documentation. Record review of CR #93's nurses notes dated 9/18/19 at 6:18AM was struck out on 10/8/19 for incorrect documentation. The struck-out note read, Resident was found in his room sitting on the floor by phlebotomist at 2:30AM. By the time phlebotomist notified the nurse and all return to resident room, resident is sitting on the chair in his room. RN observed skin tear to the right shin. Resident stated he wanted to take a walk around the room when he lost his balance and fell . Assessment was done. Cleanse right shin and applied dry dressing. Neurological assessment initiated. Resident in the room sleeping and closely monitored. Endorse the next shift in a stable condition. Record review of CR #93's nurse notes dated 9/26/19 at 2:11PM revealed, Around 1:40PM I was called to resident room. Upon entrance resident was observed laying on the left side of bed on his right side on top his floor mat and wheel chair positioned next to it. Resident had a gash of 0.5cm long with excessive serious drainage. Four staff members assisted in putting resident to bed from floor and pressure dressing was placed to resident's forehead. Unit Manager was notified, whom assessed resident and called ambulance company to take resident to hospital. Unit Manager attempted to call resident responsible party but was unsuccessful. Resident left unit on stretcher accompanied by 2 attendants to hospital. Record review of the facility's provider investigation report for CR #93's incident dated 9/26/19 at 1:45PM revealed his functional ability was extensive assistance and he required no special supervision. The resident was listed as not independently ambulatory and did not have the capacity to make informed decisions. Further review of the report revealed in part, .Resident was found by CNA on his floor mat near his bed. CNA immediately went to get the nurse. Nurse completed head to toe assessment. resident sustained [REDACTED]. Resident complained of pain to his right leg . EMS arrived and transported resident to the hospital. Resident wheeled himself to his room and does so frequently, staff encouraged him to remain in high visibility area. Resident had his call light in place and call light was not on. Resident is encouraged to utilize call light at any time when needing assistance. Record review of CR #93's incident report dated 9/26/19 at 2:52PM and revised on 10/7/19 at 10:21AM revealed, 1:45PM - Entered residents' room after morning CNA reported that he was on the floor. She stated when she left the room he was sitting in his wheel chair. Resident was found lying on his right side facing his bed, lying on top of his floor mat. Once he was turned on his back there was a large amount of red serous drainage coming from his right eyebrow draining down his cheek onto the floor. Site cleansed with soap and water. Small laceration above the right eye measuring 0.5cm long X 0 width. Pressure dressing applied to site, however resident was holding his left wrist, when asked if he hurt his wrist, he replied no its my leg. When his leg was assessed he did complain of pain when we attempted to sit him up. Report further revealed it was determined the resident was transferring to bed without assistance from staff and he required total dependence. Record review of CR #93's care plan dated 9/26/19 revealed fall with injury. Intervention was send to ER for evaluation. Record review of CR #93's hospital discharge summary revealed he was admitted on [DATE] and his discharge [DIAGNOSES REDACTED]. His hospital course revealed he was presented to the hospital after a fall and revealed in part, . (1) Acute displaced [MEDICAL CONDITION] femoral diaphysis (peri - prosthetic fracture) due to ground level fall, (2) Status - post ORIF right femur and revision right total hip arthroplasty on 9/27, (3) Facial Laceration due to ground level fall . (11) Leukocytosis, possibly stress related, resolved, (12) Chronic dementia without behavioral disturbance . Interview on 10/10/19 at 3:40PM, CR #93's RP said she was upset about CR #93's fall and said the staff at the facility did not do what they were supposed to prevent his fall or injuries. The RP said she was told by the resident (CR #93) that he had rolled out of his bed. She said the resident bed was supposed to be in a low position with fall mats either on both sides of his bed or have his bed pushed up against the wall because the facility had only one fall mat on the floor only protecting him from the floor on one side of the bed. The RP said she was told by the nursing staff they would put his bed against wall since there was only one mat but never did move the bed. The RP said she was concerned the fall precautions were not in place because of the resident's injuries (gash to forehead and broken hip). She said she was told by the doctors at the hospital the resident had to fall with a hard impact to sustain his injuries which caused her to believe the bed was not low. The RP also explained that when the resident got to the hospital the bandage on his forehead had dried clotted up blood under the bandage the facility had applied and said the hospital staff implied the resident had been bleeding for a while before he arrived at the ER. The RP said that also made her think the resident had been on the floor bleeding for a while before he was found. The RP was told by the surveyor that the facility's documentation about the incident implied the resident was not in bed during the fall but in his chair transferring to his bed when he fell . The RP said that would also mean the facility was not following fall precautions because the resident was not supposed to be left in his room alone when he was up in his wheel chair. The RP said the resident had dementia and would forget he could not walk anymore, so he would try and get up on his own causing him to fall. The RP said the resident had been in therapy getting better but said he was just getting to the point where he could walk using walker with assistance from therapy. Interview on 10/11/19 at 2:58 PM, the DON said she was in her office on 9/26/19 when she was alerted that CR #93 had fallen and was bleeding from his head. She said when she entered the room the blood had already been cleaned up and the nurse was applying pressure to the area. She said the resident did complain of pain to his leg. The staff immediately called 911 because he had hit his head and was on anticoagulants. Later that night she said she said she was informed he had sustained a fracture, so she called the administrator and notified him. The DON said she had not spoken with the family after the incident and was not aware of any concerns the family had about the fall. The DON said the resident had fallen two days after he was admitted which is when they care planned him for falls and put fall interventions in place that included low bed, falls mats, and they had discussed moving his bed against the wall but had not been done yet.She added it was reported the resident had fallen on 9/18/19 and when the nurse went down to the room the resident had gotten himself up into the chair in his room. She agreed the resident admitted to the facility following a fall at home with fracture that required surgery . The DON said the resident required close supervision and monitoring by staff . Resident #88 Record review of Resident #88's face sheet revealed he was an [AGE] year old male that was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Record review of Resident #88's MDS dated [DATE] revealed he had a BIMS of 5 indicating severely impaired cognition . Resident #88 required limited assistance of one-person assistance for personal hygiene. Record review of Resident #88's care plan dated 09/05/18 revealed no ADL care plan for the resident's grooming and personal hygiene. Record review of Resident #88's ADL's care sheet revealed Resident #88 did not have documented nail care on 10/9, 10/10, and 10/11/19. Observation on 10/08/19 at 9:32 AM revealed Resident #88 was sitting in recliner chair watching television. Resident #88's had Untrimmed finger nails, with black substance under finger nails. Observation on 10/08/19 at 2:30 PM revealed Resident #88 was sitting in recliner chair watching television. Resident # 88 's finger nails were long and had black substance underneath the nails. Observation and interview on 10/11/19 at 2:42 PM revealed Resident #88 said he would allow RA #1 to trim his finger nails. In an interview on 10/11/19 at 2:30 PM Resident #88 stated he trimmed his nails himself sometimes, but he did not have anything to trim them with . He further said staff do not ask to help him trim his nails. In an interview on 10/11/19 at 2:40 PM, RA #1 stated the aides and nurses trim Resident #88's finger nails but sometimes he refuses. She said she will trim his nails. In an interview on 10/11/19 at 3:08 PM , LVN #8 stated the aides and the nurses are responsible for doing nail care for Resident #88. Sometimes he refuses. Some days he allows staff to do his nails. In an interview on 10/11/19 at 3:17 PM, LVN #3 stated the aides and nurses do nail care on residents. Resident #88 will not let staff cut his nails at times. In an interview on 10/11/19 at 3:54 PM CNA #14 stated staff did nail care as needed. In an interview on 10/11/19 at 3:56 PM CNA #3 stated she does nail care on shower days and as needed. In an interview on 10/11/19 at 3:58 PM RA#1 stated the aides complete nail care PRN, during shower days, or if nails are long, staff just cut and clean the nails. In an interview on 10/11/19 at 4:03 PM , the MDS Nurse stated the care plans are a group effort. The wound care nurse, social worker, unit managers were all involved in care plan development. She said she was not aware that Resident #88 's ADL care plan was incomplete and did not have interventions. The nail care should have been care planned. Resident #41 Record review of Resident #41 face sheet revealed an 71year old female admitted to facility on 08/12/19 and again on 10/01/19 with the following diagnoses; acute kidney failure, urinary tract infection, pneumonia,[MEDICAL CONDITIONS] embolism, cerebral infarction, [MEDICAL CONDITION] and [MEDICAL CONDITION] affecting the left side, contracture of left knee, muscle wasting and atrophy, [MEDICAL CONDITIONS], type 2 diabetes, hypertension, heart failure, gastro-[MEDICAL CONDITION] reflux disease, dysphagia, dyspnea, and cognitive communication deficit. Record review of Resident #41 admission MDS (Minimum Data Set) dated 08/19/1910/08/19 revealed a BIMS (Brief Interview for Mental Status) score of 12 indicating moderately impaired cognition. Record review revealed that Resident # 41 required extensive assistance with toileting and personal hygiene. Record review revealed that Resident #41 range of motion was impaired to the left upper and lower side. Further record review revealed that resident weight was 166 lbs. (pounds). Record review of Resident #41 MDS dated [DATE] revealed a weight of 142lbs. Further review revealed that the MDS was coded 0 (zero) signifying that resident weight had no weight loss of 5% or more in the last month of 10% or more in last 6 months. Record review of Resident #41 Physician Order dated 10/08/19 revealed a regular diet pureed texture, nectar consistency, requires 1:1 supervision during meals for nutrition/poor appetite. Record review of Resident #41 Comprehensive Care Plan did not reveal a care plan for weight loss Record review of Resident #41 Weekly Weights for (MONTH) revealed the following: 8/12/19: 166.4 lbs. 8/19/19: 157.4 lbs. 8/26/19: 154.8 lbs. Record review of Weekly Weights for Resident #41 for (MONTH) revealed the following: 9/3/19: 147.2 lbs. 9/10/19: 146.6 lbs. 9/16/19: 136.0 lbs. 9/23/19: 140.2 lbs. Record review of Resident #41 Weights Summary revealed a weight of 142lbs on 10/10/19. Record review of the Nutrition Progress Notes dated 10/08/19 revealed in part: .Resident readmitted from hospital to skill care .weight continues to decline with non- significant weight loss -3.5% times 30 (thirty) days .po intake and appetite is very poor,<25% of all meals, resident is receiving pureed/nectar diet texture and consistency with 1:1 feeding supervision .due to poor po intake and appetite, resident is at greater risk for significant weight loss .continue to recommend other means of nutrition and PEG placement . Interview on 10/11/19 at 11:00 a.m. with the DON asking why was Resident #41 not care planned for weight loss? The DON said the reason why was because the weight loss may have been resolved. The DON said she would have to look. The DON said it was the Unit Managers on each hall who were responsible for making sure the care plans were addressing each resident need as well as implementing them. Interview on 10/11/19 at 11:12 a.m. with LVN #17 said it was the responsibility of licensed nursing staff to develop care plan for a triggered significant change such as poor dietary intake, weight loss, or if the resident had to transferred to a higher level of care due to a change in condition. LVN #17 said when Resident #17 returned from the hospital on [DATE], she did not see an improvement in resident health. LVN #17 said Resident #41 still had a poor PO intake. LVN #17 said Resident #41 poor PO intake along with weight loss had been discussed in the morning meetings. Interview on 10/11/19 at 4:30 p.m. with the MDS Coordinator said the resident care plans are done with a team effort that consisted of the Unit Managers as well as the Wound Care Nurse but not the nurses on the unit. Record review of the facility Policy on Care Plans-Comprehensive read in part . The Comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS. Assessments of the residents are ongoing and care plans are revised as information about the resident's condition change .

Based on interview and record review, the facility failed to ensure each resident received adequate supervision and assistance to prevent accidents for one of 20 residents (CR #93) reviewed for accidents and hazards, in that: CR#93 was admitted to the facility following hip surgery after he fell and sustained a [MEDICAL CONDITION] at home was not provided adequate and effective intervention to prevent subsequent falls. CR #93 who required visual monitoring for falls was not adequately monitored to prevent a fall he sustained while transferring himself from his wheel chair to bed alone in his room. CR#93 sustained a head injury requiring sutures and a re-[MEDICAL CONDITION] requiring revision to total hip replacement from the fall. These failures affected one closed record and placed current facility residents in need of monitoring at risk of injuries from falls. Findings included: CR #93 Record review of CR #93's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. disturbance, [MEDICAL CONDITION], hypertension, gastro-[MEDICAL CONDITION] reflux disease (GERD), muscle weakness, abnormalities of gait and mobility, and lack of coordination. Record review of CR #93's Fall Risk assessment dated [DATE] revealed he was a moderate fall risk. Record review of CR #93's admission MDS dated [DATE] revealed Brief Interview of Mental Status (BIMS) score of 7 indicating severe cognitive impairment. Further review of the MDS revealed resident needed extensive assistance by one person for transferring and he needed limited assistance ambulating on and off unit with the assist of one person. Resident used mobility devices of wheel chair and walker. CR#93's MDS revealed he had a fall before admission resulting in serious injury and had a fall since admission with no injuries. Record review of CR #93's care plan dated 9/18/19 revealed he had an actual fall with minor injury, cognitive impairment, unsteady gait. His interventions included: check range of motion, check vital signs. Take blood pressure lying, sitting, standing X1 in first 24 hour, continue interventions on the at-risk plan, for no apparent acute, determine and address causative factor of the fall, neuro checks as indicated, observe/document/report to MD as needed for signs/symptoms: pain bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation, pharmacy consult to evaluate medications, post fall intervention, determine possible causative factors and implement proper interventions, physical therapy/occupational therapy consult for strength and mobility. Further review of CR#93's care plan dated 9/18/19 revealed no intervention indicating CR#93 required close supervision and monitoring to prevent subsequent falls. Record review of CR #93's assessments revealed his Fall Risk Assessment, Pain Assessment in Advanced Dementia, and Falls Investigation worksheet completed on 9/18/19 were all crossed out for incorrect documentation. Record review of CR #93's nurses notes dated 9/18/19 at 6:18AM was crossed out on 10/8/19 for incorrect documentation. The crossed out note read, Resident was found in his room sitting on the floor by phlebotomist at 2:30AM. By the time phlebotomist notified the nurse and all return to resident room, resident is sitting on the chair in his room. RN observed skin tear to the right shin. Resident stated he wanted to take a walk around the room when he lost his balance and fell . Assessment was done. Cleanse right shin and applied dry dressing. Neurological assessment initiated. Resident in the room sleeping and closely monitored. Endorse the next shift in a stable condition. Record review of CR #93's nurses notes dated 9/18/19, 9/19/19, and 9/20/19 revealed resident was monitored for falls and his safety was maintained. Record review of CR #93's nurses notes dated 9/21/19 at 10:12AM revealed, resident monitored for fall risk, nursing interventions applied: bed lowered, call light in reach, and c/o pain. Record review of CR #93's nurse notes dated 9/26/19 at 2:11PM revealed, Around 1:40PM I was called to resident room. Upon entrance resident was observed laying on the left side of bed on his right side on top his floor mat and wheel chair positioned next to it. Resident had a gash of 0.5cm long with excessive serious drainage. Four staff members assisted in putting resident to bed from floor and pressure dressing was placed to resident's forehead. Unit Manager was notified, whom assessed resident and called ambulance company to take resident to hospital. Unit Manager attempted to call resident responsible party but was unsuccessful . Record review of CR #93's incident report dated 9/26/19 at 2:52PM and revised on 10/7/19 at 10:21AM revealed, 1:45PM - Entered residents' room after morning CNA reported that he was on the floor. She stated when she left the room he was sitting in his wheel chair. Resident was found lying on his right side facing his bed, lying on top of his floor mat. Once he was turned on his back there was a large amount of red serous drainage coming from his right eyebrow draining down his cheek onto the floor. Site cleansed with soap and water. Small laceration above the right eye measuring 0.5cm long X 0 width. Pressure dressing applied to site, however resident was holding his left wrist, when asked if he hurt his wrist, he replied no its my leg. When his leg was assessed he did complain of pain when we attempted to sit him up. Report further revealed it was determined the resident was transferring to bed without assistance from staff and he required total dependence. Record review of the facility's provider investigation report for CR #93's incident dated 9/26/19 at 1:45PM revealed his functional ability was extensive assistance and he required no special supervision. The resident was listed as not independently ambulatory and did not have the capacity to make informed decisions. Further review of the report revealed in part, .Resident was found by CNA on his floor mat near his bed. CNA immediately went to get the nurse. Nurse completed head to toe assessment. resident sustained [REDACTED]. Resident complained of pain to his right leg . EMS arrived and transported resident to the hospital. Resident wheeled himself to his room and does so frequently, staff encouraged him to remain in high visibility area. Resident had his call light in place and call light was not on. Resident is encouraged to utilize call light at any time when needing assistance. Record review of CR #93's care plan dated 9/26/19 revealed fall with injury. Intervention was send to ER for evaluation. Record review of CR #93's hospital discharge summary revealed he was admitted on [DATE] and his discharge [DIAGNOSES REDACTED]. His hospital course revealed he was presented to the hospital after a fall and revealed in part, . (1) Acute displaced [MEDICAL CONDITION] femoral diaphysis (peri - prosthetic fracture) due to ground level fall, (2) Status - post ORIF right femur and revision right total hip arthroplasty on 9/27, (3) Facial Laceration due to ground level fall . (11) Leukocytosis, possibly stress related, resolved, (12) Chronic dementia without behavioral disturbance . Interview on 10/10/19 at 3:40PM, CR #93's RP said she was upset about CR #93's fall and said the staff at the facility did not do what they were supposed to prevent his fall or injuries. The RP said she was told by the resident (CR #93) that he had rolled out of his bed. She said the resident bed was supposed to be in a low position with fall mats either on both sides of his bed or have his bed pushed up against the wall because the facility had only one fall mat on the floor only protecting him from the floor on one side of the bed. The RP said she was told by the nursing staff they would put his bed against wall since there was only one mat but never did move the bed. The RP said she was concerned the fall precautions were not in place because of the resident's injuries (gash to forehead and broken hip). She said she was told by the doctors at the hospital the resident had to fall with a hard impact to sustain his injuries which caused her to believe the bed was not low. The RP also explained that when the resident got to the hospital the bandage on his forehead had dried clotted up blood under the bandage the facility had applied and said the hospital staff implied the resident had been bleeding for a while before he arrived at the ER. The RP said that also made her think the resident had been on the floor bleeding for a while before he was found. The RP was told by the surveyor that the facility's documentation about the incident implied the resident was not in bed during the fall but in his chair transferring to his bed when he fell . The RP said that would also mean the facility was not following fall precautions because the resident was not supposed to be left in his room alone when he was up in his wheel chair. The RP said the resident had dementia and would forget he could not walk anymore, so he would try and get up on his own causing him to fall. The RP said the resident had been in therapy getting better but said he was just getting to the point where he could walk using walker with assistance from therapy . Interview on 10/10/19 at 4:18PM, LVN #5 said she worked with CR #93 on 9/26/19 and confirmed she wrote the nurses note about his fall. LVN #5 said CR #93 was non-compliant and would not use the call light. She said he would often not ask for help and try and transfer himself, making him a fall risk. LVN #5 said the last observation she had of CR #93 on 9/26/19 before his fall was around 1:40PM (close to shift change), she was at the nurse's station typing notes while CR #93 was in his wheel chair in front the nurse's station near dining hall area. She said she looked down for about 5 minutes and that's when the CNA came and alerted her the resident was on the floor in his room. She said she did not see the resident leave the area and wheel himself to his room. She said the resident had a head wound that was actively bleeding when she entered the room. The resident was assessed and had complaints of pain. 911 was called and he was immediately sent to hospital. LVN #5 said the resident was very non-compliant and she would often chart his non-compliance and that she educated him repeatedly about asking for help. She said the resident had Dementia and would forget that he could not walk or transfer himself anymore which is why he was repeatedly reeducated and reminded he could not transfer himself without help. She said his fall interventions were low bed and he had a fall mat. She said she would also keep a close eye on him because of his non-compliance with transferring without assistance by keeping him in visible areas. The LVN said from what she knows of when the resident was last seen and the scene of his room when he was found on the floor, she thinks the resident fell transferring from his wheel chair to his bed. Interview on 10/11/19 at 1:58PM, CNA #9 said she was assigned to CR #93's room on 9/26/19. She said she always got him up as soon as she got to work because he would not stay in his bed when he was awake. CNA #9 said CR #93 would forget he could not walk and try to get up from his wheel chair without asking for assistance, so she would never leave him in his wheel chair in his room. The CNA said CR #93 was on tube feedings, so she would move him from the dining room area during lunch and have him in the hallway where she could see him. She said the last time she saw the resident on 9/26/19 was around 1:00PM while she was passing out hall trays, she said his wheel chair parked in the hallway where she could see him. She said the next time she saw the resident was during her final shift rounds around 1:30PM - 1:40PM. She said she starts her rounds from the back of the hall and the resident's room was towards the front. She said as she passed CR #93's room during her rounds she saw him on the floor in his room. She said she went into the room and saw he was bleeding from the head and immediately went to get the nurse. The CNA said she did not see the resident leave the hallway or wheel himself to his room and was not sure how he got there but said the resident could wheel himself in his wheel chair. The CNA added that she would keep CR #93 in visible areas, so she could redirect him if he tried to get up and said he sometimes attempted to wheel himself back to his room. CNA #9 said the staff would usually see CR #93 going to his room and were able to stop him and remind him to stay in visible areas. She said the resident did not refuse to stay in visible areas but would forget and needed to be reminded. Interview on 10/11/19 at 2:58 PM, the DON said she was in her office on 9/26/19 when she was alerted that CR #93 had fallen and was bleeding from his head. She said when she entered the room the blood had already been cleaned up and the nurse was applying pressure to the area. She said the resident did complain of pain to his leg. The staff immediately called 911 because he had hit his head and was on anticoagulants. Later that night she said she said she was informed he had sustained a fracture, so she called the administrator and notified him. The DON said she had not spoken with the family after the incident and was not aware of any concerns the family had about the fall. The DON said the resident had fallen two days after he was admitted which is when they care planned him for falls and put fall interventions in place that included low bed, falls mats, and they had discussed moving his bed against the wall but had not been done yet. She said they also tried to keep the resident in high visibility areas to monitor him for falls. She said CR #93 often tried to do more than he should be doing and would forget he could not do the same things he could do and mentioned the resident had Dementia but could communicate. The DON said the Administrator completed the investigation for the incident but her understanding of what happened was that the resident was trying to transfer himself from his wheel chair to his bed and fell . She said the resident was last seen in the hallways while the CNA was passing lunch trays before he was found on the floor in his room. She did not know of anyone seeing him going back to his room. The DON was also asked about the stuck out notes and reports for CR #93's first fall on 9/18/19 and she said she was unaware that they were crossed out and did not know why someone had done so. She added it was reported the resident had fallen on 9/18/19 and when the nurse went down to the room the resident had gotten himself up into the chair in his room. She said the incident was treated as a fall. Interview on 10/11/19 at 4:42PM, the Administrator said his investigation revealed CR #93 had fallen in his room transferring from his chair to bed. The fall was unwitnessed, the resident had hit his head and complained of leg pain, so he was sent out the hospital for an x-ray. He said he wasn't informed of the resident having the fracture until later that night and he then called in and reported the incident to the state agency. After further investigation he found the resident had wheeled himself to his room. He said he wasn't sure without looking at his notes, but he believed the resident was last seen in the dining room area. He said for fall interventions the staff had educated CR #93 to stay in visible areas, when asked if the resident was cognitive enough to understand or remember the education, he said he was not that familiar with the resident because he had not been at the facility very long and said he would have to review his MDS. Surveyor mentioned concerns of no one noticing CR #93 had gone back to his room and was in his room alone, the Administrators response was, it seemed like it happened really quick. Record review of the facility's Falls - Clinical Protocol (Revised (MONTH) 2012) revealed in part, .1. As part of the initial assessment, the physician will help identify individuals with a history of falls and risk factors for subsequent falling. [NAME] Staff will ask the resident and the caregiver or family about a history of falling. B. The staff and physician should document in the medical record a history of one or more recent falls (for example, within 90 days). C. While many falls are isolated individual incidents, a significant proportion occur among a few resident/patients. Those individuals may have a treatable medical disorder or functional disturbance as the underlying cause . 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. [NAME] Examples of such interventions may include calcium and vitamin D supplementation to address [MEDICAL CONDITION], use of hip protectors, addressing medical issues such as [MEDICAL CONDITION] and dizziness, and tapering, discontinuing, or changing problematic medication. 2. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stop or until a reason is identified for its continuation (for example, if the individual continues to try to get up and walk without waiting for assistance) .

Based on observation, interview and record review, the facility failed to prevent neglect for 1 of 8 residents (Resident #1) reviewed for preventative skin care, in that: -The facility failed to perform skin checks per Resident #1's plan of care resulting in two new foot wounds. This failure affected one resident and placed all 34 residents with preventative skin care at risk for injury. Findings included: Record review of Resident #1's face sheet dated August 4, 2017 indicated Resident #1 was [AGE] years old with [DIAGNOSES REDACTED]. Resident #1's original admitted was 6/13/13 and readmitted was 5/12/16. Record review of Resident #1's MDS dated [DATE] revealed Resident # 1 had a BIMs score of 00 which indicated that Resident #1's cognition was severely impaired. The MDS did not identify any concerns with mood or behaviors. MDS revealed Resident #1 was extensive or total assist with all ADL's. Falls were not identified as a concern. Observation on 8/22/17 at 10:40 AM Resident #1 was lying in bed. She was alert only to self. Her speech was garbled. Her nails were cut short and painted. She had some old bruising to bilateral lower extremities. She had a dressing over her right knee dated 8/21/17. Resident was lying in a right sided tilt. Resident's left leg was drawn up in a fetal position to her body, right leg was bent inward, but not drawn up. She had a boot on her left foot. Resident attempted to grab, scratch and pull at CNA, name unknown, when she drew back the covers. Observation on 8/22/17 at 12:37 PM Resident #1 was in a Geri chair. The Geri chair was upright but Resident #1 was sitting side ways with her back resting partially on the arm rest. Resident #1's left leg was drawn inward towards her body and the right leg was moving back and forth against the other arm of the chair and recliner part of chair. Resident #1 had a boot on her left foot. Observation on 8/23/17 at 11:14 AM revealed a skin assessment was completed on Resident #1 by LVN #1. Findings included left buttocks redness, inner knee wound, left heel eschar, and top of left foot had a healed wound as evidence by pink skin. Dressings on the wounds were dated 8/22/17. Resident was agitated during assessment and trying to grab and scratch at LVN #1. Resident was only alert and oriented to her name. Record review of Resident #1's August 2017 MAR/ TAR revealed an order that read May remove splint to left foot for skin checks. Notify MD as indicated. From 8/11/17 to 8/17/17 LVN #1 signed the MAR five out of those seven days. Record review of Resident #1's MDS dated [DATE] revealed Resident #1 had a BIMs score of 00 which indicated that Resident #1's cognition was severely impaired. The MDS did not identify any concerns with mood or behaviors. MDS revealed Resident #1 was extensive or total assist with all ADL's. Falls were not identified as a concern. Record review of Resident #1's skin integrity assessment completed on 8/14/17 at 08:55 AM by LVN #2. Nurse noted skin was intact but has chronic bruises in bilateral upper and lower extremities related to use of blood thinner. Record review of Resident #1's consolidated physician orders [REDACTED]. Resident #1 received orders on 8/14/17 to cleanse open wound on right lateral knee with normal saline, pat dry and cover. Resident #1 also had treatment order to cleanse left heel with normal saline pat dry paint with [MEDICATION NAME] daily and cleanse top of left foot with normal saline and pat dry paint with [MEDICATION NAME] daily. Record review of Resident #1's Care Plan revealed the following: -8/14/17 Resident #1 has open wound to the right lateral knee. Interventions included Observe skin injury for abnormalities, failure to heal, s/sx of infection, maceration, etc. and report to MD. -8/18/17 Resident #1 has an unstageable left heel wound secondary to ortho boot applied by ortho physician. The interventions included in part . Document changes from baseline. Report significant findings to MD . Observe/document/report to MD PRN and s/sx of infection: . Redness and swelling . -8/18/17, revised 8/23/17, Resident #1 has a stage one to top of left foot related to brace applied by ortho. Interventions included in part . Remove brace for skin check QDay. Notify MD/RP as indicated. Record review of Resident #1's Progress Notes revealed a late entry on 8/8/17 noting Resident #1 was admitted back to the facility. RN #1 identified Resident #1 had bruises to the bilateral upper extremities, open wound to the right lateral knee measuring 1.0 x 1.2 x NM cm, healing scab to the right lower knee and near right big toe. Further review of Resident #1's Progress Notes revealed on 8/17/17 resident returned from orthopedic apt this afternoon 2 new areas identified left heel stable eschar noted black hard area US 4.5 X 3 X NM, top of foot red non blanchable 17 x 7 X NM. MD updated new order obtained 1) cleanse left heel with normal saline pat dry paint with [MEDICATION NAME] daily 2) cleanse the top of left foot with normal saline pat dry paint with [MEDICATION NAME] daily. There was no further progress notes related to right lateral knee wound or left foot wounds. Record review of Resident # 1's physician's progress note dated 8/10/17 under skin identified Resident #1 had purpura of right upper arms. Discoloration secondary to long term anticoagulant use. No further skin integrity issues were identified. Record review of Resident # 1's hospital paperwork did not reveal any skin integrity concerns, no [MEDICAL CONDITION]. Resident #1 was admitted tot he hospital on [DATE] and discharged on [DATE]. Interview on 8/23/17 at 11:40 AM with LVN #3 revealed Resident #1 had 3 areas of wound care; on the right lateral knee, left heel and left top foot written on the TAR. She stated she was not aware of an order for [REDACTED]. Interview on 8/23/17 at 11:40 AM with Resident #1's family member revealed Resident #1 was sent to the hospital on [DATE] due to a change in status. During the hospitalization a CT scan indicated Resident #1 had a right sided stroke. Family member explained resident also was having pain in the left leg and an X-ray revealed a left ankle fracture. Family member explained resident had a follow-up appointment on 8/14/17, but resident missed the appointment. Family member revealed resident was seen by orthopedic doctor on 8/17/17 for a follow-up of fractured left ankle. Family member explained orthopedic physician discovered a wound to her left heel and the top of left foot related to the splint. Family member explained nursing had been doing wound care to her foot at this time. Interview on 8/23/17 at 12:17PM with LVN #1 revealed it was her initials on the MAR/ TAR for Resident #1's order to May remove splint to left foot for skin checks. Notify MD as indicated. LVN #1 revealed she did not take the splint all the way off during her skin checks because of the resident's aggressive behaviors. Interview on 8/23/17 at 12:55 PM with LVN #2 revealed that LVN #1's signature was on Resident #1's order to check skin under splint, but LVN #2 was unable to identify the second nurse who's initials were on MAR/ TAR. MAR/ TAR was requested by the surveyor, LVN #2 provided MAR/ TAR. Surveyor noted all of Resident #1's orders were on the MAR indicated [REDACTED]. Notify MD as indicated. During interview, LVN #2 was unsure why that order did not print out with the rest of the MAR/TAR. CMS form 672 identified a census of 83 residents.

Based upon record reviews and interviews, the facility failed to develop written policies that prohibit neglect for 2 of 8 residents reviewed for risk of neglect (CR #6 and CR #3): -On [DATE] CR #3 struck CR #6 multiple times in the head with an 8 pound dumbbell. CR #6 was transported to a local hospital where he expired on [DATE] due to [MEDICATION NAME] force head trauma. -The facility had no written policy for admission of residents with mental illness from psychiatric facilities or for screening of residents with mental illness prior to admission, -The facility had no written policy which provided staff guidance on the initiation of PASRR screening upon admission for residents with mental illness, An IJ was identified on [DATE] at 4:39 pm. While the IJ was removed on [DATE] at 3:24 pm, the facility remained out of compliance at a scope of pattern and a severity of actual harm that is not immediate jeopardy because the facility was continuing to monitor the effectiveness of the plan. This failure resulted in the death of one resident (CR #6) and placed the remaining 84 residents at risk of serious injury or death from Resident to Resident aggression as CR #3 was ambulatory with access to all resident areas. Findings: CR #6 Record review of CR #6's clinical record revealed that he was admitted to the facility on [DATE] and was [AGE] years old. CR #6 ' s Mental Illness [DIAGNOSES REDACTED]. No PASRR documentation was located in the clinical record. In an interview with CNA A on [DATE] at 2:45 PM, she stated that on [DATE] at 8:30 pm, she heard CR #6 call for help. She stated the room door was closed, so she knocked on the door and opened the door. CNA A said she saw CR #3 hit CR #6 in the head at least three times with an unknown object. She said CR #3 had a look like he was going to get us (come after staff). She said that she kept telling CR #3, "Don't do that." She stated she observed CR #3 and CR #6 talking to each other in the hallway 5 to 10 minutes prior in a regular tone of voice and they were not arguing. Interview with LVN A on [DATE] at 3:00 PM revealed that he was at nurses ' station one and he heard a nurse call for help on the evening of [DATE]. He stated that he went to CR #3 ' s room. LVN A stated he saw CR #3 with a dumbbell in his hands, attempting to hit CR #6. He stated that he told CR #3 to stop, and get away from CR #6. He stated that CR #3 had a "crazy look in his eye." He stated that he administered first-aid to CR #6 until EMS arrived. In an interview with MA A on [DATE] at 3:25 PM, he stated that he was notified by an unknown nurse at approximately 8:30 pm that his assistance was needed in CR #3 and #6's room. MA A said when he entered the room, he was asked by LVN A to watch CR #3 because he still had dumbbells in his hands. MA A said that CR #3 threatened him with the dumbbells. He said he verbally requested CR #3 put down the weights. MA A stated CR #3 said " I'm [MEDICAL CONDITION], my mind, call my son. He ' ll know what to do. Call my children. " MA A stated after verbal redirection, CR #3 calmed down and sat down. He stated CR #3 appeared to " snap out of it, " and calmed down. In an interview with FM on [DATE] at 9:32 AM, he stated that on Wednesday, [DATE], the family decided to discontinue life support measures for CR #6 at the hospital. He stated that CR #6 expired later on [DATE]. Cause of death was confirmed as [MEDICATION NAME] force head trauma by the local medical examiner's office. CR #3 Record review of CR #3's clinical record revealed that he was admitted to the facility initially on [DATE] and was [AGE] years old. CR #3 was admitted with following Diagnosis: [REDACTED].#3's current medication included: [MEDICATION NAME] ([MEDICATION NAME], an anti-psychotic medication for the treatment of [REDACTED]. Record review of CR #3's Admission MDS, dated [DATE], revealed he required limited assistance in transferring to/from surfaces such as bed or wheelchair, supervision with walking in the corridor, and limited assistance in locomotion within the unit; therefore, CR#3 would be able to ambulate to all resident areas. Review of facility s Nurse's Notes dated [DATE] revealed that the facility was notified by FM that CR #3, while out on pass from the facility, threatened suicide and engaged in self-injurious behavior by attempting to jump from a FM's vehicle while in travel. CR #3's FM took him to a local psychiatric hospital. Review of local psychiatric hospital discharge instructions, dated [DATE], revealed that CR #3 was admitted to a psychiatric hospital on [DATE] and discharged on [DATE] with a [DIAGNOSES REDACTED]." Warning signs were noted as talking about suicide, insulating, and being aggressive. Record Review of PPN (Psychological Progress Notes) for CR #3 revealed that he was receiving ongoing psychiatric and psychological services. Initial Psychiatric Assessment was completed on [DATE] and noted Psychiatric History of Altered Mental Status, Paranoid [MEDICAL CONDITION], and Depression. The assessment estimated his cognitive functions as poor to time and place with his thought process as incoherent. He was alert to person and could recall his name. PPN revealed [MEDICATION NAME] was adjusted on [DATE] by adding a 125 mg HS dose to the existing dose of 100mg daily for suicidal ideation. His medication change of [DATE] was reviewed on [DATE] by the Psychiatrist who noted no suicidal ideation present and improvement. Record Review of Diagnostic Interview, service date [DATE], completed by psychological services provider for CR #3, revealed initial assessment was completed with maladaptive behavior of staying to himself and isolating his room. No history or signs of harm to self. No risk level and no precautions recommended. No history of risk of harm to others with risk level low. CR #3 was noted to have a history of paranoia and abnormal thought processes, and recommendation was to monitor for any changes. Record Review of Mental and Behavioral Health Visit Note, service date [DATE], [DATE], completed by psychological services provider for CR #3 revealed the following: -"Other Signs/Symptons: Unit Nurse reported that pt (patient) told her that he was having thoughts of suicide today. Discussed need for precautions with social work and unit nurse." -"Patient's response to Intervention/Progress toward Goal: Pt reported last suicide attempt about two weeks ago during visit with his (FM). He reported trying to jump out window of a car in order to harm self. According to staff, this attempt was stopped by pt's (FM). Also, according to staff, his (FM) reported the pt tried to take his (FM)'s (a police officer)gun. ... Pt denied any current intent or plans (suicidal ideation), but he continues to have suicidal thoughts which warrant monitoring." -"Resistance to Change/Barriers to Goal Attainment: Pt appeared to have low awareness of concerns for his safety and well-being. This may be related to cognitive impairments and/or his depressed mood." -"Recommendations/Suicide Precautions: 1. Provide pt with plastic utensils for eating...2. Keep sharp objects out of room...11. Keep pt away from weapons (ie. son not having his work weapon in possession during visits with pt in SNF... Plan:...3. I will follow-up with social work and nursing about current status of behavior..." In an interview with the contract Psychiatrist on [DATE] at 2:05 PM, she stated that the facility did not indicate any changes in the resident's condition or behavior since readmission on [DATE]. Interview with contract Psychologist on [DATE] at 2:20 PM revealed that she documented on her report dated [DATE] to the facility that CR #3 had irritability not toward people but toward his situation and living in the nursing facility. In an interview with CR #6's friend on [DATE] at 11:40 AM, she stated that CR #3 asked to use her cell phone. She stated that she told CR #3 no, and CR #3 grabbed her arm and pulled her toward him. He then said to give me your phone or I will beat you. She stated that she and CR #6 felt threatened and reported the incident to the floor nurse whom could not be identified by description. CR #6's friend stated she was told by the floor nurse "We will check on that." No other reports of the incident were made by CR #6's friend. In an interview with Social Worker on [DATE] at 12:55 PM, she stated that she does not track resident's targeted behaviors identified by psychological services, and she does not monitor resident's behaviors. Social Worker also stated that she had no reports of behavior issues for CR #3 prior to the incident of [DATE]. In an interview with the DON on [DATE] at 3:25 PM, she stated that the facility does not have a PASRR for CR #3. She stated that maybe the hospital did a PASRR on CR #3 prior to his initial admission to the facility on [DATE] but she would have to check. No documented PASRR was provided by the facility. In an interview with the Admissions Coordinator on [DATE] at 10:05 AM, she stated that she never requests a PASRR prior to admission. She stated that she is not aware of any situation that would require a PASRR be completed prior to admission. Admissions Coordinator stated the facility has no written policy which addresses the admission of residents with non-dementia mental illness. Admission Coordinator stated she is not aware of any written facility policy which addresses or provides guidance for admission of residents from psychiatric hospital or residents with existing [DIAGNOSES REDACTED]. Admissions Coordinator stated that the facility will conduct an "eyes-on" evaluation of prospective residents, prior to admission, and that the Marketing Director, who holds no medical or healthcare credentials, conducts the eyes-on evaluations. Admission Coordinator stated no "eyes-on" evaluation was conducted of CR #3 prior to his readmission from the local psychiatric hospital on [DATE]. In an interview with the PPS Coordinator on [DATE] at 10:53 AM, she stated she is not aware of any facility policy which addressed admissions of residents with non-dementia mental illness. She also stated the facility has no written policy for completing or initiating PASRR screening for residents identified with non-dementia mental illness. In an interview with the DON on [DATE] at 11:40 AM, she stated that the facility provided no staff training regarding residents with mental illness prior to [DATE] had no training on how to deal with residents with Mental Illness including warning signs or triggers for behaviors prior to [DATE]. The DON stated she believed the Psychologist's recommendation on [DATE] to keep CR #3 away from weapons meant the facility should keep knives, guns, and sharp objects out of the resident's room, and that she did not believe a dumbbell would be considered a weapon for exclusion from CR #3's room. The DON stated there is a facility list of "non-allowable" items which is provided to volunteers and church groups who visit the facility. DON stated dumbbells are not on the "non-allowable" list. An IJ was identified on [DATE] at 4:39 pm and the Administrator and DON were advised at that time. A plan to remove the IJ was submitted and required revision. The following plan of removal, submitted by the facility after corrections, was accepted on [DATE] at 4:05 PM: F 224 Immediate Jeopardy Plan of Removal 1. Each resident admitted to the facility will be free from mistreatment, neglect and misappropriation of property. This will include the identification of residents whose mental health histories render them at risk for abusing other residents, and development of intervention strategies to prevent occurrences, monitor for psychological changes that would trigger abusive behavior, and reassessment of the interventions on a regular basis. 2. The Facility will ensure strict adherence to the admission policy and procedure for initial admission and readmission which includes the evaluation of health information record by a nurse manager. A nurse manager will sign off on the in-house admitting form confirming evaluation prior to the Resident admission and/or readmission from psychiatric hospitals. Please see attached Policy and Procedure and facility guidelines. The guidelines for the admission process was initiated on [DATE] and teaching on the admission process continued through [DATE]. The Administrator and DON and/or designee will review all new admissions and readmissions for strict adherence to the admissions policy and procedures during the clinical morning meeting. Any identified opportunity(s) will be addressed immediately through continuing education and/or disciplinary action. 3. The Admission team was immediately in-serviced by the administrator regarding Admission Policy and Procedure with emphasis on psychiatric [DIAGNOSES REDACTED]. The administrator ensured the Admissions team members are clearly aware of the facility Policy and Procedures which are available on the computerized secured drive. 4. The nurse management team received an in-service by the DNS (Director of Nursing Services) regarding the Admission Policy and Procedure to ensure the Resident safety, medical and nursing needs are adequately met by the facility, on [DATE]. 5. Once admitted the resident clinical record is review by the DNS/or designee to ensure any potential need for psychosocial wellbeing as well as medical needs are addressed within 72 hours. Effective [DATE] and this practice will be on-going. 6. An audit was initiated on [DATE] and completed on [DATE] during the clinical morning QA meeting to ensure residents with mood and/or behavior disorders were no potential risk for harm to self and others. This audit included all residents that were currently residing in the facility and none were found to be of potential risk for harm to self and/or others... ... 7. The management team requested the psych services provider to assist with crisis intervention and ensure psychosocial wellbeing was not a risk, initiated on [DATE] through [DATE] and a return visit the following week. On [DATE], The Administrator discussed with the psychological services provider the need for immediate awareness of any interventions recommended. The psych services provider will implement printing progress notes and provide copies to the administrator/DNS and or Social worker before exiting the facility for each visit that requires immediate recommendations. A copy of the psych services notes will be placed on the 24 hour report book during the morning clinical meeting by the DON and/or designee with the recommendations highlighted and will stay on the 24 hour report book for at least 7 consecutive days. During the morning clinical meeting each charge nurse discusses the 24 hour report for her assigned patients. The psych progress notes will be printed as of [DATE]. The department managers will be made aware during the department managers meeting to ensure their specific responsibilities are communicated to their departmental staff. 8. The DNS/designee conducted an in-service with available staff regarding Suicidal Ideation and management of aggressive behavior on ,[DATE], through [DATE]. Any concerns were address immediately. The in-service was initiated on [DATE] but carried over through [DATE] to ensure all staff would be educated. The surveyor confirmed the POR had been implemented sufficiently to remove the IJ by: Record Reviews as follows: -Completed PASRR Screening Forms for residents identified with non-dementia mental illness, whose clinical records did not previously contain PASRR screening, -Admission Policy and Guidelines, revision date [DATE], addressing mental illness such as suicidal/homicidal ideation and related behaviors, -PASRR (Screening) Clinical Policy, dated [DATE], -Psychiatric assessments completed after [DATE], -In-service Training records for Admissions Policy and Accessing policies and Procedures for Admissions Staff, Social Services Staff, and Nurse Managers. -In-service Training records for mental illness (including caring for a person who is suicidal, abuse and neglect, violence and aggression by residents, and PASRR requirements) for all staff, -Intervention audits of residents with mood/behavior disorders. Interviews with PPS Coordinator, Admissions Director, DON, ADON, to determine if they were familiar with PASRR and admissions policies as revised and to determine if admission and PASRR policies have been successfully implemented. The Administrator and the DON were informed on [DATE] at 3:24 pm that the IJ was removed. While the IJ was removed, the facility remained out of compliance at a scope of pattern and a severity of actual harm that is not immediate jeopardy because the facility was continuing to monitor the effectiveness of the plan. According to the ADON, the census was 85.

Based upon Record Reviews and Interviews, the facility's Administrator and Director of Nurses failed to utilize the facility resources effectively to maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 2 of 8 residents (CR #6 and CR #3) reviewed for mental illness. -The Administrator did not develop and implement written policy for readmission of residents with mental illness from psychiatric facilities or for screening of residents with mental illness prior to readmission, -Administrator failed to provide policy guidance to Admission Coordinator, who was not aware of the existence of any written admission policy, -Administrator failed to provide policy guidance to the PPS Coordinator, as the facility had no written policy requiring PASRR screening to be initiated upon admission of residents with mental illness, -The Administrator failed to properly supervise the DON in implementation of recommendations of contract psychological services designed to prevent harm to residents from peer-to-peer aggression. -The DON approved admission of residents with mental illness without face-to-face screening by facility staff with medical or healthcare credentials, -The DON did not coordinate with contract psychological services to implement recommendations intended to protect residents from peer to peer aggression. -There were 35 residents out of the total census of 85 residents identifed with non-dementia/depression psychiatric diagnoses. This failure resulted in the death of one resident (CR #6) and placed the remaining 84 residents at risk of serious injury or death from Resident to Resident aggression as CR #3 was ambulatory with access to all resident areas. Findings: Record review of the CMS-672, dated [DATE], revealed there were 35 residents with documented psychiatric [DIAGNOSES REDACTED]. Record review of CR #6's medical record revealed that he was admitted to the facility on [DATE] and was [AGE] years old. CR #6 ' s Mental Illness [DIAGNOSES REDACTED]. No PASRR documentation was located in the medical record. Record review of CR #3's medical record revealed that he was admitted to the facility initially on [DATE] and was [AGE] years old. CR #3 was admitted with following Diagnosis: [REDACTED].#3's current medication included: [MEDICATION NAME] 125 MG x 1 PO HS Daily, [MEDICATION NAME] 100 MG x 1 PO Q Daily, and [MEDICATION NAME] 20 MG x 1 PO Q Daily. Review of facility s Nurse's Notes dated [DATE] revealed that the facility was notified by FM that CR #3, while out on pass from the facility, threatened suicide and engaged in self-injurious behavior by attempting to jump from a FM's vehicle while in travel. CR #3's FM took him to a local psychiatric hospital. Review of local psychiatric hospital discharge instructions, dated [DATE], revealed that CR #3 was admitted to a psychiatric hospital on [DATE] and discharged on [DATE] with a [DIAGNOSES REDACTED]." Warning signs were noted as talking about suicide, insulating, and being aggressive. Record Review of PPN (Psychological Progress Notes) for CR #3 revealed that he was receiving ongoing psychiatric and psychological services. Initial Psychiatric Assessment was completed on [DATE] and noted Psychiatric History of Altered Mental Status, Paranoid [MEDICAL CONDITION], and Depression. The assessment estimated his cognitive functions as poor to time and place with his thought process as incoherent. He was alert to person and could recall his name. PPN revealed [MEDICATION NAME] was adjusted on [DATE] by adding a 125 mg HS dose to the existing dose of 100mg daily for suicidal ideation. His medication change of [DATE] was reviewed on [DATE] by the Psychiatrist who noted no suicidal ideation present and improvement. Record Review of Diagnostic Interview, service date [DATE], completed by psychological services provider for CR #3, revealed initial assessment was completed with maladaptive behavior of staying to himself and isolating his room. No history or signs of harm to self. No risk level and no precautions recommended. No history of risk of harm to others with risk level low. CR #3 was noted to have a history of paranoia and abnormal thought processes, and recommendation was to monitor for any changes. Record Review of Mental and Behavioral Health Visit Note, service date [DATE], completed by psychological services provider for CR #3 revealed the following: -"Other Signs/Symptons: Unit Nurse reported that pt (patient) told her that he was having thoughts of suicide today. Discussed need for precautions with social work and unit nurse." -"Patient's response to Intervention/Progress toward Goal: Pt reported last suicide attempt about two weeks ago during visit with his (FM). He reported trying to jump out window of a car in order to harm self. According to staff, this attempt was stopped by pt's (FM). Also, according to staff, his (FM) reported the pt tried to take his (FM)'s (a police officer)gun. ... Pt denied any current intent or plans (suicidal ideation), but he continues to have suicidal thoughts which warrant monitoring." -"Resistance to Change/Barriers to Goal Attainment: Pt appeared to have low awareness of concerns for his safety and well-being. This may be related to cognitive impairments and/or his depressed mood." -"Recommendations/Suicide Precautions: 1. Provide pt with plastic utensils for eating...2. Keep sharp objects out of room...11. Keep pt away from weapons (ie. FM not having his work weapon in possession during visits with pt in SNF... Plan:...3. I will follow-up with social work and nursing about current status of behavior..." In an interview with the contract Psychiatrist on [DATE] at 2:05 PM, she stated that the facility did not indicate any changes in the resident's condition or behavior since readmission on [DATE]. Interview with contract Psychologist on [DATE] at 2:20 PM revealed that she documented on her report dated [DATE] to the facility that CR #3 had irritability not toward people but toward his situation and living in the nursing facility. In an interview with CNA A on [DATE] at 2:45 PM, she stated that on [DATE] at 8:30 am, she heard CR #6 call for help. She stated the room door was closed, so she knocked on the door and opened the door. CNA A said she saw CR #3 hit CR #6 in the head at least three times with an unknown object. She said CR #3 had a look like he was going to get us (come after staff). She said that she kept telling CR #3, "Don't do that." She stated she observed CR #3 and CR #6 talking to each other in the hallway 5 to 10 minutes prior in a regular tone of voice and they were not arguing. In an interview with facility's Social Worker on [DATE] at 12:55 PM, she stated that she does not track resident's targeted behaviors identified by psychological services, and she does not monitor resident's behaviors. Social Worker also stated that she had no reports of behavior issues for CR #3 prior to the incident of [DATE]. In an interview with facility's DON on [DATE] at 3:25 PM, she stated that the facility does not have a PASRR for CR #3. She stated that maybe the hospital did a PASRR on CR #3 prior to his initial admission to the facility on [DATE] but she would have to check. No documented PASRR was provided by the facility. In an interview with the facility's Admission Coordinator on [DATE] at 10:05 AM, she stated that she never requests a PASRR prior to admission. She stated that she is not aware of any situation that would require a PASRR be completed prior to admission. Admission Coordinator stated she is not aware of any facility policy which addresses or provides guidance for admission or re-admission of residents from psychiatric hospital or residents with existing [DIAGNOSES REDACTED]. Admissions Coordinator stated that the facility will conduct an "eyes-on" evaluation of prospective residents, prior to admission, and that the Marketing Director, who holds no medical or healthcare credentials, conducts the eyes-on evaluations. Admission Coordinator stated no "eyes-on" evaluation was conducted of CR #3 prior to his readmission from the local psychiatric hospital on [DATE]. In an interview with CR #6's FM on [DATE] at 9:32 AM, he stated that on Wednesday, [DATE], the family decided to discontinue life support measures for CR #6 at the hospital. He stated that CR #6 expired later on [DATE]. Cause of death was confirmed as [MEDICATION NAME] force head trauma by the local medical examiner's office. In an interview with the Administrator on [DATE] at 5:32 pm, when asked what procedures are in place to make sure the nursing needs of residents are being met, he replied it begins with admission and that the facility looks at clinical, medications and what type of care the resident is seeking. Administrator stated they assess for services such as respiratory and pharmacy, and assign a a physician in the facility. When asked about staff monitoring and systems to ensure competency of staff, he replied that they use department head meetings, monthly QA meetings, and data gathering. Administrator also stated he has corporate support to review department progress, and that he conducts yearly evaluations of staff performance. Administrator stated the facility reviews the clinical record of of re-admissions. In an interview with facility's DON on [DATE] at 11:40 AM, she stated that the facility provided no staff training regarding residents with mental illness prior to [DATE] had no training on how to deal with resident's with Mental Illness including warning signs or triggers for behaviors. The DON stated she believed the Psychologist's recommendation on [DATE] to keep CR #3 away from weapons meant the facility should keep knives, guns, and sharp objects out of the resident's room, and that she did not believe a dumbbell would be considered a weapon for exclusion from CR #3's room. The DON stated there is a facility list of "non-allowable" items which is provided to volunteers and church groups who visit the facility. DON stated dumbbells are not on the "non-allowable" list. In an interview conducted with the DON on [DATE] at 4:59 pm, the DON was asked what training was provided to nurses in order to care for needs of residents with mental illness, behaviors, or special needs. She stated that she has conducted staff training on Abuse and Neglect, Crisis Intervention with role playing, suicidal ideation, violence in the workplace, and how to deal with residents acting out or being violent. The DON stated this training did not begin until after CR #3 struck CR #6 on [DATE]. When asked how she ensured nurses were competent in their skills for caring for residents with mental illness and/or special needs, she replied that the facility educates nurses, provides staff information packets, and that "we" talk to staff regarding residents with mental illness. When asked what type of plan was in place for residents with mental illness, she replied "we have psych services and the social worker is directly involved. We discuss residents in the clinical morning meetings to identify their needs and behaviors needing intervention." When asked what types of in-service training has been conducted on the admission of residents with mental illness, aggression intervention, or psychological services since admission of mentally ill residents, she replied that admissions training was conducted to focus on communication with different departments regarding the admission process and informing all departments of psychological services recommendations. DON stated she has corporate support, educational materials, an open door policy, monthly meetings and monthly staff support meetings to identify if staff is in a crisis as resources for her staff. According to the DON, the census was 85.

Based upon Record Reviews and Interviews, the facility failed to provide the necessary care to maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 2 of 8 residents (CR #6 and CR #3) reviewed for mental illness. -The facility had no written policy for readmission of residents with mental illness from psychiatric facilities or for screening of residents with mental illness prior to readmission, -The facility had no written policy to ensure PASRR screening was initiated upon admission or readmission of residents with mental illness, -CR #3 was admitted to the facility on [DATE] from a personal care home with multiple psychiatric [DIAGNOSES REDACTED]. CR #3 was admitted without a current PASRR. -Resident#3 was discharged to a local psychiatric facility on [DATE] after threatening suicide and displaying self-injurious behavior. CR #3 was readmitted to the facility on [DATE] from the psychiatric unit of a local hospital with a [DIAGNOSES REDACTED]." was not screened by the facility prior to readmission, -CR #3 was readmitted on [DATE] without a current PASRR, and screening was not initiated by the facility upon readmission, -On [DATE] CR #3 struck CR #6 multiple times in the head with an 8 pound dumbbell. CR #6 was transported to a local hospital where he expired on [DATE] due to [MEDICATION NAME] force head trauma. An IJ was identified on [DATE] at 4:39 pm. While the IJ was removed on [DATE] at 3:24 pm, the facility remained out of compliance at a scope of pattern and a severity of actual harm that is not immediate jeopardy because the facility was continuing to monitor the effectiveness of the plan. This failure resulted in the death of one resident (CR #6) and placed the remaining 84 residents at risk of serious injury or death from Resident to Resident aggression as CR #3 was ambulatory with access to all resident areas. Findings: Record review of CR #6's medical record revealed that he was admitted to the facility on [DATE] and was [AGE] years old. CR #6 ' s Mental Illness [DIAGNOSES REDACTED]. No PASRR documentation was located in the medical record. Record review of CR #3's medical record revealed that he was admitted to the facility initially on [DATE] and was [AGE] years old. CR #3 was admitted with following Diagnosis: [REDACTED].#3's current medication included: [MEDICATION NAME] 125 MG x 1 PO HS Daily, [MEDICATION NAME] 100 MG x 1 PO Q Daily, and [MEDICATION NAME] 20 MG x 1 PO Q Daily. Review of facility s Nurse's Notes dated [DATE] revealed that the facility was notified by FM that CR #3, while out on pass from the facility, threatened suicide and engaged in self-injurious behavior by attempting to jump from a FM's vehicle while in travel. CR #3's FM took him to a local psychiatric hospital. Review of local psychiatric hospital discharge instructions, dated [DATE], revealed that CR #3 was admitted to a psychiatric hospital on [DATE] and discharged on [DATE] with a [DIAGNOSES REDACTED]." Warning signs were noted as talking about suicide, insulating, and being aggressive." Record Review of PPN (Psychological Progress Notes) for CR #3 revealed that he was receiving ongoing psychiatric and psychological services. Initial Psychiatric Assessment was completed on [DATE] and noted Psychiatric History of Altered Mental Status, Paranoid [MEDICAL CONDITION], and Depression. The assessment estimated his cognitive functions as poor to time and place with his thought process as incoherent. He was alert to person and could recall his name. PPN revealed [MEDICATION NAME] was was adjusted by adding 125 mg his medication was adjusted on [DATE] for suicidal ideation. His medication change of [DATE] was reviewed on [DATE] by the Psychiatrist and noted no suicidal ideation present and improvement. Record Review of Diagnostic Interview, service date [DATE], completed by psychological services provider for CR #3, revealed initial assessment was completed with maladaptive behavior of staying to himself and isolating his room. No history or signs of harm to self. No risk level and no precautions recommended. No history of risk of harm to others with risk level low. CR #3 was noted to have a history of paranoia and abnormal thought processes, and recommendation was to monitor for any changes. Record Review of Mental and Behavioral Health Visit Note, service date [DATE], [DATE], completed by psychological services provider for CR #3 revealed the following: -"Other Signs/Symptons: Unit Nurse reported that pt (patient) told her that he was having thoughts of suicide today. Discussed need for rpecautions with social work and unit nurse." -"Patient's response to Intervention/Progress toward Goal: Pt reported last suicide attempt about two weeks ago during visit with his (FM). He reported trying to jump out window of a car in order to harm self. According to staff, this attempt was stopped by pt's (FM). Also, according to staff, his (FM) reported the pt tried to take his (FM)'s (a police officer)gun. ... Pt denied any current intent or plans (suicidal ideation), but he continues to have suicidal thoughts which warrant monitoring." -"Resistance to Change/Barriers to Goal Attainment: Pt appeared to have low awareness of concerns for his safety and well-being. This may be related to cognitive impairments and/or his depressed mood." -"Recommendations/Suicide Precautions: 1. Provide pt with plastic utensils for eating...2. Keep sharp objects out of room...11. Keep pt away from weapons (ie. son not having his work weapon in possession during visits with pt in SNF... Plan:...3. I will follow-up with social work and nursing about current status of behavior..." In an interview with the contract Psychiatrist on [DATE] at 2:05 PM, she stated that the facility did not indicate any changes in the resident's condition or behavior since readmission on [DATE]. Interview with contract Psychologist on [DATE] at 2:20 PM revealed that she documented on her report dated [DATE] to the facility that CR #3 had irritability not toward people but toward his situation and living in the nursing facility. In an interview with CNA A on [DATE] at 2:45 PM, she stated that on [DATE] at 8:30 am, she heard CR #6 call for help. She stated the room door was closed, so she knocked on the door and opened the door. CNA A said she saw CR #3 hit CR #6 in the head at least three times with an unknown object. She said CR #3 had a look like he was going to get us (come after staff). She said that she kept telling CR #3, "Don't do that." She stated she observed CR #3 and CR #6 talking to each other in the hallway 5 to 10 minutes prior in a regular tone of voice and they were not arguing. Interview with LVN A on [DATE] at 3:00 PM revealed that he was at nurses ' station one and he heard a nurse call for help. He stated that he went to CR #3 ' s room. LVN A stated he saw CR #3 with a dumbbell in his hands, attempting to hit CR #6. He stated that he told CR #3 to stop, and get away from CR #6. He stated that he administered first-aid to CR #6 until EMS arrived. In an interview with MA A on [DATE] at 3:25 PM, he stated that he was notified by a nurse that his assistance was needed in CR #3 and #6's room. MA A said when he entered the room, he was asked by the nurse to watch CR #3 because he still had dumbbells in his hands. MA A said that CR #3 threatened him with the dumbbells. He said he verbally requested CR #3 put down the weights. MA A stated CR #3 said " I'm [MEDICAL CONDITION], my mind, call my son. He ' ll know what to do. Call my children. " MA A stated after verbal redirection, CR #3 calmed down and sat down. He stated CR #3 appeared to " snap out of it, " and calmed down. In an interview with CR #6's visitor on [DATE] at 11:40 AM, she stated that CR #3 asked to use her cell phone. She stated that she told CR #3 no, and CR #3 grabbed her arm and pulled her toward him. He then said to give me your phone or I will beat you. She stated that she and CR #6 felt threatened and reported the incident to the floor nurse (no other identifiers were given). The floor nurse said, "We will check on that." No other reports of the incident were made. In an interview with facility's Social Worker on [DATE] at 12:55 PM, she stated that she does not track resident's targeted behaviors identified by psychological services, and she does not monitor resident's behaviors. Social Worker also stated that she had no reports of behavior issues for CR #3 prior to the incident of [DATE]. In an interview with facility's DON on [DATE] at 3:25 PM, she stated that the facility does not have a PASRR for CR #3. She stated that maybe the hospital did a PASRR on CR #3 prior to his initial admission to the facility on [DATE] but she would have to check. No documented PASRR was provided by the facility. In an interview with the facility's Admissions Coordinator on [DATE] at 10:05 AM, she stated that she never requests a PASRR prior to admission. She stated that she is not aware of any situation that would require a PASRR be completed prior to admission. Admission Coordinator stated she is not aware of any facility policy which addresses or provides guidance for admission or re-admission of residents from psychiatric hospital or residents with existing [DIAGNOSES REDACTED]. Admissions Coordinator stated that the facility will conduct an "eyes-on" evaluation of prospective residents, prior to admission, and that the Marketing Director, who holds no medical or healthcare credentials, conducts the eyes-on evaluations. Admission Coordinator stated no "eyes-on" evaluation was conducted of CR #3 prior to his readmission from the local psychiatric hospital on [DATE]. In an interview with FM on [DATE] at 9:32 AM, he stated that on Wednesday, [DATE], the family decided to discontinue life support measures for CR #6 at the hospital. He stated that CR #6 expired later on [DATE]. Cause of death was confirmed as [MEDICATION NAME] force head trauma by the local medical examiner's office. In an interview with facility's DON on [DATE] at 11:40 AM, she stated that the facility provided no staff training regarding residents with mental illness prior to [DATE] had no training on how to deal with resident's with Mental Illness including warning signs or triggers for behaviors. The DON stated she believed the Psychologist's recommendation on [DATE] to keep CR #3 away from weapons meant the facility should keep knives, guns, and sharp objects out of the resident's room, and that she did not believe a dumbbell would be considered a weapon for exclusion from CR #3's room. The DON stated there is a facility list of "non-allowable" items which is provided to volunteers and church groups who visit the facility. DON stated dumbbells are not on the "non-allowable" list. An IJ was identified on [DATE] at 4:39 pm and the Administrator and DON were advised at that time. A plan to remove the IJ was submitted and required revision. The following plan of removal, submitted by the facility after corrections, was accepted on [DATE] at 4:05 PM: F 309 Immediate Jeopardy Plan of Removal. 1. Each resident will receive and the facility will provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychological well-being, in accordance with the comprehensive assessment and plan of care. 2. The Facility has adopted The Texas DADS Detailed Item by Item Guide for Completing the PASRR Level I Screening Form as their Policy and Procedure. Initiated [DATE] and then the policies was refined on [DATE]. Please see attached. 3. The corporate MDS nurse in-serviced the facility MDS nurse and DON on the completion of PASRR Level 1 Screening Form on [DATE]. 4. The facility completed an audit for all residents on [DATE] to ensure each resident residing in the facility had a Level 1 PASRR screening. Any resident identified not to have a PASRR in place a PASRR was completed immediately on the date of the audit. The facility re-conducted another audit on [DATE] to ensure completion of the PASRR Level 1 Screening Form on all current residents with 100% compliance. 5. The Social Services Director will identify psychosocial needs during initial assessment and assist with obtaining an order for [REDACTED]. 6. Beginning [DATE] the PPS Nurse will complete the PASRR Level 1 Screening Form on Medicare (A) admissions within 72 hours. The MDS Nurse will complete the PASRR Level 1 Screening Form on residents not admitted on Medicare A within 72 hours. Once the PASSR has been completed a hard copy is filed in the Resident Medical Record. The DNS/Designee will review and verify completion of the PASRR during the clinical morning QA meeting. 7. On [DATE], The Administrator discussed with the psychological services provider the need for immediate awareness of any interventions recommended. The psych services provider will implement printing progress notes and provide copies to the administrator/DNS and or Social worker before exiting the facility for each visit that requires immediate recommendations. A copy of the psych services notes will be placed on the 24 hour report book during the morning clinical meeting by the DON and/or designee with the recommendations highlighted and will stay on the 24 hour report book for at least 7 consecutive days. During the morning clinical meeting each charge nurse discusses the 24 hour report for his/her assigned patients. The department managers will be made aware during the department managers meeting to ensure their specific responsibilities are communicated to their departmental staff. 8. The DNS and or designee will review provided progress notes within 72 hours; however, situations requiring immediate follow-up will be reported to the Administrator, DON and/or designee weather in person or via phone so the facility may act upon immediate recommendations to ensure proper follow up and revision to the care plan are implemented effective [DATE] during each morning clinical meeting. The surveyor confirmed the POR had been implemented sufficiently to remove the IJ by: Record Reviews as follows: -Completed PASRR Screening Forms for residents identified with non-dementia mental illness, whose clinical records did not previously contain PASRR screening, -Admission Policy and Guidelines, revision date [DATE], addressing mental illness such as suicidal/homicidal ideation and related behaviors, -PASRR (Screening) Clinical Policy, dated [DATE], -Psychiatric assessments completed after [DATE], -In-service Training records for Admissions Policy and Accessing policies and Procedures for Admissions Staff, Social Services Staff, and Nurse Managers. -In-service Training records for mental illness (including caring for a person who is suicidal, abuse and neglect, violence and aggression by residents, and PASRR requirements) for all staff, -Intervention audits of residents with mood/behavior disorders. Interviews with PPS Coordinator, Admissions Director, DON, ADON, to determine if they were familiar with PASRR and admissions policies as revised and to determine if admission and PASRR policies have been successfully implemented. The Administrator and the DON were informed on [DATE] at 3:24 pm that the IJ was removed. While the IJ was removed, the facility remained out of compliance at a scope of pattern and a severity of actual harm that is not immediate jeopardy because the facility was continuing to monitor the effectiveness of the plan. ADON reported current census was 85.

Based upon record reviews and interviews, the facility failed to develop policies or implement procedures that prohibit neglect for 2 of 8 residents reviewed for risk of neglect (CR #6 and CR #3): -On [DATE] CR #3 struck CR #6 multiple times in the head with an 8 pound dumbbell. CR #6 was transported to a local hospital where he expired on [DATE] due to [MEDICATION NAME] force head trauma. -The facility had no policy for admission of residents with mental illness from psychiatric facilities or for screening of residents with mental illness prior to admission, -The facility had no written policy which provided staff guidance on the initiation of PASRR screening upon admission for residents with mental illness, An IJ was identified on [DATE] at 4:39 pm. While the IJ was removed on [DATE] at 3:24 pm, the facility remained out of compliance at a scope of pattern and a severity of actual harm that is not immediate jeopardy because the facility was continuing to monitor the effectiveness of the plan. This failure resulted in the death of one resident (CR #6) and placed the remaining 84 residents at risk of serious injury or death from Resident to Resident aggression as CR #3 was ambulatory with access to all resident areas. Findings: CR #6 Record review of CR #6's clinical record revealed that he was admitted to the facility on [DATE] and was [AGE] years old. CR #6 ' s Mental Illness [DIAGNOSES REDACTED]. No PASRR documentation was located in the clinical record. In an interview with CNA A on [DATE] at 2:45 PM, she stated that on [DATE] at 8:30 pm, she heard CR #6 call for help. She stated the room door was closed, so she knocked on the door and opened the door. CNA A said she saw CR #3 hit CR #6 in the head at least three times with an unknown object. She said CR #3 had a look like he was going to get us (come after staff). She said that she kept telling CR #3, "Don't do that." She stated she observed CR #3 and CR #6 talking to each other in the hallway 5 to 10 minutes prior in a regular tone of voice and they were not arguing. Interview with LVN A on [DATE] at 3:00 PM revealed that he was at nurses ' station one and he heard a nurse call for help on the evening of [DATE]. He stated that he went to CR #3 ' s room. LVN A stated he saw CR #3 with a dumbbell in his hands, attempting to hit CR #6. He stated that he told CR #3 to stop, and get away from CR #6. He stated that CR #3 had a "crazy look in his eye." He stated that he administered first-aid to CR #6 until EMS arrived. In an interview with MA A on [DATE] at 3:25 PM, he stated that he was notified by an unknown nurse at approximately 8:30 pm that his assistance was needed in CR #3 and #6's room. MA A said when he entered the room, he was asked by LVN A to watch CR #3 because he still had dumbbells in his hands. MA A said that CR #3 threatened him with the dumbbells. He said he verbally requested CR #3 put down the weights. MA A stated CR #3 said " I'm [MEDICAL CONDITION], my mind, call my son. He ' ll know what to do. Call my children. " MA A stated after verbal redirection, CR #3 calmed down and sat down. He stated CR #3 appeared to " snap out of it, " and calmed down. In an interview with FM on [DATE] at 9:32 AM, he stated that on Wednesday, [DATE], the family decided to discontinue life support measures for CR #6 at the hospital. He stated that CR #6 expired later on [DATE]. Cause of death was confirmed as [MEDICATION NAME] force head trauma by the local medical examiner's office. CR #3 Record review of CR #3's clinical record revealed that he was admitted to the facility initially on [DATE] and was [AGE] years old. CR #3 was admitted with following Diagnosis: [REDACTED].#3's current medication included: [MEDICATION NAME] ([MEDICATION NAME], an anti-psychotic medication for the treatment of [REDACTED]. Record review of CR #3's Admission MDS, dated [DATE], revealed he required limited assistance in transferring to/from surfaces such as bed or wheelchair, supervision with walking in the corridor, and limited assistance in locomotion within the unit; therefore, CR#3 would be able to ambulate to all resident areas. Review of facility s Nurse's Notes dated [DATE] revealed that the facility was notified by FM that CR #3, while out on pass from the facility, threatened suicide and engaged in self-injurious behavior by attempting to jump from a FM's vehicle while in travel. CR #3's FM took him to a local psychiatric hospital. Review of local psychiatric hospital discharge instructions, dated [DATE], revealed that CR #3 was admitted to a psychiatric hospital on [DATE] and discharged on [DATE] with a [DIAGNOSES REDACTED]." Warning signs were noted as talking about suicide, insulating, and being aggressive. Record Review of PPN (Psychological Progress Notes) for CR #3 revealed that he was receiving ongoing psychiatric and psychological services. Initial Psychiatric Assessment was completed on [DATE] and noted Psychiatric History of Altered Mental Status, Paranoid [MEDICAL CONDITION], and Depression. The assessment estimated his cognitive functions as poor to time and place with his thought process as incoherent. He was alert to person and could recall his name. PPN revealed [MEDICATION NAME] was adjusted on [DATE] by adding a 125 mg HS dose to the existing dose of 100mg daily for suicidal ideation. His medication change of [DATE] was reviewed on [DATE] by the Psychiatrist who noted no suicidal ideation present and improvement. Record Review of Diagnostic Interview, service date [DATE], completed by psychological services provider for CR #3, revealed initial assessment was completed with maladaptive behavior of staying to himself and isolating his room. No history or signs of harm to self. No risk level and no precautions recommended. No history of risk of harm to others with risk level low. CR #3 was noted to have a history of paranoia and abnormal thought processes, and recommendation was to monitor for any changes. Record Review of Mental and Behavioral Health Visit Note, service date [DATE], [DATE], completed by psychological services provider for CR #3 revealed the following: -"Other Signs/Symptons: Unit Nurse reported that pt (patient) told her that he was having thoughts of suicide today. Discussed need for precautions with social work and unit nurse." -"Patient's response to Intervention/Progress toward Goal: Pt reported last suicide attempt about two weeks ago during visit with his (FM). He reported trying to jump out window of a car in order to harm self. According to staff, this attempt was stopped by pt's (FM). Also, according to staff, his (FM) reported the pt tried to take his (FM)'s (a police officer)gun. ... Pt denied any current intent or plans (suicidal ideation), but he continues to have suicidal thoughts which warrant monitoring." -"Resistance to Change/Barriers to Goal Attainment: Pt appeared to have low awareness of concerns for his safety and well-being. This may be related to cognitive impairments and/or his depressed mood." -"Recommendations/Suicide Precautions: 1. Provide pt with plastic utensils for eating...2. Keep sharp objects out of room...11. Keep pt away from weapons (ie. son not having his work weapon in possession during visits with pt in SNF... Plan:...3. I will follow-up with social work and nursing about current status of behavior..." In an interview with the contract Psychiatrist on [DATE] at 2:05 PM, she stated that the facility did not indicate any changes in the resident's condition or behavior since readmission on [DATE]. Interview with contract Psychologist on [DATE] at 2:20 PM revealed that she documented on her report dated [DATE] to the facility that CR #3 had irritability not toward people but toward his situation and living in the nursing facility. In an interview with CR #6's friend on [DATE] at 11:40 AM, she stated that CR #3 asked to use her cell phone. She stated that she told CR #3 no, and CR #3 grabbed her arm and pulled her toward him. He then said to give me your phone or I will beat you. She stated that she and CR #6 felt threatened and reported the incident to the floor nurse whom could not be identified by description. CR #6's friend stated she was told by the floor nurse "We will check on that." No other reports of the incident were made by CR #6's friend. In an interview with Social Worker on [DATE] at 12:55 PM, she stated that she does not track resident's targeted behaviors identified by psychological services, and she does not monitor resident's behaviors. Social Worker also stated that she had no reports of behavior issues for CR #3 prior to the incident of [DATE]. In an interview with the DON on [DATE] at 3:25 PM, she stated that the facility does not have a PASRR for CR #3. She stated that maybe the hospital did a PASRR on CR #3 prior to his initial admission to the facility on [DATE] but she would have to check. No documented PASRR was provided by the facility. In an interview with the Admissions Coordinator on [DATE] at 10:05 AM, she stated that she never requests a PASRR prior to admission. She stated that she is not aware of any situation that would require a PASRR be completed prior to admission. Admission Coordinator stated she is not aware of any facility policy which addresses or provides guidance for admission or re-admission of residents from psychiatric hospital or residents with existing [DIAGNOSES REDACTED]. Admissions Coordinator stated that the facility will conduct an "eyes-on" evaluation of prospective residents, prior to admission, and that the Marketing Director, who holds no medical or healthcare credentials, conducts the eyes-on evaluations. Admission Coordinator stated no "eyes-on" evaluation was conducted of CR #3 prior to his readmission from the local psychiatric hospital on [DATE]. In an interview with the DON on [DATE] at 11:40 AM, she stated that the facility provided no staff training regarding residents with mental illness prior to [DATE] had no training on how to deal with residents with Mental Illness including warning signs or triggers for behaviors prior to [DATE]. The DON stated she believed the Psychologist's recommendation on [DATE] to keep CR #3 away from weapons meant the facility should keep knives, guns, and sharp objects out of the resident's room, and that she did not believe a dumbbell would be considered a weapon for exclusion from CR #3's room. The DON stated there is a facility list of "non-allowable" items which is provided to volunteers and church groups who visit the facility. DON stated dumbbells are not on the "non-allowable" list. An IJ was identified on [DATE] at 4:39 pm and the Administrator and DON were advised at that time. A plan to remove the IJ was submitted and required revision. The following plan of removal, submitted by the facility after corrections, was accepted on [DATE] at 4:05 PM: F 224 Immediate Jeopardy Plan of Removal 1. Each resident admitted to the facility will be free from mistreatment, neglect and misappropriation of property. This will include the identification of residents whose mental health histories render them at risk for abusing other residents, and development of intervention strategies to prevent occurrences, monitor for psychological changes that would trigger abusive behavior, and reassessment of the interventions on a regular basis. 2. The Facility will ensure strict adherence to the admission policy and procedure for initial admission and readmission which includes the evaluation of health information record by a nurse manager. A nurse manager will sign off on the in-house admitting form confirming evaluation prior to the Resident admission and/or readmission from psychiatric hospitals. Please see attached Policy and Procedure and facility guidelines. The guidelines for the admission process was initiated on [DATE] and teaching on the admission process continued through [DATE]. The Administrator and DON and/or designee will review all new admissions and readmissions for strict adherence to the admissions policy and procedures during the clinical morning meeting. Any identified opportunity(s) will be addressed immediately through continuing education and/or disciplinary action. 3. The Admission team was immediately in-serviced by the administrator regarding Admission Policy and Procedure with emphasis on psychiatric [DIAGNOSES REDACTED]. The administrator ensured the Admissions team members are clearly aware of the facility Policy and Procedures which are available on the computerized secured drive. 4. The nurse management team received an in-service by the DNS (Director of Nursing Services) regarding the Admission Policy and Procedure to ensure the Resident safety, medical and nursing needs are adequately met by the facility, on [DATE]. 5. Once admitted the resident clinical record is review by the DNS/or designee to ensure any potential need for psychosocial wellbeing as well as medical needs are addressed within 72 hours. Effective [DATE] and this practice will be on-going. 6. An audit was initiated on [DATE] and completed on [DATE] during the clinical morning QA meeting to ensure residents with mood and/or behavior disorders were no potential risk for harm to self and others. This audit included all residents that were currently residing in the facility and none were found to be of potential risk for harm to self and/or others... ... 7. The management team requested the psych services provider to assist with crisis intervention and ensure psychosocial wellbeing was not a risk, initiated on [DATE] through [DATE] and a return visit the following week. On [DATE], The Administrator discussed with the psychological services provider the need for immediate awareness of any interventions recommended. The psych services provider will implement printing progress notes and provide copies to the administrator/DNS and or Social worker before exiting the facility for each visit that requires immediate recommendations. A copy of the psych services notes will be placed on the 24 hour report book during the morning clinical meeting by the DON and/or designee with the recommendations highlighted and will stay on the 24 hour report book for at least 7 consecutive days. During the morning clinical meeting each charge nurse discusses the 24 hour report for her assigned patients. The psych progress notes will be printed as of [DATE]. The department managers will be made aware during the department managers meeting to ensure their specific responsibilities are communicated to their departmental staff. 8. The DNS/designee conducted an in-service with available staff regarding Suicidal Ideation and management of aggressive behavior on ,[DATE], through [DATE]. Any concerns were address immediately. The in-service was initiated on [DATE] but carried over through [DATE] to ensure all staff would be educated. The surveyor confirmed the POR had been implemented sufficiently to remove the IJ by: Record Reviews as follows: -Completed PASRR Screening Forms for residents identified with non-dementia mental illness, whose clinical records did not previously contain PASRR screening, -Admission Policy and Guidelines, revision date [DATE], addressing mental illness such as suicidal/homicidal ideation and related behaviors, -PASRR (Screening) Clinical Policy, dated [DATE], -Psychiatric assessments completed after [DATE], -In-service Training records for Admissions Policy and Accessing policies and Procedures for Admissions Staff, Social Services Staff, and Nurse Managers. -In-service Training records for mental illness (including caring for a person who is suicidal, abuse and neglect, violence and aggression by residents, and PASRR requirements) for all staff, -Intervention audits of residents with mood/behavior disorders. Interviews with PPS Coordinator, Admissions Director, DON, ADON, to determine if they were familiar with PASRR and admissions policies as revised and to determine if admission and PASRR policies have been successfully implemented. The Administrator and the DON were informed on [DATE] at 3:24 pm that the IJ was removed. While the IJ was removed, the facility remained out of compliance at a scope of pattern and a severity of actual harm that is not immediate jeopardy because the facility was continuing to monitor the effectiveness of the plan. According to the ADON, the census was 85.

Based on observations, interviews and record review, the facility failed to provide one of 5 sampled residents with dentures (Resident #2) with the proper treatment and care for his partial dentures, a specialized prostheses service. On 12/03/10 the facility staff failed to remove Resident # 2 ' s lower partial dentures at bedtime resulting in the resident swallowing them in the early morning of 12/04/10. The resident was short of breath, choking, and not able to eat for more than 24 hours before being taken to the hospital where the partial denture was discovered and removed from his throat prior to the surgical placement of a gastrostomy tube. One resident was harmed and 18 other residents with dentures could be affected by this deficient practice. Failure to remove the resident's partial denture resulted in the swallowing of the partial denture and a hospital visit. Findings include: Incident # 7 and Complaint # 6 Review of Resident #2' s face sheet revealed that he was admitted to the facility on [DATE]. Resident #2' s [DIAGNOSES REDACTED]. Review of Resident #2' s 10/15/09 quarterly MDS assessment revealed that he was totally dependent on the staff for eating with one person ' s assistance. Review of Resident #2' s ADL Care Plan was conducted on 12/09/10. One undated care plan kept in the ADL book had no dentures noted. A second undated care plan had no upper dentures noted but the lower partial denture was marked. The mouth care section did not mark whether the resident was independent or needed assistance with oral hygienge. Resident #11, the roommate of Resident #2, was interviewed on 12/09/10 at 1:50 PM. He stated that on the night of 12/03/10 a CNA assisted Resident #2 with eating in his room, she then left and didn't return. During that night Resident #11 was awakened by Resident #2 coughing and unable to push his call light. Resident #11 then pushed his own call light to summon help. He stated that a staff member then came into their room and gave Resident #2 oxygen. Review of a Nurse's Note dated 12/04/10 at 12 midnight revealed "...in bed at this time. Noted to have bilateral wheezes." Review of a Nurse's Note, dated 12/04/10 (no time noted) revealed "..Resident is congested and lung sounds bilateral rales. I called NP at 133 (sic) pm." Review of a Nurse's Note, dated 12/04/10 at 1430 revealed "6-2 Nurse reported that he did not eat his lunch...CXR ordered...Rales noted bilaterally to lungs." Review of a Nurse's Note dated 12/04/10 at 1700 revealed "CXR done...congestion persists, will continue to monitor." Review of a Nurse's Note dated 12/05/10, no time noted, revealed "Upon entering room...resident appears lethargic...resident is observed having more difficult time swallowing than normal. Family...expressed concern for res not eating and wanting to feed him...explained to daughter that resident was having an increased difficulty trying to swallow and will put in a call to MD. Call placed to MD...Nurse Practitioner called and report given of resd having difficulty swallowing, elevated temp and appearing lethargic. Order received for transfer resd to (hospital) for evaluation." Review of the Provider Investigation Report dated 12/08/10 at 11:30 PM revealed "On Sunday, 12/05/10, (Resident #2) was transferred to the hospital to rule out aspiration pneumonia. He was experiencing mild wheezing, increased coughing with meals and a temperature of 100.2. .On Wednesday (family member #3) enterd the facility...explained that in the process of prepping (Resident #2) for a [DEVICE] placement, his lower partial plate was found in his esophagus. She and her family believe (Resident #2) swallowed his partial plate here during the night on Friday, December 3." A phone interview was conducted with family member #2 on 12/20/10 at 3:40 PM. She stated that her mother put up signs in Resident #2's room asking them to remove his dentures before bedtime approximately one month before the incident. She said "my mother's biggest fear was that he would choke." She stated that on 12/04/10 when she came to visit "I asked everyone where his teeth were." She stated that she asked one particular nurse "did he swallow his teeth? I guess they were thinking that it was a whole set and it wasn't possible to swallow something that big. They weren't thinking about that partial." She stated she was there when they came in to take him to the hospital on [DATE]. She said "I was with him in his room. They came, put him on the stretcher, they put him in (the ambulance). I followed him to the hospital. They did not take his glasses, clothes, etc. We took his upper teeth out on Saturday. I have not seen the lower teeth since, not Saturday, not Sunday. His teeth were not in when he was taken out of his room. I'm absolutely certain of that." Review of a dental group' s exam on 02/02/10 revealed that Resident #2 ' s full upper dentures fit within normal limits. The lower partial dentures fit was recorded as being loose. An interview was conducted by phone on 12/28/10 at 11:18AM with the wife of Resident #2. She stated that Resident #2's lower dentures had been loose and that a dental appointment was scheduled for the second week of December 2010. Resident #2's wife stated that she had placed a sign in his room approximately 2 weeks before the incident requesting that his lower teeth be removed at night because they were a little loose and she was afraid he would choke. She stated that she was not sure if the staff had regularly done it. Resident #2's wife stated that she noticed that his teeth were missing at lunch on 12/04/10. She stated that she then placed a sign in the resident's room about his missing teeth. When asked who she told about the missing teeth, Resident #2's wife stated that she was not sure exactly who, but that it was probably the nurse and aide. An interview was conducted with LVN B on 12/28/10 at 3:13PM by phone. She stated that she took care of Resident #2 on the 6AM to 2PM shifts from 12/03/10 to 12/05/10. LVN B stated that he was " fine " on her 12/03/10 shift, but that overnight he had a decline. LVN B stated that she cleaned his top dentures on 12/04/10 and that she didn't see his bottom ones. She stated she didn't know what kind of dentures, full or partial, that the resident had. LVN B stated that the Resident #2 ' s daughter asked her if she thought that he had swallowed the dentures. LVN B stated that she didn't think that he could had swallowed them, but that she didn't know that the dentures were not full dentures on the bottom. An interview was conducted on 12/28/10 at 2:03PM with CNA D by phone. She stated that she worked with Resident #2 on the 10PM to 6AM shifts from 12/03/10 to 12/04/10. CNA D stated that the resident was coughing a lot when she came on duty on 12/03/10. She stated that she reported his condition to the nurse. When asked if she remembered if he had his dentures in at that time, CNA D stated that she did not remember. She stated that he should not have had the dentures in because the aide that puts him to bed would be the one responsible to have removed the dentures for the night. CNA D stated that in the past she has had to remove residents' dentures a couple of times because the aide that put them to bed had failed to do it. An interview was conducted on 12/28/10 at 12:49PM with CNA E by phone. She stated that she took care of Resident #2 on 12/04/2010 from 6:00AM to 2:00PM. CNA E stated that he " looked sick " when she came on duty. She stated that she did not put dentures into his mouth that day. CNA E stated that she " didn't know he had them " . She stated that she would know if a resident had dentures and needed oral care by looking at the ADL book. A review of the facility ' s investigation report revealed a signed hand-written statement made by the CNA F who worked with the resident 12/03/10 from 6:00AM to 10:00PM. The statement read in part " . . . I took care of (Resident #2) on Friday, December 3, 2010, from 6a.m.-10p.m. I got him dressed for breakfast that morning and laid him down for the day around 1:45p.m. At dinner time I raised him up in bed so he could eat. He started coughing as he always does so I stayed with him for a couple of minutes. I went across the hall to check on another resident. I heard him coughing again. I removed him from bed and put him in his chair so he could finish his meal. He continued to cough. As he was coughing his dentures came out of his mouth. He continued to eat. I stayed with him until he finished his meal. I let him sit up until he stopped coughing. I laid him back in bed. He was fine when I left him. After my last round of the night, he was fine also. . . . " A phone interview was attempted with CNA F on 12/28/10 at 10:57AM. A message was received that the phone number was no longer in service. An interview was conducted on 12/28/10 at 12:20PM with the DON. She stated that she did not have another phone number for CNA F. An interview was conducted with the DON on 12/29/10 at 9:50AM. When asked if CNA F had removed Resident #2 ' s dentures for the night, she stated that " as far as I know she took them out " . An interview was conducted on 12/29/2010 at 9:55AM with Resident #11, the former roommate of Resident #2. He stated that he was Resident #2's roommate during the time of the incident. Resident #11 stated that he only witnessed one aide that regularly removed Resident #2's teeth at night, and that she was no longer employed there. Resident #11 stated that Resident #2 had a denture cup at the bedside, but that he only saw one aide use it. Review of a Concern Form dated "Sat. Dec. 4, 2010" was conducted on 12/29/10. The wife of Resident #2 made the report and noted that the " lower partial dentures are missing, discovered they were not in mouth during lunch time; when we arrived for eating." The SW noted that she checked the room and the laundry without finding the dentures on 12/05/2010. Review of the12/06/10 hospital Bedside Evaluation of Dysphagia report noted that Resident #2 "was very gurgly, unable to clear cough and was not allowing suction to back of mouth" . Review of the 12/07/10 hospital consultation report noted that Resident #2 "failed a bedside swallow test, has trouble clearing his airways and loss of secretions." Resident #2 was scheduled for a percutaneous endoscopic gastrostomy placement on 12/08/10. Review of the 12/08/10 hospital operative report for Resident #2 revealed that " large amount of secretions, food and mucous . . . was suctioned away . . . part of the denture was noted in the back of his pharynx next to the vocal cords . . . using finger, the partial denture was removed. There was mild trauma in the area due to the hook of the denture in the area. "After the removal of the dentures, a gastrostomy was successfully placed." An interview with hospital RN K on 12/10/10 at 9:40AM revealed that Resident #2 was admitted to the hospital on [DATE]. She stated that the resident had "a bluish cast and could not clear his throat " . After the surgical procedure and removal of the lower partial denture on 12/08/10, RN K stated that Resident #2's color was normal without the bluish cast and he didn't keep trying to clear his throat." Review of the facility's policy/procedure on "Dentures, Cleaning and Storing" from the Nursing Services Policy and Procedure Manual, 2001 MED-PASS, Inc. (revised April 2007) was conducted. The section on Purpose revealed that " the purposes of this procedure are . . . to clean the resident's dentures . . . and to store dentures at bedtime. " Review of the facility's policy/procedure on "Daily Work Assignments" from the Nursing Services Policy and Procedure Manual, 2001 MED-PASS, Inc. (revised August 2006) was conducted. The section on "Preparing Work Assignments" reveals that "Work assignments are prepared from the residents' care plan by the Nurse Supervisor/Charge Nurse." The number of residents that could be affected was obtained by cross-checking the list of "Residents Require (sic) Denture Care Daily and Removal at Night " placed in the ADL binders on 12/10/10, the sampled residents' MDSs and the CMS 802 provided by the facility on 12/08/10 and 12/28/10.