Every finding on record at Park Place Care Center

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for sanitation.The facility failed to date all items after they were opened. The facility failed to properly label and date all items in the refrigerator.The facility failed to ensure all items in the dry storage room were properly sealed after being opened.The facility failed to maintain clean cooking equipment.The facility failed to keep the garbage can closed when not in use.These failures could place residents at risk for foodborne illness.Observations of the walk-in refrigerator and interview from 03/03/2026, 9:18 AM - 9:40 AM revealed the following: *9:18 AM, the walk-in fridge contained an opened bottle of Italian dressing dated 2/25/2026. The DM stated it was a received date and it did not have an open date on it because they went by the expiration date. The DM then looked at the bottle and stated it did not have an expiration date written on it. * 9:25 AM, the walk-in fridge contained a steam pan filled with a white, creamy, unidentifiable substance dated 3/02/2026. The DM said that it was cream of mushroom soup and that it did not need to be labeled.*9:26 AM, the walk-in fridge contained an opened container of mayonnaise dated 2/26/2026. The container was not labeled with an open date and the DM stated he was unaware of when it was opened.* 9:28 AM, the walk-in fridge contained five different bags and pans of individually stored meat and egg products sitting on one large steam pan. Only one bag was labeled and this label reflected breakfast and was dated 3/03/2026. The [NAME] stated he labeled one item for the entire tray of items. The DM said that each individual item did not need to be labeled if it was on one tray.* 9:31 AM, the walk-in fridge contained a container of strawberry glaze dated 1/12/2026 had round black spots on the lid. The DM said he did not know if it was mildew because he was not an expert.*9:37 AM, the walk-in fridge contained an opened container of mustard dated 2/21/2026. The container was not labeled with an open date and the DM said, it doesn't really expire.An observation of the dry room storage on 3/03/2026 at 9:45 AM revealed a bag of pecans dated 11/21/2025 was open to air. The pecans were in a resealable bag that was not sealed.An observation of the kitchen on 3/03/2026 at 10:33 AM revealed the fryer was uncovered and was not in use. There were crumbs on top of it and it appeared to be stained with a brown substance. During an observation and interview on 3/03/2026 at 10:34 AM, a small metal pan was sitting above the range top. The pan was covered with a black substance that was flaking off. The [NAME] said, it's just old. An observation of the kitchen on 3/03/2026 at 11:47 AM revealed the back of the stove/oven had several white unidentifiable streaks. The streaks were raised and dry and did not appear wet.An observation of the kitchen on 3/03/2026 at 12:01 PM revealed a trash can next to the three-compartment sink was overflowing and uncovered-the trash can was not in use and all staff were near the service line serving lunch.During an observation and interview on 3/04/2026 at 3:06 PM, the walk-in fridge contained a clear bottle filled with an unidentifiable orange substance. The bottle was not labeled or dated. The DM stated it was thousand island dressing. During an observation and interview on 3/05/2026 at 10:10 AM, the MD observed a picture of the lid for the strawberry glaze dated 3/03/2026 at 9:31 AM. The MD said it looked like mildew from the condensation and humidity in the walk-in refrigerator. The MD said it was cleanable and preventable. The MD said if an item were sitting underneath the fan in the walk-in fridge, it would drip down. The MD said that keeping the door closed more often would prevent it as well because heat from the kitchen created condensation.During an interview on 3/05/2026 at 1:35 PM, the DM said that if items were opened with no best-by date, they would write an opened date and if items were moved out of their original package, they put a best-by date. The DM said he ensured equipment was clean and sanitary by cleaning it. The DM said the small metal pan with the black substance was just wear and tear The DM said he could get a new one, but there was no harm to the food. The DM said the fryer was used for dinner on Monday night (3/02/2026) and Tuesday night (3/03/2026). The DM stated they were on week 3 of the cycle menu. The DM said he had a cleaning schedule and that the back of the stove/oven was cleaned monthly. The DM said food needed to be sealed, labeled, and dated. The DM said he monitored the kitchen through daily rounds and trained staff upon hire and via in-services. When asked how residents could be affected if food was not stored properly or if sanitation procedures were not followed, the DM said, foodborne illness.During an interview on 3/05/2026 at 4:18 PM, the ADM said the policy on food storage included storing it in a dry, safe area and that it should be dated and labeled. The ADM said the DM had a cleaning schedule and that he monitored the DM to ensure the cleaning schedule was adhered to. The ADM said he reviewed the DM's cleaning schedule with him daily. The ADM said items should be dated when they were opened. When asked if the fryer should be covered when not in use, the ADM said, let me get back to you. The ADM said dietary staff were trained upon hire and annually. When asked how residents could be affected if food were not stored properly or if sanitation policies were not followed, the ADM said hypothetically, they could get sick through cross-contamination.A record review of the cycle menu for week 3 on Tuesday (3/03/2026) reflected that no fried items were on the menu for lunch that day.A record review of the facility's document titled MONTHLY CLEANING SCHEDULE dated 2026 reflected that staff were to clean the inside and outside of the ovens monthly. A record review of the facility's titled Food Storage and Supplies dated 2012 reflected the following: All facility storage areas will be maintained in an orderly manner that preserves the condition of foodand supplies. We will ensure storage areas are clean, organized, dry and protected from vermin, andinsects.Procedure:4. Open packages of food are stored in closed containers with covers or in sealed bags, and dated as to when opened.9. Perishable items that are refrigerated are dated once opened and used within 7 days (if they do not have an expiration date or best by/use by date), but non-perishable items that are refrigerated once opened should be dated when opened but do not need to be discarded until their expiration date or until the quality has deteriorated. A record review of the 2022 FDA Food Code reflected the following: 3-302.12 Food Storage Containers, Identified with Common Name of Food.Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the FOOD. (B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. 5-501.113 Covering Receptacles. Receptacles and waste handling units for REFUSE, recyclables, and returnable shall be kept covered: (A) Inside the FOOD ESTABLISHMENT if the receptacles and units: (1) Contain FOOD residue and are not in continuous use; or (2) After they are filled; and (B) With tight-fitting lids or doors if kept outside the FOOD ESTABLISHMENT 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. FDA Food Code 2022 Chapter 4 Equipment, Utensils, and Linens Chapter 4 - 21 (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.

Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for five of ten residents (Resident #1, Resident #34, Resident #42, Resident #51, and Resident #72) reviewed for ADLs. The facility failed to ensure Resident #1, Resident #34, Resident #42, Resident #51, and Resident #72 fingernails were trimmed and maintained. This failure could place residents at risk of not receiving care services, diminished quality of life, and decreased self-esteem.1.Record review of Resident #1's face sheet dated 3/05/2026 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of metabolic encephalopathy, altered mental status, type 2 diabetes (uncontrolled blood sugar), vascular dementia (reduced blood flow to the brain), depression, pain in left wrist, traumatic subdural hemorrhage (bleeding inside the head) with loss of consciousness, cognitive communication deficit (difficulty communicating) cerebral infarction (stroke), hemiplegia and hemiparesis (one-side paralysis) following cerebral infarction affecting left non-dominant side, and need for assistance with personal care. Record review of Resident #1's MDS assessment dated [DATE] reflected that she had a BIMS score of 6, indicating moderately impaired cognition. Record review of Resident #1's care plan last reviewed on 1/23/2026 reflected that she required assistance with ADLs and staff were to check Resident #1's nail length, trim, and clean on bath days or as needed.Record review of Resident #1's POC response history for personal hygiene dated 3/05/2026 reflected that she received assistance every day from 2/04/2026-3/04/2026. The response history did not specify whether nail care was provided.During an interview and observation on 3/04/2026 at 9:52 a.m., Resident #1 was observed lying in bed and her fingernails were observed to have about 3-4 mm past edge of the fingertip. Resident #1 stated she did not like her fingernails long like that and asked, what can I do? Resident #1 stated that her family member trimmed her fingernails and she had not asked staff to.During an interview and observation on 3/05/2026 at 10:02 a.m., CNA A observed Resident #1's fingernails and then he stated they needed to be cleaned and they definitely need to be trimmed for sure. Resident #1's left hand was observed to be slightly contracted. CNA A stated that nail care happened as needed. CNA A said that the AD used to do nail care for some residents but not all of them-CNA A stated that at first, CNAs were not doing nail care.2.Record review of Resident #34's face sheet dated 3/05/2026 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of cerebral infarction due to embolism of left middle cerebral artery, type 2 diabetes (uncontrolled blood sugar), Parkinson's disease (progressive neurological disorder), unspecified protein-calorie malnutrition, contracture in right hand, weakness, aphasia (language disorder) following cerebral infarction (stroke), muscle wasting and atrophy (muscle loss), cognitive communication deficit (difficulty communicating), and need for assistance with personal care. Record review of Resident #34's MDS assessment dated [DATE] reflected that she had a BIMS score of 00, which indicated severely impaired cognition. Record review of Resident #34's care plan last reviewed on 3/04/2026 reflected that she had an ADL self-care performance deficit and required a one-person assist for bathing.Record review of Resident #34's POC response history for personal hygiene dated 3/05/2026 reflected that she received assistance every day from 2/04/2026-3/04/2026. The response history did not specify whether nail care was provided.During an observation and interview on 3/03/2026 at 1:34 p.m., Resident #34 was observed at the front of the building sitting in a geri chair and both of her hands appeared contracted with the right hand being the most contracted. Resident #34's fingernails were observed to be about 3 mm past edge of the fingertip. Resident #34 was non-interviewable and could not provide an opinion on her nails. During an observation and interview on 3/05/2026 at 9:22 a.m., LVN B observed Resident #34's fingernails and said they were a little long and they needed to be cleaned. Resident #34's hand was observed to be contracted and Resident #34's right hand fingernails were observed to have a dark unidentifiable substance underneath them resembling unclean fingernails. LVN B stated that CNAs and LVN did nailcare. LVN B stated that with the contracture, Resident #34 could scratch herself and it could get infected. 3.Record review of Resident #42's Face Sheet, dated 03/04/2026, reflected an [AGE] year-old male, admitted [DATE] with diagnoses that included cognitive communication deficit (a condition that affects how individuals think and communicate), muscle weakness (is decreased muscle strength), need for assistance with personal care (requires help with ADL's), diabetes mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired), chronic diastolic heart failure (leading to impaired heart function and various symptoms), lack of coordination (refers to difficulty in controlling voluntary movements, resulting in clumsy, unsteady, or awkward motions), and major depression (is a serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems).Record review of Resident #42's quarterly MDS dated [DATE], reflected a BIMS Score of 4, which cognitively impaired.Record review of Resident #42's Care Plan, dated 01/13/2026, reflected Resident #42 required assistance and supervision with bed mobility, bathing, hygiene, toileting, dressing, grooming, eating, and all assisted daily living care needs. The goals were for Resident #42 to maintain current level of function with assistance in his ADL care needs.Record review of Resident #42's ADL personal hygiene dated 03/05/2026 reflected to be provided during every shift. There was no fingernail ADL documentation for fingernail trimming from 02/04/2026 to 03/05/2026 in the ADL tasks checklist. Record review of nursing progress notes file for Resident #42 dated 03/05/2026 reflected no documentation that Resident #42 received ADL nail care services for fingernail trimming in the months of 12/3/2025 to 03/05/2026. During an interview on 03/03/2026 at 10:45 a.m. with Resident #42, he stated he does not like his fingernails long. Resident #42 stated that staff have not come around to trim his fingernails or offer to have them trimmed. Resident #42 does not know how long it's been, but his fingernails are too long. During an observation on 03/03/2026 at 10:47 a.m. of Resident #42 revealed the resident had untrimmed long fingernails, approximately one-inch-long from the fingernail bed on both his left and right hand.During an observation on 03/04/2026 at 10:00 a.m. of Resident #42 revealed the resident was peacefully sleeping. Resident #42 was observed to still have approximately one-inch-long fingernails that appeared to not be trimmed. During an interview on 03/04/2026 at 10:46 a.m. with ADM, he stated that the Resident #42 long fingernails will be addressed immediately. ADM stated he will have nursing staff take care of trimming Resident #42 fingernails.4.Record review of Resident #51's face sheet dated 3/05/2026 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of Parkinson's disease (progressive neurological disorder), cognitive communication deficit (difficulty communicating), weakness, need for assistance with personal care, and muscle wasting and atrophy (muscle loss).Record review of Resident #51's MDS assessment dated [DATE] reflected that he had a BIMS score of 15, which reflected no cognitive impairment.Record review of Resident #51's care plan last reviewed on 3/01/2026 reflected that he had an ADL self-care performance deficit related to musculoskeletal impairment and required a one-person assist with bathing. Record review of Resident #51's POC response history for personal hygiene dated 3/05/2026 reflected that he received assistance every day from 2/04/2026-3/04/2026 except for on 2/12/2026 and 2/22/2026. The response history did not specify whether nail care was provided.During an observation and interview on 3/04/2026 at 10:18 a.m., Resident #51 was observed lying in bed with his feet crossed. Resident #51's fingernails were observed to have about 3 mm past edge of the fingertip and he stated that staff had offered to trim his toenails, but not his fingernails. During an observation and interview on 3/05/2026 at 9:28 a.m., Resident #51 was observed in bed and his fingernails appeared to be the same length as they were on 3/04/2026. CNA H stated that Resident #51's nails looked clean but like they needed to be trimmed. 5.Record review of Resident #72's face sheet dated 3/05/2026 reflected a [AGE] year old male admitted on [DATE] with diagnoses of cerebral infarction (stroke), type 2 diabetes (uncontrolled blood sugar), vascular dementia, hemiplegia and hemiparesis (one-side paralysis) following unspecified cerebrovascular disease (condition that affects blood flow to the brain) affecting left non-dominant side and right dominant side, schizophrenia (brain disorder), cognitive communication deficit (difficulty communicating), weakness, unspecified abnormalities of gait and mobility, and need for assistance with personal care. Record review of Resident #72's MDS assessment dated [DATE] reflected that he had a BIMS score of 14, which indicated he had minimally impaired cognition.Record review of Resident #72's care plan last reviewed on 1/12/2026 reflected that he had an ADL self-care performance deficit and staff were to check his nail length and trim on bath days and as necessary.Record review of Resident #72's POC response history for personal hygiene dated 3/05/2026 reflected that he received assistance every day from 2/04/2026-3/04/2026. The response history did not specify whether nail care was provided.During an observation and interview on 3/04/2026 at 10:12 a.m., Resident #72 was observed sitting in a wheelchair in his room. Resident #72's fingernails were observed to have about 4 mm of past edge of the fingertip and there was a dark unidentifiable substance underneath them. Resident #72 said they just kind of grew out and said it had been a couple of weeks since had his nails cut. During an interview and observation on 3/04/2026 at 9:22 a.m., LVN B observed Resident #34's fingernails. Resident #34 was observed lying in bed and her right hand appeared contracted. LVN B stated that Resident #34's nails were long and needed to be cleaned. LVN B stated that CNAs trimmed residents' fingernails if they were not diabetic. LVN B stated she was familiar with Resident #34 but she had not trimmed her nails before. LVN B said she had not trimmed Resident #72's or Resident #51's nails and she did not know whether they were diabetic. During an interview on 3/05/2026 at 12:11 p.m., the AD stated that she used to work as a CNA and she was familiar with the facility's policy on nail care. The AD stated that CNAs did not do showers on Sundays, so they had more time to do nail care. The AD said that CNAs were supposed to check nails during every shower and that it was a part of their shower check list. The AD said that it was everyone's responsibility to do nail care and that she did manicures as an activity with around 10 residents per month. The AD stated that she did not recall doing Resident #1's nails and she could not recall the last time she trimmed Resident #34's nails. The AD said she did Resident #51's nails the last week of November (2025) or the first week of December (2025) and she said she had done Resident #72's nails twice since he was admitted -the AD said Resident #72's nails grew fast and the last time she trimmed them was 7 weeks ago. During an interview on 03/05/2026 at 12:30 p.m. with CNA A, he stated he worked at the facility for 10 months. The CNA A stated he received training on ADL care and trimming residents' fingernails. CNA A stated he has not performed any ADL fingernail trimmings for any residents since working here, but if he sees fingernails needing to be trimmed, he will ask the resident or tell a nurse. CNA A stated this goes for all residents as he works on all halls at the facility. CNA A stated training on ADL care and trimming residents' fingernails went over residents' fingernails need to be trimmed, sanded down, and cleaned as needed. CNA A stated residents' fingernails should be trimmed and cleaned. CNA A stated the facility verbally went over fingernail and nail care today. CNA A stated if resident's fingernails were not trimmed, it will be a concern since a resident can break a fingernail and prevent them from doing tasks, hurt themselves, or cause an infection. CNA A stated ADL care and trimming residents' fingernails are monitored by the nurses, but he is not entirely sure. CNA A stated that residents that are diagnosed as diabetic get nail care services from nurses only. CNA A stated he has received complaints from residents that staff were not providing nail care in which he stated to the residents that he would let a nurse or the DON know. CNA A stated it's the responsibility of all nursing staff to ensure ADL care and trimming residents' fingernails was taking place. CNA A stated if ADL care and trimming a resident's fingernails was not taking place, it could affect and diminish the resident's quality of life and potentially affect the resident's self-esteem, making the resident feel as if the facility staff do not care, and cause bacteria fungal. CNA A stated it's ultimately the overall responsibility of the DON to ensure ADL care and residents' fingernails were trimmed timely for all residents. During an interview on 03/05/2026 at 1:40 p.m. with LVN B, she stated she worked at the facility for 9 months. LVN B stated she received ADL care and trimming resident's fingernails timely training. LVN B stated ADL care and trimming resident's fingernails timely training goes over mindfulness of residents nails being maintained, trimmed, and to help with infection control. LVN B stated she does not remember the last time she received ADL fingernail care training besides verbally today. LVN B stated it's the responsibility of the CNAs and nursing staff to make sure residents' fingernails were trimmed and cleaned. LVN B stated ADL care and trimming resident's fingernails timely were monitored by the nursing staff. LVN B stated it's the responsibility of the LVN and nursing staff to ensure ADL care and trimming resident's fingernails was taking place for residents as residents can potentially scratch themselves cause an infection. LVN B stated if ADL care and not trimming resident's fingernails was not taking place, it could affect and diminish the resident's quality of life by the resident's potentially developing an infection in which may lead to many things like issues or be neglectful. LVN B stated it's ultimately the overall responsibility of the DON to check and ensure ADL care and resident's fingernails are trimmed for the residents at the facility.During an interview on 03/05/2026 at 3:39 p.m. with the DON, she stated she worked at the facility since 11/17/2025. The DON stated she received training on ADL care and trimming for residents' fingernails, she has provided that training to most staff. The DON stated that training on ADL care and trimming residents' fingernails for the nursing staff went over CNAs and nurses are to perform nail care, preventing residents from discomfort or pain with their fingernails not being trimmed, and residents have the right to have longer fingernails if they choose too. The DON stated ADL care and trimming of residents' fingernails were monitored by all nursing staff and any staff member, it's a group effort. The DON stated she had not received complaints from residents that staff were not trimming their fingernails. The DON stated if ADL care and trimming residents' fingernails was not taking place, it could affect and diminish the residents' quality of life as it could cause bacterial infection, injuries to the resident's skin, and effect the resident's dignity. The DON stated it's the responsibility of the DON to ensure ADL care and trimming residents' fingernails was taking place including the nursing department. The DON stated it's ultimately the overall responsibility of the DON to make sure residents are getting ADL care services for their fingernails. During an interview on 03/05/2026 at 4:00 p.m. with the ADM, he stated he worked at the facility since 12/01/2025. The ADM stated he was not trained on ADL care and trimming residents' fingernails as that was not in his scope as an ADM, and his nursing staff has received training for ADL care and fingernail trimming. The ADM stated that ADL care with trimming fingernails was the responsibility of CNAs and nursing staff. The ADM stated ADL care and trimming residents' fingernails were monitored by the CNAs and nursing staff. The ADM stated he had not received complaints from residents that staff were not trimming fingernails. The ADM stated it's the responsibility of the DON to ensure ADL care and trimming residents' fingernails was taking place. ADM stated the AD can assist with providing fingernail care, but it was not the AD's responsibility. The ADM stated if ADL care and trimming residents' fingernails was not taking place, it could affect and diminish the residents' quality of life by potentially scratching or hurt themselves if the residents fingernails get too long. The ADM stated it's ultimately the overall responsibility of the DON to ensure ADL care and residents' fingernails were trimmed for all residents. The ADM stated it's his expectation for ADL care and fingernails being trimmed is taking place for all residents by the nursing staff. Record review of facility in-service education for ADL documentation dated 10/21/2025 reflected to have been provided and completed by nursing staff including LVN B, but not completed by AD, CNA A, or CNA H. Record review of ADL Nail Care policy with no date reflected Nail management is the regular care of the toenails and fingernails to promote cleanliness, and skin integrity of tissues, to prevent infection, and injury from scratching by fingernails or pressure of shoes on toenails. It includes cleansing, trimming, smoothing, and cuticles are and is usually done during the bath. Nails can become thinner and more brittle in the elderly and thicker if peripheral circulation is impaired. Nails are also important in assessment, as changes occur with certain medical conditions, such as clubbing with chronic obstructive pulmonary disease or cardiac disease. Color changes with circulatory or lymphatic impairment and certain drug therapy is common. Nail care, especially trimming, is performed by a podiatrist in those with diabetes and peripheral vascular disease. Goals: Nail care will be performed regularly and safely. The resident will be free from abnormal nail conditions.

Based on observation, interview, and record review, the facility failed to ensure that each resident has the right to secure and confidential personal and clinical records for 1 (Resident #92) out of 20 residents reviewed for confidentiality.LVN D left the 400-hall charting computer's screen unlocked with personal medical information of Resident #92 displayed. This failure could result in residents' personal medical information being exposed to unauthorized individuals. Observation on 03/03/2026 at 9:22 a.m. revealed that the charting computer's screen on 400 Hall nursing station was open with Resident #92's personal information displayed and visible to unauthorized individuals, including visitors or other residents not present at that time. The nurse for 400 Hall, LVN D, was not present at the nursing station. She came 5 minutes later to turn the computer screen off.During an interview on 3/03/2026 at 9:26 a.m. with LVN D, she stated that she had an in-service on HIPAA a few months ago and it included instructions on not discussing residents' private clinical information with unauthorized individuals and to lock the computer screen when stepping away from the nursing station. She stated that everybody who worked with charting computers were responsible for closing it and locking it when not in attendance. She stated that leaving the screen unlocked with Resident #92's clinical information left on display could be harmful for this resident as anybody could see it. She stated that she stepped away from the charting computer to answer the call light and forgot to lock the computer's screen.During an interview on 3/05/2026 at 3:41 p.m. with DON, she stated that the facility's policy was to minimize the charting computers' screens when stepping away. She stated that if the screen was not minimized, someone could have unauthorized access to private clinical information displayed on the screen. She stated that HIPAA in-service was provided to all employees at hire and annually through computer modules which include instructions on locking the computer screens. She stated that the person who works with residents' private clinical information should lock the screen before walking away. She stated that the potential negative effect was unauthorized disclosure of residents' private information and could be a dignity issue. During an interview on 3/05/2026 at 4:05 p.m. with ADM, he stated that he had the HIPAA training at hire which covered the importance of maintaining the residents' private information. He stated that whoever used the computer was responsible for shutting it down to ensure the residents' information was not visible. He stated that the potential risk for not shutting down charting computers was a breach of residents' privacy and could affect their dignity. He stated that all staff complete HIPAA in-service at hire and annually through computer modules. He stated that LVN D completed her annual training but he could not provide documentation. Record review of facility's Confidentiality policy, dated 2023, revealed, To guarantee the residents' privacy regarding personal information: 1. No information regarding any resident will be released to any person, organization, or institution without the residents' consent. Record review of facility's Resident Rights policy, undated, revealed The resident has a right to personal privacy and confidentiality of his or her personal and medical records. No policy regarding closing computer screens were available.

Based on observation, interview, and record review, the facility failed to establish a system of accurate reconciliation and determine that drug records were in order, and that an account of all controlled drugs were maintained and periodically reconciled for 1 of 5 medication carts (400-hall med cart) in the facility affecting 1 resident (Resident # 50) reviewed for pharmacy services.The facility failed to ensure CMA C accurately reconciled Resident #50's narcotic medication log when she administered but did not sign for Resident #50's Lorazepam 0.5mg three tablets. These failures could place residents at risk for loss of prescribed medications, potential for not receiving their prescribed medications, and risk of drug diversion. During an observation on 3/05/2026 at 9:34 a.m of the 400-hall medication cart's reconciliation with the CMA C, revealed the CMA C opened the 400-hall's med cart at the surveyor's request. She was briefed on the purpose of the med cart and controlled medications reconciliation for accuracy with the CMA C showing understanding. The reconciliation of controlled medications on the 400 Hall med cart revealed the blister pack with Lorazepam 0.5mg.Record review of controlled medication log for Resident #50 reflected Lorazepam 0.5mg, three tablets for Resident #50 contained 117 tablets with count of 120 tablets on the.Record review of Resident #50's face sheet, dated 3/05/2026, revealed a 77-years-old female admitted on [DATE]. Resident #50's diagnoses included cerebral infarction (a medical emergency caused by blocked blood flow to the brain, leading to oxygen deprivation and tissue death), anemia (a common blood disorder defined by a deficiency of healthy red blood cells or hemoglobin, leading to reduced oxygen transport to body tissues), and Alzheimer's disease with late onset (the most common form of the dementia, typically developing after age [AGE] and characterized by progressive memory loss, cognitive decline, and personality changes).Record review of Resident #50's quarterly MDS assessment, dated 1/27/2026, revealed BIMS score of 11 indicating the moderate cognitive impairment. Further MDS assessment review for Resident #50 indicated present of mood like feeling down, depressed, or hopeless, but no behaviors like hallucinations or delusions present currently.Record review of Resident #50's care plan, dated 11/19/2025, revealed Resident #50 had behavior problem related to yelling, screaming, hitting with interventions: Administer anti-anxiety medications as ordered by physician. Monitor/document for side effects and effectiveness. Record review of Resident #50's orders, revealed that Resident #50 had an active order, started on 03/05/2026, for Lorazepam Oral Tablet 0.5 MG (Lorazepam) Give 3 tablets by mouth three times a day related to generalized anxiety disorder. Record review on 03/05/2026 of MAR for Resident #50 revealed that Lorazepam oral tablet 1.5 mg was administered on 03/05/2026 at 7:00 a.m. by CMA C.During an interview on 3/05/2026 at 9:35 a.m. with CMA C, she said that she administered Resident #50's Lorazepam 0.5mg 3 pills to her this morning but did not sign for it in the controlled medication log reviewed during observation. She said that she was supposed to sign it right away and made a mistake not signing it. CMA C said she got busy and forgot to sign for controlled medications administered to Resident #50 this morning, on 03/05/2026 between 7:00 a.m. and 8:00 a.m. She said that not documenting administration of controlled medications could cause a discrepancy in the count or a medication error, since other nursing staff could not know Resident #50 had already received the controlled medication. She stated that she received the controlled medication administration training annually but could not recall the exact date.During an interview on 03/05/2026 at 3:41 p.m. with DON, she said that she had the medication administration in-service annually and provided this training to nursing staff in the facility annually and on as needed basis. The DON said that charge nurses and CMAs were responsible for monitoring accurate controlled medication count and signing controlled medications as soon as they administered to each resident. She said that herself and the ADONs were auditing the medication carts on a weekly basis. She stated if the administration of controlled medications were not properly counted and signed for, it could lead to a drug diversion and medication error.During an interview on 03/05/2026 at 4:05 p.m. with the ADM, he said that he was not trained on medication administration and storage policy as he was not medically licensed. He said that DON, ADON, charge nurses, and medication aides were responsible for counting controlled medications at shift change and monitoring medications' discrepancies especially with controlled medication to prevent drug diversion and medication errors. He said if a discrepancy was noted, the nurse or med aide was responsible for notifying the ADON, DON or himself. The ADM said that if the controlled medications were not monitored and properly counted it could potentially harm the residents.Record review of facility's PCU019 - Controlled Medications - Administration policy, dated 3/2025, indicated that When a controlled medication is administered, the licensed nurse administering the medication immediately enters all of the following information on the accountability record: Date and time of administration, amount administered, signature of the nurse administered the dose, completed after the medication is actually administered.Record review of facility's In-Services for last 12 months, 02/2025-02/2026, reveal the record of completed nursing staff training, dated 07/01/2025, on Narcotic in-service: You must sign out narcotics when you pull them, not when you administered them. This in-service was completed and signed by 34 nursing staff including CMA C.

Based on observation, interview, and record review, the facility failed to prepare food in a form designed to meet individual needs for 2 of 8 (Resident #72 and Resident #11) residents reviewed for texture-modified diets.The facility failed to serve ground ribs to Resident #72 and Resident #11 who required ground meat.This failure could place residents at risk for choking, reduced intake, and weight loss. 1.A record review of Resident #72's face sheet dated 3/05/2026 reflected a [AGE] year old male admitted on [DATE] with diagnoses of cognitive communication deficit (difficulty communicating), weakness, dysphagia (difficulty swallowing), and need for assistance with personal care. A record review of Resident #72's MDS assessment dated [DATE] reflected that he had a BIMS score of 14, which indicated he had minimally impaired cognition.A record review of Resident #72's care plan last reviewed on 1/12/2026 reflected that he had a mechanically altered diet and staff were to serve his diet as ordered.A record review of Resident #72's diet order dated 10/06/2025 reflected an order for mechanical soft texture.A record review of Resident #72's weight report from 12/08/2025-3/04/2026 reflected no weight loss.2.A record review of Resident #11's face sheet dated 3/05/2026 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of dysphagia (difficulty swallowing), muscle weakness, need for assistance with personal care, and gastro-esophageal reflux disease (acid reflux).A record review of Resident #11's MDS assessment dated [DATE] reflected that she had a BIMS score of 15, which indicated no cognitive impairment. A record review of Resident #11's care plan last reviewed on 3/04/2026 reflected that she required a mechanically altered diet and staff were to offer her a diet as ordered by the physician. A record review of Resident #11's diet order dated 7/07/2025 reflected that she required mechanically ground meat.A record review of Resident #11's weight report from 12/08/2025-2/8/2026 reflected no weight loss.During an observation of lunch service on 3/03/2026 at 12:06 PM, the DM placed some ribs in a blender and pulsed them. When the DM finished pulsing the ribs in the blender, he placed them in a steam pan and put them on the service line. The pulsed ribs appeared stringy and were not ground. During an observation and interview on 3/03/2026 at 12:17 PM, Resident #11 was observed eating in the dining room. When asked how her meal was, Resident #11 stated, it would be better if I could eat the meat. Resident #11 stated that the meat just wouldn't go down. Resident #11 stated that her meat needed to be mechanically chopped and it looked like they just pulled it apart. Resident #11 said, I need it to be juicy so it goes down. Observed that Resident #11's meal ticket listed GROUND MEAT in two different places. During an interview on 3/04/2026 at 12:21 PM, Resident #11's family member said that Resident #11 complained to him about the meat. Resident #11's family member said he knew that Resident #11 had talked to the aides and to the SW but they might be understaffed. Resident #11's family member said that Resident #11 complained about the meat being hard to swallow and said she saw a speech therapist.During an observation and interview on 3/03/2026 at 12:27 PM, Resident #72 was observed eating at a table. Resident #72's meal ticket reflected that his meat needed to be grounded but it was observed to be shredded. Resident #72 said he was able to eat it okay.During an observation and interview on 3/03/2026 at 12:30 PM, LVN I stated she was responsible for checking meal trays that day during lunch. LVN I stated she checked for texture when checking trays. LVN I looked at Resident #11's tray and said her meat did not look ground up like hamburger meat. LVN I looked at Resident #72's plate and said no it did not look ground. LVN I said Resident #72 should have mechanical soft meat. LVN I said she did not see anyone get ground meat and that she would have to ask the DM about that.During an observation and interview on 3/05/2026 at 10:58 AM, the DOR stated that she was a speech therapist. The DOR stated that Resident #72 had a history of stroke, had dysphagia (difficulty swallowing), and required ground meat. The DOR said that Resident #11 used to receive speech therapy services for weight loss and she required mechanical soft meat. The DOR said mechanical soft meat should be like hamburger meat. The DOR said Resident #11 was kyphotic (curved spine) and that absolutely contributed to Resident #11's swallowing difficulty. The DOR stated that Resident #72 had a history of stroke and required ground meat. The DOR observed a photo taken by the HHSC surveyor dated 3/03/2026 at 12:24 PM of Resident #11's tray and said the meat did not look ground. The DOR said residents could have aspiration if they were served meat that was not ground. The DOR stated that neither Resident #11 nor Resident #72 had any choking incidents that she could recall.During an interview on 3/05/2026 at 1:45 PM, the DM said he could not tell the surveyor the policy on texture-modified diets verbatim, but that mechanical soft was a ground beef texture for meats. The DM said staff were trained through hands-on training and that he already had the knowledge upon hire. The DM said he monitored to ensure food was the appropriate consistency by watching staff prepare it. The DM said he was unaware that Resident #11 and Resident #72 received meat that was not ground. The DM said that charge nurses checked trays and cooks checked as they were plating the food. The DM said if food was not the correct texture, it could be a choking hazard.An attempt to interview the RD was made on 3/05/2026 at 3:02 PM, a detailed voicemail was left requesting a call back but the call was not returnedDuring an interview on 3/05/2026 at 3:47 PM, the DON stated that trays were passed through multiple hands-the DM, CNAs nurses, and cooks-and that they were all educated. The DON said nurses and CNAs checked trays to see if the ticket matched the tray. When asked why Resident #11 and Resident #72 received chopped meat instead of ground met, the DON said it was a possible oversight. The DON said if residents received food that had the incorrect texture, they could choke. During an interview on 3/05/2026 at 4:22 PM, the ADM said the kitchen staff used a machine to mince and chop meat and that cooks were trained upon hire, annually, and as needed. The ADM said trays went through several check points starting with the cook .The ADM said their policy was that a department head was in the dining room with a licensed nurse to check that food matched the ticket. The ADM stated that once it was cleared by the nurse, they gave it to a CNA to be passed to residents. The ADM said if food was not truly ground, residents could aspirate. A record review of the facility's policy titled MECHANICAL SOFT DIET OR REGULAR WITH MECHANICAL GROUND MEAT DIET dated 2025 reflected the following: The Mechanical Soft Diet is designed to provide a texture modification of the Regular Diet orany other therapeutic diet for persons with chewing or swallowing difficulty. Minced and moistmeat and flaked fish is served in sauce or gravy, with an average particle size of approximately 4mm (slightly less than half a centimeter) in width and less than 15 mm (1 1/2 centimeters) inlength; most fruits and vegetables are not served raw, and others may be finely or coarselychopped. Fried breaded vegetables are not served. The Mechanical Soft Diet is individualized asneeded. If a resident can tolerate regular consistency fruits and vegetables, a Regular with MechanicalGround Meat Diet may be appropriate. This diet will consist of the Regular Diet, but mincedand moist meat and flaked fish is served in sauce or gravy, with an average particle size ofapproximately 4 mm (slightly less than half a centimeter) in width and less than 15 mm (1 /2centimeters) in length. No other consistency modifications will be made. If a resident requestswhole meats, a doctor's order must be obtained.

Based on observation, interview and record review, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's mental and psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications), and need to alter treatment significantly for one (Resident #1) of eight residents reviewed for notification of changes. The facility failed to ensure LVN A notified the doctor, nurse practitioner, director of nursing and family when Resident #1 fell on [DATE]. The facility failed to ensure LVN C notified the doctor, nurse practitioner, director of nursing and family immediately when Resident #1 appeared withdrawn and had changes in behavior. An Immediate Jeopardy (IJ) was identified on 01/08/2026. The IJ template was provided to the facility on [DATE] at 5:30 PM. While the IJ was removed on 01/09/2026 at 6:00 PM, the facility remained out of compliance at a scope of isolated and severity level of no actual harm. This failure could place residents at risk of delayed identification of injuries, treatment, hospitalization and/or death. Findings included: Review of Resident #1's face sheet dated 01/08/2026 reflected a [AGE] year-old man admitted on [DATE] and readmitted on [DATE] with diagnoses of displaced intertrochanteric fracture of right femur (a severe break in the upper thigh bone), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis and weakness on right side of body caused by stroke), type 2 diabetes mellitus (condition where the body does not use insulin effectively or cannot produce enough insulin leading to high blood sugar levels), aphasia (language disorder often after stroke of brain injury that impairs speaking, understanding, reading or writing), muscle weakness, unspecified abnormalities of gait and mobility (difficulties with walking or movement where the specific cause is not identified), dysphagia (difficulty swallowing), cerebral infarction due to thrombosis of right anterior cerebral artery (type of store caused by a blood clot leading to brain tissue death) and unsteadiness on feet. Review of Resident #1's care plan reflected Resident #1 had hemiplegia/hemiparesis with revision date of 10/24/2025 with interventions to assist with ADLs/mobility as needed. Review reflected Resident #1 had an ADL self-care performance deficit and required assistance of one staff for toilet use, bathing, and dressing. Review reflected Resident #1's care plan dated 10/22/2025 reflected Resident #1 was at risk for falls, goal included Resident #1 would not sustain serious injury with interventions to be sure the resident's call light was within reach, educate resident about safety reminders, and reeducate Resident #1 to lock wheelchair brakes prior to transferring. Review of Resident #1's assessments reflected there were no neurological checks initiated or completed incident documentation for Resident #1's fall on 12/07/2026. Review of Resident #1's quarterly MDS dated [DATE] reflected a BIMS score of 07 which indicated severe cognitive impairment. Review reflected Resident #1 utilized a wheelchair. Review of Resident #1's functional abilities reflected Resident #1 required set up assistance (help provider verbal cues and/or touching/steadying as resident completes activity) for chair/bed-to-chair transfers, toilet transfers, going from sitting to standing and going from lying to sitting on the edge of the bed. Review reflected Resident #1 required supervision or touching assistances (helper providers verbal cues and/or touching/steadying and/or contact guard as resident completed activity) when walking 10 feet to 50 feet. Review reflected Resident #1 was occasionally incontinent of bladder and always continent of bowel. Review reflected Resident #1 had no falls since admission. Review of Resident #1 quarterly MDS dated [DATE] reflected a BIMS of 8 which indicated moderate cognitive impairment. Review reflected Resident #1 required partial/moderate assistance (helper does less than half the effort, helper listens, holds or supports trunk of limbs, but providers less than half the effort) for going from sitting to lying and for going from lying-to-sitting on edge of position. Review reflected Resident #1 required substantial/maximal assistance (helper does more than half the effort, helper lifts or holds trunk or limbs and providers more than half the effort) going from sitting to standing, transfers from chair/bed-to-chair transfers and toilet transfers. Walking 10 feet with Resident #1 was not attempted due to medical condition or safety concerns. Review reflected Resident #1 was frequently incontinent of bladder and bowel. Review of NP progress note with date of service of 12/12/2025 reflected Resident #1 was seen for increased withdrawal and a recent fall. NP progress note reflected Resident #1 had been more withdrawn over the past week as noted by nursing staff. Review reflected Resident #1 reported a fall had occurred approximately 4 days ago which was not previously reported. Resident reported pain in right arm and difficulty with movement during visit with NP. Arm appeared more limp that usual and bruising was observed on the inner forearm and upper arm. X-ray was ordered for further evaluation and will evaluate Monday (12/15/2025) pending results. Review of late entry progress note put in 12/17/2025 by LVN A reflected Resident #1 had a previous fall on 12/07/2025 and was noted on floor by bed at lowest position. Vitals were within normal limits and Resident #1 complained of leg pain and PRN tramadol was administered. Resident #1 was assisted back to bed at approximately 11:20 PM and there were no injuries noted. Review of progress note reflected there was no notification to the NP/MD/RP or DON. Review of progress notes from 12/07/2025 through 12/13/2025 reflected no updated interventions were put in place for Resident #1 after each fall. Review of incident report dated 12/18/2025 reflected fall occurred on 12/08/2026 for Resident #1 with no additional information notated. Review of progress note dated 12/13/2025 by LVN C reflected Resident #1 had an unwitnessed fall and missed sitting on his wheelchair after he used the bathroom. Notification was made to NP and RP. Encouraged Resident #1 to use call light or ask for assistance to go to the bathroom or transfer were interventions in place prior to the fall and no interventions were documented as put in place in response to the fall. Neurological assessments were initiated with no abnormalities. Review of incident report for Resident #1's 12/13/2025 fall noted resident self-transferred causing a fall due to poor strength and intervention was to encourage resident to call for help and therapy evaluation dated 12/16/2025 (eleven days after Resident #1's initial fall and three days after Resident #1's second fall). Review of NP progress note dated 12/17/2025 reflected Resident #1 was seen for increased withdrawal and continued pain within his shoulder and head. X-ray was performed on his arm on 12/12/2025 which showed some soft tissue swelling, but no fracture. Resident #1 reported right shoulder pain and head pain which began at the same time. Review of progress note by LVN C dated 12/17/2025 reflected Resident #1 was transferred to hospital on [DATE] related to dislocated right shoulder. NP was notified of results and gave order to be sent out to the hospital. Review of radiology report dated 12/12/2025 reflected x-ray of Resident #1's right knee reflected no acute fracture or effusion (abnormal build up of fluid) only mild osteoarthritis (when protective cartilage cushioning your bones wears down). Review of radiology report dated 12/12/2025 reflected x-ray was completed on Resident #1's right elbow reflected posterior elbow soft tissue swelling with no evidence of fracture. Review of radiology report dated 12/12/2025 reflected x-ray was completed on Resident #1's right tibia/fibula with no acute osseous (things made of bone) abnormality. Review of radiology report dated 12/12/2025 reflected x-ray was completed on Resident #1's right forearm with no dislocation or evidence of acute fracture. Review of radiology report dated 12/17/2025 reflected x-ray was completed on Resident #1's right clavicle (collarbone) indicated anterior inferior dislocation noted of the humeral head from the glenoid fossa (ball of upper arm bone popped forward and down out of its socket in the shoulder blade). Review of emergency room diagnostic radiology report dated 12/17/2025 reflected x-ray of shoulder reflected no acute fractures or dislocations. Review reflected Resident #1 was found to have a nondisplaced fracture of the greater trochanter of the right proximal femur (break in upper thigh bone near the hip). Operation included a right hip intramedullary nail. During an interview on 01/08/2026 at 9:51 AM, CNA B stated she worked at the facility for thirteen years. CNA B stated that she usually worked the night shift from 7:00 pm to 7:00 am. CNA B stated she usually worked on the 500 hall, and she was familiar with Resident #1. CNA B stated that at the beginning of December 2025 she recalled Resident #1 had a fall. CNA B stated that she answered Resident #1's call light and found him on the floor. CNA B stated that Resident #1 appeared to have fallen as he tried to transfer to his wheelchair. CNA B stated that Resident #1 faced his bed and that his feet were under his bed. CNA B stated she called LVN A, and they assisted Resident #1 to his wheelchair. CNA B stated that Resident complained of pain and pointed to his chest, but had difficult speaking. CNA B stated that she did not see any bruising on Resident #1 at that time. CNA B stated that she did not stay after she assisted LVN A with helping Resident #1 into his wheelchair. CNA B stated LVN A gave Resident #1 pain medication and then they assisted Resident #1 into bed. CNA B stated that Resident #1 had an arm and leg on one side of his body that did not function well, but she could not recall which side it was. CNA B stated that she checked on Resident #1 a few times that night and he did not have any signs of pain after he was put into bed. CNA B stated she did not recall the time of the fall. CNA B stated she was then off for a few days and when she returned, she saw that Resident #1 had bruising. CNA B stated she was off for at least three days. CNA B stated since the fall Resident #1 was total assistance and incontinent. CNA B stated that prior to the fall Resident #1 was able to transfer himself and used a pull-up and not a brief. CNA B before the fall, Resident #1 was a 1 person transfer and required limited assistance. CNA B stated Resident #1 was able to bear weight and assisted by holding the back of his pants and he was able to pivot himself during transfers. CNA B stated after the fall, staff then had to do most of the work. CNA B stated that fall protocol was to ensure the resident was okay, stay with the resident and call the nurse. CNA B stated it was sometimes difficult to understand Resident #1 because he had a difficult time speaking. During an interview on 01/08/2026 at 10:11 AM, LVN C stated she usually worked 6:00 am to 6:00 pm. LVN C stated she usually worked 500 hall and was familiar with Resident #1. LVN C stated that at the beginning of December 2025 she noticed Resident #1 behaved differently and had not been getting out of bed. She stated Resident #1 did not want to go to the dining room. LVN C stated she thought Resident #1 was depressed because he thought he may have been discharging home. LVN C stated she did not think Resident #1 seemed like himself because he did not want to go to the dining room or come out of his room as often. LVN C stated that he was sometimes late to dinner because he ambulated around the facility or sat at the end of the hall and listened to music while he looked out the window. LVN C stated that the NP talked with Resident #1 and he stated he was in pain. LVN C stated the NP asked if Resident #1 had a fall and LVN C stated she was not aware of a fall. LVN C stated that the NP found Resident #1 had bruising and swelling to his right arm. LVN C stated she was upset with herself because she thought Resident #1 was depressed and did not observe the bruising. LVN C stated the protocol for falls was to go and assess the resident which included assessing the resident's skin, check range of motion, notify the NP, DON, ADON, and notify the family. LVN C stated then an incident report was completed with all of the information from the assessment and neurological checks were initiated. LVN C stated in the incident report, she documented what was seen, and document which family member that was notified and the NP name that was notified. LVN C stated neurological checks were initiated immediately for an unwitnessed fall because the resident may have hit their head and staff may be unaware and neurological checks help identify if there are any changes. LVN C stated it was important to complete the incident report so that the documentation was there and everyone was aware and extra eyes could be put on the resident and they could also be monitored. LVN C stated that monitoring would help catch any changes, identify a pattern and put extra precautions in place such as fall mat. LVN C stated staff thought Resident #1 was still mostly independent and that he needed more help. LVN C stated after a fall residents were monitored for at least 72 hours. LVN C stated rounds were conducted at least every 2 hours. LVN C stated that Resident had another fall on 12/13/2025 and she notified the NP and she ordered 2 tramadol a day for three days and would follow up when she returned the next week. LVN C stated that the NP told her to do an x-ray on Resident #1's shoulder and chest and the results returned that the shoulder was broken. LVN C stated the first x-rays were completed on Resident #1's elbow and knee on 12/12/2025. During an interview on 01/08/2025 at 11:42 AM, LVN D stated she usually worked on 500 hall. LVN D stated that she had just returned to work at the facility after being on leave. She stated that prior to going on leave Resident #1 was able to transfer himself from bed to wheelchair and to the toilet. LVN D stated that Resident #1 spent a lot of time up and went to the dining room for his meals. LVN D stated Resident #1 liked to sit at the window at the end of the hall and listen to music. LVN D stated that Resident #1 needed more help with transferring and toileting after she returned from leave. LVN D stated that when there was a fall the nurse immediately went to complete an assessment and then the ADON/DON, ADM, RP and NP were notified. LVN D stated if the resident was injured they would be sent to the hospital. If there is no injury, neurological checks would be started, and the nurse should ensure the fall was documented. LVN D stated there was a 72 hour monitoring period after a fall. LVN D stated an incident report should be completed after a fall which cued the neurological checks in PCC (charting system). The incident report also had a place to document who was notified of the fall, description of the fall and initial vitals. LVN D stated it was important to notify the MD or NP of a fall in case they wanted to send the resident to the hospital or if nothing looks physically wrong, they may have other orders or if the resident had started new medication they could see if there was a pattern. LVN D stated it was important to document a fall not only for the resident's health but if anything were to happen later such as a fracture and there was not anything documented the facility could have possibly known when it happened. LVN D stated documentation was also important for communication purposes so anyone could look at who was actually notified and communication can be consistent with everyone. During an interview on 01/08/2026 at 11:53 AM, RN E stated the fall protocol was to ensure the resident's safety, take vital signs, assess the resident, assist them back to bed, notify the provider, DON, family member and ADM. RN E stated if the fall was witnessed and they did not hit their head then neurological checks would not be initiated, but if they resident had an unwitnessed fall then neurological checks would initiated. RN E stated that a risk management note or incident report would be completed and that would trigger other assessments such as the neurological checks, notification to the family, DON and provider. RN E stated that it was important to document falls to assess barriers and safety issues that may have been able to be prevented. RN E stated it was also important to document to monitor for changes, and prevent another fall happening again. RN E stated that it was important to notify the provider of a fall for any new orders or change in the resident as the provider was responsible for the resident's safety as well. During an interview on 01/08/2026 at 12:03 PM, DOR stated that if a resident had a fall and were not already working with therapy a screening would be completed to determine if they needed to be on therapy services and to look at what interventions could be done to prevent falls. DOR stated that Resident #1 was evaluated right before he went to the hospital. DOR stated she was unsure if he had a screening prior to the day he went out to the hospital. DOR stated Resident #1 started speech therapy services on 12/12/2025 and had a physical therapy and occupational therapy evaluation on 12/16/2025 due to a fall within the last week. DOR stated she was not made aware of a fall prior to the fall within the last week and no screening was completed prior to the evaluations. During interview and observation on 01/08/2026 at 12:13 PM with a Spanish translator via phone, Resident #1 was able to answer yes or no questions. Resident #1 was interviewed in his room on 500 hall and there was no observation of hazards in his room. Resident #1 answered yes if it was difficult for him to speak. Resident #1 answered yes when asked if he understood Spanish best. Resident #1 answered yes when asked if he had a fall by his bed and a fall by his bathroom. Resident #1 answered no when asked if he had any pain at the time of the interview. Resident #1 answered yes that he hit his head and yes that he had a headache for a few days. Resident #1 answered yes that he tried to use the bathroom by himself and yes that the staff assisted him and responded to his call light. During interview, resident was not observed with any bruising or non-verbal signs of pain. During an interview on 01/08/2026 at 12:31 PM, the DON stated that CNAs were expected to call the nurse when there was a fall. The DON stated that when there was a fall the nurse was supposed to get help to transfer the resident back to the bed or wheelchair, complete a fall report, notify the DON whether or not there is an injury and then follow provider's orders. The DON stated the nurse should notify the provider, DON and RP. The DON stated notification gets documented in the event notes under risk management (incident report). The DON stated the nurses were supposed to notify the provider for every fall. The DON stated it was important that the provider was notified of a fall for possible injury, need to do therapy or input to prevent future falls. The DON stated it was important she was notified of a fall so she could follow up on a fall and see about preventing future falls and to be aware of what is going on in the building. The DON stated staffing for the facility was also dependent on acuity of the residents. The DON stated that it was important that a fall was documented in the event there was an injury because bruising can take days to show and if it did show up later or redness started there may be a reason to associate it with. The DON stated it also lets the staff know to monitor the resident for signs or symptoms of injury so there is no delay in treatment. The DON stated neurological checks were initiated for an unwitnessed fall or if it is known that the resident hit their head. The DON stated that there is a 3 day monitoring period in which neurological checks occur after a fall. The DON stated that LVN A did not notify her of a fall prior to 12/13/2025 and she was unsure of LVN A notified the provider of the fall. The DON stated depending on the resident's cognition, they may be interviewed about the fall to get what happened. The DON stated some residents have impulse control issues or poor safety awareness. The DON stated she was made aware of a fall on 12/12/2025 for Resident #1 that occurred prior. The DON stated that on 12/12/2025 the interventions that were put in place were to encourage Resident #1 to ask for assistance with transferring. The DON stated he did have another fall shortly after. The DON stated Resident #1's right side is flaccid(hanging loosely). The DON stated she thought therapy did a screening. The DON stated that reminding Resident #1 to use the call light was a fall intervention that was already in place. The DON stated that once it was noted there was a potential injury x-rays were ordered. The DON stated that she was not aware of a fall on 12/07/2025 and believed it occurred the morning of 12/08/2025 at 5:15 AM. The DON stated that LVN A was the nurse during that fall. The DON stated Resident #1 had another fall on 12/13/2025 around 9:30 AM. The DON reviewed documentation from the provider investigation report and stated that she did not put interventions in the documentation for the 12/08/2025 or 12/13/2025 fall. The DON stated after a fall, intervention did not have a set time frame to be put in place, but that the facility tried to look at a situation quickly and that interventions could take time depending on each resident. The DON stated ideally interventions would be put into place within the same week. The DON stated that Resident #1's level of assistance was that he was independent and needed some assistance that required help. The DON stated that Resident #1 sat in his wheelchair at the end of the hall and stood up himself when he grabbed the hand rail and predominately did things independently. The DON stated that Resident #1 now required more supervision than he previously required. The DON stated that the facility tried to have the same staff work on the same hall for continuity of care. The DON stated unfortunately Resident #1's right arm is flaccid and he kept it close to his body and the bruising wasn't found until 12/12/2025. The DON stated there were no increased complaints of pain. The DON stated a counseling was done with LVN A via phone that LVN A needed to document falls in a timely manner, notify all parties, complete a skin and pain assessment and address injuries immediately. The DON stated staff were supposed to finish documentation prior to ending their shift at the latest but ideally staff would document in real time. During an interview on 01/08/2025 at 3:02 PM, the ADM stated that the DON should be notified of a fall as soon as safely possible. The ADM stated that he expected that the fall be documented, the DON be notified and an incident report be completed. The ADM stated that it was important a fall was documented because it notified clinical leadership and allowed the team to take action and put interventions into place. The ADM stated it was also important the provider was notified of a fall. The ADM stated that when a fall occurred it was expected that the nurse notify the DON, the fall would be then brought into the morning clinical meeting and discussed to ensure appropriate steps have been taken. The ADM stated ideally it was discussed the following day if not the same day, to discuss interventions and root cause of the fall. The ADM stated the nurses had to notify the physician and responsible parties. The ADM stated the interventions should be put into place pretty soon after a fall and there was no specific timeframe. The ADM stated it did not meet his expectations that fall interventions were not put into place until 12/12/2025 after a fall on 12/07/2025. The ADM stated he became aware of Resident #1's fall the same time as the DON and believed it was on 12/12/2025. The ADM stated that he thought Resident #1's fall was on 12/08/2025 not 12/07/2025. The ADM stated he was not sure why LVN A documented a fall on 12/07/2025 and believed it was an error. The ADM stated he was unsure why LVN A documented a fall on 12/17/2025 if it happened on 12/07/2025. The ADM stated the DON provided counseling to LVN A. The ADM stated that he expected documentation to be completed on the same shift prior to leaving. The ADM stated he did not have interventions for Resident #1's 12/13/2025 fall memorized. The ADM stated that it was tricky to interview Resident #1 because he had intense dysphagia. The ADM stated that when he interviewed Resident #1, Resident #1 indicated that he knew he needed to use his call light and stated Resident #1 did not like to use his call like or got impatient. The ADM stated fall interventions would be documented in the care plan and would be dated 12/13/2025 or later. The ADM stated he was unsure if interventions were documented on risk management. During an interview on 01/08/2025 at 3:27 PM, NP stated she saw Resident #1 on 12/12/2025 and noticed bruising on his arm. NP stated prior to this, a fall was never reported. NP stated she visited with Resident #1's roommate and noticed Resident #1 was withdrawn and sat in then wheelchair, turned the opposite direction which was out of the ordinary for Resident #1. The NP stated that when she looked at Resident #1 more closely, she noticed bruising. NP stated bruising was different colors, some part was green, some dark purple, some more fresh and looked like it had happened in the past couple of days. The NP stated it could have happened hours to a day or two before and there was no way to exactly tell. The NP stated when there is a fall, she expected the facility to reach out and she could usually see the resident within a few days or the next day or so. The NP stated she did not recall if she was notified about Resident #1's fall on 12/13/2025 and would have to review her notes. The NP stated she normally saw a resident post fall and believed she saw him not too long after. The NP stated that she and PT looked at Resident #1 more closely because he seemed more withdrawn and she ordered an x-ray of his collar bone because it looked swollen. NP stated from that x-ray a shoulder dislocation was noted and she sent him to the hospital, but the hospital did not see a dislocation only a leg fracture. During an interview on 01/08/2025 at 4:37 PM, LVN A stated that she worked at the facility for about 6 years. LVN A stated that she believed it was a weekend that she was informed by CNA B that Resident #1 was on the floor. LVN A stated CNA B translated for her and he stated he was in pain. LVN A stated that there was no injury and she took his vitals and completed an assessment. LVN A stated that she gave Resident #1 a PRN tramadol and monitored him. LVN A stated that Resident #1's fall was a night and denied that he had a fall on 12/08/2025 at 5:00 AM. LVN A stated that nurses were supposed to document time of the fall, vitals, pain assessment, visible injuries and notify the chain of command (DON/ADON, MD and family). LVN A stated she did a late document note and she should have done right away. LVN A stated there were no injuries at the time of the fall. LVN A stated that Resident #1 reported generalized pain and it was relieved by tramadol. LVN A stated neurological checks should have been initiated because it was an unwitnessed fall. LVN A stated documentation was supposed to be completed by the end of the shift for continuity of care. LVN A stated she did not notify the DON, NP or family because it was a long night, we were short staffed, and I was helping out on other halls that night. LVN A stated she did follow up with Resident #1 about his pain, and he did not have any. LVN A stated she let the oncoming nurse know that she provided Resident #1 with pain medication but did not notify the nurse of a fall. LVN A stated it was important to notify providers and clinical management team about a fall in the event of delayed injury and it could cause a delay in care for the resident. LVN A stated it was important to document so that the nurse could monitor for any type of change if the resident is not at their base line. LVN A stated she worked her next shift on 12/10/2025 and 12/11/2025 and noticed Resident #1 did not look out the window like he usually did after dinner. LVN A stated that Resident #1's routine after dinner was not the same and he went straight to bed instead of hanging out. LVN A stated she did not note that change in behavior on the 24 hour report to the oncoming nurse or anyone else. Review of undated facility policy titled Notifying the Physician of Change in Status reflected nurses will document time and call of physician and should contact the physician when an assessment deem it necessary for medical attention. Review of facility policy titled Fall Policy reflected falls resulting in serious injury will be reported to the DON or the ADM. Review reflected an in-service dated 12/30/2025 was conducted with staff over topic notifying the physician of change in status. Review reflected an in-service dated 12/30/2025 was conducted over topic completing the incident report with nursing staff and included instructions on how to physically complete the incident report, but did not include when to complete the incident report. Review reflected there were no in-services completed on falls after Resident #1's fall on 12/07/2025 or 12/13/2025. Review of coaching form dated 12/12/2025 with LVN A reflected documentation of any fall / injury that was not completed as situation with specific coaching as all and injuries must be documented at the time of the incident with employee response as states understanding. Form was signed by the DON, but not LVN A and did not include coaching on notifications of change to the provider, the DON or the RP. Review of CNA 2-hour rounding sheets reflected routine rounding was completed with Resident #1 on 12/14/2025, 12/15/2025, and 12/16/2025 with no indication of increased rounding following 2 falls. Review of documentation that included staff knowledge check on abuse and neglect reflected 16 documents that were undated and/or did not include information on which staff completed the check. The knowledge check did not include information about falls or reporting change of condition. The ADM, the DON, and RNC were notified on 01/08/2026 at 5:30 PM, that an IJ had been identified. An IJ template was provided and a POR was requested. The following POR was approved on 01/09/2026 at 11:38 AM and indicated: Plan of Removal F580On 01/08/2026 an abbreviated survey was initiated at the facility. On 01/08/2026 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. Problem: The facility failed to immediately consult the resident's physician when there is, an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications); Interventions: Immediate in-service training for all licensed nursing staff including PRN, Agency and new staff will be conducted by the DON and Administrator on 1.8.2026. DON and Administrator were in-serviced prior to by Regional Compliance Nurse. Training will focus on the facility's Notification of Physician Change in Condition policy, emphasizing mandatory immediate reporting of any resident falls or significant changes in condition to the physician and DON, including documentation requirements and timelines. Facility Administrator and DON in-serviced on Risk Management protocol by Area Director of Operations and Regional Compliance Nurse. 1.8.2026A revised notification protocol will be implemented requiring the nurse discovering or responding to a fall to: a) Conduct an immediate assessment of the resident; b) Notify the DON and treating physician or N[TRUNCATED]

Based on observations, interviews and record review, the facility failed to ensure residents' environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of eight residents reviewed for accidents and hazards.The facility failed to ensure Resident #1 was monitored after a fall on 12/07/2025 which resulted in a subsequent fall on 12/13/2026 and femur fracture.The facility failed to ensure new interventions were put into place after Resident #1's 12/07/2025 fall was reported to the DON on 12/12/2025 to prevent a second fall on 12/13/2025.The facility failed to ensure new interventions were not delayed and put into place immediately after Resident #1's fall on 12/13/2025.An Immediate Jeopardy (IJ) was identified on 01/08/2026. The IJ template was provided to the facility on [DATE] at 5:30 PM. While the IJ was removed on 01/09/2026 at 6:000 PM, the facility remained out of compliance at a scope of isolated and severity level of no actual harm. This failure could place residents at risk of delayed identification of injuries, treatment, hospitalization and/or death.Findings included: Review of Resident #1's face sheet dated 01/08/2026 reflected a [AGE] year-old man admitted on [DATE] and readmitted on [DATE] with diagnoses of displaced intertrochanteric fracture of right femur (a severe break in the upper thigh bone), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis and weakness on right side of body caused by stroke), type 2 diabetes mellitus (condition where the body does not use insulin effectively or cannot produce enough insulin leading to high blood sugar levels), aphasia (language disorder often after stroke of brain injury that impairs speaking, understanding, reading or writing), muscle weakness, unspecified abnormalities of gait and mobility (difficulties with walking or movement where the specific cause is not identified), dysphagia (difficulty swallowing), cerebral infarction due to thrombosis of right anterior cerebral artery (type of store caused by a blood clot leading to brain tissue death) and unsteadiness on feet. Review of Resident #1's care plan reflected Resident #1 had hemiplegia/hemiparesis with revision date of 10/24/2025 with interventions to assist with ADLs/mobility as needed. Review reflected Resident #1 had an ADL self-care performance deficit and required assistance of one staff for toilet use, bathing, and dressing. Review reflected Resident #1's care plan dated 10/22/2025 reflected Resident #1 was at risk for falls, goal included Resident #1 would not sustain serious injury with interventions to be sure the resident's call light was within reach, educate resident about safety reminders, and reeducate Resident #1 to lock wheelchair brakes prior to transferring. Review of Resident #1's assessments reflected there were no neurological checks initiated or completed incident documentation for Resident #1's fall on 12/07/2026. Review of Resident #1's quarterly MDS dated [DATE] reflected a BIMS score of 07 which indicated severe cognitive impairment. Review reflected Resident #1 utilized a wheelchair. Review of Resident #1's functional abilities reflected Resident #1 required set up assistance (help provider verbal cues and/or touching/steadying as resident completes activity) for chair/bed-to-chair transfers, toilet transfers, going from sitting to standing and going from lying to sitting on the edge of the bed. Review reflected Resident #1 required supervision or touching assistances (helper providers verbal cues and/or touching/steadying and/or contact guard as resident completed activity) when walking 10 feet to 50 feet. Review reflected Resident #1 was occasionally incontinent of bladder and always continent of bowel. Review reflected Resident #1 had no falls since admission. Review of Resident #1 quarterly MDS dated [DATE] reflected a BIMS of 8 which indicated moderate cognitive impairment. Review reflected Resident #1 required partial/moderate assistance (helper does less than half the effort, helper listens, holds or supports trunk of limbs, but providers less than half the effort) for going from sitting to lying and for going from lying-to-sitting on edge of position. Review reflected Resident #1 required substantial/maximal assistance (helper does more than half the effort, helper lifts or holds trunk or limbs and providers more than half the effort) going from sitting to standing, transfers from chair/bed-to-chair transfers and toilet transfers. Walking 10 feet with Resident #1 was not attempted due to medical condition or safety concerns. Review reflected Resident #1 was frequently incontinent of bladder and bowel. Review of NP progress note with date of service of 12/12/2025 reflected Resident #1 was seen for increased withdrawal and a recent fall. NP progress note reflected Resident #1 had been more withdrawn over the past week as noted by nursing staff. Review reflected Resident #1 reported a fall had occurred approximately 4 days ago which was not previously reported. Resident reported pain in right arm and difficulty with movement during visit with NP. Arm appeared more limp that usual and bruising was observed on the inner forearm and upper arm. X-ray was ordered for further evaluation and will evaluate Monday (12/15/2025) pending results. Review of late entry progress note put in 12/17/2025 by LVN A reflected Resident #1 had a previous fall on 12/07/2025 and was noted on floor by bed at lowest position. Vitals were within normal limits and Resident #1 complained of leg pain and PRN tramadol was administered. Resident #1 was assisted back to bed at approximately 11:20 PM and there were no injuries noted. Review of progress note reflected there was no notification to the NP/MD/RP or DON, and no neurological checks were documented. Review of progress notes from 12/07/2025 through 12/13/2025 reflected no updated interventions were put in place for Resident #1 after each fall. Review of incident report dated 12/18/2025 reflected fall occurred on 12/08/2026 for Resident #1 with no additional information notated. Review of progress note dated 12/13/2025 by LVN C reflected Resident #1 had an unwitnessed fall and missed sitting on his wheelchair after he used the bathroom. Notification was made to NP and RP. Encouraged Resident #1 to use call light or ask for assistance to go to the bathroom or transfer were interventions in place prior to the fall and no interventions were documented as put in place in response to the fall. Neurological assessments were initiated with no abnormalities. Review of incident report for Resident #1's 12/13/2025 fall noted resident self-transferred causing a fall due to poor strength and intervention was to encourage resident to call for help and therapy evaluation dated 12/16/2025 (eleven days after Resident #1's initial fall and three days after Resident #1's second fall). Review of NP progress note dated 12/17/2025 reflected Resident #1 was seen for increased withdrawal and continued pain within his shoulder and head. X-ray was performed on his arm on 12/12/2025 which showed some soft tissue swelling, but no fracture. Resident #1 reported right shoulder pain and head pain which began at the same time. Review of progress note by LVN C dated 12/17/2025 reflected Resident #1 was transferred to hospital on [DATE] related to dislocated right shoulder. NP was notified of results and gave order to be sent out to the hospital. Review of radiology report dated 12/12/2025 reflected x-ray of Resident #1's right knee reflected no acute fracture or effusion (abnormal build up of fluid) only mild osteoarthritis (when protective cartilage cushioning your bones wears down). Review of radiology report dated 12/12/2025 reflected x-ray was completed on Resident #1's right elbow reflected posterior elbow soft tissue swelling with no evidence of fracture. Review of radiology report dated 12/12/2025 reflected x-ray was completed on Resident #1's right tibia/fibula with no acute osseous (made of bone) abnormality. Review of radiology report dated 12/12/2025 reflected x-ray was completed on Resident #1's right forearm with no dislocation or evidence of acute fracture. Review of radiology report dated 12/17/2025 reflected x-ray was completed on Resident #1's right clavicle (collarbone) indicated anterior inferior dislocation noted of the humeral head from the glenoid fossa (ball of upper arm bone popped forward and down out of its socket in the shoulder blade). Review of emergency room diagnostic radiology report dated 12/17/2025 reflected x-ray of shoulder reflected no acute fractures or dislocations. Review reflected Resident #1 was found to have a nondisplaced fracture of the greater trochanter of the right proximal femur (break in upper thigh bone near the hip). Operation included a right hip intramedullary nail. During an interview on 01/08/2026 at 9:51 AM, CNA B stated she worked at the facility for thirteen years. CNA B stated that she usually worked the night shift from 7:00 pm to 7:00 am. CNA B stated she usually worked on the 500 hall, and she was familiar with Resident #1. CNA B stated that at the beginning of December 2025 she recalled Resident #1 had a fall. CNA B stated that she answered Resident #1's call light and found him on the floor. CNA B stated that Resident #1 appeared to have fallen as he tried to transfer to his wheelchair. CNA B stated that Resident #1 faced his bed and that his feet were under his bed. CNA B stated she called LVN A, and they assisted Resident #1 to his wheelchair. CNA B stated that Resident complained of pain and pointed to his chest, but had difficult speaking. CNA B stated that she did not see any bruising on Resident #1 at that time. CNA B stated that she did not stay after she assisted LVN A with helping Resident #1 into his wheelchair. CNA B stated LVN A gave Resident #1 pain medication and then they assisted Resident #1 into bed. CNA B stated that Resident #1 had an arm and leg on one side of his body that did not function well, but she could not recall which side it was. CNA B stated that she checked on Resident #1 a few times that night and he did not have any signs of pain after he was put into bed. CNA B stated she did not recall the time of the fall. CNA B stated she was then off for a few days and when she returned, she saw that Resident #1 had bruising. CNA B stated she was off for at least three days. CNA B stated since the fall Resident #1 was now total assistance and incontinent. CNA B stated that prior to the fall Resident #1 was able to transfer himself and used a pull-up and not a brief. CNA B before the fall, Resident #1 was a 1 person transfer and required limited assistance. CNA B stated Resident #1 was able to bear weight and assisted by holding the back of his pants and he was able to pivot himself during transfers. CNA B stated after the fall, staff then had to do most of the work. CNA B stated that fall protocol was to ensure the resident was okay, stay with the resident and call the nurse. CNA B stated it was sometimes difficult to understand Resident #1 because he had a difficult time speaking. During an interview on 01/08/2026 at 10:11 AM, LVN C stated she usually worked 6:00 am to 6:00 pm. LVN C stated she usually worked 500 hall and was familiar with Resident #1. LVN C stated that at the beginning of December 2025 she noticed Resident #1 behaved differently and had not been getting out of bed. She stated Resident #1 did not want to go to the dining room. LVN C stated she thought Resident #1 was depressed because he thought he may have been discharging home. LVN C stated she did not think Resident #1 seemed like himself because he did not want to go to the dining room or come out of his room as often. LVN C stated that he was sometimes late to dinner because he ambulated around the facility or sat at the end of the hall and listened to music while he looked out the window. LVN C stated that the NP talked with Resident #1 and he stated he was in pain. LVN C stated the NP asked if Resident #1 had a fall and LVN C stated she was not aware of a fall. LVN C stated that the NP found Resident #1 had bruising and swelling to his right arm. LVN C stated she was upset with herself because she thought Resident #1 was depressed and did not observe the bruising. LVN C stated the protocol for falls was to go and assess the resident which included assessing the resident's skin, check range of motion, notify the NP, DON, ADON, and notify the family. LVN C stated then an incident report was completed with all of the information from the assessment and neurological checks were initiated. LVN C stated in the incident report, she documented what was seen, and document which family member that was notified and the NP name that was notified. LVN C stated neurological checks were initiated immediately for an unwitnessed fall because the resident may have hit their head and staff may be unaware and neurological checks help identify if there are any changes. LVN C stated it was important to complete the incident report so that the documentation was there and everyone was aware and extra eyes could be put on the resident and they could also be monitored. LVN C stated that monitoring would help catch any changes, identify a pattern and put extra precautions in place such as fall mat. LVN C stated staff thought Resident #1 was still mostly independent and that he needed more help. LVN C stated after a fall residents were monitored for at least 72 hours. LVN C stated rounds were conducted at least every 2 hours. LVN C stated that Resident had another fall on 12/13/2025 and she notified the NP and she ordered 2 tramadol a day for three days and would follow up when she returned the next week. LVN C stated that the NP told her to do an x-ray on Resident #1's shoulder and chest and the results returned that the shoulder was broken. LVN C stated the first x-rays were completed on Resident #1's elbow and knee on 12/12/2025. During an interview on 01/08/2025 at 11:42 AM, LVN D stated she usually worked on 500 hall. LVN D stated that she had just returned to work at the facility after being on leave. She stated that prior to going on leave Resident #1 was able to transfer himself from bed to wheelchair and to the toilet. LVN D stated that Resident #1 spent a lot of time up and went to the dining room for his meals. LVN D stated Resident #1 liked to sit at the window at the end of the hall and listen to music. LVN D stated that Resident #1 needed more help with transferring and toileting after she returned from leave. LVN D stated that when there was a fall the nurse immediately went to complete an assessment and then the ADON/DON, ADM, RP and NP were notified. LVN D stated if the resident was injured they would be sent to the hospital. If there is no injury, neurological checks would be started, and the nurse should ensure the fall was documented. LVN D stated there was a 72 hour monitoring period after a fall. LVN D stated an incident report should be completed after a fall which cued the neurological checks in PCC (charting system). The incident report also had a place to document who was notified of the fall, description of the fall and initial vitals. LVN D stated it was important to notify the MD or NP of a fall in case they wanted to send the resident to the hospital or if nothing looks physically wrong, they may have other orders or if the resident had started new medication they could see if there was a pattern. LVN D stated it was important to document a fall not only for the resident's health but if anything were to happen later such as a fracture and there was not anything documented the facility could have possibly known when it happened. LVN D stated documentation was also important for communication purposes so anyone could look at who was actually notified and communication can be consistent with everyone. During an interview on 01/08/2026 at 11:53 AM, RN E stated the fall protocol was to ensure the resident's safety, take vital signs, assess the resident, assist them back to bed, notify the provider, DON, family member and ADM. RN E stated if the fall was witnessed and they did not hit their head then neurological checks would not be initiated, but if they resident had an unwitnessed fall then neurological checks would initiated. RN E stated that a risk management note or incident report would be completed and that would trigger other assessments such as the neurological checks, notification to the family, DON and provider. RN E stated that it was important to document falls to assess barriers and safety issues that may have been able to be prevented. RN E stated it was also important to document to monitor for changes, and prevent another fall happening again. RN E stated that it was important to notify the provider of a fall for any new orders or change in the resident as the provider was responsible for the resident's safety as well. During an interview on 01/08/2026 at 12:03 PM, DOR stated that if a resident had a fall and were not already working with therapy a screening would be completed to determine if they needed to be on therapy services and to look at what interventions could be done to prevent falls. DOR stated that Resident #1 was evaluated right before he went to the hospital. DOR stated she was unsure if he had a screening prior to the day he went out to the hospital. DOR stated Resident #1 started speech therapy services on 12/12/2025 and had a physical therapy and occupational therapy evaluation on 12/16/2025 due to a fall within the last week. DOR stated she was not made aware of a fall prior to the fall within the last week and no screening was completed prior to the evaluations. During an interview on 01/08/2026 at 12:13 PM with a Spanish translator via phone, Resident #1 was able to answer yes or no questions. Resident #1 answered yes if it was difficult for him to speak. Resident #1 answered yes when asked if he understood Spanish best. Resident #1 answered yes when asked if he had a fall by his bed and a fall by his bathroom. Resident #1 answered no when asked if he had any pain at the time of the interview. Resident #1 answered yes that he hit his head and yes that he had a headache for a few days. Resident #1 answered yes that he tried to use the bathroom by himself and yes that the staff assisted him and responded to his call light. During an interview on 01/08/2026 at 12:31 PM, the DON stated that CNAs were expected to call the nurse when there was a fall. The DON stated that when there was a fall the nurse was supposed to get help to transfer the resident back to the bed or wheelchair, complete a fall report, notify the DON whether or not there is an injury and then follow provider's orders. The DON stated the nurse should notify the provider, DON and RP. The DON stated notification gets documented in the event notes under risk management (incident report). The DON stated the nurses were supposed to notify the provider for every fall. The DON stated it was important that the provider was notified of a fall for possible injury, need to do therapy or input to prevent future falls. The DON stated it was important she was notified of a fall so she could follow up on a fall and see about preventing future falls and to be aware of what is going on in the building. The DON stated staffing for the facility was also dependent on acuity of the residents. The DON stated that it was important that a fall was documented in the event there was an injury because bruising can take days to show and if it did show up later or redness started there may be a reason to associate it with. The DON stated it also lets the staff know to monitor the resident for signs or symptoms of injury so there is no delay in treatment. The DON stated neurological checks were initiated for an unwitnessed fall or if it is known that the resident hit their head. The DON stated that there is a 3 day monitoring period in which neurological checks occur after a fall. The DON stated that LVN A did not notify her of a fall prior to 12/13/2025 and she was unsure of LVN A notified the provider of the fall. The DON stated depending on the resident's cognition, they may be interviewed about the fall to get what happened. The DON stated some residents have impulse control issues or poor safety awareness. The DON stated she was made aware of a fall on 12/12/2025 for Resident #1 that occurred prior. The DON stated that on 12/12/2025 the interventions that were put in place were to encourage Resident #1 to ask for assistance with transferring. The DON stated he did have another fall shortly after. The DON stated Resident #1's right side is flaccid(hanging loosely). The DON stated she thought therapy did a screening. The DON stated that reminding Resident #1 to use the call light was a fall intervention that was already in place. The DON stated that once it was noted there was a potential injury x-rays were ordered. The DON stated that she was not aware of a fall on 12/07/2025 and believed it occurred the morning of 12/08/2025 at 5:15 AM. The DON stated that LVN A was the nurse during that fall. The DON stated Resident #1 had another fall on 12/13/2025 around 9:30 AM. The DON reviewed documentation from the provider investigation report and stated that she did not put interventions in the documentation for the 12/08/2025 or 12/13/2025 fall. The DON stated after a fall, intervention did not have a set time frame to be put in place, but that the facility tried to look at a situation quickly and that interventions could take time depending on each resident. The DON stated ideally interventions would be put into place within the same week. The DON stated that Resident #1's level of assistance was that he was independent and needed some assistance that required help. The DON stated that Resident #1 sat in his wheelchair at the end of the hall and stood up himself when he grabbed the hand rail and predominately did things independently. The DON stated that Resident #1 now required more supervision than he previously required. The DON stated that the facility tried to have the same staff work on the same hall for continuity of care. The DON stated unfortunately Resident #1's right arm is flaccid and he kept it close to his body and the bruising wasn't found until 12/12/2025. The DON stated there were no increased complaints of pain. The DON stated a counseling was done with LVN A via phone that LVN A needed to document falls in a timely manner, notify all parties, complete a skin and pain assessment and address injuries immediately. The DON stated staff were supposed to finish documentation prior to ending their shift at the latest but ideally staff would document in real time. During an interview on 01/08/2025 at 3:02 PM, the ADM stated that the DON should be notified of a fall as soon as safely possible. The ADM stated that he expected that the fall be documented, the DON be notified and an incident report be completed. The ADM stated that it was important a fall was documented because it notified clinical leadership and allowed the team to take action and put interventions into place. The ADM stated it was also important the provider was notified of a fall. The ADM stated that when a fall occurred it was expected that the nurse notify the DON, the fall would be then brought into the morning clinical meeting and discussed to ensure appropriate steps have been taken. The ADM stated ideally it was discussed the following day if not the same day, to discuss interventions and root cause of the fall. The ADM stated the nurses had to notify the physician and responsible parties. The ADM stated the interventions should be put into place pretty soon after a fall and there was no specific timeframe. The ADM stated it did not meet his expectations that fall interventions were not put into place until 12/12/2025 after a fall on 12/07/2025. The ADM stated he became aware of Resident #1's fall the same time as the DON and believed it was on 12/12/2025. The ADM stated that he thought Resident #1's fall was on 12/08/2025 not 12/07/2025. The ADM stated he was not sure why LVN A documented a fall on 12/07/2025 and believed it was an error. The ADM stated he was unsure why LVN A documented a fall on 12/17/2025 if it happened on 12/07/2025. The ADM stated the DON provided counseling to LVN A. The ADM stated that he expected documentation to be completed on the same shift prior to leaving. The ADM stated he did not have interventions for Resident #1's 12/13/2025 fall memorized. The ADM stated that it was tricky to interview Resident #1 because he had intense dysphagia. The ADM stated that when he interviewed Resident #1, Resident #1 indicated that he knew he needed to use his call light and stated Resident #1 did not like to use his call like or got impatient. The ADM stated fall interventions would be documented in the care plan and would be dated 12/13/2025 or later. The ADM stated he was unsure if interventions were documented on risk management. During an interview on 01/08/2025 at 3:27 PM, NP stated she saw Resident #1 on 12/12/2025 and noticed bruising on his arm. NP stated prior to this, a fall was never reported. NP stated she visited with Resident #1's roommate and noticed Resident #1 was withdrawn and sat in then wheelchair, turned the opposite direction which was out of the ordinary for Resident #1. The NP stated that when she looked at Resident #1 more closely, she noticed bruising. NP stated bruising was different colors, some part was green, some dark purple, some more fresh and looked like it had happened in the past couple of days. The NP stated it could have happened hours to a day or two before and there was no way to exactly tell. The NP stated when there is a fall, she expected the facility to reach out and she could usually see the resident within a few days or the next day or so. The NP stated she did not recall if she was notified about Resident #1's fall on 12/13/2025 and would have to review her notes. The NP stated she normally saw a resident post fall and believed she saw him not too long after. The NP stated that she and PT looked at Resident #1 more closely because he seemed more withdrawn and she ordered an x-ray of his collar bone because it looked swollen. NP stated from that x-ray a shoulder dislocation was noted and she sent him to the hospital, but the hospital did not see a dislocation only a leg fracture. During an interview on 01/08/2025 at 4:37 PM, LVN A stated that she worked at the facility for about 6 years. LVN A stated that she believed it was a weekend that she was informed by CNA B that Resident #1 was on the floor. LVN A stated CNA B translated for her and he stated he was in pain. LVN A stated that there was no injury and she took his vitals and completed an assessment. LVN A stated that she gave Resident #1 a PRN tramadol and monitored him. LVN A stated that Resident #1's fall was a night and denied that he had a fall on 12/08/2025 at 5:00 AM. LVN A stated that nurses were supposed to document time of the fall, vitals, pain assessment, visible injuries and notify the chain of command (DON/ADON, MD and family). LVN A stated she did a late document note and she should have done right away. LVN A stated there were no injuries at the time of the fall. LVN A stated that Resident #1 reported generalized pain and it was relieved by tramadol. LVN A stated neurological checks should have been initiated because it was an unwitnessed fall. LVN A stated documentation was supposed to be completed by the end of the shift for continuity of care. LVN A stated she did not notify the DON, NP or family because it was a long night, we were short staffed, and I was helping out on other halls that night. LVN A stated she did follow up with Resident #1 about his pain, and he did not have any. LVN A stated she let the oncoming nurse know that she provided Resident #1 with pain medication but did not notify the nurse of a fall. LVN A stated it was important to notify providers and clinical management team about a fall in the event of delayed injury and it could cause a delay in care for the resident. LVN A stated it was important to document so that the nurse could monitor for any type of change if the resident is not at their base line. LVN A stated she worked her next shift on 12/10/2025 and 12/11/2025 and noticed Resident #1 did not look out the window like he usually did after dinner. LVN A stated that Resident #1's routine after dinner was not the same and he went straight to bed instead of hanging out. LVN A stated she did not note that change in behavior on the 24 hour report to the oncoming nurse or anyone else. Review of undated facility policy titled Notifying the Physician of Change in Status reflected nurses will document time and call of physician and should contact the physician when an assessment deem it necessary for medical attention. Review of facility policy titled Fall Policy reflected falls resulting in serious injury will be reported to the DON or the ADM. Review reflected there were no in-services completed on falls after Resident #1's fall on 12/07/2025 or 12/13/2025. Review reflected there were no in-services on 01/08/2026 training staff on new fall prevention interventions or increased rounding for Resident #1. Review of coaching form dated 12/12/2025 with LVN A reflected documentation of any fall / injury that was not completed as situation with specific coaching as alls and injuries must be documented at the time of the incident with employee response as states understanding. Form was signed by the DON, but not LVN A and did not include coaching on notifications of change to the provider, the DON or the RP. Review of CNA 2-hour rounding sheets reflected routine rounding was completed with Resident #1 on 12/14/2025, 12/15/2025, and 12/16/2025 with no indication of increased rounding following 2 falls. Review of documentation that included staff knowledge check on abuse and neglect reflected 16 documents that were undated and/or did not include information on which staff completed the check. The knowledge check did not include information about falls or reporting change of condition. The ADM, the DON, and RNC were notified on 01/08/2026 at 5:30 PM, that an IJ had been identified. An IJ template was provided and a POR was requested. The following POR was approved on 01/09/2026 at 11:38 AM and indicated: Plan of RemovalF684 On 01/08/2026 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety.Problem: The facility failed to ensure residents received treatment and care in accordance with professional standards of practice. The facility failed to ensure Resident #1 was monitored after falls on 12/7/2025 and new interventions were put in place to prevent future falls.Interventions:Effective immediately, all licensed nursing staff including PRN, Agency and New Staff will be in-serviced by the Director of Nursing (DON) and Administrator (ADM) , who were trained prior by Regional Compliance Nurse on 1.8.2026, on the facility's Fall Prevention Policy (emphasizing mandatory post-fall assessments, including neurological checks, vital signs monitoring, and timely notification of providers and administration for every fall). Training completion is required by 1.8.2026 for all current staff, and orientation for all new hires will include this training before assuming duties.Facility Administrator and DON in-serviced on Risk Management protocol by Area Director of Operations and Regional Compliance Nurse. 1.8.2026The facility will implement a fall follow-up protocol requiring the nurse assigned at the time of the fall to complete a detailed incident report immediately and document all neurological and vital signs assessments in the resident's medical record within the same shift. The DON or designee will ensure consistent compliance with this protocol starting 1.8.2026.The interdisciplinary team including the DON, Medical Director, and Therapy Director will review and update Resident #1's care plan to incorporate individualized fall prevention interventions tailored to his multiple fall risks and clinical status, including frequent monitoring, assistance with transfers, and immediate post-fall interventions. 1.8.2026The facility will initiate dai

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 2 residents reviewed for accidents and supervision. The facility failed to supervise Resident #1 when she exited the facility through a door at the end of a hallway, walked down eight steps, across the parking lot and two traffic lanes then on to the center median of the road on 09/01/25. The speed limit on the road was 40 MPH. The noncompliance was identified as PNC (Past non-compliance). The IJ (Immediate Jeopardy) began on 09/01/25 and ended on 09/03/25. The facility had corrected the noncompliance before the survey began. This failure placed residents at risk of injuries and accidents.Findings included: Review of Resident #1's face sheet, printed on 10/01/25, reflected an [AGE] year-old female readmitted to the facility on [DATE]. Her diagnoses included metabolic encephalopathy (brain dysfunction causing confusion or memory loss), age-related cognitive decline, cerebral infarction (stroke), and vascular dementia (cognitive impairment caused by impaired blood flow to the brain). Review of Resident #1's quarterly MDS assessment dated [DATE], Section C (Cognitive Patterns) reflected a BIMS score of 7 which indicated severely impaired cognition. Section E (Behavior) reflected no wandering or other behaviors. Section GG (Functional Abilities) reflected Resident #1 was able to walk 150 feet with supervision or touching assistance. Review of Resident #1's comprehensive care plan, dated 07/21/25, reflected entries for impaired cognition, risk for falls, self-care deficit, and others. There were no entries regarding elopement. Review of Resident #1's elopement assessment dated [DATE], reflected a score of 7 which indicated she was not at risk for elopement. Review of Resident #1's progress note dated 09/01/25 at 3:51 PM, written by LVN A, reflected, Res walked out of the premises through the 500 door, res stated hse[sic] was going to sons house, son was already in the building during the incident. Res is ok with no issues. [sic] Review of Resident #1's progress note dated 09/01/25 at 4:11 PM, written by LVN A, reflected, Event - Elopement/Attempted BP-124/75. T-98.0. P-79. R-18. BS-N/A. Door Exited: 500 How long missing: less 10minutes Where was the resident discovered: outside the premises Injuries: No. Cognition / Behavior at Time of Event: Cognitive Impairment, Wanders, Requires cueing, res was walking along the 200 and 500 halls as usual when the family came to visit and the staff could not locate where the res was, seconds later res was noted to have gone out through the 500 back door without any supervision. res redirected back to the facility and head to assessment done, no injuries or bruises noted. np, don/adon aware. Initial Treatment/New Orders: n/a . Resident Statement: ' I WAS GOING TO MY SON HOUSE' [sic]Review of a statement dated 09/01/25, written by LVN V, reflected LVN V saw Resident #1 walking, with her walker, on the 500-hall at 4:20 PM. They spoke briefly and LVN V continued towards the nurses station. Review of a statement dated 09/01/25, written by MA W, reflected MA W was on the 500-hall after a medication pass and saw Resident #1 and LVN V have a brief encounter in the hall. Review of a statement dated 09/01/25, written by HA X, reflected HA X went to open the front door for a visitor around 4:30 PM. The visitor pointed towards the road where a few people were gathered. HA X notified a nurse in case the resident was in need of medical attention. Review of an email dated 09/02/25 at 6:51 PM, written by the ADM, reflected in part, It appears that the alarms on the doors work some of the time and not all the time. The alarm automatically shuts off at 15 seconds and no one heard it even in the offices at the beginning of the hall. During an observation and interview on 10/01/25 at 10:12 AM, MW B stated the door alarms were wired into the fire panel near the nurse's station. He stated if the door was pushed, it would open, and the alarm would sound. He stated staff must enter the proper code to turn off the alarm. MW B opened the door at the far end of the 300-hall and the alarm made a very loud constant noise. Several staff were observed responding to the alarm. MW B entered a code into the keypad and the alarm went quiet. During an observation and attempted interview on 10/01/25 at 12:39 PM, Resident #1 was observed lying in her bed in the secured unit. She smiled and stated she liked it in her room. She did not engage in further conversation and did not answer if she remembered walking out of the building. During a telephone interview on 10/02/25 at 9:05 AM, the CN stated as part of the elopement prevention plan, anyone who was at high risk for elopement had care plan interventions in place and that information was available to nurses and aides. She stated prior to the elopement on 09/01/25, Resident #1 was not assessed as being at risk for elopement. During an interview on 10/02/25 at 10:22 AM, the MS stated he started working at the facility on 09/08/25, but he was aware of the elopement on 09/01/25. He stated the old door alarm used batteries, and the new alarms were wired and worked without batteries. He stated the exit doors were all wired into the system and would turn off after a code was entered into the keypad at the door. He stated the staff had the code for the door alarms. He stated he was responsible to change the code every month or more often if needed. He stated they facility had conducted elopement drills three times a week on various shifts since the elopement. During an interview on 10/02/25 at 10:48 AM, MA C stated she received training from ADON I on elopements about a month ago. She stated if she could not find a resident, she notified the nurse or ADM immediately then searched everywhere. She stated any time a door alarm was activated, the area by that door was searched before the alarm was turned off. During an interview on 10/02/25 at 10:57 AM, LVN D stated a Code Orange referred to an elopement. She stated in the in-service she learned when the code orange was called, staff searched and counted every resident. Once it was established that someone was missing, the searchers looked outside and kept looking. She stated there were elopement drills, almost daily and staff actively participated in the drills. She stated she received training on elopements and ANE provided by ADON I. LVN D was able to speak to the ANE policy and gave an example of neglect. During an interview on 10/02/25 at 11:36 AM, LVN E stated she was trained on elopement prevention and response by ADON I. She learned if a resident was missing, she let everyone know and began the search. She stated staff had to look in every room and bathroom then the ADM or other leader gave further directions. She stated when a door alarm sounded, staff checked inside and outside before the alarm was turned off with the code. LVN E stated if a resident got out unnoticed, they could have been injured on the highway out in front of the facility. During an interview on 10/02/25 at 11:36 AM, CNA F stated she had received training on elopement and abuse and neglect from ADON I. She described the process of how they searched for a missing resident and responded to a door alarm. She learned if an alarm sounded, you checked the whole area around the door, inside and outside to make sure someone did not go outside. She stated if someone got out, they could get hurt in the road. She was able to speak to the Abuse and Neglect policy. During an interview on 10/02/25 at 11:44 AM, CNA G learned if a resident was missing, it was reported to the charge nurse and the ADM, and a Code Orange was called and everyone searched for the resident. She stated the facility had frequent elopement drills. She stated she worked with Resident #1 on the secured unit. CNA G stated she received the elopement and Abuse and Neglect training that was provided by ADON I. During a telephone interview on 10/02/25 at 12:04 PM, the DON stated she had worked at the facility for about a month. She described the process for Code Orange, elopement prevention, and elopement response. She stated when Resident #1 eloped on 09/01/25, there was some kind of issue with a door. The DON stated she was in the ADM's office when there was a commotion at the front door of the facility. She stated a passerby saw Resident #1 in the median of the road and came to the facility door to alert staff. She stated Resident #1's FM had entered the facility a few minutes before, and the FM had been looking for her in the facility. The DON stated Resident #1 was brought inside and a head-to-toe assessment was conducted with no injuries identified. She stated the resident was assessed and moved to the secured unit. The DON stated the following day she completed new elopement assessments on every resident in the facility. The DON stated the facility had conducted elopement drills three times a week since the elopement. On 10/02/25 at 2:43 PM, a telephone voice message was left for LVN A. A telephone call was not returned prior to exit. During an interview on 10/02/25 at 3:08 PM, ADON H stated when a resident was missing, they completed a room sweep, looked in restrooms, bedrooms, and common areas. The charge nurse who was not assigned to the missing resident, delegated where staff went to look. If the resident was not found inside, they continued the search outside. She stated residents were assessed for elopement risk on admission, quarterly and as needed. She stated if a resident was a high-risk for elopement and actively exit-seeking, the Secure Care team assessed the resident and if appropriate, the resident was moved to the secure unit. During an interview on 10/02/25 at 3:35 PM, the ADO stated Resident #1 went out the hallway door looking for her FM at the same time the FM entered the building. She stated the door alarm sounded briefly then stopped so staff assumed it was okay. The ADO stated they contracted a company to install new locks and alarms. She stated the new alarms were in place. She stated the alarm will continue to sound until staff enter a code. She stated it was her expectation that staff checked the area before they turned off the alarm. During an interview on 10/02/25 at 4:18 PM, the ADM stated staff had been educated on elopement prevention and elopement response. She stated the facility had elopement drills three times per week. She stated after Resident #1 eloped, they checked all the exit doors then monitored the doors every 15 minutes until the new alarm was in place. The ADM stated she sent out messages to all staff when there was an issue. She stated she attached policies to the messages for staff to review. She stated their messaging program showed if the messages were sent and received. She stated the ADONs, and treatment nurse also provided in-services to staff. During an interview on 10/06/25 at 9:36 AM, LVN J stated she was in-serviced on elopement by administration recently. She learned code orange meant someone was missing. She learned to conduct a resident head count and assign staff to search the premises and assign staff to notify administration, police, and the responsible parties. During an interview on 10/06/25 at 9:39 AM, LVN K stated she had been in-serviced on elopement again last week by administration. She learned to check sign-in and sign-out sheets, check common areas, yell out code orange. She stated staff were assigned to search specific areas or notify the ADM, DON, and responsible parties. During an interview on 10/06/25 at 9:42 AM, LA L stated she was in-serviced on elopement by administration. She learned to stop what she was doing and join the staff huddle at the nursing station. Staff would then be assigned specific tasks like searching inside or outside. During an interview on 10/06/25 at 9:45 AM, PTA M stated she was in-serviced on elopement by administration. She learned to stop what she was doing, notify the nurse, and staff huddle at nursing station, where staff got assigned to search for a resident inside and outside premises whenever there was a code orange (missing resident). During an interview on 10/06/25 at 9:47 AM, using an interpreter, HSKP N stated she had been in-serviced on elopement by administration. She stated she learned to search for residents inside and outside facility premises whenever a code orange was called. During an interview on 10/06/25 at 9:50 AM, HSKP O stated she had been in-serviced on elopement by administration. She learned to search for residents inside and outside facility premises whenever there was a code orange. During an interview on 10/06/25 at 9:51 AM, OTA P stated she was in-serviced on elopement by administration recently. She learned if a code orange is called, she was required to search for resident in the facility, alert the on-call nurse, check the exits, and search for resident inside and outside facility. During an interview on 10/06/25 at 9:53 AM, RN Q stated she was in-serviced last Wednesday during a drill, on elopement by administration. She learned to coordinate staff search parties, search rooms, bathrooms and exit doors, conduct resident head count, and notify ADM, DON, family, and responsible party. She stated she had been in-serviced on Abuse and Neglect and identified the ADM as the abuse coordinator. During an interview on 10/06/25 at 9:56 AM, DA R stated he was in-serviced by the administration on elopement recently. He learned to check sign in and out sheets, notify the ADM and DON , and search inside and outside facility premises. During an interview on 10/06/25 at 9:58 AM, [NAME] S stated he was in-serviced by the administration on elopement. He learned to notify the Administrator, go to nursing station, get assigned search party, and search inside and outside facility premises. During an interview on 10/06/25 at 10:02 AM, ADON I stated she was responsible for most of the training in the facility. She stated the day Resident #1 eloped, she in-serviced staff in the facility on elopement prevention and response, and neglect in general. She stated messages were sent to all staff not in the facility. ADON I stated there were staff assigned to look at the doors, around the clock, until the alarms were installed. On 10/06/25 at 10:20 AM, a telephone voice message was left for LVN A. A telephone call was not returned prior to exit. During a telephone interview on 10/06/25 at 10:23 AM, CNA T stated he was new to the facility, and he worked the night shift. He stated he had been in-serviced by administration on elopement. He learned if a resident was missing, he notified the nurse and began to search as directed by the charge nurse. He stated he had been in-service on Abuse and Neglect and had also received the documents by text. He was able to speak to the ANE policy and named the ADM as the abuse coordinator. During a telephone interview on 10/06/25 at 10:31 AM, CNA U stated she usually worked night shift. She stated she had been in-serviced on elopement and Abuse and Neglect by administration. She learned an elopement was called a code orange. When the code orange was announced, everyone looked for the missing resident. She stated she participated in elopement drills and attended a group in-service. CNA U stated she was in-serviced on ANE by administration. She stated the ADM was the abuse coordinator. She stated she learned abuse must be reported immediately. CNA U verbalized types of abuse and examples. She learned neglect was not doing whatever it was that the resident needed. Review of the facility's self-report to HHSC, dated 09/01/25, reflected the ADM reported Resident #1's elopement the same day it occurred. Review of the AD Hoc QAPI agenda, dated 09/02/25, reflected the ADM, DON, ADON H, ADON I, SSD, DFN, AD, MDSN, HSKP Sup, CN, and two others attended the meeting. The MD participated by telephone. Review of Resident #1's care plan, revised 09/02/25, reflected she was a high elopement risk. Interventions included providing structured activities, and if exit-seeking stay with the resident and call out for assistance. Review of Resident #1's elopement assessment dated [DATE], reflected a score of 27 which indicated she was at high risk for elopement. Review of the progress noted dated 09/02/25 at 5:01 PM, written by the SSD, reflected a Trauma Informed Assessment was completed. The assessment reflected no signs of distress or agitation observed. Review of an email dated 09/02/25 at 9:22 AM, written by ADON H, reflected Resident #1's RP was notified of the room change to the secured unit. Review of a service proposal, dated 09/03/25, reflected the work to be performed by (Company) to add various locks, timers, and power supplies for repair/replacement of current door alarms. The proposal was approved and signed by the ADO. Review of a Midnight Census Report, dated 09/02/25, reflected each resident in the facility had an Elopement Risk Assessment completed. Review of six sampled electronic medical records reflected an Elopement Risk Assessments had been completed on 09/02/25. Review of an in-service, dated 09/01/25 and conducted by ADON I, reflected all staff were in-serviced on Elopement Response. Review of an in-service, dated 09/01/25 and conducted by ADON I, reflected all staff were in-serviced on Code Orange - Elopement Policy, Elopement Response when alarm sounds, Abuse and Neglect Policy, and Abuse Coordinator is the Administrator. Review of an in-service, dated 09/01/25 and conducted by ADON I, reflected all staff were in-serviced on Abuse and Neglect. Review of an employee roster dated 09/02/25 reflected a text message sent by the ADM to all employees on 09/01/25 at 6:23 PM. The message read, Please find attached for your review the In-services on Elopement Prevention and Elopement Response. Review of a screen shot of a group text message, dated 09/03/25 at 2:07 PM, reflected eleven therapy staff had received and reviewed the Elopement response, elopement prevention, and Abuse and Neglect in-services that had recently been sent to all employees. Review of an elopement Prevention QA Check List, dated 09/08/25, reflected in part, (Company) started replacement of door alarms beginning 9/4, 9/5 - returned 9/8 ETA completion 9/9. Review of Q 15 Minute Check sheets dated 09/01/25 and 09/02/25, reflected the exit doors on the 100/DR, 200-, 300-, and 500-hall and dining room were monitored every 15 minutes. Review of the 30 Minute Check sheets dated 09/02/25, reflected the monitoring of the exit doors were changed to every 30-minute monitoring at 8:30 PM. Monitoring continued until 09/09/25 at 7:00 PM when the last door alarm was fixed. Review of Resident Elopement Search Drill sign in sheets dated 09/03/25 through 10/01/25, reflected the facility conducted elopement search drills twice the week of the elopement, three times per week for the next three weeks, and twice during the fifth week. Review of a letter from (Company), the work outlined on the service proposal dated 09/03/25, had been completed as of 09/26/25. Review of the undated Elopement Prevention policy reflected in part, Every effort will be made to prevent elopement episodes while maintaining the least restrictive for residents who are at risk for elopement. 1. The Elopement Risk Assessment will be completed upon admission. The Elopement Risk Assessment is to be completed at least quarterly and upon change of condition. 4. The resident's care plan will be modified to indicate the resident is at risk for elopement episodes. 5. Interventions into elopement episodes will be entered onto the resident's care plan and medical record. 6. Should an elopement episode occur, the contributing factors, as well as the interventions tried. will be documented on the nurses' notes. Director of Risk Management and\or Director of Nursing Services should be notified of elopement. 7. If a resident is discovered to be missing, a search shall begin immediately. All facility exits that residents have access to will have a device in place to alert staff of possible elopement attempts.The noncompliance was identified as PNC (Past non-compliance). The IJ (Immediate Jeopardy) began on 09/01/25 and ended on 09/03/25. The facility had corrected the noncompliance before the survey began.

Based on observation, interview, and record review, the facility failed to ensure the resident's right to be free from misappropriation of resident property for one of one controlled medication storage cabinet reviewed for misappropriation. The facility failed to prevent the misappropriation of an unknown number of controlled medications being stored for destruction. The medications and the Drug Destruction Log were discovered missing on 09/30/25. This failure could place residents at risk of misappropriation of property.Findings included: Review of the facility self-report dated 09/30/25 reflected in part, Medications from the drug destruction (some narcs) went missing - log for these medications also went missing. Review of a Drug Destruction Log Prescription Drug Inventory reflected the sheet was initiated on 09/30/25. The log reflected the five controlled medications that were left in the drawer when the previous log and unknown medications went missing. Review of the AD Hoc QAPI meeting sign in sheet, dated 09/30/25, reflected the ADM, DON, ADON H, ADON I, SSD, DFN, AD, HRC, CN, and MDSN attended the meeting. The MD participated by text. The facility initiated an investigation. Review of 14 employee drug screens reflected 12 employees tested negative for the 12 drugs listed. One employee tested positive for two drugs and a second employee tested positive for five drugs. Both staff provided proof of current prescriptions to rule out elicit use. During an interview on 10/01/25 at 9:11 AM, the ADM stated the current DON was suspended while the investigation regarding the missing medications was conducted. The ADM stated they performed drug testing on the DON, ADONs, nurses and med aides who had been in the facility recently but had a couple more people to test. ADON H stated initially the DON had the keys for the controlled drug storage but did not want to hold the keys, so they were kept in a drawer in the DON/ADON shared office. ADON H stated she currently had the keys on her person while the DON was out. She stated the cabinet drawer was kept locked and the office door had a keypad lock. ADON H stated one day last week, between 09/22/25 and 09/26/25, she did not remember which day, she put some discontinued narcotics in the drawer and straightened the medications cards, so they fit neatly in the drawer. She stated there were multiple cards of different medications for various residents but did not know how many as that information was recorded on the drug destruction log. ADON H stated, yesterday (09/30/25) as she walked in the front door, a nurse approached her with narcotics to put in the discontinued cabinet. She stated when she opened the cabinet drawer, all but one card and a few bottles of liquid medication were gone, and the drug inventory log was gone too. During an observation and interview on 10/01/25 at 10:23 AM, the DON office was observed, a black 2-drawer filing cabinet was in the corner of the room. The cabinet was secured to the wall with three visible brackets. There was one built in lock on one cabinet drawer and a padlock on each drawer. ADON H stated she had the key to the lock on cabinet, and the ADM had the key to the padlocks. ADON H stated the code to the lock on the office door had just been changed. ADON H stated the cabinet had been under a desk, but the desk was just moved to another office. During an interview on 10/02/24 at 9:21 AM, the CN stated it was her expectation that narcotics to be destroyed were kept in the locked cabinet in the DON office. She stated the meds were counted and signed by two nurses. A sticker from the medication label was placed on the log sheet and the quantity of medication was added to the log. The medication and log sheet were then locked in the drawer. She stated the DON was responsible for the key to the locked cabinet and now with a second lock on the drawers, the ADM was responsible for the second key. The CN stated it now required both the DON and the ADM to unlock the cabinet. During an interview on 10/02/25 at 11:17 AM, LVN E stated the process was discontinued controlled medications were taken off the medication cart and given to the DON or ADON when they did not have a DON in the building. She stated the medication was counted, both nurses signed the count sheet then the DON stored the medications. During an interview on 10/02/25 at 11:44 AM, CNA G stated she worked as both a CNA and a medication aide. She stated when controlled medications were discontinued, the DON was notified. The medications were counted and the count sheet signed by both staff. The DON then secured the medications. During a telephone interview on 10/02/25 at 12:04 PM, the DON stated she had worked at the facility for about a month. She stated she was not familiar with the policy for medication disposal at the facility as she had not reviewed all the facility policies. She stated she was told ADON H managed discontinued controlled medications, and she did not ask any questions. She stated the medications were supposed to be always double locked. She stated she was responsible for the keys to the locked medication storage. During an interview on 10/02/25 at 3:08 PM, ADON H stated after she discovered the medications were missing, she ran a report for discontinued controlled medications since the previous drug destruction on 08/28/25. Some of the medications on the report were reordered and on the medication cart or otherwise accounted for. She stated there was no way to know how many pills were missing as the control drug count sheets, usually wrapped around the medication cards, were also missing. During an interview on 10/02/25 at 3:53 PM, the ADO stated the DON was responsible for medication storage and destruction. She stated missing controlled medications did not meet her expectations. During an interview on 10/02/25 at 4:18 PM, the ADM stated she left the medication storage to the DON. She stated the DON was experienced and had clinical knowledge regarding controlled mediations and medication storage. She stated she expected the medications were stored properly and secure. The ADM stated the DON was responsible for the controlled medication storage, destruction, and keys. The ADM stated the cabinet for controlled medications waiting for destruction, required her and the DON, or ADON while the DON was out, to access the medications in the drawer. She stated she had the key to the padlocks on the drawers, and the DON had the key to the cabinet lock. She stated the new process required the Drug Destruction Log was copied every time medications were added or removed from the drawer. She stated the Drug Destruction Log was also copied every Friday. The ADM stated the copies of the logs were kept in her office. The ADM stated the code to the DON office had been changed and only a limited number of people had the new code. The ADM stated ADON I had in-serviced the nurses and medication aides on the new procedure. The ADM stated the facility received authorization to terminate the DON. During a telephone interview on 10/06/25 at 9:21 AM, the local Police Department dispatcher stated a detective had not yet been assigned to the case and there was no new information available regarding the report of missing controlled medications. Review of the Abuse/Neglect policy, revised 09/09/24, reflected in part, The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. Definitions: 9. Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Prevention: 3. All reports of abuse or suspicion of abuse/neglect or potentially criminal behavior will be investigated as per facility protocol. Review of the Controlled Medication Disposal policy, dated v3-2025, reflected in part, 1. The Director of Nursing and when applicable the Consultant Pharmacist are responsible for the facilities compliance with federal and state laws and regulations in the handling of controlled medications. Only authorized licensed nursing, legally authorized personnel and pharmacy personnel have access to controlled medications. 3. Schedule II, III, IV and V medications remaining in the facility after the resident has been discharged , or the order discontinued, are disposed either in the facility by legally authorized personnel, Director of Nursing, and Consultant Pharmacist. Review of the Drug Destruction policy, dated v3-2025 reflected, Policy - In the event that the facility must destroy medications (Controlled or Non-Controlled) the facility will adhere to the rules and regulations of their specific State Health Department as well as any other regulating body including but not limited to the Drug Enforcement Agency (DEA), State Board of Pharmacy, and OSHA. If contracted with a (Pharmacy) Consultant Pharmacist, they will be able to provide guidance as it to a drug destruction process for the facility. Procedure - 1. Each facility will review and adhere to all governing bodies related to the subject of Drug Destruction. 2. Specific consideration to NIOSH and other Hazardous medications will be strictly adhered to.

Based on observation, interview, and record review, the facility failed to ensure the residents had the right to be free from psychosocial abuse and neglect for five (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) of ten residents reviewed for abuse and neglect. The facility failed to:Ensure Resident #1 was free from verbal and emotional abuse by NA A on or around 05/30/25 and they failed to immediately suspend NA A (per their policy) as she had worked at the facility (26 shifts) since the incident. The facility did not investigate/report the incident because the DON stated Resident #1 later denied the allegation.Conduct thorough abuse/neglect investigations as they (staff) were photo-copying Abuse and Neglect in-services and changing the date without in servicing the staff for four separate self-reports, dated 06/14/25, 06/22/25, 06/26/25, and 07/02/25.Conduct thorough abuse/neglect investigations as they (staff) were photo-copying resident safe surveys for Residents #2, #3, #4, and #5 for two separate self-reports, dated 06/14/25 and 06/22/25. An Immediate Jeopardy (IJ) was identified on 07/09/25 at 3:24 PM and an IJ template was provided. While the IJ was removed on 07/10/25 at 5:00 PM, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy.These failures could place residents at risk of abuse, neglect, trauma, and psychosocial harm. Findings included:Resident #1Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including morbid obesity, need for assistance with personal care, anxiety disorder, and age-related cognitive decline. Review of Resident #1's quarterly MDS assessment, dated 06/12/25, reflected a BIMS score of 15, indicating she was cognitively intact. Section GG (Functional Abilities) reflected she required substantial/maximal assistance for toileting hygiene. Review of Resident #1's quarterly care plan, dated 5/28/25, reflected she had an ADL self-care performance deficit with an intervention of requiring two staff participation to toilet. Resident #2Review of Resident #2's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including mild cognitive impairment, muscle weakness, and a history of falling. Review of Resident #2's quarterly MDS assessment, dated 05/30/25, reflected a BIMS score of 14, indicating he was cognitively intact. Review of Resident #2's quarterly care plan, dated 05/27/25, reflected he had an ADL self-care performance deficit with an intervention of requiring two staff for assistance with bed mobility. During an interview on 07/09/25 at 10:08 AM, Resident #2 was shown a completed safe survey with his name on it. He stated he believed he had been asked those questions before, but if he had, it had only been one time. Resident #3Review of Resident #3's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including cognitive communication deficit, mild cognitive impairment, anxiety disorder, and need for assistance with personal care. Review of Resident #3's quarterly MDS assessment, dated 05/01/25, reflected a BIMS score of 14, indicating he was cognitively intact. Review of Resident #3's quarterly care plan, dated 05/05/25, reflected he had an ADL self-care deficit with an intervention of requiring one staff for assistance with bed mobility. During an interview on 07/09/25 at 10:11 AM, Resident #3 was shown a completed safe survey with his name on it. He stated he had never been asked those questions before and had never seen the document. Resident #4Review of Resident #4's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including anxiety disorder, acute respiratory failure, history of falling, and muscle weakness. Review of Resident #4's quarterly MDS, dated [DATE], reflected a BIMS score of 10, indicating a moderate cognitive impairment. Review of Resident #4's quarterly care plan, dated 03/04/25, reflected he had an ADL self-care performance deficit with an intervention of requiring one staff for assistance with bed mobility. Resident #5Review of Resident #5's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including joint disorders, cerebral infraction (stroke), cognitive communication deficit, and muscle weakness. Review of Resident #5's quarterly MDS, dated [DATE], reflected a BIMS score of 15, indicating she was cognitively intact. Review of Resident #5's quarterly care plan, dated 07/08/25, reflected she had an ADL self-care performance deficit with an intervention of requiring one staff for assistance with bed mobility. Review of safe surveys, dated 06/25/25 and included in the facility's 3613 (facility investigation report), from a self-report, dated 06/14/25, reflected the following questions/answers documented by the SW for Residents #2, #3, #4, and #5: 1. Do you feel safe in the facility? Yes2. Do the staff treat you with respect? Yes3. Do you know what to do if you witness or experience any kind of abuse? Tell the nurse4. Do you know who the Abuse Coordinator is? Unsure - explained it is the Admin. Review of safe surveys, dated 06/25/25 and included in the facility's 3613 (investigation report), from a self-report, dated 07/01/25, reflected the following questions/answers documented by the SW for Residents #2, #3, #4, and #5, which were photo-copied and identical from the ones completed for the self-report from 06/14/25: 1. Do you feel safe in the facility? Yes2. Do the staff treat you with respect? Yes3. Do you know what to do if you witness or experience any kind of abuse? Tell the nurse4. Do you know who the Abuse Coordinator is? Unsure - explained it is the Admin. Review of in-services entitled Abuse and Neglect and conducted by ADON D, dated 06/14/25, 06/25/25, 07/02/25, and one that was undated, reflected they were photo-copied with the date changed at the top. The staff in-serviced and their signatures were identical. They were included with the facility's 3613s from self-reports dated 06/14/25, 06/22/25, 06/26/25, and 07/02/25. Review of the facility's self-reports from 06/14/25, 06/22/25, 06/26/25, and 07/02/25, reflected the reporter was the DON and her signature was on the 3613s. During an interview on 07/09/25 at 9:41 AM, CNA B stated the management staff were lax when it came to abuse and neglect. She stated the residents were in a vulnerable state and it was not fair to them to not take abuse seriously. She stated a couple of days after she first started working at the facility, on approximately 05/30/25, she was in training and shadowing CNA C. She stated Resident #1 had said something about not getting changed by NA A and CNA C asked Resident #1 about the situation. She stated NA A was walking past the room and heard the conversation. She stated NA A she charged into the room and at the resident and yelled, Keep my mother f****** name out of your mother f****** mouth! She stated Resident #1 was shaking and was terrified. She stated she told NA A she needed to leave Resident #1's room and CNA C had to walk NA A out of the room. She stated she told CNA C to ensure that incident was reported to management as it was verbal abuse. She stated she continued to see NA A working and asked ADON E why nothing had been done and ADON E told her CNA C had changed her statement and stated she had walked NA A out of the room before she said anything to Resident #1. She stated she wrote a statement and had assumed it had gone to the DON and was self-reported to the state. She was told the DON told ADON E that without two written statements confirming it had happened, they could not do anything about it. CNA B was shown the four in-services (that had her name and signature on them) and she stated, You can tell these are copies! Look at the signatures - they are all the same! She stated she had not worked on any of those four dates and had been out of town on vacation. She stated, None of these are real.Review of NA A's time sheets, from 05/30/25 - 07/09/25, reflected she had worked 26 shifts during that timeframe. During an interview on 07/09/25 at 10:01 AM, Resident #1 stated she remembered NA A was sometimes mean to her. She stated she remembered (her account from the incident on 05/30/25) NA A telling her she was so big and her butt was so big it was hard to change her. She stated she had made her feel humiliated, ashamed, and scared. She stated the DON told her NA A would not work with her anymore, but NA A continued to come and try to change her, and she would tell her no because she did not want her to provide care. She stated she did not believe NA A ever got talked to by management. During an interview and observation on 07/09/25 at 11:50 AM, ADON E stated the ADM was the abuse and neglect coordinator. She stated she did not witness the incident regarding NA A and Resident #1 on 05/30/25 but was told about it by CNA B. She stated she reported it to the DON and the DON told her she found it to be unsubstantiated. She stated she would expect for the incident to have been reported the state if it had not been. She stated the DON told her she would not bring it to corporate's attention unless there were two witnesses confirming it happened. She stated when she initially interviewed CNA C, she confirmed the events of the incident that CNA B had relayed to her. She stated when she wrote her statement, she changed the story and wrote that she never heard anything. She stated she told CNA C to document the truth, but she would not. She stated both witness statements were given to the DON. She stated NA A was never suspended and continued to work on Resident #1's hall. She stated the DON conducted in-services every other Tuesday when they received their paychecks, and ADON D conducted in-services on the floor whenever they were needed. ADON E was shown the in-services and safe surveys that had been photo-copied. She stated they were obviously being copied which meant the staff were not getting appropriately educated and they were not ensuring residents felt safe. She stated it absolutely did not meet her expectations. She stated she did not believe ADON D had conducted them, and she probably had no idea her name was attached to them. ADON E became tearful and stated she could not believe that was going on and that the residents relied on them and they were not being taken care of the way they should be. During an interview on 07/09/25 at 12:24 PM, the DON stated her expectations regarding safe surveys were that the SW conduct new surveys any time there was an incident of abuse or neglect. She stated the surveys should pertain to the residents who were cared for by the staff member that it had been alleged against. She stated, typically, the ADM was responsible for completing self-reports, but for the last five weeks (how long the new ADM had been working at the facility), the responsibility had fallen on the nursing side. She was shown the photo-copied in-services and stated they looked like they were copied. She could not remember who completed those particular in-services, but it did not meet her expectations, as there should be new in-services conducted every time abuse or neglect was alleged. She stated she remembered CNA B had reported (at the end of May 2025) to ADON E that Resident #1 told her NA A had yelled at her. She stated she believed statements were gotten from CNAs B and C. She stated when she interviewed Resident #1, she denied the allegation and she believed her because they had a therapeutic relationship. She stated she would have reported it to the state if Resident #1 had been cognitively impaired, but she had denied it and was cognitively intact. The witness statements for CNAs B and C were requested. During an interview on 07/09/25 at 12:51 PM, the SW stated she was responsible for conducting safe surveys when she was told to. She was shown the photo-copied safe surveys and stated she never made copies of them and believed they were put in the wrong binders. She stated it was important to interview residents that could have been affected by a staff member who had been accused of possible abuse or neglect and it was important to interview the residents that were cognitively intact. During a telephone interview on 07/09/25 at 12:51 PM, the NP stated if there was an incident of alleged verbal abuse, she would expect the facility to investigate it if the patient was with it. She stated if the resident was confused, she was not sure if they should investigate it. She stated if the abuse was witnessed by another staff member, then that was a different story. She stated they should escalate it through their chain of command. She stated it was very important for staff to be in-serviced regularly on abuse and neglect to refresh them. During an interview on 07/09/25 at 2:11 PM, the ADM stated the DON could only find CNA C's witness statement regarding the incident with Resident #1. She stated that did not meet her expectations to only have the one statement. She stated ADON E told her she gave both statements to the DON and she was not sure what happened. She stated she started working at the facility around the time of the incident and was never notified of the allegation. She stated it did not matter if only one statement had been obtained. She stated the second an allegation of abuse or neglect was made towards a staff member; she would immediately suspend them and start her investigation. She stated if a resident then denied it, she would not go solely on that interview. She stated she would interview other staff that worked the same shift and the roommate of the resident alleging the abuse or neglect. The ADM was shown the photo-copied in-services and safe surveys and she stated they appeared to be duplicates and she considered that to be falsification. She stated that did not meet her expectations. She stated the DON was responsible for all self-reports as she (the DON) was clinical. She stated ADON D only conducted in-services on the weekends when an allegation of abuse or neglect was made, and the DON conducted them during the week. (All four copied in-services reflected week-day dates.) She stated after an allegation was made; she should be made aware immediately. She stated the sooner they could get to the root cause, the sooner she could make the necessary adjustments. She stated not investigating was putting the residents in jeopardy of being harmed. Telephone interviews were attempted with NA A on 07/09/25 at 10:27 AM and 1:32 PM. A returned call was not received prior to exit. Telephone interviews were attempted with CNA C on 07/09/25 at 10:29 AM and 1:35 PM. A returned call was not received prior to exit. Telephone interviews were attempted with ADON D on 07/09/25 at 10:07 AM and 2:12 PM. A returned call was not received prior to exit. Review of CNA C's witness statement, dated 06/04/25, reflected the following: On Friday the 30th [of May], we [CNAs B and C] were passing out morning trays. We went into [Resident #1]'s room and she was telling me something about the day before. As she was talking, [NA A] came in and saying things [sic]. So I politely turn [sic] [NA A] out of the room and let the resident finish talking. Then I went to report what had to place [sic]. It was noted under the statement that CNA C did not want to sign the statement. On the back of the statement, the DON documented, [Resident #1] (BIMS 15) denied hearing any cobe [sic] words or abusive language. Accusation unfounded. Review of the facility's Abuse/Neglect Policy, revised 05/09/17, reflected the following: The resident has the right to be free from abuse. Verbal Abuse: Any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents. Mental Abuse: Includes, but not limited to, humiliation, harassment, threats of punishment or deprivation. Training: The facility will train through orientation and on-going in-services on issues related to abuse/neglect prohibition practices regularly. All reports of abuse or suspicion of abuse/neglect or potentially criminal behavior will be investigated as per facility protocol. Investigations will be reviewed by the facility administrator and/or Abuse Preventionist within 24 hours of complaint. With an allegation of abuse or neglect, the employee(s) will immediately be suspended pending an investigation. Review of the facility's Resident Rights Policy, revised 11/28/16, reflected the following: A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life. The ADM was notified on 07/09/25 at 3:24 PM that an IJ situation had been identified and an IJ template was provided. The following POR was approved on 07/10/25 at 1:33 PM and indicated: Problem: FREE FROM ABUSE AND NEGLECT- On 07/09/2025, an abbreviated survey was initiated at the facility. On 07/09/2025 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. Interventions: One on One documented in-service on Abuse Investigation with the Administrator/DON was conducted by the Regional Compliance Nurse on 07/09/2025. This in-service included reviewing and conducting timely investigations for allegations. Staff verbalized understanding One on one documented inservice with DON by regional compliance nurse on events about reporting all allegations of abuse to the administrator as defined in 2014-14. Alleged perpetrators are to be suspended immediately, new inservices and new staff and resident assessments are to be initiated with every new allegation. DON verbalized understanding. Staff working with NA A have been interviewed on 07/09/2025 NA A, was suspended by facility administrator on 07/09/2025, pending investigation for abuse Resident safe surveys were completed on 07/9/2025 by Activity Director. No negative findings. Un-interviewable residents had a head-to-toe assessment completed on 07/09/2025 by charge nurses. No negative findings. The following in-services were initiated, documented and signed to confirm verbal understanding on 07/09/2025 by admin and DON, and any staff member not present or in-serviced on 07/09/2025, will not be allowed to assume their duties until in-services have been completed. Any new employees or agency staff or PRN staff utilized will receive the following in-services before first shift to be worked.o All StaffS Abuse/NeglectS Abuse/Neglect ReportingS Who to Report Abuse/Neglect to Inservice included reporting timelines and abuse and neglect coordinator notification . Staff will be questioned on inservices randomly, 3 x week x 4 weeks or until compliance is met by DON, ADON, Admin or Designee. The medical director was notified of the immediate jeopardy situation on 07/09/2025 at 1709 by ADON. On 07/09/2025, a trauma informed assessment was completed for Resident #1, by social worker which was negative for findings that required follow up interventions. 07/09/2025 Staff that worked with perpetrator were interviewed by Administrator, DON and ADON and asked if they had noted any abuse by the alleged perpetrator, no negative findings. ADHOC QAPI discussed with IDT on 07/09/2025. Monitoring DON/Admin/Designee will interview 5-10 staff weekly x 6-week situational abuse scenarios had how to address effective 07/09/2025 DON/Admin/Designee will interview 5 residents how staff treat them weekly x 6 weeks effective 07/09/2025 ADO/Regional Compliance Nurse will monitor weekly x 6 weeks monitoring tools for staff and resident interviews effective 07/09/2025 The QA committee will review the findings monthly x 3 months and makes changes as needed. The Administrator will resolve once no further issues have been identified. Effective 07/09/2025 The Surveyor monitored the POR on 07/10/25 as followed: During interviews on 07/10/25 from 1:55 PM - 4:29 PM, staff from both shifts were interviewed, which included CNA F, LVN G, CNA H, LVN I, MA J, the SW, and the AD. They all stated they were in-serviced on abuse and neglect before their shifts as well as receiving text message alerts about reporting abuse to the ADM immediately. They all knew their abuse and neglect coordinator was the ADM. All staff stated they have the ADM's personal phone number, and it was also located by the copy machine. The staff stated they were required to notify the ADM of any suspicion of abuse or neglect immediately - any day, any time. They all were able to give examples of abuse which included verbal, mental, physical, and emotional. During an interview on 07/10/25 at 3:53 PM, ADON E stated the abuse and neglect coordinator was the ADM. She stated she had never seen a resident at the facility being abused or neglected. She stated if she had, she would ensure their safety which was the main priority, then would report it to the ADM. She stated it was not their duty to determine if something happened, it was their duty to report it immediately. She stated all residents received either a skin assessment or safe survey on 07/09/25. During an interview on 07/10/25 at 4:29 PM, the ADM stated she was the abuse and neglect coordinator. She stated she expected to be notified immediately of any allegation of abuse or neglect. She stated, if you see something, say something. She stated she was in-serviced the night prior (07/09/25) by their regional corporate nurse regarding abuse and neglect. She stated the team had ensured all staff had her contact information, they sent mass text messages to all staff through their scheduling system, and did follow-up interviews with staff. She stated the DON was suspended because the IJ and not communicating to her the allegation of abuse with Resident #1. She stated NA A was suspended and then terminated due to the allegations made against her. Review of the facility's AD Hoc QAPI agenda, dated 07/09/25, reflected the ADM, the DON, ADON E, the SW, the AD, the HRD, and the MD were in attendance. Review of a Trauma Informed Assessment for Resident #1, dated 07/09/25 and completed by the SW, reflected no concerns. Review of witness statements, dated 07/09/25, reflected seven staff members' statements that had worked with NA A in some capacity alleging they had never seen NA A being abusive towards the residents. Review of safe surveys, dated 07/09/25, reflected interviewable residents had a safe survey completed by the AD with no concerns noted. Review of skin assessments, dated 07/09/25, reflected all non-interviewable residents had a completed skin assessment by a nurse with no concerns noted. Review of an in-service, dated 07/09/25 and conducted by the RCN, reflected the DON was in-serviced on the following: DON must report all allegations of abuse to the administrator as defined in 2014-14, asap. Every new allegation requires - Alleged perpetrators to be suspended immediately, new in-services initiated, new staff interviews, and new resident safe surveys. Review of an in-service, dated 07/09/25 and conducted by the RCN, reflected the DON, the ADM, ADON D, and ADON E, were in-serviced on the following: All allegations of abuse require a thorough investigation to include staff interviews and resident safe surveys. Review of an in-service, dated 07/09/25 and conducted by the RCN, reflected the DON, the ADM, ADON D, and ADON E, were in-serviced on the Abuse and Neglect provider letter. Review of an in-serviced, dated 07/09/25 and conducted by ADON E, reflected all staff for all shifts were in-serviced on the facility's Abuse and Neglect Policy. Review of an Employee Disciplinary Report for NA A, dated 07/09/25, reflected the following: [NA A] will be placed on investigatory suspension pending an investigation into allegations of resident mistreatment. Review of a Personnel Action Form for NA A, dated 07/10/25, reflected she was terminated due to failing to adhere to corporate code of conduct. The ADM was notified on 07/10/25 at 5:00 PM that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of pattern that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse and establish policies and procedures to investigate any such allegations for one (Resident #1) of ten residents reviewed for abuse and neglect. The facility failed to: - Follow their Abuse and Neglect policy after Resident #1 was verbally/emotionally abused by NA A on or around 05/30/25 by not investigating the incident, not suspending NA A, and not reporting it to the ADM which resulted in psychosocial harm for Resident #1. An Immediate Jeopardy (IJ) was identified on 07/09/25 at 3:24 PM and an IJ template was provided. While the IJ was removed on 07/10/25 at 5:00 PM, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy. These failures could place residents at risk of abuse, neglect, trauma, and psychosocial harm.Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including morbid obesity, need for assistance with personal care, anxiety disorder, and age-related cognitive decline. Review of Resident #1's quarterly MDS assessment, dated 06/12/25, reflected a BIMS score of 15, indicating she was cognitively intact. Section GG (Functional Abilities) reflected she required substantial/maximal assistance for toileting hygiene. Review of Resident #1's quarterly care plan, dated 5/28/25, reflected she had an ADL self-care performance deficit with an intervention of requiring two staff participation to toilet. Review of CNA A's time sheets, from 05/30/25 - 07/09/25, reflected she had worked 26 shifts during that timeframe. During an interview on 07/09/25 at 9:41 AM, CNA B stated the management staff were lax when it came to abuse and neglect. She stated the residents were in a vulnerable state and it was not fair to them to not take abuse seriously. She stated a couple of days after she first started working at the facility, on approximately 05/30/25, she was in training and shadowing CNA C. She stated Resident #1 had said something about not getting changed by NA A and CNA C asked Resident #1 about the situation. She stated NA A was walking past the room and heard the conversation. She stated NA A she charged into the room and at the resident and yelled, Keep my mother f****** name out of your mother f****** mouth! She stated Resident #1 was shaking and was terrified. She stated she told NA A she needed to leave Resident #1's room and CNA C had to walk NA A out of the room. She stated she told CNA C to ensure that incident was reported to management as it was verbal abuse. She stated she continued to see NA A working and asked ADON E why nothing had been done and ADON E told her CNA C had changed her statement and stated she had walked NA A out of the room before she said anything to Resident #1. She stated she wrote a statement and had assumed it had gone to the DON and was self-reported to the state. She was told that the DON told ADON E that without two written statements confirming it had happened, they could not do anything about it. CNA B was shown the four in-services (that had her name and signature on them) and she stated, You can tell these are copies! Look at the signatures - they are all the same! She stated she had not worked on any of those four dates and had been out of town on vacation. She stated, None of these are real. During an interview on 07/09/25 at 10:01 AM, Resident #1 stated she remembered NA A was sometimes mean to her. She stated she remembered (her account from the incident on 05/30/25) NA A telling her she was so big and her butt was so big it was hard to change her. She stated she had made her feel humiliated, ashamed, and scared. She stated the DON told her NA A would not work with her anymore, but NA A continued to come and try to change her, and she would tell her no because she did not want her to provide care. She stated she did not believe NA A every got talked to by management. During an interview and observation on 07/09/25 at 11:50 AM, ADON E stated the ADM was the abuse and neglect coordinator. She stated she did not witness the incident regarding NA A and Resident #1 on 05/30/25 but was told about it by CNA B. She stated she reported it to the DON and the DON told her she found it to be unsubstantiated. She stated she would expect for the incident to have been reported the state if it had not been. She stated the DON told her she would not bring it to corporate's attention unless there were two witnesses confirming it happened. She stated when she initially interviewed CNA C, she confirmed the events of the incident that CNA B had relayed to her. She stated when she wrote her statement, she changed the story and wrote that she never heard anything. She stated she told CNA C to document the truth, but she would not. She stated both witness statements were given to the DON. She stated NA A was never suspended and continued to work on Resident #1's hall. During an interview on 07/09/25 at 12:24 PM, the DON stated her expectations regarding safe surveys were that the SW conduct new surveys any time there was an incident of abuse or neglect. She stated the surveys should pertain to the residents who were cared for by the staff member that it had been alleged against. She stated, typically, the ADM was responsible for completing self-reports, but for the last five weeks (how long the new ADM had been working at the facility), the responsibility had fallen on the nursing side. She was shown the photo-copied in-services and stated they looked like they were copied. She could not remember who completed those particular in-services, but it did not meet her expectations, as there should be new in-services conducted every time abuse or neglect was alleged. She stated she remembered CNA B had reported (at the end of May 2025) to the ADON that Resident #1 told her NA A had yelled at her. She stated she believed statements were gotten from CNAs B and C. She stated when she interviewed Resident #1, she denied the allegation and she believed her because they had a therapeutic relationship. She stated she would have reported it to the state if Resident #1 had been cognitively impaired, but she had denied it and was cognitively intact. The witness statements for CNAs B and C were requested.During a telephone interview on 07/09/25 at 12:51 PM, the NP stated if there was an incident of alleged verbal abuse, she would expect the facility to investigate it if the patient was with it. She stated if the resident was confused, she was not sure if they should investigate it. She stated if the abuse was witnessed by another staff member, then that was a different story. She stated they should escalate it through their chain of command. During an interview on 07/09/25 at 2:11 PM, the ADM stated the DON could only find CNA C's witness statement regarding the incident with Resident #1. She stated that did not meet her expectations to only have the one statement. She stated ADON E told her she gave both statements to the DON and she was not sure what happened. She stated she started working at the facility around the time of the incident and was never notified of the allegation. She stated it did not matter if only one statement had been obtained. She stated the second an allegation of abuse or neglect was made towards a staff member; she would immediately suspend them and start her investigation. She stated if a resident then denied it, she would not go solely on that interview. She stated she would interview other staff that worked the same shift and the roommate of the resident alleging the abuse or neglect. She stated after an allegation was made; she should be made aware immediately. She stated the sooner they could get to the root cause, the sooner she could make the necessary adjustments. She stated not investigating was putting the residents in jeopardy of being harmed. Telephone interviews were attempted with NA A on 07/09/25 at 10:27 AM and 1:32 PM. A returned call was not received prior to exit. Telephone interviews were attempted with CNA C on 07/09/25 at 10:29 AM and 1:35 PM. A returned call was not received prior to exit.Review of CNA C's witness statement, dated 06/04/25, reflected the following: On Friday the 30th [of May], we [CNAs B and C] were passing out morning trays. We went into [Resident #1]'s room and she was telling me something about the day before. As she was talking, [NA A] came in and saying things [sic]. So I politely turn [sic] [NA A] out of the room and let the resident finish talking. Then I went to report what had to place [sic]. It was noted under the statement that CNA C did not want to sign the statement. On the back of the statement, the DON documented, [Resident #1] (BIMS 15) denied hearing any cobe [sic] words or abusive language. Accusation unfounded. Review of the facility's Abuse/Neglect Policy, revised 05/09/17, reflected the following: The resident has the right to be free from abuse. Verbal Abuse: Any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents. Mental Abuse: Includes, but not limited to, humiliation, harassment, threats of punishment or deprivation. Training: The facility will train through orientation and on-going in-services on issues related to abuse/neglect prohibition practices regularly. All reports of abuse or suspicion of abuse/neglect or potentially criminal behavior will be investigated as per facility protocol. Investigations will be reviewed by the facility administrator and/or Abuse Preventionist within 24 hours of complaint. With an allegation of abuse or neglect, the employee(s) will immediately be suspended pending an investigation. Review of the facility's Resident Rights Policy, revised 11/28/16, reflected the following: A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life. The ADM was notified on 07/09/25 at 3:24 PM that an IJ had been identified and an IJ template was provided. The following POR was approved on 07/10/25 at 1:33 PM: Problem: On 07/09/2025, an abbreviated survey was initiated at the facility. On 07/09/2025 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. The facility must develop and implement written policies and procedures that prohibit and prevent abuse, establish policies and procedures to investigate any such allegations, and include training as required Facility failed to keep resident #1 free from verbal and emotional abuse by NA A on or around 5/28/25 The facility failed to immediately suspend NA A (per their policy) as she has worked at the facility since the incident on 5/28/25. The facility did not investigate the incident because the DON stated Resident #1 later denied the allegation. One to one documented inservice provided to the DON by Regional Compliance Nurse over notification of administrator of any allegation and reporting per state provider letter 2024-14. This was completed on 07/10/2025. Signature confirmed verbal understanding. The facility failed to conduct thorough abuse/neglect investigation as they copied Abuse and Neglect in-service and changed the date without in-servicing the staff for four separate self reports. The facility failed to conduct thorough abuse/neglect investigation as they copied resident safe surveys for residents #2,#3,#4, and #5 for three separate self reports Interventions: One on One documented in-service on Abuse Investigation with the Administrator/DON was conducted by the Regional Compliance Nurse on 07/09/2025. This in-service included reviewing and conducting timely investigations for allegations per CMS provider letter _PL2024-14____. Signature to confirm verbal understanding. Staff working with Alleged perpetrator (NA A) have been interviewed on 07/09/2025 by DON with no negative findings The alleged perpetrator, NA A was suspended by facility administrator on 07/09/2025. Resident safe surveys were completed on 07/09/2025 by Activity Director. No negative outcomes. Administrator and DON and ADON were in-serviced by the Regional Compliance Nurse on conducting staff in-services for each individual self report on 07/09/2025. Administrator and DON and ADON were in-serviced by the Regional Compliance Nurse related to conducting thorough investigation including current safe surveys for each separate self report on 07/09/2025. Un-interviewable residents had a head-to-toe assessment completed on 07/09/2025 and completed by charge nurse. No negative findings. The medical director was notified of the immediate jeopardy situation on 07/09/2025 by ADON. On 07/09/2025 a trauma informed assessment was completed for Resident #1 by Social Worker. No negative outcomes. Resident denied past or present trauma. All events / risk management will be reviewed 5 times a week by the IDT members for 6 weeks ADHOC QAPI discussed with IDT on 07/09/2025. Monitoring DON/Admin/Designee will interview 5-10 staff weekly x 6-week situational abuse scenarios had how to address effective 07/09/2025. DON/Admin/Designee will interview 5 residents how staff treat them weekly x 6 weeks effective 07/09/2025. ADO/Compliance Nurse will review all events/risk management to ensure timely/accurate investigation and reporting if needed weekly for 6 weeks. ADO/Regional Compliance Nurse will monitor weekly x 6 weeks monitoring tools for staff and resident interviews effective 07/09/2025. The QA committee will review the findings monthly x 3 months and makes changes as needed. The Administrator will resolve once no further issues have been identified. Effective 07/09/2025. The Surveyor monitored the POR on 07/10/25 as followed: During interviews on 07/10/25 from 1:55 PM - 4:29 PM, staff from both shifts were interviewed, which included CNA F, LVN G, CNA H, LVN I, MA J, the SW, and the AD. They all stated they were in-serviced on abuse and neglect before their shifts as well as receiving text message alerts about reporting abuse to the ADM immediately. They all knew their abuse and neglect coordinator was the ADM. All staff stated they have the ADM's personal phone number, and it was also located by the copy machine. The staff stated they were required to notify the ADM of any suspicion of abuse or neglect immediately - any day, any time. They stated that was to ensure all residents were safe and protected. They all were able to give examples of abuse which included verbal, mental, physical, and emotional. During an interview on 07/10/25 at 3:53 PM, ADON E stated the abuse and neglect coordinator was the ADM. She stated she had never seen a resident at the facility being abused or neglected. She stated if she had, she would ensure their safety which was the main priority, then would report it to the ADM. She stated it was not their duty to determine if something happened, it was their duty to report it immediately. She stated all residents received either a skin assessment or safe survey they day prior, 07/09/25. During an interview on 07/10/25 at 4:29 PM, the ADM stated she was the abuse and neglect coordinator. She stated she expected to be notified immediately of any allegation of abuse or neglect. She stated, if you see something, say something. She stated she was in-serviced the night prior (07/09/25) by their regional corporate nurse regarding abuse and neglect. She stated the team had ensured all staff had her contact information, they sent mass text messages to all staff through their scheduling system, and did follow-up interviews with staff. She stated the DON was suspended because the IJ and not communicating to her the allegation of abuse with Resident #1. She stated NA A was suspended and then terminated due to the allegations made against her. Review of the facility's AD Hoc QAPI agenda, dated 07/09/25, reflected the ADM, the DON, ADON E, the SW, the AD, the HRD, and the MD were in attendance. Review of a Trauma Informed Assessment for Resident #1, dated 07/09/25 and completed by the SW, reflected no concerns. Review of witness statements, dated 07/09/25, reflected seven staff members' statements that had worked with NA A in some capacity alleging they had never seen NA A being abusive towards the residents. Review of safe surveys, dated 07/09/25, reflected interviewable residents had a safe survey completed by the AD with no concerns noted. Review of skin assessments, dated 07/09/25, reflected all non-interviewable residents had a completed skin assessment by a nurse with no concerns noted. Review of an in-service, dated 07/09/25 and conducted by the RCN, reflected the DON was in-serviced on the following: DON must report all allegations of abuse to the administrator as defined in 2014-14, asap. Every new allegation requires - Alleged perpetrators to be suspended immediately, new in-services initiated, new staff interviews, and new resident safe surveys. Review of an in-service, dated 07/09/25 and conducted by the RCN, reflected the DON, the ADM, ADON D, and ADON E, were in-serviced on the following: All allegations of abuse require a thorough investigation to include staff interviews and resident safe surveys. Review of an in-service, dated 07/09/25 and conducted by the RCN, reflected the DON, the ADM, ADON D, and ADON E, were in-serviced on the Abuse and Neglect provider letter. Review of an in-serviced, dated 07/09/25 and conducted by ADON E, reflected all staff for all shifts were in-serviced on the facility's Abuse and Neglect Policy. Review of an Employee Disciplinary Report for NA A, dated 07/09/25, reflected the following: [NA A] will be placed on investigatory suspension pending an investigation into allegations of resident mistreatment. Review of a Personnel Action Form for NA A, dated 07/10/25, reflected she was terminated due to failing to adhere to corporate code of conduct. The ADM was notified on 07/10/25 at 5:00 PM that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of pattern that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made for one (Resident #1) of ten residents reviewed for abuse. The facility failed to: - Ensure Resident #1 was free from verbal and emotional abuse by NA A on or around 05/30/25 and they failed to immediately suspend NA A (per their policy) as she had worked at the facility (26 shifts) since the incident. The facility did not investigate/report (to HHSC) the incident because the DON stated Resident #1 later denied the allegation. - Notify the Abuse and Neglect Coordinator (ADM) of the alleged abuse by NA A towards Resident #1 so it could be investigated and handled appropriately to ensure her safety. An Immediate Jeopardy (IJ) was identified on 07/09/25 at 3:24 PM and an IJ template was provided. While the IJ was removed on 07/10/25 at 5:00 PM, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy. These failures could place residents at risk of abuse, neglect, trauma, and psychosocial harm. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including morbid obesity, need for assistance with personal care, anxiety disorder, and age-related cognitive decline. Review of Resident #1's quarterly MDS assessment, dated 06/12/25, reflected a BIMS score of 15, indicating she was cognitively intact. Section GG (Functional Abilities) reflected she required substantial/maximal assistance for toileting hygiene. Review of Resident #1's quarterly care plan, dated 5/28/25, reflected she had an ADL self-care performance deficit with an intervention of requiring two staff participation to toilet. Review of the facility's self-reports to HHSC from 05/01/25 - 07/01/25, reflected no self-report regarding Resident #1 and NA A from 05/30/25. During an interview on 07/09/25 at 9:41 AM, CNA B stated the management staff were lax when it came to abuse and neglect. She stated the residents were in a vulnerable state and it was not fair to them to not take abuse seriously. She stated a couple of days after she first started working at the facility, on approximately 05/30/25, she was in training and shadowing CNA C. She stated Resident #1 had said something about not getting changed by NA A and CNA C asked Resident #1 about the situation. She stated NA A was walking past the room and heard the conversation. She stated NA A she charged into the room and at the resident and yelled, Keep my mother f****** name out of your mother f****** mouth! She stated Resident #1 was shaking and was terrified. She stated she told NA A she needed to leave Resident #1's room and CNA C had to walk NA A out of the room. She stated she told CNA C to ensure that incident was reported to management as it was verbal abuse. She stated she continued to see NA A working and asked ADON E why nothing had been done and ADON E told her CNA C had changed her statement and stated she had walked NA A out of the room before she said anything to Resident #1. She stated she wrote a statement and had assumed it had gone to the DON and was self-reported to the state. She was told that the DON told ADON E that without two written statements confirming it had happened, they could not do anything about it. CNA B was shown the four in-services (that had her name and signature on them) and she stated, You can tell these are copies! Look at the signatures - they are all the same! She stated she had not worked on any of those four dates and had been out of town on vacation. She stated, None of these are real. During an interview on 07/09/25 at 10:01 AM, Resident #1 stated she remembered NA A was sometimes mean to her. She stated she remembered (her recollection from the incident on 05/30/25) NA A telling her she was so big and her butt was so big it was hard to change her. She stated she had made her feel humiliated, ashamed, and scared. She stated the DON told her NA A would not work with her anymore, but NA A continued to come and try to change her, and she would tell her no because she did not want her to provide care. She stated she did not believe NA A every got talked to by management. During an interview on 07/09/25 at 11:50 AM, ADON E stated the ADM was the abuse and neglect coordinator. She stated she did not witness the incident regarding NA A and Resident #1 on 05/30/25 but was told about it by CNA B. She stated she reported it to the DON and the DON told her she found it to be unsubstantiated. She stated she would expect for the incident to have been reported the state if it had not been. She stated the DON told her she would not bring it to corporate's attention unless there were two witnesses confirming it happened. She stated when she initially interviewed CNA C, she confirmed the events of the incident that CNA B had relayed to her. She stated when she wrote her statement, she changed the story and wrote that she never heard anything. She stated she told CNA C to document the truth, but she would not. She stated both witness statements were given to the DON. She stated NA A was never suspended and continued to work on Resident #1's hall. During an interview on 07/09/25 at 12:24 PM, the DON stated her expectations regarding safe surveys were that the SW conduct new surveys any time there was an incident of abuse or neglect. She stated the surveys should pertain to the residents who were cared for by the staff member that it had been alleged against. She stated, typically, the ADM was responsible for completing self-reports, but for the last five weeks (how long the new ADM had been working at the facility), the responsibility had fallen on the nursing side. She stated she remembered CNA B had reported (at the end of May 2025) to the ADON that Resident #1 told her NA A had yelled at her. She stated she believed statements were gotten from CNAs B and C. She stated when she interviewed Resident #1, she denied the allegation and she believed her because they had a therapeutic relationship. She stated she would have reported it to the state if Resident #1 had been cognitively impaired, but she had denied it and was cognitively intact. The witness statements for CNAs B and C were requested.During a telephone interview on 07/09/25 at 12:51 PM, the NP stated if there was an incident of alleged verbal abuse, she would expect the facility to investigate it if the patient was with it. She stated if the resident was confused, she was not sure if they should investigate it. She stated if the abuse was witnessed by another staff member, then that was a different story. She stated they should escalate it through their chain of command. She stated it was very important for staff to be in-serviced regularly on abuse and neglect to refresh them. During an interview on 07/09/25 at 2:11 PM, the ADM stated the DON could only find CNA C's witness statement regarding the incident with Resident #1. She stated that did not meet her expectations to only have the one statement. She stated ADON E told her she gave both statements to the DON and she was not sure what happened. She stated she started working at the facility around the time of the incident and was never notified of the allegation. She stated it did not matter if only one statement had been obtained. She stated the second an allegation of abuse or neglect was made towards a staff member; she would immediately suspend them and start her investigation. She stated if a resident then denied it, she would not go solely on that interview. She stated she would interview other staff that worked the same shift and the roommate of the resident alleging the abuse or neglect. She stated she would report all allegations of abuse or neglect to HHSC within two hours. She stated the DON was responsible for all self-reports as she (the DON) was clinical. She stated after an allegation was made; she should be made aware immediately. She stated the sooner they could get to the root cause, the sooner she could make the necessary adjustments. She stated not investigating was putting the residents in jeopardy of being harmed. Telephone interviews were attempted with NA A on 07/09/25 at 10:27 AM and 1:32 PM. A returned call was not received prior to exit. Telephone interviews were attempted with CNA C on 07/09/25 at 10:29 AM and 1:35 PM. A returned call was not received prior to exit. Review of CNA C's witness statement, dated 06/04/25, reflected the following: On Friday the 30th [of May], we [CNAs B and C] were passing out morning trays. We went into [Resident #1]'s room and she was telling me something about the day before. As she was talking, [NA A] came in and saying things [sic]. So I politely turn [sic] [NA A] out of the room and let the resident finish talking. Then I went to report what had to place [sic]. It was noted under the statement that CNA C did not want to sign the statement. On the back of the statement, the DON documented, [Resident #1] (BIMS 15) denied hearing any cobe [sic] words or abusive language. Accusation unfounded. Review of the (reporting website), from 05/28/25 - 07/09/25, reflected no self-report for the incident on 05/30/25. Review of the facility's Abuse/Neglect Policy, revised 05/09/17, reflected the following: The resident has the right to be free from abuse. Verbal Abuse: Any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents. Mental Abuse: Includes, but not limited to, humiliation, harassment, threats of punishment or deprivation. Training: The facility will train through orientation and on-going in-services on issues related to abuse/neglect prohibition practices regularly. All reports of abuse or suspicion of abuse/neglect or potentially criminal behavior will be investigated as per facility protocol. Investigations will be reviewed by the facility administrator and/or Abuse Preventionist within 24 hours of complaint. With an allegation of abuse or neglect, the employee(s) will immediately be suspended pending an investigation. Review of the facility's Resident Rights Policy, revised 11/28/16, reflected the following: A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life. The ADM was notified on 07/09/25 at 3:24 PM that an IJ had been identified and an IJ template was provided. The following POR was approved on 07/10/25 at 1:33 PM: The Surveyor monitored the POR on 07/10/25 as followed: Problem: On 07/09/2025 an abbreviated survey was initiated at the facility. On 07/09/2025, the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. Facility failed to notify the ADM (the abuse and neglect coordinator) when NA A verbally abused Resident #1 on or about 5/28/25 Interventions: One on One documented in-service on Abuse Investigation with the Administrator/DON was conducted by the Regional Compliance Nurse on 07/09/2025. This in-service included reviewing and conducting timely investigations and reporting for allegations per CMS provider letter PL-2024-14. Signatures confirmed verbal understanding. NA A suspended pending investigation on 07/09/2025 by facility administrator. Administrator and DON and ADON were provided a documented in-serviced by the Regional Compliance Nurse on conducting staff in-services for each individual self report on 07/09/2025, signatures confirmed verbal understanding. One on one documented inservice with DON on events about reporting all allegations of abuse to the administrator as defined in 2014-14. Alleged perpetrators are to be suspended immediately, new inservices and new staff and resident assessments are to be initiated with every new allegation. Signatures confirmed verbal understanding. Administrator and DON and ADON were in-serviced by the Regional Compliance Nurse related to conducting thorough investigation including current safe surveys for each separate self report on 07/09/2025. The medical director was notified of the immediate jeopardy situation on 07/09/2025 by ADON. On 07/09/2025 a trauma informed assessment was completed for Resident #1 BY SOCIAL WORKER. The resident denies all past and current trauma. ADHOC QAPI discussed with IDT on 07/09/2025.Monitoring All events / risk management will be reviewed 5 times a week by the IDT members for 6 weeks DON/Admin/Designee will interview 5-10 staff weekly x 6-week situational abuse scenarios had how to address effective 07/09/2025. DON/Admin/Designee will interview 5 residents how staff treat them weekly x 6 weeks effective 07/09/2025. ADO/Compliance Nurse will review all events/risk management to ensure timely/accurate investigation and reporting if needed weekly for 6 weeks effective 07/09/2025. ADO/Regional Compliance Nurse will monitor weekly x 6 weeks monitoring tools for staff and resident interviews effective 07/09/2025. The QA committee will review the findings monthly x 3 months and makes changes as needed. The Administrator will resolve once no further issues have been identified. Effective 07/09/2025. During interviews on 07/10/25 from 1:55 PM - 4:29 PM, staff from both shifts were interviewed, which included CNA F, LVN G, CNA H, LVN I, MA J, the SW, and the AD. They all stated they were in-serviced on abuse and neglect before their shifts as well as receiving text message alerts about reporting abuse to the ADM immediately. They all knew their abuse and neglect coordinator was the ADM. All staff stated they have the ADM's personal phone number, and it was also located by the copy machine. The staff stated they were required to notify the ADM of any suspicion of abuse or neglect immediately - any day, any time. They stated that was to ensure all residents were safe and protected. They all were able to give examples of abuse which included verbal, mental, physical, and emotional. During an interview on 07/10/25 at 3:53 PM, ADON E stated the abuse and neglect coordinator was the ADM. She stated she had never seen a resident at the facility being abused or neglected. She stated if she had, she would ensure their safety which was the main priority, then would report it to the ADM. She stated it was not their duty to determine if something happened, it was their duty to report it immediately. She stated all residents received either a skin assessment or safe survey they day prior, 07/09/25. During an interview on 07/10/25 at 4:29 PM, the ADM stated she was the abuse and neglect coordinator. She stated she expected to be notified immediately of any allegation of abuse or neglect. She stated, if you see something, say something. She stated she was in-serviced the night prior (07/09/25) by their regional corporate nurse regarding abuse and neglect. She stated the team had ensured all staff had her contact information, they sent mass text messages to all staff through their scheduling system, and did follow-up interviews with staff. She stated the DON was suspended because the IJ and not communicating to her the allegation of abuse with Resident #1. She stated NA A was suspended and then terminated due to the allegations made against her. Review of the facility's AD Hoc QAPI agenda, dated 07/09/25, reflected the ADM, the DON, ADON E, the SW, the AD, the HRD, and the MD were in attendance. Review of a Trauma Informed Assessment for Resident #1, dated 07/09/25 and completed by the SW, reflected no concerns. Review of witness statements, dated 07/09/25, reflected seven staff members' statements that had worked with NA A in some capacity alleging they had never seen NA A being abusive towards the residents. Review of safe surveys, dated 07/09/25, reflected interviewable residents had a safe survey completed by the AD with no concerns noted. Review of skin assessments, dated 07/09/25, reflected all non-interviewable residents had a completed skin assessment by a nurse with no concerns noted. Review of an in-service, dated 07/09/25 and conducted by the RCN, reflected the DON was in-serviced on the following: DON must report all allegations of abuse to the administrator as defined in 2014-14, asap. Every new allegation requires - Alleged perpetrators to be suspended immediately, new in-services initiated, new staff interviews, and new resident safe surveys. Review of an in-service, dated 07/09/25 and conducted by the RCN, reflected the DON, the ADM, ADON D, and ADON E, were in-serviced on the following: All allegations of abuse require a thorough investigation to include staff interviews and resident safe surveys. Review of an in-service, dated 07/09/25 and conducted by the RCN, reflected the DON, the ADM, ADON D, and ADON E, were in-serviced on the Abuse and Neglect provider letter. Review of an in-serviced, dated 07/09/25 and conducted by ADON E, reflected all staff for all shifts were in-serviced on the facility's Abuse and Neglect Policy. Review of an Employee Disciplinary Report for NA A, dated 07/09/25, reflected the following: [NA A] will be placed on investigatory suspension pending an investigation into allegations of resident mistreatment. Review of a Personnel Action Form for NA A, dated 07/10/25, reflected she was terminated due to failing to adhere to corporate code of conduct. The ADM was notified on 07/10/25 at 5:00 PM that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of pattern that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interviews, and record reviews the facility failed to ensure in response to allegations of abuse, neglect, or mistreatment, have evidence that all alleged violations were thoroughly investigated and report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident for two of ten (Resident #6 and Resident #7) residents reviewed for Abuse and Neglect. The facility failed to thoroughly investigate and report within 5 working days, when Resident #6 reported her roommate, Resident #7, hit her and twisted her arm on 06/14/25. The Provider Investigation Report was due on 06/19/25 but was not submitted until 07/09/25 This failure could place residents at risk for abuse, neglect, and exploitation. Findings included: Resident #6 Review of Resident #6’s undated face sheet reflected a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Her primary diagnosis was unspecified dementia, moderate, without behavioral disturbance, mood disturbance, and anxiety. Secondary diagnoses included major depressive disorder, hypertension (high blood pressure), rheumatoid arthritis (chronic inflammation, usually in the joints causing pain and swelling but can affect the eyes, lungs, and heart), heart failure, and insomnia. Review of Resident #6’s quarterly MDS assessment, dated 04/02/25, reflected a BIMS score of 11 which indicated moderately impaired cognition. The MDS reflected some feelings of isolation but no other mood or behavior symptoms. The MDS reflected no hallucinations or delusions. Review of Resident #6’s comprehensive care plan, revised 02/11/25, reflected in part, “Focus – The resident has impaired cognitive function and impaired thought process due to dementia. Goal – The resident will be able to communicate basic needs on a daily basis through the next review date. Interventions – Administer meds as ordered. Communicate with the resident//family/caregivers regarding residents’ capabilities and needs…” Review of Resident #6’s progress note written by LVN K, dated 06/14/25 at 11:51 AM, reflected, “This nurse was notified by (Resident #6) that her roommate (Resident #7) twisted her right arm while they were both in their room. Resident (#6) stated, (Resident #7) held my arm and twisted it and she was hitting my arm and now my arm is twitching. Assessed resident's arm, no bruising, no swelling, or redness noted. Resident rates right arm pain 4/10, PRN Tylenol 325mg x2=650mg admin. Resident able to move arm without any facial grimacing. VS 100/68, 77, 16, 98.4 97% on room air. Resident's room was changed to (number). On call NP (name) notified, received new order for X-ray to right arm and to call back with results. DON notified, administrator was notified by DON. RP (Name) Notified.” [sic] Resident #7 Review of Resident #7’s undated face sheet reflected an [AGE] year-old female initially admitted to the facility on [DATE] and readmitted [DATE]. Her diagnoses included vascular dementia unspecified severity with agitation, unspecified fracture of right femur (large bone in the top of the leg), hypertension (high blood pressure), and diabetes. Review of Resident #7’s quarterly MDS assessment, dated 06/26/25, reflected a BIMS score of 3 which indicated severely impaired cognition. The assessment reflected no inattention, no disorganized thinking, and no behavior symptoms. Review of Resident #7’s comprehensive care plan, revised 04/02/25, reflected in part, “Focus – The resident has potential to demonstrate physical behaviors Dementia [sic]. Goal – The resident will not harm self or others through the review date. Interventions – Assess and address for contributing sensory deficits. Assess and anticipate resident’s needs… Communication: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation…” Review of Resident #7’s progress note written by LVN K, dated 06/14/25 at 2:44 PM, reflected, “this writer was notified by (Resident #6) that (Resident #7) twisted her right arm while hitting her. Resident (#7) stated, ‘I didn’t do it, that’s a lie.’ Resident is alert and confused, does not appear to be in distress or discomfort. Resident keeps following roommate everywhere she goes… DON/Administrator notified, called RP (name) notified, NP notified by communication form…” Review of the facility’s self-report binder reflected the initial Self Reporting Template but no Provider Investigation Report – form 3613 -A. Review of the intake reporting system reflected the PIR was submitted on 07/09/25. During an interview on 07/08/25 at 3:06 PM, the Provider Investigation Report (PIR) was requested from the DON. During an interview on 07/09/25 at 12:23 PM, the DON stated for last 5 weeks, nursing had been investigating and completing the self-reports. Regarding the incident on 06/14/25 between Resident #6 and Resident #7, the DON stated she had reported and investigated the allegation. The DON stated she was told, “Resident #6 reported someone came in the room and hit her.” The DON stated she asked Resident #7 if anyone had been in the room and Resident #7 denied anyone else being in the room. The DON stated she was not aware that Resident #7 was the person accused of hitting Resident #6. The DON stated the SW was responsible for completing safe surveys. She stated it did not meet her expectations that the surveys were completed 11 days after the allegation was made. She stated the surveys should have been done the next practicable business day. The DON stated the Abuse Coordinator was responsible for investing and reporting. During an interview on 07/09/25 at 2:10 PM, the ADM stated she was the Abuse Coordinator. She stated the DON was not able to locate the Provider Investigation Report yesterday after the document was requested. The ADM stated she checked her email and did not find a copy of the report. The ADM stated she submitted a PIR report to HHSC on the evening of 07/08/25. She stated it was her expectation that every allegation was thoroughly investigated, safe surveys were conducted, and staff were in-serviced within the five-day period. Review of the facility’s Abuse/Neglect policy, revised 05/09/17, reflected in part, “D. Identification. The facility will identify and investigate events that may constitute abuse/neglect. The facility will determine the direction of the investigation based on a thorough examination of events… F. Investigation. Comprehensive investigations will be the responsibility of the administrator and/or Abuse Preventionist. All allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property and injuries of unknow source will be investigated. 1. The administrator in consultation with Risk Management Department will be responsible for investigating and reporting cases to the HHSC… 3… The written report must be sent to HHSC no later than the fifth working day after the initial report. The facility will use the designated state reporting form. 6. The Abuse Preventionist and/or administrator will conduct a thorough investigation of the incidents(s)… Resident to Resident. The above policy will apply to potential resident-to-resident abuse. Provider letter 17-18 will be reviewed to determine if resident-to-resident abuse occurred.”

Based on observation, interview, and record review the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 1 of 4 (400) halls observed for housekeeping and maintenance services. The facility failed to ensure there were not a black circular substance under the wallpaper in three residents (Resident #1, Resident #2, and Resident #3) rooms. This deficient practice could place residents at risk of living in an unclean and unsanitary environment and result in potential health issues or affecting the airway. The findings were: Record review of Resident #1's face sheet, dated 05/21/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included dementia (memory, thinking, difficulty), anemia (not enough healthy red blood cells), type 2 diabetes mellitus without complications (high blood sugar), hyperlipidemia (high cholesterol), hypertension (high blood pressure), kidney disease, and hypertensive chronic kidney disease (damage to kidneys due to chronic high blood pressure). Record review of Resident #1's Quarterly MDS dated [DATE] revealed Resident #1 had a BIMS score of 99 indicating she was unable to complete the interview. Record review of Resident #2's face sheet, dated 05/21/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included dementia (memory, thinking, difficulty), hypertension (high blood pressure), Alzheimer's disease (progressive disease that destroys memory and other important mental function), anxiety (feeling of uneasiness or worry), Migraine, repeated falls, insomnia (difficulty sleeping), muscle weakness, history of falling, hypertensive heart disease with heart failure (damage to heart and heart failure due to chronic high blood pressure), dysphagia oropharyngeal phase (inability to empty from the throat to the esophagus), and vitamin D deficiency. Record review of Resident #2's Quarterly MDS dated [DATE] revealed Resident #2 had a BIMS score of 03 indicating severe cognitive impairment. Record review of Resident #3's face sheet, dated 05/21/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #3 had diagnoses which included metabolic encephalopathy (brain disease), hyperlipidemia (high cholesterol), hypertension (high blood pressure), other forms of tremor, and benign prostatic hyperplasia with lower urinary tract symptoms (enlarged prostate). Record review of Resident #3's admission MDS dated [DATE] revealed Resident #3 did not have a BIMS score. Record review of Resident #3's progress notes dated 05/21/2025 revealed Resident #3 rarely/never made self-understood. During an interview with the Housekeeper on 05/21/2025 at 10:02 am revealed that the wall in the housekeeping storage room was tore out and had mold on the walls. She said that she informed MAIN, and nothing had been done. She said that it had been that way for about three or four months. During an interview with the MAIN Director on 05/21/2025 at 2:3 he said that Resident #1, Resident #2, and Resident #3's rooms on the 400-hall had mold behind the wallpaper. He said there was not a resident in one of the rooms. He said the residents and staff could get sick from the mold. He said that he informed the ADM and had not gotten a response. He said that he informed the ADM on 04/28/2025. He said that he had torn the wallpaper and started to take it off, saw the mold, and let the facility know. Observation of 400 hall on 05/21/2025 at 2:53 PM revealed that there was a black circular substance of different sizes underneath the wallpaper in Resident # 1, Resident #2, and Resident #3's room. Interview attempted with Resident #2 on 05/21/2025 at 2:53 revealed she would only say she was fine and was just resting. During an interview with the DON on 05/21/2025 at 3:07pm she said that she had not gotten any complaints about mold. She said that she had not heard from MAIN regarding any mold. She said if she thought there was mold in a resident's room she would move the resident to another room. She said mold was black and furry. The DON stated that the picture shown to her of the rooms looked like mold. She said that mold could cause health issues. During an interview on 05/21/2025 at 3:33pm, the ADM stated that the maintenance person had not told her about mold in rooms. She said if she had any suspicion of mold the resident would be taken out of the room. She said that she could not tell if it was mold in the pictures from the room because she was not a mold expert. She said that MAIN was responsible for letting her know so the facility could send it up and get someone out to check it. She said that she would call someone to inspect it. She said that mold or mildew could affect the airway. Interview attempted with Resident #1 on 05/21/2025 at 4:04pm was unsuccessful. Resident #1 started talking about her glasses and having an appointment. Interview attempted with Resident #3 on 05/21/2025 at 4:20pm revealed he did not want to talk to the surveyor. Record Review of Resident Rights Policy not dated revealed: The resident has a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior.

Based on interview and record review the facility failed to, in response to allegations of abuse, neglect, exploitation, or mistreatment, have evidence that all alleged violations are thoroughly investigated and report the results of all investigations to the state survey agency within five working days of the incident for two (2) of five (5) residents reviewed for abuse and neglect. (Resident #2 and Resident #4). The facility failed to thoroughly investigate two facility reported incidents regarding Resident #2 and Resident #4 within five (5) days regarding allegations of neglect and injury of unknown origin. This deficient practice placed all residents at risk of harm form neglect due to not having a thorough investigation done for facility reported incidents. Findings Include: Record review of Resident #2's face sheet, dated 05/21/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included dementia (memory, thinking, difficulty), hypertension (high blood pressure), Alzheimer's disease (progressive disease that destroys memory and other important mental function), anxiety (feeling of uneasiness or worry), Migraine, repeated falls, insomnia (difficulty sleeping), muscle weakness, history of falling, hypertensive heart disease with heart failure (damage to heart and heart failure due to chronic high blood pressure), dysphagia oropharyngeal phase (inability to empty from the throat to the esophagus), and vitamin D deficiency. Record review of Resident #2's Quarterly MDS dated [DATE] revealed Resident #2 had a BIMS score of 03 indicating severe cognitive impairment. Record review of Resident #4's face sheet, dated 05/21/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #4 had diagnoses which included atrial fibrillation (abnormal heart rhythm), obesity, kidney disease, hypertension (high blood pressure), hypertensive chronic kidney disease (damage to kidneys due to chronic high blood pressure), heart disease, lymphedema (localized swelling), constipation, and impulse disorder (inability to resist harmful urges leading to behaviors that can negatively impact oneself or others). Record review of Resident #4's Quarterly MDS dated [DATE] revealed Resident #4 had a BIMS score of 15 indicating intact cognitive response. Review of the facility's Investigation Report provided on 05/21/2025 reflected a report was submitted by the ADM to the state agency on 05/16/2025 at 8:22 AM for Resident #4 with an allegation of neglect. Schedules, and investigation report, provided to surveyor revealed that CNA C and CNA D who worked with Resident #4 when the incident occurred did not have documented interviews regarding the allegation of neglect. The findings were not submitted to HHSC within 5 days. The investigation report also revealed that there was no documentation as to the findings were unfounded. Review of the facility's Investigation Report provided on 05/21/2025 reflected a report was submitted by the ADM to the state agency on 05/10/2025 at 6:37 PM for Resident #2 with an allegation of injury of unknown origin. Schedules, and investigation report provided to surveyor revealed that RN A and MA B who worked with Resident #2 when the incident occurred did not have documented interviews regarding the allegation of injury of unknown origin. The findings were not submitted to HHSC within 5 days. The investigation report also revealed the findings were inconclusive. Record Review of the Self-Reporting Protocol/Neglect and/or Injury of Unknown Origin checklist dated 05/16/2025 revealed that the ADM did not complete interviews with staff who worked with Resident #4 regarding the allegation of neglect. Record Review of the Self-Reporting Protocol/Neglect and/or Injury of Unknown Origin checklist dated 05/10/2025 revealed that the ADM checked off that she interviewed staff about the injury of unknown origin for Resident #2. No staff interviews were in the documents provided to the surveyor. During an interview with the ADM on 05/21/2025 at 3:33pm, she stated that she did interviews with RN A, MA B, CNA C and CNA D that worked with the residents at the time and that they were in the binder. The only staff interview that was in the binder was for LVN C She said if they were not in the binder then she had them in her office. She did not remember what the staff stated in their interview. Surveyor requested those interviews and ADM did not provide them. She also said that she had completed the investigations. Record review of the incident intake Binders for Resident #2 and Resident #4's incidents revealed there were no staff interviews in the binders. Requested the interviews from the ADM and they were not provided at exit. Record review of the Facility Abuse and Neglect Policy not dated revealed the facility will determine the direction of the investigation based on a thorough examination of events. The written report must be sent to HHSC no later than the fifth working day after the initial report. The facility will use the designated state reporting form.

Based on interview and record review, the facility failed to notify the resident and the resident's representative(s) of the discharge and the reasons for the discharge in writing and in a language and manner they understand for 1 of 5 residents reviewed for discharge notification. (Resident #1) The facility did not give a written notice of discharge, when Resident #1 was transferred into Police custody on 02/19/2025. This failure could affect residents by placing them at risk of being transferred and not having access to available advocacy services, discharge/transfer options, and appeal processes. Findings included: Review of Resident #1's face sheet dated 04/09/2025 reflected initial admission date of 03/29/2023 and readmission date of 01/14/2025 with diagnoses of Type 2 Diabetes Mellitus with diabetic peripheral angiopathy without gangrene, pain unspecified, chronic pulmonary edema (buildup of fluids in the lungs), benign prostatic hyperplasia (a condition in which the flow of urine is blocked due to the enlargement of prostate gland) without lower urinary tract symptom, repeated falls. Review of Resident#1's admission MDS assessment dated [DATE] reflected a BIMS score of 15 indicating no cognitive impairment. Review of Resident #1's care plan initiated 10/29/2025 reflected Resident #1 had potential for falls, related to unsteady gait, and history of fall, fluctuating blood sugars related to diabetes mellitus and his noncompliance with need to restrict carbs/sugars, Acute Pain / Chronic Pain related to Arthritis (is a condition characterized by pain, swelling, and stiffness in one or more joints), neuropathy (a condition that affects the nerves in the body), and migraine. Review of Resident #1's progress notes dated 02/19/2025 at 09:36 am written by the DON reflected: [name]County detective arrived this am to take [Resident #1] into custody, all belongings to accompany him. Badge verified by this nurse. no additional information given. all medications and face sheet sent with resident. Per detective, the DA will email documents to our legal team. Resident sent in detective vehicle, no s/s distress. Review of Resident #1's progress notes dated 02/19/2025 at 02:12 pm written by the DON reflected: spoke with ombudsman, notified him of resident taken into custody of [name] County sheriff dept, DC' d from facility permanently. He voiced surprise and understanding. VMs left with POA and ombudsman to update them. Review of Resident #1's progress notes dated 02/21/2025 at 11:13 am written by the DON reflected: VM left POA notifying of need to collect resident belongings in a timely manner due to residents permanent DC due to change of residence. During an interview on 04/10/2025 at 09:57 am Resident #1's POA stated Resident #1 was immediately discharged from the facility without 30-day notice after he was taken into custody by the police. Resident #1's POA stated she was called and told Resident #1 was discharged same day because he was in police custody. Resident #1's POA stated Resident #1 was taken into police custody on 2/19/2025 due to warrant that was out, and Resident #1 had his court hearing on 02/28/2025 and was transferred to the ER from the court due to injuries. Resident #1's POA stated the facility refused accepting Resident #1 back to the facility. During an interview on 04/09/2025 at 10:32 am the Social Worker stated Resident #1 was discharged from the facility because he got arrested from the facility for sexual abuse of a minor. The Social Worker stated she did not know if Resident #1 was guilty. The Social Worker stated it was their policy to give 30-day notice for facility-initiated discharge, but she did not give Resident #1 30-day notice because it was out of her hands. During an interview on 04/09/2025 at 11:00 am the Administrator stated Resident #1 was discharged to the county jail. The Administrator stated she was told by the DON that Resident #1 would be in custody until his trial date. The Administrator stated the facility did not accept Resident #1's referrals back to the facility because the facility was next to a school. The Administrator stated she did not know if Resident #1 was found guilty of the charges on him. The Administrator stated Resident #1 or his POA were not issued a 30-day notice of discharge. During an interview on 4/09/2025 at 3:37 pm the DON stated she was present when Resident #1 was taken into custody and was told by the Deputy that Resident #1 would be in police custody until his trial date. The DON stated the facility did not anticipate Resident #1 coming back to the facility because the Deputy stated Resident #1 would be in police custody until his trial date. The DON stated she spoke with the case manager and told the case manager Resident #1 was not going back to the facility because he was permanently discharged from the facility. The DON stated the Administrator made the decision to discharge Resident #1. The DON stated, We notify the POA of what happened. We also notify her to pick up his things. I don't know what he did to post threat to staff or resident, I have to go back and look. During an interview on 04/09/2025 at 4:09 pm, the Ombudsman stated Resident #1 was given a 30-day discharge in the past, appealed and won the appeal on 2/18/2025. The Ombudsman stated Resident #1 should be accepted back to the facility after his arrest and hospital stay. During an interview on 04/10/2025 at 09:32 am the Administrator stated the DON got a call from the Sheriff's office on 04/09/2025 stating Resident #1 cannot be next to a child and the facility was close to a school. The Administrator also stated they had children volunteering at the facility therefore Resident #1 cannot be accepted back to the facility. The Administrator stated, I will have to discuss with my cooperate. Right now, we do not have reason for not readmitting, once we have a reason not to, we will not re-admit him. During an interview on 04/10/2025 at 10:13 am, the Sergeant with the Special Verdict Unit with name County (Contact provided by the DON) stated the facility had just made contact with him and he explained Resident #'1s trial findings. He stated, the court would have stipulated in the deferred adjudication that Resident #1 could not be in a certain radius of a school. The Sergeant said he explained to the facility that this was not in the case of Resident #1, Resident #1 was not allowed to live in a residence with a child but a facility next to the school would not apply. During an interview on 04/10/2025 at 10:57 am the Administrator stated Resident #1 will not be allow back in the facility due to the facility's policy on Registered sex offender and the findings from his court hearing on 02/28/2025. Review of facility's policy titled Discharge or Transfer to another facility revised 04/10/2025 reflected: The facility will permit each resident to remain in the facility, and not transfer or discharge the resident from the facility. In the following limited circumstances, this facility may initiate transfers or discharges: A. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility. B. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility. C. The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident. D. The health of individuals in the facility would otherwise be endangered. When a resident is temporarily transferred on an emergency basis to an acute care facility, this type of transfer is considered to be a facility-initiated transfer and a notice of transfer will be provided to the resident and resident representative as soon as practicable. Copies of notices for emergency transfers will also still be sent to the ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis. In situations where the facility has decided to discharge the resident while the resident is still hospitalized , the facility will send a notice of discharge to the resident and resident representative and will also send a copy of the discharge notice to a representative of the Office of the State LTC Ombudsman. Review of facility's policy titled Resident Rights undated reflected, The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.) Review of facility's policy titled Registered Sex Offender dated 1/1/2020 reflected, It is the policy of this facility not to admit known registered sex offenders (as defined by Texas Chapter 62 of the Code of Criminal Procedure) into this facility.

Based on, interview, and record review the facility failed to ensure residents were free from neglect for 1 of 4 residents (Resident #1) reviewed for abuse and neglect. CNA A and LVN B failed to check on Resident #1 on the night of 01/09/2025 from about 10:00 pm through the morning of 01/10/2025 at about 4:40 am, leaving Resident # 1 unattended for about 6 hours. Resident #1 fell on the floor and was on the floor the entire night unattended by staff. When Resident #1 was found on the morning of 01/10/2025, he was noted with abrasion at his left arm, combative, angry and speaking Spanish. The noncompliance was identified as PNC. The IJ began on 01/09/2025 and ended on 01/17/2025. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of Neglect, injury, and psychosocial harm. Finding included: Review of Resident #1's undated care plan reflected a [AGE] year-old male that was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease with late onset, Generalized Anxiety disorder, Dementia in other diseases classified elsewhere. Review of Resident #1's significantly change in status MDS assessment, dated 12/24/24, reflected a BIMS score of 99, indicating he had a severe cognitive impairment. It was also noted a staff assessment for mental status was conducted which indicated short and long-term memory problem and cognitive skills for daily decision-making being moderately impaired. Section GG -Functional Abilities of the MDS reflected Resident #1 required supervision or touching assistance with toileting. Review of Resident #1's quarterly care plan, initiated 10/15/2024, reflected Resident #1 had communication problems, with intervention to anticipate and meet needs. Resident #1 was on the secure unit related to diagnosis of dementia and risk for elopement. Resident was at risk for fall related to gait/balance problems, with intervention to anticipate and meet resident's needs. Resident #1 had impaired cognitive function/dementia or impaired thought processes. Review of Resident #1's fall risk assessment dated [DATE] reflected a score of 13 which indicated high risk. Review of Resident #1's progress notes dated 10/10/2025 at 05:41 am written by LVN B reflected At 0440 resident was found on the floor, near the toilet door by the CNA (xx). He sustained an injury (abrasion) to his left elbow, and also refused further assessments as he was being combative. He was not able to tell the reason for his fall as he just kept on speaking in Spanish. Upon routine care no other injury was noted, no vitals were documented. Hospice nurse (xxx), DON (xxx), RP (xxx) were being notified. Wound is left too air dry, and resident is being monitored for any changes. Review of Resident #1's progress notes dated 10/10/2025 at 05:43 am reflected: .The fall caused an abrasion to left elbow. Size of the abrasion in cm: 1-2cm.Painful, At 0440 resident was found on the floor, near the toilet door by the CNA (XX). He sustained an injury (abrasion) to his left elbow, and also refused further assessments as he was being combative. Review of written statement provider by Administrator, undated reflected the following, On 1/10/25, Administrator was notified?ed of allegation of neglect from resident [family member]. Allegation made regarding potential neglect of resident not being rounded overnight for six hours. Administrator reviewed cameras with DON and identified?ed resident fell and remained on ?floor from around 10:20pm until around 5am. Resident's room had light on all night, resident was laying on ?floor half on fall mat and head closest to resident bathroom. DON and administrator assessed the room to identify if staff opened door if they could easily see resident; both identified?ed if you crack open the door you can see resident if he is lying in bed. According to camera footage, the resident was laying on the ground from stated hours and would not have been witnessed in his bed. During an observation on 01/28/2025 at 11:26 am revealed Resident #1 lying in bed. Bed was noted in the lowest position with floor mat present. Attempted to interview Resident #1 and he was not responding appropriately. During an interview on 1/28/2025 at 12:44 pm CNA A stated she worked the 7pm to 7 am shift on the night of 1/09/2025 to the morning of 1/10/2025 on the secure unit. CNA A stated she got to work late that evening but could not remember how late she was. CNA A stated LVN B had already done the first checks on the residents when she got at the Facility. CNA A stated she and LVN B did their second check at about 11:30 pm but she did not check Resident #1. CNA A said she saw Resident #1 lying in bed at about 1:30 am. CNA A stated, at about 4:30 am while making her rounds, she found Resident #1 on the floor next to the bathroom door and notified LVN B. CNA A stated LVN B went to Resident #1's room and assessed Resident #1. CNA A stated she and LVN B provided care for Resident #1 and put him back in the bed. CNA A stated she did not know how long Resident #1 was on the floor. CNA A stated staff were supposed to check on the residents every 2 hour and if it was not done, that was neglect . CNA A stated she was aware Resident #1 had camera in his room, the sign was posted at the door. CNA A stated she was suspended on 01/10/2025 and terminated a week later. During an interview on 01/28/2025 at 1:21 pm LVN B stated she worked the 6pm to 6 am shift on the night of 01/09/2025 to the morning of 01/10/2025 on the secure unit. LVN B stated she checked Resident #1 on 01/09/2025 at about 10:00 pm and the next time she saw Resident #1 was when she was notified by CNA A that the resident was on the floor on the morning of 01/10/2025 at about 4:40 am. LVN B stated she tried to assess Resident #1, but he was refusing care, she noted bruise and scratch on Resident #1's hand. LVN B stated they were supposed to make rounds/checks every 2 hours, not making rounds or frequent checks on the residents was considered neglect. LVN B stated it was not ok for a resident to fall and remain on the floor for hours because it could lead to injuries and concussion. LVN B stated once Resident1 #'s door was opened, staff would see him on the bed or on the floor. LVN B stated the night was busy. LVN B stated she was suspended on 01/10/2025 and terminated a week later. During an interview on 01/28/2025 at 2:58 pm the DON stated she watched the video footage provided by Resident #1's family dated 01/09/2025 through 01/10/2025. The DON stated, according to the time stamp on the video footage, Resident #1 got out of bed on 01/09/2025, took himself to the toilet, on his way back to bed, fell at about 10:15 to 10:20 pm and remained on the floor, floor mat present, his head was towards the bed and the legs to the bathroom, until about 4:40 am on 01/10/2025 when he was found by staff. The DON stated, Resident #1 made several attempts to get back up and repositioned himself but was not successful. The DON stated, according to the video footage, CNA A entered Resident #1's room at about 4:40 am on 01/10/2025 and alerted LVN B. The DON stated LVN B attempted assessing Resident #1, both staff cleaned Resident #1 and helped him back to bed. The DON stated staff were expected to check on residents frequently , six hours was a long time not to check on a Resident. The DON stated once Resident #1's door was opened, the staff would see him on the floor or on his bed which indicated he was not checked on by staff. The DON stated both staff were suspended pending investigation and terminated after viewing of the video footage provided fob the family. She stated Staff were in-serviced on abuse and neglect and making frequent checks on Residents. The DON stated Resident #1's medications were review by hospice. During an interview on 01/28/2025 at about 3:35 pm the Administrator stated she was made aware by Resident #'1 family that he fell the night of 01/09/2025 at about 10:20 pm and remained on the floor until 01/10/2025 at about 4:40 before staff found him. The Administrator stated she watched the video footage provided by family along with the DON. The Administrator stated the video camera did not face the doorway, but no staff was seen in Resident #1's room for about 6 hours. The Administrator stated from the location of Resident #1's bed, even if his door was cracked opened a little, the staff would have seen him on the bed or on the floor. The Administrator stated she did not believe the staff had checked on Resident #1 for the period being reviewed. The Administrator stated staff were expected to make frequent checks on residents. She stated there was no facility policy on how frequent staff should check on the residents, but 6 hours was a long time to not check on the resident. The Administrator stated both CNA A and LVN B were suspended immediately pending investigation, staff were educated on abuse and neglect and frequent rounding on residents. She stated Resident #1 was assessed; the facility completed full skin sweep of all the residents on the secure unit. The Administrator stated CNA A and LVN B were terminated. The Administrator stated Resident #1 was later sent to the ER for further evaluation but came back quickly the same day. During an interview on 01/30/2025 at about 1:51 pm, Resident #1's family stated she followed Resident #1 to the local ER and CAT scan (is an imaging test that uses a combination of x-ray and a computer to create detailed picture of organs, bones, and other tissue inside the body) of his head came back negative. She stated the Resident was fine and was transferred back to the facility. During an interview on 01/30/2025 at about 1:51 pm, Resident #1's family stated she followed Resident #1 to the local ER and CAT scan (is an imaging test that uses a combination of x-ray and a computer to create detailed picture of organs, bones, and other tissue inside the body) of his head came back negative. She stated the Resident was fine and was transferred back to the facility. During interview on 01/28/2025 from 11:41 am through 2:49 pm with 1 ADON, 1 RNs, 2 LVNs, 3 CNAs , 1 HA, the Staffing Coordinator revealed they were in-serviced on abuse and neglect and making frequent rounds/checks on residents after the incident with Resident #1 when he was found on the floor. Staff stated they were supposed to make rounds every 2 hours alternating trips. Review of the facility's in-services reflected an in-service dated 01/10/2025 presented by the DON for all facility staff. In-service: Attached lessons -- Neglect Reporting --Frequent Rounding on Residents Review of CNA A and LVN B's personnel files reflected they both were terminated on 01/17/2025. Review of the facility's investigation dated 01/17/2025 reflected a thorough investigation was completed, and the allegation of was injury of Unknown injury was confirmed. Review of the facility's Policy revised 09/09/24 titled Abuse/Neglect reflected: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Training The facility will train through orientation and on-going in-services on issues related to abuse/neglect prohibition practices regularly. Protection The facility will take necessary measures to protect residents and employees from harm during and following an abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property investigation. 1. Allegations of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property will remain confidential.

Based on observations, interviews, and record reviews, the facility failed to ensure parenteral fluids were administered consistent with professional standards for 2 (Resident #1 and Resident #2) of 2 residents reviewed for intravenous care. The facility failed to ensure Resident #1 had orders to change her PICC line dressing after the PICC was placed. She went from 12/18/24 until 01/09/25 without a PICC dressing change. The facility failed to ensure the ADON changed Resident #1's PICC line dressing per the facility protocol. The facility failed to ensure Resident #1 had orders to flush the PICC or to monitor the PICC insertion site for signs/symptoms of infection from 12/18/24 through 01/09/25. The facility failed to ensure Resident #2 had orders to flush the PICC or to monitor the PICC insertion site for signs/symptoms of infection from 11/13/24 through 11/27/24. The facility failed to ensure nursing staff (ADON, RN A, LVN B, LVN C, LVN D, and LVN E) were trained/educated on, and able to demonstrate competency on, managing a PICC line. The failures resulted in the identification of an Immediate Jeopardy (IJ) on 01/09/25 at 5:15 PM. While the IJ was removed on 01/11/25 at 4:10 PM, the facility remained at a level of no actual harm with potential for more than minimal harm that is not immediate jeopardy at a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for decreased quality of care, not receiving intravenous medication as ordered, and risk for infection, hospitalization , and death. Findings included: 1.Review of Resident #1's face sheet printed on 01/09/25, reflected a [AGE] year-old female originally admitted to the facility on [DATE] with a recent readmission on 12/01/23. Her diagnoses included non-pressure chronic ulcer left lower leg, chronic venous hypertension, peripheral vascular disease, and cellulitis. Review of Resident #1's quarterly MDS assessment dated [DATE], Section C (Cognitive Patterns) reflected a BIMS score of 15 indicating intact cognition. Section O (Special Treatments, Procedures, and Programs) reflected the resident received IV medications. Review of Resident #1's Order Recap Report for orders from 12/01/24 through 01/31/25, reflected orders dated 12/18/24: PICK [sic] LINE STAT one time only until 12/18/24, Piperacillin-Tazobactam 3.375 grams intravenously every 6 hours for infection for 28 days, ending 01/16/25, Vancomycin 1GM/250ml, use 1 gram intravenously one time a day for infection for 28 days, ending 01/16/25. Review of Resident #1's current Clinical Physician Orders, an order dated 01/09/25 reflected a revised Piperacillin-Tazobactam 3.375 grams intravenously every 6 hours for infection for 8 days, changed the end date to 01/17/25. Review of Resident #1's CVAD Procedure form, dated 12/18/24, reflected a PICC was inserted using ultrasound guidance on 12/18/24 at 7:30 PM. The catheter was trimmed and measured 38cm. The upper arm circumference was 31cm. Review of Resident #1's chest x-ray report dated 12/18/24, reflected the PICC terminated over expected level of the superior cavoatrial junction. Review of Resident #1's comprehensive care plan, on 01/09/25, last review completed 10/20/24, did not address the central line. Review of Resident #1's nursing progress note written 01/09/25 at 4:27 AM by LVN B reflected, Resident PICC line was clogged which made resident not able to receive 3:00 AM Piperacillin Sod-Tazobactam Sod Solution Reconstituted 3-0.375 GM IV. On call NP was notified, [company name] vascular was called but they were not picking up. Review of Resident #1's December 2024 MAR/TAR reflected the Vancomycin and Piperacillin-Tazobactam intravenous medications were both administered for 13 days. The MAR/TAR did not reflect any dressing changes, flushes, or monitoring of the site. Review of Resident #1's January 2025 MAR/TAR reflected a missed does of Piperacillin-Tazobactam on 01/09/25. The record reflected no monitoring of the central line site until 01/09/25, no flushing of the line until 01/09/25, and the first dressing and cap change scheduled for 01/10/25. During an observation and interview on 01/09/25 at 9:23 AM, Resident #1 was lying in bed with an IV infusing. She stated the IV was connected to the PICC in her arm. She stated she had asked several nurses to change the dressing because it was loose, but the dressing had not been changed since the PICC was inserted. When asked if there was a date on the dressing, she stated there was a date, but it was covered with tape, so it was no longer visible. Resident #1 attempted to adjust her sleeve to expose the dressing but could not do it without assistance. During an observation and interview on 01/09/25 at 9:29 AM, RN A entered Resident #1's room and offered the resident assistance to visualize the PICC dressing. The PICC dressing was completely covered with white tape. The PICC insertion site was not visible. The edges of the dressing were not visible. Upon exiting the room, RN A stated this was the first PICC line she had worked with. She stated she had not been trained on changing the PICC dressing and did not feel comfortable attempting the procedure. She stated she had been shown how to flush the line and adjust the flow rate on the IV. She stated she had put some tape on the dressing to keep it in place until another nurse could change the dressing. She stated she had been trained on infection control and EBP. She stated not following infection control procedures could increase the spread of germs or infection. She stated she believed central line dressings were supposed to be changed daily and the IV tubing changed every 72 hours. During an observation and interview on 01/09/25 at 10:38 AM, the ADON sanitized an over the bed table and placed her dressing change supplies on the table and prepared to change Resident #1's PICC dressing. The ADON applied clean gloves and explained the procedure to the resident. She did not ask the resident to turn her head away from the insertion site. The ADON removed the dressing from the resident's arm. A bio patch (a small sponge-like wound dressing used to reduce local infections) coated with dry blood was attached to the dressing. The ADON removed the tape from the clear dressing. The dressing was dated 12/18/24. The ADON disposed of the old dressing and gloves then applied another pair of clean gloves. The resident repositioned her arm and viewed the site. The ADON opened the IV dressing change kit and retrieved the package of alcohol swabs. She used one swab to clean the insertion site and in a circular motion cleaned from the inside towards the outside. She continued to clean with the other two swabs in the package. The PICC line stabilization device that secured the line to the resident's arm was swabbed during the cleaning. The catheter line remained attached to the device and thus, the back of the line and the skin under the line was not cleansed. After the alcohol dried, the ADON took the clear dressing out of the dressing change kit and covered the insertion site and the stabilization device. She repositioned the resident then gathered her supplies. She did not change the caps. After exiting the room, the ADON stated she had training on central lines early in 2024. She stated some lady from the IV company came in and did a class for the nurses. She stated they did not get a competency or certificate from that training. During an interview on 01/09/25 at 1:26 PM, the ADON started to describe the procedure for changing a PICC dressing then stated, It's pretty much what you observed earlier. She stated there probably should have been orders for changing the dressing and the caps. Requested competencies/skills checks for central lines. During an interview on 01/10/25 at 3:57 PM, when asked is she should have followed sterile technique when changing Resident #1's PICC dressing, the ADON stated she thought she was changing the dressing on a peripheral IV and not a central line when she changed Resident #1's PICC dressing on 01/09/25. During a telephone interview on 01/09/25 at 1:52 PM, the NP stated Resident #1 was on IV antibiotics for osteomyelitis. He stated the wound care doctor had ordered the antibiotics. The NP stated he was sick and did not want to answer any other questions. During an interview on 01/09/25 at 3:07 PM, the MD stated he was the attending physician for Resident #1. He stated the staff informed him about the 12/18/24 date on Resident #1's PICC dressing. He stated it was an unfortunate miss. He stated he worked in infectious disease in a large hospital in [city] and he was aware of the major focus on preventing CLABSIs. He stated they rarely used PICCS or central lines at the facility, but the staff were very cautious when they did use them. He stated it was his expectation that the insertion site was monitored at least daily and assessed for redness, bleeding, and drainage. He expected the dressing to was monitored daily to ensure it was intact and sealed, and changed every 3 days. He stated the risk of infection increased if central lines were not properly maintained. 2. Review of Resident #2's face sheet, printed on 01/09/24, reflected a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included diabetes mellitus, persistent vegetative state, hemiplegia following cerebral infarction, and pressure ulcers. Review of Resident #2's quarterly MDS assessment dated [DATE], Section C (Cognitive Patterns) reflected no BIMS score as resident was rarely/never understood. Staff assessment of her cognitive status reflected both short and long-term memory impairment. Review of Resident #2's order Summary Report for active orders as of 11/27/24, reflected the following orders: -Zosyn Intravenous Solution 3-0.375 GM/50ML use 3.375 gram intravenously for times a day for wound infection for 28 days, ordered 11/13/24. -Change PICC/Central line dressing Q3D one time a day every 7 day(s) for wound infection, ordered 11/14/24. -There were no orders to monitor the for s/s infection or to flush the central line. Review of Resident #2's Order Recap Report for all physician orders from 11/01/24 to 12/31/24, reflected an order, written 11/24/24, for Cath flow as directed one time only for clogged PICC line for 1 day. Review of Resident #2's CVAD Procedure form, dated 11/13/24, reflected a PICC was inserted using ultrasound guidance on 11/13/24 at 6:30 PM. The catheter was trimmed and measured 38cm. The upper arm circumference was 28cm. Review of Resident #2's chest x-ray report dated 11/13/24, reflected the PICC terminated in the region of the SVC. Review of Resident #2's November 2024 MAR/TAR reflected the Cath flow, was administered on 11/24/24 to unclog the PICC. The MAR/TAR reflected the PICC dressing changes were scheduled every 7 days. The dressing change was initialed as completed on 11/22/24. Review of Resident #2's SBAR, completed by LVN F, reflected Resident #1 transferred to an acute hospital on 11/27/24. Her temperature was 104.6 degrees Fahrenheit, and her pulse was 109. Review of Resident #2's History and Physical Reports from the acute hospital, dated 11/27/24, reflected a chief complaint of fever. The admitting diagnoses included sepsis and pneumonia. Blood culture positive for Candidiasis, IV medication ordered. IV antibiotics were also initiated for pneumonia. During a brief interview on 01/09/25 at 9:40 AM, a policy for central lines and nurse competencies/skill checks were requested from the DON. During an interview on 01/09/25 at 2:32 PM, the DON stated she expected central lines to be cared for according to the policy. She described the dressing change process as, Apply clean gloves and remove the old dressing. Remove those gloves and perform hand hygiene. Apply sterile gloves. Clean 3 times with the alcohol and let it air dry. Apply the clear dressing and change the caps. She stated the dressing change kits were the same for peripheral IVs and central lines. She stated she expected the dressings and caps to be change weekly. She stated PICCs were flushed after each use, and periodically if the PICC was not used. She stated a PICC dressing dated 12/18/24 did not meet her expectations. She stated the dressings were clear, so the insertion site was visible, and they watched for any changes so there were no inherent risks from the dressing not being changed. She stated she was not aware that Resident #1's insertion site was covered with white tape. She stated that a covered dressing did not meet her expectations. The DON stated she was not sure if Resident #2 had orders to monitor or maintain her PICC line. The DON provided Nurse Skill Audits, but no competencies or skills checks specific to central lines. During an interview on 01/10/25 at 3:19 PM, RN G stated she had worked with Resident #2. She stated she did not remember the specific orders for the care and maintenance of her PICC line. She stated she remembered Resident #2 had a midline IV (an IV line, over 3 inches long, inserted in a large vein the arm upper and ends in the axilla or armpit) and not a PICC line. She stated the line became clogged but the IV company was able to get the line working again, so the line did not have to be replaced. Review of the Licensed Nurse Proficiency Audit, dated 11/16 (no year), for RN A reflected in part, 4. IV skills A. Initiating IV therapy N (needs improvement) B. Maintaining IV therapy S (satisfactory) C. Assessment S (satisfactory) D. Proper documentation S (satisfactory). No competencies or skills checks specific to central lines were provided. Review of the Nurse Proficiency Audit, dated 11/29 (no year), for the ADON reflected in part, 4. IV skills A. Initiating IV therapy S (satisfactory) B. Maintaining IV therapy S (satisfactory) C. Assessment S (satisfactory) D. Proper documentation S (satisfactory). No competencies or skills checks specific to central lines were provided. Review of the Nurse Proficiency Audit, dated 07/31 (no year), for LVN B reflected in part, 4. IV skills A. Initiating IV therapy S (satisfactory) B. Maintaining IV therapy S (satisfactory) C. Assessment S (satisfactory) D. Proper documentation S (satisfactory). No competencies or skills checks specific to central lines were provided. Review of the Nurse Proficiency Audit, dated 08/07 (no year), for nurse LVN C reflected in part, 4. IV skills A. Initiating IV therapy S (satisfactory) B. Maintaining IV therapy S (satisfactory) C. Assessment S (satisfactory) D. Proper documentation S (satisfactory). No competencies or skills checks specific to central lines were provided. Review of the Licensed Nurse Proficiency Audit, dated 03/05/24 for LVN D, reflected in part, 4. IV skills A. Initiating IV therapy S (satisfactory) B. Maintaining IV therapy S (satisfactory) C. Assessment S (satisfactory) D. Proper documentation S (satisfactory). No competencies or skills checks specific to central lines were provided. Review of the Licensed Nurse Proficiency Audit, dated 06/14 and 06/17 (no year) for LVN E, reflected in part, 4. IV skills A. Initiating IV therapy S (satisfactory) B. Maintaining IV therapy S (satisfactory) C. Assessment S (satisfactory) D. Proper documentation S (satisfactory). No competencies or skills checks specific to central lines were provided. Review of the Care of Central Venous Catheter, Dressing Change policy dated 2003, reflected, Central venous catheters are used for long-term intravenous administrations. Invasive lines can also be used for a variety of care needs such as hyperalimentation and blood draws. The sites are high risk for infections and catheter care including dressing changes are performed to maintain sterility and prevent infection in central access catheters. Dressing changes are performed every 48 hours and prn if gauze is used or every week if transparent dressing is used. Sterile technique is used. Goals 1. The resident will be free from infection. 2. The resident will maintain skin integrity. Procedure 1. Explain the procedure and expected results to the resident. 2 Perform hand washing. 3 Create sterile field by opening glove wrapper. 4. Put on exam gloves. 5. Remove existing dressing using a no-touch technique. Discard dressing according to Universal Precautions. Remove exam gloves. 6 Perform hand hygiene. Apply sterile gloves. 7. Cleanse site with alcohol wipe x3. Let the site air dry. 8 Apply clear dressing. Label the new dressing with the date, time, and initials or label provided. Do not write on dressing, as ink will absorb through the dressing. 9. Lure lock injection caps will be changed as needed. 10. Clamp pigtail tubing. 11. Wear sterile gloves and prep pigtail cap connection with an alcohol swab. 12. Quickly twist off old cap and apply new cap. 13. Prepare top of cap with an alcohol swab. 14. Discard used supplies according to Universal Precautions. 15. Perform hand washing. 16. Document care and residents' response to treatment. Review of the Intravenous Medication Policy dated 2003, reflected in part, 1. The Physician may order any IV fluids and IV medications for resident in the nursing facility . 3. IV medication may be administered only by LVN or RN familiar with IV administration techniques . 8. Flush the IV according to physician's orders . Review of the Infection Control Plan: Overview, revised 03/2024, reflected in part, .II. Preventing infections related to the use of specific devices: Central venous catheters (CVCs) have also been associated with infectious complications. Other intravascular catheters such as dialysis catheters and implanted ports may be accessed multiple times per day, such as for hemodynamic measurements, or to obtain samples for laboratory analysis, thus increasing the risk of contamination and subsequent clinical infection. Limiting access to central venous catheters for only the primary purpose may help reduce the risk of infection. 1. Consistent use of appropriate infection control measures when caring for residents with vascular access catheters reduces the risk for catheter-related infections. 2. Surveillance consistently includes all residents with vascular access, including those with venous access and implanted ports such as peripherally inserted central catheter lines, and midline access catheters. 3. Activities to reduce infection risk includes surveillance such as observation of insertion sites, routine dressing changes, use of appropriate PPE and hand hygiene during the care and treatment of residents with venous catheters, and review of the resident for clinical evidence of infection. It is important that practices reflect the most current CDC guidelines. The ADM and DON were notified on 01/09/25 at 5:15 PM that an IJ had been identified and an IJ template was provided. The following POR was approved on 01/10/25 at 2:13 PM: 01/09/25 Plan of Removal On 0109/2025 an abbreviated survey was initiated at 10am. On 01/09/2025 the surveyor provided an Immediate Threat (IT) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. Problem: Central Venous Line Management Interventions: o DON completed 100% audit of current residents with central venous line on 1/9/2025 - no further issues identified (current resident in question). o The following in-services were initiated: 1. All nurses will be in-serviced on proper dressing change and care of a central venous line by the DON and/or Designee 2. All nurses will be in-serviced on infection prevention and monitoring for infection of a central venous line by the DON and/or Designee 3. All nurses will be in-serviced on receiving and validating central venous line management care with ordering physician by the DON and/or Designee 4. All nurses/agency nurses will not be allowed to begin work until they have received the above in-services/trainings by the DON and/or Designee - staff were able to verbalize comprehension post in-servicing. 5. DON in-serviced by compliance nurse 1/9/2025. - DON was able to verbalize comprehension post in-servicing. 6. Facility anticipates having this task completed by today, 1/10/2025. o The medical director was notified of the immediate jeopardy situation on 1/9/2025 at 7:00 pm Monitoring o The DON / designee will view each PICC/central venous line dressing 3xwk for 6 weeks and periodically thereafter to ensure compliance - it will be maintained on a monitoring log. o The DON / designee will review Real time key word for any new orders for PICC/Central Venous Line 5 times a week for 6 weeks and periodically thereafter to ensure compliance it will be maintained on a monitoring log. o DON/Designee will validate all new orders of PICC/Central Venous Line 5 times a week for 6 weeks and periodically thereafter to ensure compliance it will be maintained on a monitoring log. o The QA committee will review findings and makes changes to the plan if needed. The investigators monitored the Plan of Removal on 01/10/25 and 10/11/25 as followed: During interviews conducted from 01/10/25 at 3:19 PM and 01/11/25 at 3:18 PM, 6 LVNs and 3 RNs from both shifts. 6 of the nurses stated they received in-service and had in-person training. 3 of the nurses stated they had received the training e-mail but had not been to the facility yet for the in-person training. They stated they would receive training prior to working their next shift. The nurses were able to speak to the central line dressing change procedure, infection control, and validating central venous line management care with the physician. The nurses stated the central line dressing and caps were changed every 7 days and prn if soiled or loose. The nurses stated the PICC site was monitored for signs and symptoms of infection and flushed as ordered. Review of the in-service given by the Regional RN on 01/09/25 to the DON, had the Care of Central Venous Catheter, Dressing Change policy attached. Review of a PICC in-service given by the DON, initiated on 01/09/25, reflected, Central line dressings must be changed at least weekly including cap change, and PRN, using sterile technique. The sign-in sheet contained 13 signatures. Review of a second PICC in-service given by the DON, initiated on 01/09/25, reflected, All residents with IVs of any type will have the order set for that IV type entered upon insertion, and site monitored for s/s complications at least every shift. The sign-in sheet contained 13 signatures. Review of the Nursing Scope in-service given by the DON, initiated on 01/09/25, reflected, if you as a nurse do not feel comfortable that you can safely perform a nursing task you must notify your supervisor immediately. We will either re-assign the task or teach it to you by doing it while you observe. You should never perform a skill you aren't confident in.[sic] The sign-in sheet contained 7 signatures. Review of the Clinicals in-service given by the DON, initiated on 01/09/25, reflected, all charge nurses who are working that day will be in the DON office every weekday at 9 AM for clinicals, no exceptions. The sign-in sheet contained 13 signatures. Review of the message sent by the ADM on 01/10/25 from 8:54 AM through 8:56 AM reflected 20 nurses were sent the message with the in-service trainings attached. The facility completed an audit of the record for Resident #1. Resident #1's orders for dressing and cap changes, monitoring, and flushing were implemented. The physician orders dated 01/09/25 included, IV-PICC monitor site every shift for signs/symptoms of infection and/or infiltration every day and night shift; PICC Line dressing and cap change weekly using sterile technique pre protocol on time a day every 7 days and PRN, The physician order dated 01/10/25 reflected IV-PICC when being used intermittently, infuse medication and then flush with 10ml NS before and after medication five times a day. Review of the audits reflected the DON monitored their order system for any key word or new orders for PICC/Central Venous Lines. There were no new orders during the auditing on 01/09/25 or 01/10/25. The audits were scheduled for 5 times per week. The ADM and DON were notified on 01/11/25 at 4:10 PM that the IJ had been removed. While the IJ was removed on 01/11/25 at 4:10 PM, the facility remained at a level of no actual harm with potential for more than minimal harm that is not immediate jeopardy at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure that licensed nurses were able to demonstrate the specific competencies and skill sets necessary to care for the resident's needs for 1 (Resident #1) of 1 resident provided care by 6 of 6 nurses (ADON, RN A, LVN B, LVN C, LVN D, and LVN E) reviewed nursing competency. The facility failed to ensure the ADON, RN A, LVN B, LVN C, LVN D, and LVN E who provided central line care and maintenance to Resident #1 from 12/18/24 through 01/09/25 were knowledgeable and competent on the facility's central line policy. These failures could place residents with central lines at risk of infection, line malfunction, hospitalization , and not receiving medication as ordered. Findings included: Review of Resident #1's face sheet printed on 01/09/25, reflected a [AGE] year-old female originally admitted to the facility on [DATE] with a recent readmission on 12/01/23. Her diagnoses included non-pressure chronic ulcer left lower leg, chronic venous hypertension, peripheral vascular disease, and cellulitis. Review of Resident #1's quarterly MDS assessment dated [DATE], Section C (Cognitive Patterns) reflected a BIMS score of 15 indicating intact cognition. Section O (Special Treatments, Procedures, and Programs) reflected the resident received IV medications. Review of Resident #1's Order Recap Report for orders from 12/01/24 through 01/31/25, reflected orders dated 12/18/24: PICK [sic] LINE STAT one time only until 12/18/24, Piperacillin-Tazobactam 3.375 grams intravenously every 6 hours for infection for 28 days, ending 01/16/25, Vancomycin 1GM/250ml, use 1 gram intravenously give one time a day for infection for 28 days, ending 01/16/25. Review of Resident #1's current Clinical Physician Orders, an order dated 01/09/25 reflected a revised Piperacillin-Tazobactam 3.375 grams intravenously every 6 hours for infection for 8 days, changed the end date to 01/17/25. Review of Resident #1's CVAD Procedure form reflected a PICC was inserted using ultrasound guidance on 12/18/24 at 7:30 PM. The catheter was trimmed and measured 38cm. The upper arm circumference was 31cm. Review of Resident #1's chest x-ray report dated 12/18/24, reflected the PICC terminated over expected level of the superior cavoatrial junction. Review of Resident #1's nursing progress note written 01/09/25 at 4:27 AM by LVN B reflected, Resident PICC line was clogged which made resident not able to receive 3:00 AM Piperacillin Sod-Tazobactam Sod Solution Reconstituted 3-0.375 GM IV. On call NP was notified, [company name] vascular was called but they were not picking up. Review of Resident #1's December 2024 MAR/TAR reflected the Vancomycin and Piperacillin-Tazobactam intravenous medications were both administered for 13 days. The MAR/TAR did not reflect any dressing changes, flushes, or monitoring of the site. The MAR/TAR reflected Piperacillin Sod-Tazobactam Sod Solution Reconstituted 3-0.375 GM IV was administered by LVN B on 01/01/25, 01/05/25, and 01/09/25, by LVN C on 01/03/25, 01/04/25, 01/05/25, and 01/06/25, by LVN D on 01/01/25, 01/02/25, 01/06/25, and 01/07/25, and by LVN E on 01/01/25, 01/02/25, 01/03/25, 01/06/25, 01/07/25, and 01/08/25. Review of Resident #1's January 2025 MAR/TAR reflected a missed does of Piperacillin-Tazobactam on 01/09/25. The record reflected no monitoring of the central line site until 01/09/25, no flushing of the line until 01/09/25, and the first dressing and cap change scheduled for 01/10/25. During an observation and interview on 01/09/25 at 9:23 AM, Resident #1 was lying in bed with an IV infusing. She stated the IV was connected to the PICC in her arm. She stated she had asked several nurses to change the dressing because it was loose, but the dressing had not been changed since the PICC was inserted. When asked if there was a date on the dressing, she stated there was a date, but it was covered with tape, so it was no longer visible. Resident #1 attempted to adjust her sleeve to expose the dressing but could not do it without assistance. During an observation and interview on 01/09/25 at 9:29 AM, RN A entered Resident #1's room and offered the resident assistance to visualize the PICC dressing. The PICC dressing was completely covered with white tape. The PICC insertion site was not visible. The edges of the dressing were not visible. Upon exiting the room, RN A stated this was the first PICC line she had worked with. She stated she had not been trained on changing the PICC dressing and did not feel comfortable attempting the procedure. She stated she had been shown how to flush the line and adjust the flow rate on the IV. She stated she had put some tape on the dressing to keep it in place until another nurse could change the dressing. She stated she believed central line dressings were supposed to be changed daily and the IV tubing changed every 72 hours. During an observation and interview on 01/09/25 at 10:38 AM, the ADON sanitized an over the bed table and placed her dressing change supplies on the table and prepared to change Resident #1's PICC dressing. The ADON applied clean gloves and explained the procedure to the resident. The ADON removed the dressing from the resident's arm. A bio patch (a small sponge-like wound dressing used to reduce local infections) coated with dry blood was attached to the dressing. The ADON removed the tape from the clear dressing. The dressing was dated 12/18/24. No redness or drainage was noted at the insertion site. The ADON disposed of the old dressing and gloves then applied another pair of clean gloves. She opened the IV dressing change kit and retrieved the package of alcohol swabs. She used one swab to clean the insertion site and in a circular motion cleaned from the inside towards the outside. She continued to clean with the other two swabs in the package. The PICC line stabilization device that secured the line to the resident's arm was swabbed during the cleaning. The catheter line remained attached to the device and thus, the back of the line and the skin under the line was not cleansed. After the alcohol dried, the ADON took the clear dressing out of the dressing change kit and covered the insertion site and the stabilization device. She repositioned the resident then gathered her supplies. She did not change the caps. After exiting the room, the ADON stated she had training on central lines early in 2024. She stated some lady from the IV company came in and did a class for the nurses. She stated they did not get a competency or certificate from that training. The surveyor requested competencies/skills checks for Central Lines for the nurses. The ADON stated she would let the DON know about the request for the competencies. During an interview on 01/09/25 at 1:26 PM, the ADON started to describe the procedure for changing a PICC dressing then stated, It's pretty much what you observed earlier. She stated there probably should have been orders for changing the dressing and the caps. The surveyor requested competencies/skills checks for central lines. During an interview on 01/09/25 at 2:32 PM, the DON stated she expected central lines to be cared for according to the policy. She described the dressing change process as, Apply clean gloves and remove the old dressing. Remove those gloves and perform hand hygiene. Apply sterile gloves. Clean 3 times with the alcohol and let it air dry. Apply the clear dressing and change the caps. She stated the dressing change kits were the same for peripheral IVs and central lines. She stated she expected the dressings and caps to be change weekly. She stated PICCs were flushed after each use, and periodically if the PICC was not used. She stated a PICC dressing dated 12/18/24 did not meet her expectations. She stated the dressings were clear, so the insertion site was visible, and they watched for any changes so there were no inherent risks from the dressing not being changed. She stated she was not aware that Resident #1's insertion site was covered with white tape. She stated that a covered dressing did not meet her expectations. The DON provided Nurse Skill Audits, but no competencies or skills checks specific to central lines. During an interview on 01/09/25 at 3:07 PM, the MD stated it was his expectation that the insertion site was monitored at least daily and assessed for redness, bleeding, and drainage. He expected the dressing was monitored daily to ensure it was intact and sealed, and changed every 3 days. He stated the risk of infection increased if central lines were not properly maintained. During an interview on 01/10/25 at 3:57 PM, the ADON stated central line dressing changes were supposed to be sterile and a mask should have been worn during the procedure. She stated she thought she was changing the dressing on a peripheral IV and not a central line when she changed Resident #1's PICC dressing on 01/09/24. During an interview on 01/10/25 at 5:22 PM, the DON stated LVNs can perform central line dressing changes if they have had further training after completing nursing school. She stated LVNs could not insert or discontinue a central line nor draw blood through a central line. She stated there was an IV training class on their computer system that all nurses take upon hire and annually. She stated HR monitored the computer training and the clinical management monitored annual evaluation skill check offs. Review of Proficiency Audits for 5 licensed nurses who administered Resident #1's IV medications through the PICC line, and 1 licensed nurse who changed the PICC dressing with the following results. Review of the Licensed Nurse Proficiency Audit, dated 11/16 (no year), for RN A reflected in part, 4. IV skills A. Initiating IV therapy N (needs improvement) B. Maintaining IV therapy S (satisfactory) C. Assessment S (satisfactory) D. Proper documentation S (satisfactory). No competencies or skills checks specific to central lines were provided. Review of the Nurse Proficiency Audit, dated 11/29 (no year), for the ADON reflected in part, 4. IV skills A. Initiating IV therapy S (satisfactory) B. Maintaining IV therapy S (satisfactory) C. Assessment S (satisfactory) D. Proper documentation S (satisfactory). No competencies or skills checks specific to central lines were provided. Review of the Nurse Proficiency Audit, dated 07/31 (no year), for LVN B reflected in part, 4. IV skills A. Initiating IV therapy S (satisfactory) B. Maintaining IV therapy S (satisfactory) C. Assessment S (satisfactory) D. Proper documentation S (satisfactory). No competencies or skills checks specific to central lines were provided. Review of the Nurse Proficiency Audit, dated 08/07 (no year), for nurse LVN C reflected in part, 4. IV skills A. Initiating IV therapy S (satisfactory) B. Maintaining IV therapy S (satisfactory) C. Assessment S (satisfactory) D. Proper documentation S (satisfactory). No competencies or skills checks specific to central lines were provided. Review of the Licensed Nurse Proficiency Audit, dated 03/05/24 for LVN D, reflected in part, 4. IV skills A. Initiating IV therapy S (satisfactory) B. Maintaining IV therapy S (satisfactory) C. Assessment S (satisfactory) D. Proper documentation S (satisfactory). No competencies or skills checks specific to central lines were provided. Review of the Licensed Nurse Proficiency Audit, dated 06/14 and 06/17 (no year) for nurse LVN E, reflected in part, 4. IV skills A. Initiating IV therapy S (satisfactory) B. Maintaining IV therapy S (satisfactory) C. Assessment S (satisfactory) D. Proper documentation S (satisfactory). No competencies or skills checks specific to central lines were provided. Review of the ADONs Certificate of Completion reflected she completed the course, Management of Intravenous Devices on 04/24/24 for 1 hour of training. A second Certificate of Completion reflected she completed Infusion Therapy: Central Lines on 01/09/25 for 0.13 of training hours (7.8 minutes). Review of the Care of Central Venous Catheter, Dressing Change policy dated 2003, reflected, Central venous catheters are used for long-term intravenous administrations. Invasive lines can also be used for a variety of care needs such as hyperalimentation and blood draws. The sites are high risk for infections and catheter care including dressing changes are performed to maintain sterility and prevent infection in central access catheters. Dressing changes are performed every 48 hours and prn if gauze is used or every week if transparent dressing is used. Sterile technique is used. Goals 1. The resident will be free from infection. 2. The resident will maintain skin integrity. Procedure 1. Explain the procedure and expected results to the resident. 2 Perform hand washing. 3 Create sterile field by opening glove wrapper. 4. Put on exam gloves. 5. Remove existing dressing using a no-touch technique. Discard dressing according to Universal Precautions. Remove exam gloves. 6 Perform hand hygiene. Apply sterile gloves. 7. Cleanse site with alcohol wipe x3. Let the site air dry. 8 Apply clear dressing. Label the new dressing with the date, time, and initials or label provided. Do not write on dressing, as ink will absorb through the dressing. 9. Lue lock injection caps will be changed as needed. 10. Clamp pigtail tubing. 11. Wear sterile gloves and prep pigtail cap connection with an alcohol swab. 12. Quickly twist off old cap and apply new cap. 13. Prepare top of cap with an alcohol swab. 14. Discard used supplies according to Universal Precautions. 15. Perform hand washing. 16. Document care and residents' response to treatment. Review of the Intravenous Medication Policy dated 2003, reflected in part, 1 3. IV medication may be administered only by LVN or RN familiar with IV administration techniques .

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for sanitation. 1.The facility failed to ensure sanitation practices was occurring including cleaning the ice machine, cleaning the microwave, cleaning the meat slicer and utilizing a meat slicer that had a rusty slicing blade, having trash receptacles without lids secured, having ingredient bins with scoops in them, utilizing a ice scoop holding receptacle with no lid and that had dirt and debris in the bottom touching the ice scoop, cleaning the juice gun nozzle, and proper hair restraints. 2.The facility failed to label and date all food items in the kitchen. 3.The facility failed to have hand wash sinks that did not leak. 4.The facility failed to ensure food items was covered, secured, and stored properly. These failures could place residents at risk of foodborne illness. Findings included: Observation on 12/9/2024 at 9:12 AM, of the kitchen revealed the hand washing sink outside of dish room to be leaking when in use from the pipes underneath. Observation on 12/9/2024 at 9:14 AM, of the kitchen microwave revealed the interior top of the microwave to not be clean. Interior top had what appeared to be dried splattered food debris caked on surface. Observation on 12/9/2024 at 9:15 AM, of kitchen meat slicer revealed the slicer to be dirty with what appeared to be dried food debris on the slicing arm near blade. Further observation revealed the slicing blade to be rusty. Observation on 12/9/2024 at 9:16 AM, of kitchen preparation area revealed a 55-gallon trash can in preparation without a lid. Observation on 12/9/2024 at 9:20 AM, of kitchen walk-in freezer revealed the following: -Box contained what appeared to be 1 bag of frozen hushpuppies unsealed not labeled and dated, -1 bag of what appeared to be breaded onion rings not labeled and dated, -1 bag of what appeared to be breaded chicken tenders unsealed not labeled and date, -1 bag of what appeared to be breaded fish fillets not labeled and dated, -1 bag of broccoli cuts not labeled and dated, and -1 bag of what appeared to be individual cherry pies unlabeled and undated. Observation on 12/9/2024 at 9:22 AM of kitchen revealed a 55-gallon trash can near the door of the dry storage without a lid. Observation on 12/9/2024 at 9:23 AM of kitchen dry storage area revealed: - an open bag of brown sugar unlabeled and undated, -an opened bag of bowtie pasta unlabeled and undated, -an opened bag of macaroni pasta unlabeled and undated, -an opened bag of yellow cake mix, unlabeled and undated inside of a gallon storage bag, -an opened bag of cherry gelatin dated 11/1 unsure if this is open date or discard date inside a gallon storage bag with a plastic spoon in storage bag with dry gelatin mix on spoon, -an opened bag of granulated peanuts dated 4/1/24 unsure if this is open date or discard date inside a gallon storage bag, -an opened bag of pistachio pudding mix, dated 8/22 unsure if this is open date or discard date inside a gallon storage bag, a gallon storage bag with an opened bag of cocoa and powdered sugar with a date on the gallon storage bag of 2/1/24 unsure if this is open date or discard date or for which product this is for, and -2 packages of tortillas unlabeled and undated. Observation on 12/9/2024 at 9:28 AM, of chest deep freezer revealed what appeared to be 2 unopened bags of tater tots unlabeled and undated, 1 unopened bag of what appeared to hushpuppies unlabeled and undated, 2 unopened bags of chicken nuggets unlabeled and undated. Observation on 12/9/2024 at 9:30 AM of kitchen hand washing sink by preparation table leaking from faucet. Observation on 12/9/2024 at 9:31 AM of kitchen storage bin of sugar with scoop inside of bin pushed halfway down into sugar. Observation on 12/9/2024 at 9:31 AM of kitchen storage bin of tea bags uncovered, unlabeled, and undated. Observation on 12/9/2024 at 9:33 AM of kitchen ice scoop storage receptacle revealed storage receptacle did not have lid and storage receptacle to have what appeared to be a black mold substance and white string in the bottom of the storage receptacle. Observation on 12/9/2024 at 9:35 AM of kitchen ice machine revealed seal on top of ice machine door to have a crack in it approximately 2 inches long. Further observation revealed ice machine to have what appeared to be a brown, black, and white mold type substance on the inside door and inner upper wall of ice machine. A pink and black mold type substance was observed on the inside on the shield to guard where the ice falls from. Observation on 12/9/2024 at 9:40 AM of kitchen juice gun nozzle revealed an orange and red substance buildup on the inside of the juice gun. Observation on 12/10/2024 at 9:25 AM of kitchen revealed DM wearing a ball cap as hair restraint with hair extending below ball cap approximately 2 inches. Observation on 12/12/2024 at 4:30 PM of kitchen revealed [NAME] F with beard guard under chin and beard exposed. Interview on 2/12/2024 at 1:49 PM, of kitchen DM revealed DM was asked about cleaning logs/ cleaning schedule, labeling, and dating policy, ice machine cleaning log and or policy, and hair restraint policy. DM stated that he will get them for me. DM stated they do in-service online trainings, but he cannot see them. DM stated his expectation is to have everything in the kitchen, and for the kitchen to be clean and sanitized as well as for it to remain a safe environment. DM stated if the kitchen and dining is not cleaned or sanitized appropriately, it may cause foodborne illnesses. DM stated that the kitchen staff follow the first in and first out policy for all food products unless it has a used by date printed on it. DM stated if food was not appropriately labeled or dated, it can be bad to give out that food or give someone the wrong food if you do not know what it is. DM stated that his expectation is anyone that enters the kitchen area is to wear hair nets as you can have food fall in the food during preparation and can cause cross contamination. DM stated the food slicer is cleaned after each use, there is no logs to track who cleans it after usage, but if there was any leftover food on it, they would clean and sanitized before usage. DM stated as for rust on the food preparation equipment such as, the food slicer, he does not know what exactly rust would do to the residents since he is not a medical professional. DM stated that he thinks if rust is directly consumed by an individual, it could harm the individual, but he does not know in what way. Interview on 12/12/2024 at 4:30 PM, revealed [NAME] F stated that everyone who enters the kitchen must wear a hair restraint. [NAME] F stated that for staff members with facial hair a beard guard must be worn to cover the facial hair. [NAME] F stated they were trained about hair restraints upon hire. Interview on 12/12/2024 at 4:45 PM, revealed the DM stated they do not complete daily or monthly cleaning logs. DM states they only complete the weekly logs. DM states the ice machine interior was cleaned last month. DM stated there is no documentation of the ice machine cleaning log as they do not keep that log. Interview on 12/12/2024 at 4:55 PM, revealed the ADM stated for general kitchen sanitation and cleaning that their expectation was that the kitchen staff would follow company policies. ADM stated if policies for general kitchen sanitation and cleaning are not followed that this could negatively affect residents by uncleanliness. ADM stated concerning hair restraints she expects everyone who enters the kitchen is required to wear a hair restraint and beard restraint, for staff wearing hats hair restraint would be required if hair extends out from hat and is shoulder length. The ADM stated by staff not wearing hair restraints it could negatively affect residents by hair getting into the food. ADM states they expect all kitchen equipment to be properly maintained according to manufacturer and policies. ADM was unsure how rust on a meat slicer blade could be a negative effect on residents besides possibly not cutting the meat properly. ADM stated her expectation regarding food labeling and dating is that all food items was labeled and dated and that the company policies was being followed. ADM stated it could negatively affect residents if food is not being labeled and dated by residents possibly getting sick. Record review of Food Storage and Supplies policy undated reflected: All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean, organized, dry and protected from vermin, and insects. Procedure: 3. Dry bulk foods (example: flour, sugar) are stored in seamless metal or plastic containers with tight covers or bins which are easily sanitized. Containers are labeled. Best practice is that scoops should not be left in food containers or bins, but if so, handles should be upright and not contacting the food item. Containers are cleaned regularly. 4. Open packages of food are stored in closed containers with covers or in sealed bags and dated as to when opened. 6. When items are received from the vendor, they should be first examined for expiration date, and if an expiration date is present, it is beneficial to mark it by circling it so it is readily visible and noticeable. It is important to distinguish between an expiration date and a production date, or a best by or use by date. Production dates indicate when the product was manufactured, not when it expires, and should not be interpreted as a best by or use by date. Best by or use by dates indicate when a product will have best flavor or quality and are not an indicator of the product's safety. As the quality may deteriorate after the date passes, the dietary manager should closely inspect any products that are past the best by date to determine if they are still good quality. If in doubt, discard the product. If any stamped date is unclear, contact the food vendor for clarification. If an item does not have a date designated by the manufacturer as an expiration date, then the item should be dated as to when it is received, and shelf-stable items will be stored in a first in, first out manner, to be used within one year. After one year, any product that is shelf stable will be inspected by the dietary manager to ensure that it is good quality before it is used. Any product with a stamped expiration date will be discarded once that date passes. Sanitation and Food Handling: 1. All employees receive instruction on sanitation during orientation and thru in-service training programs. 2. Hair nets or hats covering the hairline are worn at all times. [NAME] guards are required for facial hair. 3. Wash your hands (with soap and hot water) before starting work, after coughing or sneezing, handling garbage, picking up an article from the floor, after handling soaps or detergents, after using the toilet, after smoking, and after all breaks. Touching something that is not clean and then handling food can cause food poisoning. 4. Handle all utensils and dishes so the food or customer contact surfaces are not touched. All disposables are opened from the bottom of the package. 5. Do not handle food with bare hands. Use the proper utensil or wear disposable gloves. Remember to change gloves after touching anything that should not contact food, including clothing, hair, doorknobs, etcetera. 6. Wash and sanitize any utensil or non-food supply that has fallen on the floor before allowing it to contact food. 7. Dispose of food that has fallen on the floor. Any food that has come in contact with broken dishes will be discarded, and another food substituted. 8. Work surfaces must be kept as neat and clean as possible during preparation and service. Clean up your area as you work, and do not let sinks become full of [NAME] utensils and bowls. 9. All utensils, pots, and pans must be properly washed and sanitized after use. I 0. All work areas must be thoroughly cleaned and sanitized after use. Red sanitation buckets with moist cleaning cloths should be prepared and the sanitation concentration verified every four hours. 11. All unused food must be securely covered. All items are to be dated and labeled as to their content. Store items in their original container unless instructed to do otherwise. Plastic containers from pickles, salad dressings, etc. are to be discarded as they are emptied, unless otherwise instructed. 12. Do not leave any serving tools in refrigerated or dry storage food containers. Record review of Equipment Sanitation policy undated reflected: We will provide clean and sanitized equipment for food preparation. The facility will clean all food service equipment in a sanitary manner. Procedure: 5. Meat slicer and meat preparation areas. a. Slicing of cooked meat (ready for serving) should not follow the slicing of raw foods or uncooked meat. b. Slicer parts are removed and washed after each use with sanitizer, rinsed well, and allowed to air dry. c. Counter on which uncooked meat has been placed should be thoroughly cleaned with detergent after use. d. Meat preparation areas should be cleaned and sanitized at the end of preparation of each product. Record review of the Cleaning of the Ice Machine policy undated reflected: The ice machine shall be cleaned and sanitized according to manufacturer's instructions to maintain sanitary conditions in order to prevent food contamination and the growth of disease producing organisms and toxins. Procedure: 1. Unplug from electricity and/or turn off. 2. Empty, dispose of ice and drain completely. 3. Clean any hard water deposits with de-[NAME], per manufacturer instructions for mixing and use, and rinse well. 4. If any type of soil/food stains are present, wash with all-purpose cleaner and rinse well. 5. Wipe down all food/ice contact surfaces with a sanitizer solution, per manufacturer instructions, DO NOT rinse. Iodine: 12.5 to 25 ppm Chlorine: 50 to I 00 ppm Quaternary ammonia: 150 -400 ppm 6. Allow to air dry. 7. Turn ice machine back on.

Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent falls and injury for 1 of 5 residents (Resident #1) reviewed for accidents. The facility failed to safely perform a one-person transfer and prevent fall and injury for Resident #1, which resulted in Resident #1 falling straight forward and landing on his forehead and sustaining an 8-centimeter large forehead laceration and an acute compression fracture of T-3 vertebra. EMS was activated, and Resident #1 was hospitalized from 11/07/23 - 11/10/23. This failure could place residents at risk of not receiving the care and services to meet their needs and services to prevent serious harm, serious impairment, or death. Findings include: Record review of Resident #1's face sheet, dated 11/10/23, reflected an [AGE] year-old male who was admitted to the facility on [DATE] and re-entered on 11/29/22. Resident #1 had diagnoses which included Supranuclear Palsy (an uncommon brain disorder that causes serious problems with walking, balance, and eye movements, and later with swallowing), Rheumatoid arthritis (a long-term disease that causes inflammation of the joints), Atrial fibrillation (irregular heartbeat), Osteoarthritis (joint pain), Pain, Alzheimer's disease (progressive mental deterioration due to generalized degeneration of the brain), Cognitive communication deficit (an impairment in thought organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), Weakness, abnormal gait and mobility (Injuries and medical conditions can affect walking pattern), and history of malignant neoplasm of prostate (history of prostate cancer). Record review of Resident #1's annual MDS, dated [DATE], reflected the resident had a BIMS score of 14, which indicated his cognition was mildly impaired. The MDS reflected the resident required extensive assistance with two-person assist for transfers and toileting, and one-person assist for dressing, eating, and toileting required limited to extensive assistance with one or more persons. The functional abilities reflected Resident #1 was dependent on staff for toileting hygiene, shower, bathing, dressing upper and lower extremities, and transfers from bed to wheelchair for mobility. The resident had no falls or injuries since admission or reentry at the time of the MDS assessment. Active Diagnosis included Supranuclear Palsy (an uncommon brain disorder that causes serious problems with walking, balance, and eye movements, and later with swallowing), Rheumatoid arthritis (a long-term disease that causes inflammation of the joints), Atrial fibrillation (irregular heartbeat), Osteoarthritis, Pain, Alzheimer's disease, Cognitive communication deficit, Weakness, abnormal gait and mobility, and history of malignant neoplasm of prostate. Record review of Resident #1's Care Plan, with review date of 09/12/23, reflected Resident #1 was at risk for falls, had an ADL Self Care Performance Deficit, impaired balance, limited range of motion, and musculoskeletal impairment and required one person assistance for transfers. Goal: Resident will maintain or improve current level of functioning with activities of daily living (ADLs) through the next review date. Intervention: Encourage the resident to fully participate possible with each interaction. Goal: Resident will be free of falls through review date. Interventions: Ensure the resident's call light is within reach and encourage the resident to use it for assistance as needed, ensure the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair, and review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate the resident and family/caregivers/IDT as to causes. Record review of Resident #1 Fall Risk Assessment, dated 11/07/23, reflected a score of 11, which indicated the resident was high risk for falls. No falls were reflected for the past 3 months. Resident #1 had a balance problem while standing, walking, decreased muscular coordination, and required use of assistive devices. Record review of Resident #1 Hospital Record dated 11/10/23 at 11:00 AM reflected a primary diagnosis of Fall, scalp laceration, and t spine compression fracture. Record review of Resident #1 CT Spine Cervical w/o contrast done on 11/07/23 reflected acute T3 compression fracture with approximately 50% height loss and mild retropulsion of the superior/posterior [NAME] resulting in mild spinal canal stenosis. Record review of Resident #1 MR Spinal canal w/o contrast done on 11/07/23 reflected a stable appearing acute compression fracture T3 vertebral body with very minimal encroachment on spinal canal. Posterior elements and posterior paraspinal soft tissues appeared intact. Observation on 11/10/23 at 2:30 PM conducted with CNA A revealed the resident's room was clean and organized. The bed was along the wall with the entry way, and nightstand and recliner were on the wall in line with the head of bed. There were signs above the head of the bed which stated, Please let me do as much as I can when getting me out of bed .Elevate head of bed at least 30 degrees .Use my walker to transfer. Interview on 11/10/23 at 12:02 PM with the DON revealed CNA A transferred Resident #1 from the bed to the wheelchair, and noticed his pants were twisted so she straightened them. Resident #1 fell forward with his head to the ground. EMS was called immediately, and Resident #1 was sent to the ER . The DON stated the hospital was going to discharge him on 11/09/23 and then decided to monitor him for one more night.The DON further stated CNA A was a witness to the incident and Resident #1 was able to attest to falling, and concluded the incident did not need to be reported to the state. Interview on 11/10/23 at 12:12 PM with CNA A revealed when Resident #1 was standing in front of the wheelchair she told him his pants were crooked and told him not to sit down yet, and to keep his chin up, bring his feet together and stand up tall. CNA A gently straightened Resident #1 pants and Resident #1 began to tilt to the right and fell straight down, with his head hitting the floor which resulted in a forehead laceration. CNA A stated she screamed for nurses to come help, and bleeding from Resident #1's forehead laceration was treated by the nurse applying pressure. Interview on 11/10/23 at 2:35 PM with CNA A revealed she used a gait belt during Resident #1's transfer and when he was in front of the wheelchair, she told him she was going to adjust his pants. CNA A took her hands off the gait belt to adjust Resident #1's sweatpants. Resident #1 then began tilting to right and fell straight down to the ground in front of the nightstand and recliner and hit his head on the floor . CNA A tearfully stated Resident #1 clothing was on straight when he was sitting on side of the bed, and pants had somehow twisted going from bed to wheelchair. CNA A further stated if she had not fixed Resident #1's pants and continued with assisting into wheelchair this terrible incident would not have happened to Resident #1. CNA A shared she had wanted to ensure Resident #1 looked presentable for the day and had never intended for any of this to happen. Observation on 11/10/23 at 2:45 PM revealed Resident #1 returning to his room from the hospital via EMS and stretcher. Resident #1's forehead laceration was sutured. Signs on Resident #1 wall above bed reflected, Please let me do as much as I can when getting me out of bed, Elevate head of bed at least 30 degrees and Use my walker to transfer. Interview on 11/10/23 at 3:00 PM with Resident #1 revealed he was fearful of being transferred and sustaining another fall. Interview on 11/10/23 at 3:30 PM with DON revealed Resident #1 would be a 2-person transfer on return from the hospital, as per Physical Therapy recommendation. Record review of recent in-servicing for all staff on fall prevention was conducted on 11/07/23. CNA A was present for the training. Interview on 11/11/23 at 3:13 PM with CNA B revealed in-serviced before shift on Abuse and Neglect, and the ADMIN was the ANE Coordinator. Types of Abuse included mental, physical, financial, verbal. CNA B stated when using a gait belt during a transfer to never let go, even if you need to adjust pants. CNA B further stated always make sure resident wearing proper shoes when transferring, enough proper help before transferring anyone, and find in their POC to figure out if weight bearing, etc. Interview on 11/11/23 at 3:24 PM revealed CNA C was in-serviced on Abuse and Neglect including types of abuse: physical, neglect, and emotional. CNA C revealed Abuse and Neglect coordinator was the ADMIN. CNA C stated when transferring a resident, place gait belt under their ribs to fit snuggly with 2-finger grip, and make sure you have all your equipment. CNA C further stated the gait belt was going to save the resident, and never let the belt go. CNA C stated if pants falling, set resident back on the bed and get someone to help you. Interview conducted on 11/11/23 at 3:42 PM with LVN B revealed important to look at Kardex before doing a transfer to determine transfer status, use gait belt whether it's one person or 2-person assist, put gait belt on properly - not too tight, not too loose, never remove your hands from the gait belt until resident seated where they need to be safely. LVN B further stated in-servicing today on gait belt, Abuse and Neglect, and transfers, and types of abuse included neglect, emotional, physical, verbal, and exploitation. Observation on 11/11/23 at 3:54 PM revealed CNA B conducting transfer for Resident #2 from recliner to wheelchair. CNA B washed her hands, put on gloves, and explained to resident what she was going to do. CNA B placed the gait belt around Resident #2 waist, and ensured it wasn't too tight by putting 2 fingers between the resident and the belt. CNA B put the wheelchair next to the recliner and locked the breaks. CNA B then scooted Resident #2 to the edge of the recliner and had Resident #2 put her hands around CNA B's neck. CNA B explained the process the whole time, now we are going to pivot - then set her gently in the wheelchair. CAN B never took her hands off the gait belt. Record review of the facility's, undated, Policy & Procedure for Moving a resident from bed to chair/chair to bed reflected, If moving a resident from bed to chair, and support the resident by placing a gait belt around the resident's waist for you to hold and steady the resident .move with the resident and be sure the resident is all the way back in the chair . The ADM was notified on 11/10/2023 at 5:05 PM an IJ situation was identified due to the above failures and the IJ template was provided. The facility failed to investigate to determine the causative factors of falls to help prevent and/or reduce risk for falls and implement new fall interventions, if needed; and failed to ensure fall interventions were implemented to help prevent falls. This affected 1 of 5 residents (Resident #1) reviewed for falls. Resident #1 had sustained a fall during a one-person transfer resulting in a forehead laceration and hospitalization . Interview on 11/10/23 at 12:12 pm revealed CNA A adjusted Resident #1 sweatpants in the middle of one-person transfer. CNA A told Resident #1 his pants were crooked and told him not to sit down yet, to keep his chin up, feet together and stand up tall. CNA A took hands off gait belt and twisted sweatpants to right x 2 and resident began to tilt to the right and fell straight down and hit his forehead on the floor, causing a large forehead laceration. CNA called for nurse immediately. Resident #1 was admitted on [DATE] and had diagnoses of Progressive supranuclear palsy, Rheumatoid arthritis, Osteoarthritis right shoulder, age-related physical debility, muscle wasting and atrophy, and muscle weakness. Resident #1 had no documented falls during the past 3 months. A review of Resident #10's face sheet revealed the resident was admitted to the facility on [DATE] with diagnoses including Progressive supranuclear palsy, Rheumatoid arthritis, Osteoarthritis right shoulder, age-related physical debility, muscle wasting and atrophy, and muscle weakness. Review of the annual MDS dated [DATE] revealed that the resident had a BIMS of 14. The Staff Assessment for Mental Status revealed that the resident cognition was only mildly impaired. The resident required one-person assistance for ADLs, one-person assistance for personal hygiene and bathing. Resident was always incontinent of bladder and bowel. The resident uses a wheelchair. Review of Care Plan dated 8/30/23 reflected Resident #1 was transferred with gait belt and assist of one staff. Most recent in-servicing on Fall Prevention was conducted on 11/07/23. Interview on 11/10/23 at 6:25pm revealed DON requested Human Resources to assign Relias training for resident transfers. On return from hospital today 11/10/23 Resident #1 updated to two-person transfer and P.T. to evaluate. Investigation included after fall occurred DON, ADMIN and Resident #1 RP went to room for demonstration of how fall occurred. Resident #1 had sustained a fall during a one-person transfer, which resulted in a forehead laceration and hospitalization . The lack of falls investigations and fall interventions has the potential to result in residents continuing to experience falls that could likely lead to serious injury or death. The facility needs to take immediate action to prevent continued falls that could result in major injuries or death, which includes investigating falls to determine causal factors and implementing interventions to reduce injury from subsequent falls. Immediate Jeopardy IJ Monitoring was conducted on 11/11/23: Review conducted on 11/11/23 of In-services: Abuse/neglect, fall prevention, gait belt transfers, determining transfer status, following Care Plan. Interview conducted on 11/11/23 at 3:13 PM with CNA B revealed in-serviced before shift on ANE, fall prevention, gait belt transfers, determining transfer status, following care plan, and the ADMIN was the ANE Coordinator. Types of Abuse included mental, physical, financial, verbal. CNA B stated when using a gait belt during a transfer to never let go, even if you need to adjust pants. CNA B further stated always make sure resident wearing proper shoes when transferring, enough proper help before transferring anyone, and find in their POC to figure out if weight bearing, etc. Interview on 11/11/23 at 3:24 PM revealed CNA C was in-serviced on Abuse and Neglect including types of abuse: physical, neglect, and emotional. CNA C revealed Abuse and Neglect coordinator was the ADMIN. CNA C stated when transferring a resident, place gait belt under their ribs to fit snuggly with 2-finger grip, and make sure you have all your equipment. CNA C further stated the gait belt was going to save the resident, and never let the belt go. CNA C stated if pants falling, set resident back on the bed and get someone to help you. Transfer status located in plan of care. Interview on 11/11/23 at 3:35 PM revealed CNA D was in-serviced before shift today on transferring with gait belt. CNA D stated they had them do demonstrations with therapy. CNA D stated to never let the belt go. CNA D further stated transfer status was in the care plan, where you find everything out about your resident. CNA D stated types of abuse were neglect, verbal, and physical and the ANE coordinator was the ADMIN. Interview conducted on 11/11/23 at 3:42 PM with LVN B revealed important to look at Kardex before doing a transfer to determine transfer status, use gait belt whether it's one person or 2-person assist, put gait belt on properly - not too tight, not too loose, never remove your hands from the gait belt until resident seated where they need to be safely. LVN B further stated in-servicing today on gait belt, Abuse and Neglect, and transfers, and types of abuse included neglect, emotional, physical, verbal, and exploitation. Observation on 11/11/23 at 3:54 PM revealed CNA B conducting transfer for Resident #2 from recliner to wheelchair. CNA B washed her hands, put on gloves, and explained to resident what she was going to do. CNA B placed the gait belt around Resident #2 waist, and ensured it wasn't too tight by putting 2 fingers between the resident and the belt. CNA B put the wheelchair next to the recliner and locked the breaks. CNA B then scooted Resident #2 to the edge of the recliner and had Resident #2 put her hands around CNA B's neck. CNA B explained the process the whole time, now we are going to pivot - then set her gently in the wheelchair. Never took her hands off the gait belt. The Plan of Removal was accepted on 11/11/2023 at 4:00 PM and included: Problem: F689 The facility failed to ensure that the residents received adequate supervision to prevent accidents hazards for 1(Resident #1) of 5 residents reviewed for falls. This deficient practice has the potential to effect residents that require 1 person assistance with ADL's and use of Gait Belt for transfers. Interventions: o Resident #1 was transferred to the hospital for evaluation as of 11/10/23. o CNA A was 1:1 in-serviced by the DON on 11/10/23 on fall prevention and gait belt transfers (not to remove hands off the gait belt during transfer or when adjusting clothing). o Administrator and DON were in-serviced 1:1 by the Regional Compliance Nurse on investigating incidents and accidents; initiating in-servicing and training immediately. Completed 11/10/23. o All residents were evaluated for the proper amount of transfer assistance on 11/10/23 by the DON/ADON/Designee. o All resident care plans were reviewed for the proper amount of transfer assistance DON/ADON/MDS nurse on 11/10/23. In-services: The following in-services were initiated by Admin/ DON on 11/10/23. Any staff member not present or in-serviced on 11/11/23 will not be allowed to assume their duties until in-serviced. All new hires, PRN, and agency staff will be in-service prior to the start of their assignment. Admin/DON/Designee will ensure staff have received in-services prior to the start of their assignment. All staff present during the night shift for 11/10/23 to the current day shift for 11/11/2023 have completed the below in-services. o Abuse/Neglect policy. o Fall Prevention o Gait belt transfers (not to remove hands off gait belt during the transfer or when adjusting clothing) with return demonstration/competency. o How to use the Kardex in PCC to determine the transfer status of a resident. o Following the care plan interventions including how much staff and the proper equipment required for transfers. o If unable to provide the required staff or equipment to perform a transfer, do not perform until staff are available. Do not rush. o The Medical Director was notified by the Administrator of the immediate jeopardy on 11/10/23. o An ADHOC QAPI meeting IDT was held on 11/10/23 to discuss the immediate jeopardy and plan of removal. Monitoring: o During incident/event review in standup, the DON and Admin will monitor Events in Realtime and PCC for any incidents surrounding transfers. Monitoring will continue x 5 days per week indefinitely. During weekends and holidays the DON/designee RN will monitor Events in Realtime and PCC for any incidents surrounding transfers. Monitoring will start 11/10/23. o The Administrator/DON/Designee will ask 10 staff members per week x 4 weeks, how to locate how much assistance/equipment is needed for a resident transfer and what they would do if the proper amount of staff/equipment is not available. Monitoring will start 11/10/23. o The DON/Designee will monitor at least 10 resident transfers per week to ensure proper technique was demonstrated. Monitoring will start 11/10/23 and continue x 4 weeks. o Area Director/Compliance Nurse will review all incidents and accidents weekly x 4 weeks to ensure all investigations and in-services/training have been initiated timely. o The above will be reviewed during the facility monthly QA meeting for no less than 60 days, or until the Administrator determines substantial compliance has been achieved and maintained.

Based on interview, and record review, the facility failed to ensure residents were free from any type of abuse, including corporal punishment, and neglect, that results in, or has the likelihood to result in physical harm, pain, or mental anguish abuse and neglect for 6 of 6 residents reviewed for abuse/neglect. The facility failed to take sufficient protective measures after on 04/12/2023, Resident #2 pushed Resident #1, who fell and fractured (broke) his hip. The facility failed to take sufficient protective measures after, on 04/17/2023, Resident #3 pushed Resident #5 into a wall and Resident #5 hit her head. Resident #5 was sent to the hospital, was assessed as having no significant injuries, and she returned to the facility. The facility failed to take sufficient protective measures after, on 04/20/2023, Resident #4 broke two bedside tables, hit Resident #3 and pushed down a nurse. EMS was called and both Resident #3 and Resident #4 were taken to the hospital. Resident #4 was assessed to be not a harm to herself or others and returned to the facility. Resident #3 was assessed as having no significant injuries and returned to the facility. The facility failed to take sufficient protective measures after, on 04/23/2023 when Resident #6 was seated on a recliner when Resident #4 grabbed his groin area, squeezed, and did not release her hold until staff intervened. Resident #s 1,2,3,4,5,6 all resided in the facility's locked/secure unit. An IJ was identified on 04/25/2023. The IJ template was provided to the facility on [DATE] at 5:45 PM. While the IJ was removed on 04/27/2023, the facility remained out of compliance at actual harm that is not immediate jeopardy at a scope of a pattern because the facility continued to monitor the implementation and effectiveness of the These failures could place residents at risk of physical and psychosocial injury, including serious injury or death. Findings included: Review of the undated face sheet for Resident #1 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of unspecified dementia (progressive impairments in memory, thinking, and behavior which negatively affects a person's ability to function and carry out everyday activities), unspecified severity, without behavioral disturbance, psychotic disturbance (severe mental disorders that cause abnormal thinking and perceptions), mood disturbance (disturbance in the person's mood is the main underlying feature), and anxiety. Review of the admission MDS for Resident #1 dated 04/21/2023 reflected a BIMS score of 99 and indicated the resident was unable to complete the interview and behavior review indicated Resident #1 had verbal behavioral symptoms directed toward others every one to three days but not physical aggression. Review of the care plan for Resident #1 dated 04/2/2023 reflected the following: physical behavioral symptoms directed towards others as evidenced by, however, the care plan did not elaborate, describe, or list evidence of the physical behavioral symptoms. Interventions listed in care plan included address wandering behavior by walking with resident; redirect from inappropriate area; engage in diversional activity, administer and monitor the effectiveness and side effects of medications as ordered - see physician orders, anticipate care needs and provide them before the resident becomes overly stressed, explain care to resident in advance, in terms resident understands, if reasonable, discuss behavior with resident; explain/reinforce why behavior is unacceptable, intervene as needed to protect the rights and safety of others; approach in calm manner; divert attention, remove from situation and take to another location as needed, investigate/monitor need for psychological support, provide services if desired by resident/responsible party and as ordered by physician. Review of the undated face sheet for Resident #2 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of dementia (progressive impairments in memory, thinking, and behavior which negatively affects a person's ability to function and carry out everyday activities) in other diseases classified elsewhere, unspecified severity with agitation (nervous excitement), generalized anxiety disorder (excessive worrying about daily matters), and psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions) with delusions (unshakable, false, and irrational beliefs that defy normal reasoning and evidence) due to known psychological condition. Review of the admission MDS for Resident #2 dated 01/21/2023 reflected a BIMS score of 3, indicating a severe cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) impairment and the behavioral review indicated Resident #2 had verbal behavioral symptoms directed towards others (threatening others, screaming at others, cursing at others) that occurred one to three days; and other behavioral symptoms not directed toward others (physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily waste, or verbal/vocal symptoms like screaming, disruptive sounds) that occurred one to three days. Review of the care plan for Resident #2 dated 01/09/2023 reflected the following: Resident #2 displays socially inappropriate behavior, attempting to put feces on the floor and will state that it belongs to roommate. Removes sheets and mattress off the bed. Interventions in care plan included calmy approach him and call his name to gain his attention, offer comfort and reassurance, remove from room or area, if necessary, stay with him until calm, or alternate staff, validate his emotions. Review of the care plan for Resident #2 dated 02/09/2023 reflected the following: Resident #2 has a behavior problem as evidenced by making sexual advances towards staff. Attempting to kiss on the lips and touch aide while providing assistance with shower. Interventions in care plan included administer medications as ordered, monitor/document for side effects and effectiveness, if reasonable, discuss the resident's behavior, explain/reinforce why behavior is inappropriate and/or unacceptable to the resident, intervene as necessary to protect the rights and safety of others, approach/speak in a calm manner, divert attention, remove from situation, and take to alternate location as needed. Review of the care plan for Resident #2 dated 02/09/2023 reflected the following: Resident #2 has a potential to demonstrate verbally abusive behaviors related to dementia. Interventions in care plan included give as many choices as possible about care and activities, when he becomes agitated intervene before agitation escalates, guide away from source of distress, engage calmly in conversation, if response is aggressive, staff to walk calmly away, and approach later. Review of the care plan for Resident #2 dated 04/13/2023 reflected the following: Resident #2 has episodes of agitation and can become irritated easily when being redirected with a goal that Resident #2 will have a decrease in episodes of angry outbursts and allow staff to redirect him and assist him. Resident #2 has physical behavioral symptoms directed towards others; however, the care plan did not elaborate, describe, or list evidence of the physical behavioral symptoms. Interventions in care plan included when he becomes agitated intervene before agitation escalates, guide away from source of distress, engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later. Review of the care plan for Resident #2 dated 04/14/2023 reflected the following: Resident #2 has a potential to demonstrate physical behaviors related to dementia with a goal of decrease in episodes of physically striking out. Interventions in care plan included analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document, assess and anticipate his needs: food, thirst. toileting needs, comfort level, body positioning, pain etc., when he becomes agitated: Intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Review of the care plan for Resident #2 dated 04/14/2023 reflected the following: Resident #2 has low tolerance for other residents who are lowering functioning than he is. Resident #2 often has conflicts with other residents and can lose patience towards other residents. He makes derogatory remarks towards other residents or attempts to tell them how to correctly participate in activities. When staff redirects, he has a difficult time identifying what they have done wrong, or feels it is the other resident's fault, or that staff is picking on him. Interventions in care plan included allow him to voice frustrations and concerns, do q15mins (check on him every 15 minutes) and q1hrly (check on him hourly) visual checks and encourage him to keep a distance from other residents and psychological services as needed. Review of the undated face sheet for Resident #3 reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of unspecified dementia, (unspecified severity, without behavioral disturbance, psychotic disturbance (severe mental disorders that cause abnormal thinking and perceptions), mood disturbance, and anxiety, other abnormalities of gait and mobility, cognitive communication deficit. Review of the quarterly MDS for Resident #3 dated 11/14/22 reflected a BIMS score of 99, indicating the resident was unable to complete the interview and the behavior review indicated Resident #3 had no behavioral symptoms. Review of the undated face sheet for Resident #4 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions) with delusions (severe mental disorders that cause abnormal thinking and perceptions) due to known psychological condition, generalized anxiety disorder and Alzheimer's disease unspecified. Review of the quarterly MDS for Resident #4 dated 03/13/2023 reflected a BIMS score of 3, indicating severe cognitive impairments. The behavioral review indicated Resident #4 had physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) that occurred one to three days and verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) occurring one to three days. Review of the care plan for Resident #4 dated 03/27/2023 reflected the following: Resident #4 displays physical behavioral symptoms directed towards others as evidenced by, however, the care plan did not elaborate, describe, or list evidence of the physical behavioral symptoms. Interventions in care plan included administer and monitor the effectiveness and side effects of medications as ordered, do a Q15mins (check on her every 15 minutes) and q1hrly (check on her hourly) visual checks, explain care to resident in advance, in terms resident understands, intervene as needed to protect the rights and safety of others; approach in calm manner; divert attention, remove from situation and take to another location as needed, investigate/monitor need for psychological support, provide services if desired by resident/responsible party and as ordered by physician, monitor behavior episodes and attempt to determine underlying cause - consider location time of day, person involved, etc., provide non-confrontational environment for care, provide opportunities for positive interaction, attention by stopping and talking with resident as passing by her. Review of the undated face sheet for Resident #5 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic (severe mental disorders that cause abnormal thinking and perceptions) disturbance, mood disturbance, and anxiety pseudobulbar affect (a neurological condition involving involuntary, sudden, and frequent episodes of laughing or crying) anoxic brain damage (complete lack of oxygen to the brain), not elsewhere classified, encephalopathy (brain is affected by some agent or condition such as viral infection or toxins in the blood), unspecified, cognitive communication deficit (difficulty with thinking and how someone uses language), anxiety disorder, unspecified major depressive disorder, recurrent unspecified, and psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions) with delusions (unshakable, false, and irrational beliefs that defy normal reasoning and evidence) due to known psychological condition. Review of the quarterly MDS for Resident #5 dated 03/07/2023 reflected a BIMS score of 99 indicating the resident was unable to complete the interview. The behavioral review indicated Resident #5 had physical behavioral symptoms directed toward others (hitting, kicking, pushing, scratching, grabbing, abusing others sexually) that occurred every one to three days, verbal behavioral symptoms directed toward others (threatening others, screaming at others, cursing at others) that occurred every one to three days, and other behavioral symptoms not directed toward others (physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) that occurred every one to three days. Review of the care plan for Resident #5 dated 07/19/2022 reflected the following: Resident #5 has behavioral symptoms not directed toward others as evidenced by: she throws her food everywhere, and breaks utensils at mealtimes. Hence, she's at risk of hurting herself and others with broken utensils and injuries from slips. Interventions as listed in care plan included administer and monitor the effectiveness and side effects of medications as ordered, anticipate care needs, and provide them before the resident becomes overly stressed, educate the resident/responsible party on the causal factors of the behavior and the planned interventions, encourage patient to eat in the dining room as much as possible, keep patient's room clean and pick up food crumps as quickly as possible to prevent slips and falls, explain care to resident in advance, in terms resident understands, intervene as needed to protect the rights and safety of others; approach in calm manner; divert attention, remove from situation and take to another location as needed, invite and encourage activity programs consistent with resident's interest, monitor behavior episodes and attempt to determine underlying cause consider consider location time of day, person involved, etc., provide non-confrontational environment for care, re-approach resident later, when she becomes agitated, report to physician changes in behavior status. Review of the care plan for Resident #5 dated 04/17/2023 reflected the following: Resident #5 has physical behavioral symptoms directed towards others as evidenced by: she has the tendency to hit on Residents and staff while passing by them. Interventions as listed in care plan included address wandering behavior by walking with resident, redirect from inappropriate area; engage in diversional activity, administer and monitor the effectiveness and side effects of medications as ordered - see physician orders, anticipate care needs and provide them before the resident becomes overly stressed, do Q15mins (check on her every 15 minutes) and q1hrly (check on her hourly) visual check on patient for aggressive behavior, explain care to resident in advance, in terms resident understands, if reasonable, discuss behavior with resident; explain/reinforce why behavior is unacceptable, intervene as needed to protect the rights and safety of others; approach in calm manner; divert attention, remove from situation and take to another location as needed, investigate/monitor need for psychological support, provide services if desired by resident/responsible party and as ordered by physician, invite and encourage activity programs consistent with resident's interest, monitor behavior episodes and attempt to determine underlying cause. Review of the undated face sheet for Resident #6 reflected an [AGE] year-old male admitted to the facility on [DATE] with diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance, and psychosis (severe mental disorders that cause abnormal thinking and perceptions disturbance). Review of the quarterly MDS for Resident #6 dated 02/19/2023 reflected a BIMS score of 99; the resident was unable to complete the interview and the behavior review indicated Resident #6 had no behavioral symptoms. Review of the care plan for Resident #6 dated 04/28/2023 reflected the following: Resident #6 has behavioral symptoms not directed toward others as evidenced by however, the care plan did not elaborate, describe, or list evidence of the physical behavioral symptoms. Interview on 04/25/2023 at 9:45 AM with the ADM regarding resident-to-resident altercations that occurred on 04/13/2023 involving Resident #1 and Resident #2. CNA A and LVN A were in resident rooms on the 400-hallway locked/secured unit and heard noises. Both CNA A and LVN A came out of the resident rooms and went to the dining area and saw Resident #1 hitting Resident #2, then Resident #2 pushed Resident #1 and Resident #1 fell to the floor with Resident #2 falling on top of Resident #1. After the residents fell , they stopped hitting each other. Both residents were assessed by LVN B. Resident #1 complained of hip pain, was assessed, and was sent to the hospital and diagnoses with a hip fracture and received surgery to repair his hip. The ADM said the facility was trying to locate a new facility for Resident #2, but the facilities had, turned him down. Interview on 04/25/2023 at 9:45 AM with the ADM regarding a resident-to-resident altercation that occurred on 4/17/23 revealed Resident #5 and Resident #3 were walking opposite of each other down the hall of the 400-hallway of the locked/secured unit. Resident #5 (unprovoked by Resident #3) pushed Resident #3 into a wall and Resident #3 hit her head against the wall. Resident #5 had a history of aggressive behavior but, the pushing is kind of new. Resident #3 was assessed by a nurse, and it was revealed that Resident #3 had a hematoma (a localized bleeding outside of blood vessels, due to either disease or trauma including injury or surgery and may involve blood continuing to seep from broken capillaries) and was sent to the hospital. She returned from the hospital a couple of hours later. The ADM revealed the facility increased staffing by one CNA in the locked/secured unit (bringing the staffing from one to three CNAs and one nurse for each 24-hour period). The ADM realized behaviors had increased on that hall. The facility began charting resident 15-minute visual checks by the CNAs and hourly checks by nurses. The facility conducted an in-service consisting of two videos entitled Communicating with Older Adults and Dementia and How to Handle Aggressive Residents. Interview on 04/25/2023 at 9:45 AM with the ADM regarding a resident-to-resident altercation on 4/20/23. Resident #4 was really aggressive and violent and broke the bedside tables. Resident #3 was walking up and down the hallway and Resident #4 attempted to push her into the nurse's station, but a nurse intervened. Later during this event Resident #4 did shove Resident #3 and Resident #3 fell . The police were called but they did not come. EMS took both residents to the hospital and Resident #4 was assessed not to be a danger to herself or others and returned to the facility and Resident #3 was assessed as not having any injuries. Interview on 04/25/2023 at 9:45 AM with the ADM regarding a resident-to-resident altercation on 04/23/2023. Residents #4 and #6 were in the dining area of the 400-hallway of the locked/secured unit. Resident #6 was sitting in a reclining chair and Resident #4 was sitting on the left arm of the same reclining chair. Resident #4 grabbed Resident #6's groin area and Resident #6 began to yell. Resident #4 released Resident #6 when staff intervened. Resident #6 was assessed, and it was reported he had no injury that required EMS. Resident #6's groin area was red and inflamed and he suffered pain that ceased after re-assessment. Interview on 04/25/2023 at 1:12 PM with LVN B who worked in worked in locked unit with Resident #2 revealed Resident #2 had been at the facility for a while and he had declined and has been depressed because he was in the locked unit. He has been physically aggressive towards other residents and hourly checks by the nurse and every 15 minute checks by the CNA has been installed to keep eyes on him, but it did not help with the aggression because he would go, from 0 to 100 just like that explaining that he would seem calm one minute then he was aggressive with other residents the next minute. She revealed she was concerned about the other residents' safety, and she was concerned for his safety because of his decline. She considered a resident hitting another resident to be abuse. Interview on 04/25/2023 at 12:04 PM with LVN D revealed Resident #2 had become aggressive and hit walls, kicked the doors and windows. She revealed the more staff talked to him the more agitated he got. She revealed that facility had increased staff in the locked unit partly because of Resident #2's behaviors. Interview on 04/25/2023 at 12:04 with LVN C revealed Resident #4 verbally attacked other residents when they would walk by her. LVN C revealed she was concerned about the other residents, but it was hard to say if the other residents are concerned about Resident #4 because of their lack of ability to verbalize. LVN C told the DON that Resident #4 is really going to hurt someone, either a resident or a staff member and Resident #4 is very aggressive and, comes after staff members. She revealed the DON told her there has been discussion of trying to see if Resident #4 can be transferred to another facility. LVN C revealed Resident #4 started out in a pleasant way when people begin to interact with her then she, flips out and yells and is very aggressive. Interview on 04/25/2023 at 1:34 PM with CNA B who worked in locked unit revealed that Resident #2 did not have a staff member who was a one-on-one person monitoring him. CNA B said Resident #2 would hurt the other residents. The staff has been doing visual checks on Resident #2 every 15 minutes. CNA B did not think the 15-minute visual checks would keep him from hitting other residents because he was very aggressive. The staff have talked amongst themselves that they are concerned about Resident #1 and Resident #4 hurting other residents and both the ADM and the DON are concerned because Resident #1 has 15-minute visual checks and Resident #4 has a one-on-one staff member sitting with her. CNA B revealed staff cannot predict what Resident #4 is going to do, anything can happen. CNA B revealed that during rounds the nurse was trying to give her pills to Resident #3 and Resident #4 physically held Resident #3 trying to help the nurse and the nurse told Resident #4 to leave Resident #3 alone and Resident #4 pushed Resident #3 and Resident #4 tried to hit the nurse. CNA B was concerned about the other residents' safety because Resident #2 and Resident #4 were unpredictable. Interview on 04/25/2023 at 2:14 PM with the AD who did activities in the 400-hallway of the locked/secured unit and has worked with Resident #4. The AD revealed that most of the time they would sing and pray together then suddenly Resident #4 will change and get excited and start to fight. The AD revealed she has not told the DON and ADM about the Resident #4's behaviors. The AD revealed that Resident #1 fights. The AD revealed, You think everything is fine and he gets upset. The AD revealed that both Resident #2 and Resident #4 would hit and yell at staff and residents and she feels like their behavior has been abusive to other residents. She revealed the definition of abuse is pushing and hitting, and the behavior has happened with both Resident #1 and Resident #4 and she was concerned about the safety of the other residents. She revealed they have added more nurses to cover the locked/secured unit and that has been a help but if Resident #4 is in that mood she will hit the CNA and knock the CNA out. She revealed that the ADM has had to bribe staff to work in the locked unit by giving bonuses. Interview on 04/25/2023 at 2:14 PM with CNA C revealed there was no way of telling when Resident #4 will become upset, and staff are breaking off a fight. She revealed there is no way of telling what will trigger the outbursts of violence. CNA C revealed Resident #4 had made statements along the lines of, I told those children to stop jumping on the couch and will thenbecome verbally and physically aggressive. CNA C revealed she is concerned for the other residents and is absolutely concerned for the staff. Resident #4 hit a staff member with a hanger last Thursday and she pushed a nurse to the floor. CNA C revealed Resident #4 cursed and yelled and was disrespectful. CNA C feels the staff tip toed around Resident #4 and walked on eggshells worried about their safety because of Resident #4. Interview on 04/25/2023 at 2:14 PM the Psychiatric PA revealed Resident #4 came into the facility prescribed with a lot of mental health medications and he had been trying to simplify her medication, working to get her stable. The Psychiatric PA revealed, she will go after people and it is quick as it can be, it happens so quick. Nurses report she is out of the blue very psychotic and agitated. He revealed he, absolutely feels like she is a danger to other residents and she is not in the right facility. Resident #4 needs to be in another facility that has staff that is equipped to handle her. The Psychiatric PA revealed that tonight absolutely something could happen, and Resident #4 needs to be in a facility that is a little better at crisis situations. The Psychiatric PA revealed that having a one-on-one sitter is a good thing, but he is absolutely concerned about residents and other staff, and she could do some damage. The Psychiatric PA revealed that Resident #2 is difficult because of his paranoia and delusions, and he goes after residents and Resident #2 is strong and mobile. The Psychiatric PA revealed, he can be a scary [NAME] and he is absolutely concerned about the safety of the residents. The Psychiatric PA revealed that Resident #2 told the PA straight up that Resident #2 is angry, and he is going to hurt someone. Interview on 05/25/2023 at 5:00 PM with Resident #4. She was on the 300-hallway with a CNA sitting with her in Resident #4's room. They were watching TV. Resident #4 was calm and displayed no verbally or physically inappropriate behavior. She discussed her children coming to visit her. Resident #4 said that the CNA had been sitting with her for a while, but she did not seem to know details about when or how long she had been in the room or with someone on the room with her. Interview on 04/25/2023 at 10:38 PM with the ADM revealed the 400-hallway locked/secured unit was always staffed with 2 CNAs and a nurse for each 24-hour period. On 04/23/2023 two CNAs continued to report to the 400-hallway locked/secured until and one CNA reported to the 300-hallway and monitored Resident #4 (who was assigned to the 400-hallway locked/secured unit) exclusively for 24-hours a day. The 400-hallway and the 300-hallway are separate units. The 400-hallway is the locked/secured unit. The 300-hallway is not locked/secured. He revealed he felt the residents who were discharged , Resident #2, Resident #4, and Resident #5, were unmanageable. Resident #2, Resident #4, and Resident #5 were hitting staff and going after other residents and, wearing out the staff. No staff wanted to work in the 400-hallway unit because of incidents of staff being bitten on the breast and the arm and hit in the face. The ADM revealed he gave them gift cards or bought them lunch to get them to work in the secured unit. Interview on 04/25/2023 with the ADM revealed that the facilty had no room available for Resident #4 on the 400-hallway locked/secured unit for her to have a room to herself. On 04/23/2023 Resident #4 was moved to a room on the 300-hallway, did not have a roommate, and had a one-on-one CNA with her 24 hours a day. Resident #4 was the only resident who was moved from the 400-hallway locked/secure unit. The other residents, Residents #2, #3, and #5 remained in the 400-hallway locked/secure unit and received 15-minute visual checks by the CNAs and hourly checks by nurses. Resident #6 received two days of hourly visual checks for a 24-hours period. A review of 13 documents titled 15-Minute Visual Check for Resident #2 dated 04/15/2023 - 04/26/23 reflected that 15-minute visual checks were begun for Resident #2 on 04/15/2023 and ended on 04/26/2023. A review of 3 documents titled 15-Minute Visual Check for Resident #3 dated 04/14/2023, 04/15/2023, and 04/18/2023 reflected that 15-minute visual checks were begun for Resident #3 on 04/15/2023 and ended on 04/18/2023. A review of 11 documents titled 15-Minute Visual Check for Resident #4 dated 04/14/2023 through 04/18/2023 and 04/21/2023 through 04/26/2023 reflected that 15-minute visual checks were begun for Resident #4 on 04/14/2023, ceased, and began again on 04/21/2023 and ended on 04/26/2023. A review of 5 documents titled 15-Minute Visual Check for Resident #5 dated 01/24/2023, 01/30/2023, 04/17/2023, 04/21/2023, and 04/29/2023 reflected that 15-minute visual checks were begun for Resident #5 on 01/23/2023, ceased, and began again on 04/17/2023 and ended on 04/18/2023. A review of 2 documents titled Hourly Visual Check for Resident #6 dated 01/20/2023 and 01/21/2023 reflected that hourly visual checks were begun for Resident #6 on 01/21/2023 and ended on 01/21/2023 but no visual checks were conducted for Resident #6 after 01/21/2023. A review of undated documents titled Q15 mins - 1 hlry. Visual Check for Residents reflected that the document indicated the time interval of which the staff set their eyes on the residents to prevent cases of abuse and neglect which can be achieved by doing the following: close monitoring of residents to determine patient safety to decrease the number of unwitnessed incidents/accidents, to facilitate staff ability to round on patients, to assist staff in always knowing resident location to reduce resident to resident occurrence resulting from wandering into other residents rooms, prevent cases of elopement and help staff being proactive in meeting the needs of residents. A review of inservice dated 04/13/2023 reveals an inservice was conducted on abuse and neglect including a video on Communicating with Older Adults and Dementia and a video on Dealing with Residents with Agressive Behavior. The following Plan of Removal submitted by the facility was accepted on 11/30/22 at 12:45 PM: Impact Statement F600 Failed to protect a resident's right to be free from any type of abuse, including corporal punishment, and neglect, that results in, or has the likelihood to result in physical harm, pain, or mental anguish. The notification of the immediate jeopardy states as follows: On 04.25.2023 an abbreviated survey was initiated at [facility name and address]. The surveyor has determined that the conditions at the center constitute immediate jeopardy to resident health. The notification of the immediate jeopardy states as follows: F600 The facility failed to have policies and procedures in place to keep the resident free from neglect. Facility policy [TRUNCATED]

Based on observation, interview, and record review; the facility failed to ensure the resident remained free of accident hazards as is possible. The noncompliance was identified as Past Noncompliance (PNC). The IJ began on 12/28/2022 and ended 01/13/2023. The facility had corrected the noncompliance before the survey began. The facility failed to provide an environment free from accidents and hazards over which the facility had control and provided supervision to prevent avoidable accidents. On 12/28/2022, Resident #1 was able to elope from the facility's locked unit thru another resident's room window. The resident was found 0.8 miles away from the facility by local law enforcement. Resident #1 was brought back to the facility, and only then Resident #1 was identified by the facility as leaving the facility grounds. The noncompliance was identified as Past Noncompliance (PNC). The IJ began on 12/28/2022 and ended 01/13/2023. The facility had corrected the noncompliance before the survey began. This deficient practice placed residents at risk for accidents, falls, fractures, and a diminished quality of life. Findings included: Review of Resident #1's Face Sheet, undated, revealed an [AGE] year-old-male admitted to the facility on [DATE] with a diagnosis of dementia (group of symptoms that affects memory, thinking and interferes with daily life), psychotic disturbance (mental health problem that causes people to perceive or interpret things differently from those around them), mood disturbance, and anxiety. Review of Resident #1's Care Plan, initiated 6/2/2022, revealed a focus of an elopement risk/wanderer, a goal of not leaving the facility unattended, interventions of Disguise exit: cover doorknobs and handles, tape floor, and further interventions of placed on secured unit for safety. Review of Resident #1's Quarterly MDS Assessment, dated 11/19/2022, revealed a BIMS of 99 indicating that a resident was not able to complete the interview. Further review revealed Resident #1's functional status, local motion on unit and local motion off unit at limited assistance with one-person physical assist at limited assistance with one-person physical assist. Resident #1's MDS further revealed that wander/elopement alarm was not used. Review of Resident #1s order summary, dated 1/26/2023, revealed the resident was on services with hospice ordered on 5/9/2022. Review of Resident #1's Risk of Elopement/Wandering Review, dated 5/9/2022, revealed the resident was at risk for wandering/elopement. Review of Resident #1's electronic records in the miscellaneous documents revealed the Consent to Voluntarily Reside on a Secure Unit, dated 5/12/22, signed by two verbal consents and one staff witness. Review of Resident #1's Progress Notes entry, note text, dated 12/28/2022, revealed while leaving the facility nurse called and stated that Local Police was in the building stating that resident was found walking around nearby high school and was inside the police car, Resident #1 was assisted back to the into the facility and back into secured unit; nurse practitioner, responsible party, and hospice provider were notified. Further review revealed a health status note, dated 12/28/2022, revealed hospice nurse assessed Resident #1, no significant findings or injuries noted. Interview on 1/25/2023 at 9:20 a.m., AIT, DON, and ADON explained that Resident #1, residing in the locked unit, was able to exit out of the facility by going into another resident's room and opening the window and eloped out the facility grounds on 12/28/2022 approximately at 6:00 p.m. Interview on 1/25/23 at 3:42 p.m., local law enforcement-records department, revealed Resident #1 was picked up by local law enforcement on 12/28/22 at 18:37 (6:37pm), close to the nearby high school, within city limits. Interview on 1/25/23 at 3:59 p.m., ADON stated that local law enforcement arrived at the facility to check if Resident #1 lived at the facility. The ADON confirmed Resident #1's identity, assessed the resident and contacted Resident #1's hospice provider, responsible party, and nurse practitioner. ADON was not initially aware Resident #1 had eloped. Further into the interview, ADON stated she went to the locked unit and asked staff working on how long ago they saw Resident #1, staff informed the ADON they saw the resident 30 minutes prior from the ADON arriving in the locked unit. The ADON looked around the unit and noticed a window half way open in another resident's room, and with the window screen laying outside on the ground, ADON then proceeded to contact all responsible parties, and administration. Interview on 1/26/2023 at 1:30 p.m., LVN A stated Resident #1 was last seen on 12/28/2024 at 6:34 p.m. while doing rounds, LVN A stated she did not know that Resident #1 was missing. Review of the facility's witness statements, dated 12/28/22, revealed LVN A stated that Resident #1 was last seen on 12/28/22 on 6:34 p.m. Review of the facility's Root Cause Analysis of the incident, completed 12/30/2022, refelected Resident #1 was last seen by staff in the dining area, it was noticed that Resident #1 was not in his room, an elopement procedure was initiated with a head count. In the process of finding the resident, a police officer brought the Resident #1 into the building. Observation on 1/25/2023 at 10:25 a.m., revealed the room Resident #1 eloped from the facility having a window alarm. Further observation revealed staff demonstrated the alarm functioned when opened, creating a noticeable alarm sound. Observation of Resident #1's room window alarm, and staff demonstrated the alarm functioned when opened creating a noticeable alarm sound. Observation on 1/25/2023 at 10:30 a.m., revealed Resident #1 in the dining/activity area participating in a daily activity with staff and other residents, Resident #1 did not appear to be in any physical or emotional distress, and no visual signs of injuries. Interview on 1/26/2023 at 8:11 a.m., Resident #1's hospice provider stated they received a call from the facility on 12/28/2022 at 7:52 p.m., informing that Resident #1 had left the facility and local law enforcement brought the resident back to the facility. Further into the interview revealed the hospice provider sent the on call nurse to the facility with a starting date and time of 12/28/2022 at 8:23 p.m, and arriving at the facility on 12/28/2022 at 8:54 p.m. The hospice provider stated that Resident #1 was found to be alert and oriented x2 with no injuries noted, the hospice provider was not aware of Resident #1 having previous elopement incidents from the facility. Interview on 1/25/2023 at 9:16 a.m., AIT stated that the facility had move forward with an intervention to place window alarms on all windows of residents in the locked unit, and checks are done daily to confirm alarms are functioning properly. Further into the interview the AIT stated that staff had been in-serviced on abuse, neglect, and elopement. Interview on 1/25/2023 at 9:16 a.m., the DON stated Resident #1 had orders to be checked 1 hour, due to the elopement risk and that staff have been in-serviced (trained) on abuse, neglect, and elopement. Interview on 1/25/2023 at 10:32 a.m., LVN B recalled that in-services related to abuse, neglect, and elopement were taken after the elopement incident involving Resident #1. LVN B further confirmed that orders were in place for staff to check on Resident #1 every hour and document any findings and to immediately report any signs of elopement. LVN B stated that staff must be alert and respond to any alarms associated in the locked unit to assure resident health and safety. Interview on 1/25/2023 on 10:44 a.m., CNA A revealed recalled completing in-services related to abuse, neglect, and elopement after the elopement incident involving Resident #1. CNA A confirmed that orders had been initiated to check on Resident #1 every 1 hour and document all findings, CNA A included that staff must have eyes on Resident #1, and all other residents. CNA A revealed alarms placed on all resident windows in the locked unit, and staff were to respond immediately when the alarm went off. Interview on 1/25/2023 on 10:49 a.m., CNA B revealed in-services (training) were taken related to abuse, neglect, and elopement after the elopement incident involving Resident #1. CNA B confirmed Resident#1's order to check on the Resident#1 every 1 hour and document all findings, CNA B included that staff were to respond to window alarms, and all alarms accordingly. Review of Resident #1's Elopement Risk Assessment, dated 12/29/2022, reflected the assessment completed and reflecting that Resident #1 risk score at 18, indicating a score of 5 or more was at a risk for elopement. Review of Resident #1's Orders, dated and started on 1/13/2023, reflected Quarterly 1 hour checks every hour for elopement risk. Review of Resident #1's TAR, dated [DATE], reflected documentation of Quarterly 1 hour checks every hour for elopement risk documented by staff from 1/13/2023 to 1/25/2023. Review of in-services for staff occurred on 12/29/22 related to Wandering/Elopement should be managed by staff properly; if not, it is nursing home neglect. Review of QAPI minutes, dated 01/9/2023, reflected the Interdisciplinary Team met and the incident of elopement was discussed. Review of 400 hall window alarms and window latch checklist, dated 12/29/2022 to 1/25/2023, documenting all window alarm checks good. Review of the facility's safety and supervision of residents, revised December 2008, highlights the facility-oriented approach to safety, resident-oriented approach to safety, systems approach to safety, and resident risks and environmental hazards. Review of the facility's elopement policy statement, revised December 2007, reporting practices, 1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the charge nurse or director of nursing.

Based on observation, interview, and record review the facility failed to ensure residents who needed [CONDITION(S)] care were provided such care, consistent with professional standards of practice for 1 of 1 resident (Resident #1) reviewed for [CONDITION(S)] care in that: The facility had no [CONDITION(S)] bags available when they admitted Resident #1, who had an [CONDITION(S)], to the facility. This resulted in her [CONDITION(S)] leaking waste for seven days before she was transported to the hospital, causing serious chemical [CONDITION(S)] to the surrounding skin. An Immediate Jeopardy (IJ) was identified on 1/27/2022 at 1:34 p.m. While the IJ was removed on 1/31/2022 at 12:30 p.m., the facility remained out of compliance at a scope of isolated and severity of actual harm due to the facility's need to evaluate the effectiveness of the corrective systems. This failure resulted in Resident #1 sustaining chemical [CONDITION(S)] on the skin around her [CONDITION(S)] which required hospitalization and caused substantial pain. It also placed other residents with [CONDITION(S)] and [CONDITION(S)] status at risk of skin breakdown, pain, and decreased quality of life. Findings included: Review of face sheet for Resident #1 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of admission MDS for Resident #1 dated 1/18/2022 reflected an ostomy status with a bowel continence rating of 9, indicating Resident had an ostomy or did not have a bowel movement for the entire seven days. Review of comprehensive care plan for Resident #1 reflected there was none entered in the EMR. Review of baseline care plan for Resident #1 dated 1/11/2022 reflected that she was incontinent with an [CONDITION(S)] appliance. It also reflected the use of a wound vac that had been discontinued. Review of undated admission referral packet from the referring nursing facility reflected wound care orders dated 12/5/2021 for the following: Wound 1- mucocutaneous separation location peristoma. Primary dressing is for stoma powder and thin [MEDICATION(S)] dressing; Wound 2- Unstageable, sacrum. Cleanse topically with normal saline. 4% topical [MEDICATION(S)] to be applied 10 minutes prior to wound care. Mesalt Sodium Chloride dressing calcium alginate [MEDICATION(S)] HCS island dressing; Wound 3- Middle abdominal, surgical, dehisced, skin intact 19.1 length/4 width/2.1 depth. Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Patient apparently with same issues last year, colonic stent was placed for obstruction, she was not a surgical candidate, and conservative management was used. CT abdomen showed mechanical obstruction in the region of colonic stent, some pneumatosis of the bowel may represent ischemic [CONDITION(S)]. Surgery was consulted. She initially refused surgery but agreed after discussions. Emergency ex lap, subtotal colectomy, small bowel resection and an [CONDITION(S)] were performed on 11/24 and patient was admitted to ICU and remained intubated. Patient was extubated after 24 hours but her respiratory status declined and had hypercarbia and some respiratory distress. Patient was on [CONDITION(S)] most of her hospital stay. Patient made DNI in the hospital. She is S/P course of [MEDICATION(S)] , [MEDICATION(S)] and [MEDICATION(S)]. She had a presumed ESBL infection and was switched to [MEDICATION(S)]. On 11/27 patient had DHT placed endoscopically and was noted to have esophagitis and gastric ulcers, that were bleeding and cauterized. Patient improved some being able to wean to nasal cannula. Patient on the day of discharge with significant congestion in her chest and had previously refused a NT suction with therapy. Family and patient made patient DNR/DNI discussed possibly making comfort care if continued decline. Patient transferred here to (short term NF) for further care and management. Patient seen today sleeping soundly in bed. Aroused some to voice and tactile stimulation. Patient only moans, didn't open her eyes. On NC. No signs of distress. No new issues per nursing. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Change [CONDITION(S)] bag as needed; Empty [CONDITION(S)] bag two times a day Clean wound to mid abdomen with NS, pat dry, apply wet to dry dressing and cover with ABD pad and secure with tape; Unstageable wound of the sacrum, cleanse with NS, pat dry, apply med honey with calcium alginate and cover with bordered foam dressing. Apply skin prep to peri-wound margins; ABD wound cleanse with NS, pat dry, apply negative pressure wound therapy wound VAC three times a week for 30 days continue wet to dry dressing for wound VAC malfunction and unable to apply NPWT. Review of January 2022 TAR for Resident #1 reflected that staff had signed off twice daily for Empty [CONDITION(S)] bag from 1/11/2022 at 9:00 p.m. it also reflected that no staff had signed off for treatment item Change [CONDITION(S)] bag as needed from 1/12/2022 to 1/25/2022. Review of physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . [CONDITION(S)] of colon: laparotomy, subtotal colectomy, small bowel resection and [CONDITION(S)] placement on 11/24/21. Now having dehisced wound, followed by wound care team, wound bed with sutures visible to the base of the wound with additional granulation tissues. Wound bed is now covered with biofilm, slough and non-viable tissues, no foul odor or purulent exudate, peri-wound intact with no arrhythmia or maceration, S/P debridement and was using VAC therapy. Now using wet to dry dressing until seen by wound care and supplies available. Review of NP progress note for Resident #1 dated 1/18/2022 reflected the following: Patient was seen in her room today, resting in bed. Awake and alert, oriented times 3 to 4. VSS, tolerate anything to feeding. Staff reports [CONDITION(S)] bag has been leaking and it's causing irritation to her abdominal wound, currently causing wet to dry dressing. Peri-wound is intact. She has liquid stool due to [CONDITION(S)], [MEDICATION(S)] added for BID for changing the stool consistency. Patient reports her pain is managed, she is afebrile. Labs ordered . issues with obtaining [CONDITION(S)] bag, currently using [CONDITION(S)] bag and noted leaking around and draining with wound VAC suction, using wet to dry dressing again, labs ordered. Review of wound care physician notes for Resident #1 dated 1/14/2022 reflected the following: Recent [CONDITION(S)] and open ABD wound. [CONDITION(S)] adjacent to wound leaking. Discussed with nurse practitioner when [CONDITION(S)] output more solid will try NPWT. Review of wound care physician notes for Resident #1 dated 1/18/2022 reflected the following: Recent [CONDITION(S)] and open ABD wound. [CONDITION(S)] adjacent to wound leaking [CONDITION(S)] liquid, poor seal leaking into wound VAC. Discussed with nurse [CONDITION(S)] bag back order, discussed measures to seal bag. Discussed [CONDITION(S)] output/risks volume depletion, etc. with nurse practitioner increase meds hold NPWT for now. Review of wound care physician notes for Resident #1 dated 1/25/2022 reflected the following: Out of ostomy bags and draining on ABD with extensive irritation, plan is for her to go to hospital today for ostomy complications. At risk for dehiscence. Review of nursing progress notes for Resident #1 reflected the following: 1/17/2022 7:02 p.m. Note Text: Resident's [CONDITION(S)] was leaking out and leaking into the wound vac and the wound vac was absorbing all the [CONDITION(S)] contents. Writer cleaned resident up and replaced the [CONDITION(S)] bag and changed the wound dressing. At the end of the shift the same thing happened again and the [CONDITION(S)] leaked to the wound vac all the way to resident's vulva area. Writer and Night shift nurse cleaned resident up, changed the [CONDITION(S)] bag and removed wound vac after writer got approval from DON. Wound vac was removed, wound was cleaned and dressed with wet to dry dressing and ABD pad applied. Will continue to monitor. 1/18/2022 10:00 a.m. Late Entry: Note Text: Writer did rounds with wound care doctor to see if doctor would have any recommendations on what to do with wound since there no [CONDITION(S)] bags on site and the [CONDITION(S)] bags being used were causing the [CONDITION(S)] waists to leak out of the bag into resident's skin. Wound care DR assessed the wound and stated that there was nothing he could do until the facility can get the appropriate bag for the [CONDITION(S)] sit. He stated to keep using wet to dry dressing and we can put the wound vac back after the [CONDITION(S)] problem is solved. Writer spoke to Anu about the lack of [CONDITION(S)] bag supply in the building and she asked if I can speak to the supply manager and writer explained to Anu NP that writer and supply manager already tried to order some [CONDITION(S)] but they were on back stock. Writer spoke to admissions coordinator to see if she could help to find the write supplies for the [CONDITION(S)]. [CONDITION(S)] bags were still being used with no s/s of infection. 1/20/2022 2:01 p.m. Late Entry: Note Text: Resident resting in bed. [CONDITION(S)] bag leaking. This nurse cleansed the site and applied new [CONDITION(S)] bag to site as we had no [CONDITION(S)] bags on site. I secured the [CONDITION(S)] bag in place tape. No redness noted to site. Illeostomy was not inflamed or irritated. Resident tolerated well. This nurse also cleansed wound site to abdomen. No s/s infection noted. No redness to site. New dressing applied. Resident tolerated well. Denies pain and discomfort, no distress noted. Respirations even and unlabored, no SOB. Call bell in reach. 1/21/2022 10:32 a.m. Late Entry: Note Text: Writer and RN training nurse cleaned wound to mid abdomen, no s/s of infection noted wet to dry dressing applied and covered with ABD pad. [CONDITION(S)] bag was used for [CONDITION(S)] site, no [CONDITION(S)] available and all waists from elliostomy were leaking out of the [CONDITION(S)] bag into the residents lower abdomen area. Cleaned and replaced the area with a new [CONDITION(S)] bag and applied ABD pad to absorb the waists from the [CONDITION(S)] and to prevent leaking to the abdominal wound. Resident was crying due to pain and was given PRN pain pill, was effective. 1/22/2022 2:43 p.m. Late Entry: Note Text: Writer went to do wound care and found resident wet in the abdomen area covered in waists from the [CONDITION(S)] area, writer and CNA gave resident a bed bath, changed sheets and did wound care to sacrum and changed [CONDITION(S)] and replaced it with another [CONDITION(S)] bag and used and used ABD pad for absorption of the leaking waits products and to prevent from getting into the abdominal wound. Resident was given PRN pain pill and routine meds before doing wound care. Very mild redness was noted to skin from removing [CONDITION(S)] bag and putting it back on. Resident was positioned in right lateral position to prevent leaking into the skin and the wound. Resident was monitored closely for any changes. 1/23/2022 3:13 p.m. Late Entry: Note Text: Writer changed [CONDITION(S)] and replaced it with another [CONDITION(S)] bag and used ABD pad for absorption of the leaking waits products and to prevent from getting into the abdominal wound. Resident was given PRN pain pill and routine meds before doing wound care. Very mild redness was noted to skin from removing [CONDITION(S)] bag and putting it back on. Resident was positioned in right lateral position to prevent leaking into the skin and the wound. Resident was monitored closely for any changes. 1/24/2022 2:30 p.m. Late Entry: Note Text: When this nurse came on to the floor after not being on this hall for 3 days I was informed by the night nurse that the facility was out of [CONDITION(S)] bags and that the staff was using towels to cover the [CONDITION(S)] site. This nurse asked about the bags and was informed that the [CONDITION(S)] bags were on back order and there were no bags in the surrounding facilities. This nurse and ADON went into resident's room to do wound care and evaluate [CONDITION(S)] site. Upon removing the towels from site the skin surrounding the [CONDITION(S)] was red and bleeding. It also was leaking bm and blood into to the abdominal wound. This nurse and ADON told DON about the situation and that we believed she needed to be sent out to the hospital. DON stated she would go evaluate resident shortly. This nurse had to leave and ADON resumed care of resident. 1/25/2022 10:29 a.m. Note Text: Wound doctor came to eval and treat resident. Illeostomy site inflamed and bleeding. He gave order to send to (Hospital) to eval and treat. This nurse also spoke with NP Anu she states to send resident to (hospital) Resident was sent via EMS to hospital with copy of facesheet, orders and DNR. Resident son, POA, informed of resident transfer. He states he has no further concerns at this time. 1/25/2022 10:45 a.m. Note Text: Saw patient today during wound rounds with the wound doctor, noticed area around [CONDITION(S)] site is excoriated and bleeding, wound doctor suggest patient be sent out for expert care and since facility is out of [CONDITION(S)] care supply, and might not get one right now. Wound doctor tried to apply [MEDICATION(S)] but cream will not stay on skin, this writer suggested xerofrom gauze, which was applied, and a large tegarderm transparent dressing used to cover all affected areas including the ABD wound after a separate wound is dressing has been applied to the ABD wound, to keep xeroform gauze in place, a small opening created at the [CONDITION(S)] site to channel drainage away from patient skin to prevent further skin irritation. A glove was attached to the small open site as an improvise to collect drainage as patient is being transported to the hospital. Wound doctor inform NP and Charge nurse notified RP and called EMS to transport patient to (hospital). Review of hospital records for Resident #1 dated 1/25/2022 reflected the following: Patient came by EMS. She resides at a nursing home. She is leaking around her ostomy site. Noted patient arrived she had a clear glove over ostomy with drainage everywhere irritated skin and feces on abdomen . Ostomy site present but there is a glove as a bag with significant leakage all around it and leaking feces in her abdomen. Diffuse widespread [CONDITION(S)] was very angry red raw skin bleeding. Sutures present from prior surgery. Dobbhoff tube present . I talked with NP and notified her my concerns of possible lack of care, severe skin irritation and [CONDITION(S)] around the ostomy site with the presence of a clear glove over the ostomy. She tells me last time she saw the patient was over week ago. She said the wound care doctor came to see the patient and was upset about the physical exam and said to send her to the hospital. Also have a conversation with the Director the nursing home and nursing at the facility regarding my concerns. Observation on 1/26/2022 at 8:35 a.m. revealed Resident #1 laying in her hospital bed in the acute care department of the hospital while the department's wound care PT was in the room with her. She was calling out Oh, it [CONDITION(S)]! It [CONDITION(S)]! over and over. The physical therapist was reassuring her that it would stop hurting in a few minutes when the treatment took effect. During an interview on 1/26/2022 at 8:35 a.m., the hospital PT stated that Resident #1 had chemical [CONDITION(S)] from the [CONDITION(S)] waste in a huge circle around the stoma site. He stated he does her wound care daily and as needed, and she has been in a lot of pain every time he has performed it. He stated the skin is red and blistered on an area almost a foot in diameter. He stated that it is blistered all the way into her abdominal suture. During an interview on 1/26/2022 at 8:52 a.m., the director of acute care at the hospital stated that Resident #1 came from the facility to the hospital with a glove around the stoma. She stated that hospital NP called, and the facility told her they had been out of supplies. The Director stated that Resident #1 had been in the department after her [CONDITION(S)] procedure, and the only thing wrong with her skin at that time was that her buttocks were red when she left and discharged to the short-term nursing facility. She stated that the unstageable ulcer developed since then, but she stated that was not the primary concern. She stated that the main concern was that the resident's skin was so badly burned by the [CONDITION(S)] waste and that the second nursing facility she entered did not have the supplies to take care of her yet let her stay there with the waste spilling onto her skin. During an interview on 1/26/2022 at 10:09 a.m., the MR/CS stated that he was aware that Resident #1 had an [CONDITION(S)] that was leaking waste on her skin and had to be hospitalized . told about Resident #1's [CONDITION(S)] status upon her arrival and not given any advance notice to obtain the [CONDITION(S)] bags. He stated he began trying to order the bags immediately but was told by all the regular medical supply companies they use, and several others that they have not used before, that it would be months before any could arrive, as they would be on back order. He stated he talked to charge nurse and administrator to try to solve the problem, but no one had any luck getting bags specifically for [CONDITION(S)]. He stated he did not know exactly why she didn't start leaking [CONDITION(S)] waste until she had been in the facility for a few days, but he assumed she had a bag on her from the facility she came. He stated when that ran out, they used what they had, and he only had [CONDITION(S)] bags available. He stated he was not asked to order any additional [CONDITION(S)] bags. During an interview on 1/26/2022 at 11:24 a.m., LVN A stated she worked regularly with Resident #1 while she was in the facility. She stated the resident had been admitted with a wound vac, but when they had to change the [CONDITION(S)] bag she came to the facility with, and the [CONDITION(S)] bag they replaced it with began leaking, the wound vac was sucking up the waste from the ostomy. She stated they removed the wound vac. She stated they had been using [CONDITION(S)] bags on the resident starting her second week there. She stated the reason the [CONDITION(S)] bags were leaking was that the adhesive on the bags that was meant to keep a seal between the bag and the skin was eaten away by the acidic content of the [CONDITION(S)] waste. She stated that she worked with Resident #1 on the previous Thursday, 1/20/2022, and they had [CONDITION(S)] bags. She stated she had been going in three times a day to clean up the waste that was leaking all over her and trying to keep the waste off her skin, but when she came back to work on Monday 1/24/2022, there was only a towel on the [CONDITION(S)] site. She stated apparently there were no [CONDITION(S)] bags available. She stated she went in with the ADON to do wound care on the abdominal suture, and when they went to remove the suture bandage and the towels, Resident #1's skin started bleeding. She stated they went and told the DON that Resident #1 needed to go to the hospital, because it looked really bad. LVN A stated the DON said she would check on Resident #1. She stated the ADON took over the situation, and then when she came back to work Tuesday 1/25/2022, Resident #1 was still in the facility. She stated that day the WCD came to the facility and asked if he was going to see Resident #1. LVN A stated they went to do Resident #1's wound care, and the WCD said he was going to send her to the hospital. LVN A stated she wasn't sure how many days the towel was on Resident #1, as she was not working those days. She stated that it was obvious the leaking [CONDITION(S)] waste had burned Resident #1's skin. She stated the resident never should have been admitted if they didn't have the supplies needed to care for her. During an interview on 1/26/2022 at 11:28 am, the WCD stated he was familiar with Resident #1 as he saw her in the facility a few times. He stated his understanding is a [CONDITION(S)] bag will substitute for an [CONDITION(S)] bag, but the [CONDITION(S)] bags couldn't stick to her skin and wouldn't stay on. He stated ultimately, he had to send her out to the hospital on 1/25/2022. He stated the time he saw her before on 1/18/2022, there was leakage going into the wound vac, so he called the NP and had her discontinue the wound vac until they could get the right supplies. He stated that [CONDITION(S)] waste is liquid, and they hoped if they could get it thickened up, it would not leak as much. They ordered the resident [MEDICATION(S)] which can thicken the waste. When he left on 1/18/2022, there was no skin breakdown, and he had no concerns. He stated that at some point the bag came off, and the facility left it off because they couldn't find a replacement bag. He stated he was not notified when they could not find any [CONDITION(S)] bags for her and found when he arrived on 1/25/2022 that there was not a bag on it. He stated the waste had leaked all over her body, bed, and onto the abdominal wound. He stated that judging by the state of the skin it looked like it had been off for more than a day. He stated that ileostomies were very hard, and the surgeon put it right there by the abdominal wound. The WCD stated that his concern was that the abdominal wound might dehisce (gape or pop open) if waste continued to spill onto and into it. He stated that if it had been his decision, when he realized there were no [CONDITION(S)] bags, he would have said to send Resident #1 to the hospital. He stated he wouldn't have let it just spill out of the ostomy. He stated he wouldn't have admitted her if the decision had been his. He stated it is a big struggle with managing an [CONDITION(S)] even in the hospital, and he would not have advised they take on that hardship. During an interview on 1/26/2022 at 12:38 p.m., the ADMD stated that the process when she receives a referral is, she gives the referral to the nursing department, and if the nursing department thinks the facility can meet the resident's needs, then she notifies the referring facility that they will accept the referral. She stated the person who makes the final decision is usually either the DON or the MDSC. She stated she doesn't believe there were questions about Resident #1's admission. She stated that Resident #1 had a wound vac, so ADMD had to make sure they had the supplies for that. She stated if something like the [CONDITION(S)] or [CONDITION(S)] bag was needed, they would make sure the supplies were available. She stated she doesn't know why that process did not occur with Resident #1, as it is the nursing department's responsibility. An attempt was made on 1/26/2022 at 12:39 p.m. to interview the MDSC, and the ADM notified that the MDSC was on leave. During an interview on 1/26/2022 at 12:40 p.m., LVN B stated that she cared for Resident #1 on many of her days in the facility. She stated they were using [CONDITION(S)] bags for Resident #1's [CONDITION(S)] after the bag she came with needed to be replaced. She stated the [CONDITION(S)] bag the resident came with was sticking to her skin just fine, and LVN B had three days off, came back, and they only had [CONDITION(S)] bags, which were leaking. She stated the [CONDITION(S)] bag leaked while there had been no issues with the [CONDITION(S)]. She stated that when she first cared for Resident #1, she did rounds with the wound care doctor on 1/18/2022. She stated he told her there was nothing he could do about the leaking until the facility got the [CONDITION(S)] bags. She stated that she and the MR/CS went online and everywhere was out of stock. She stated she thought if the referring short term facility had the correct supplies, she did not understand how they could not get the correct supplies. She stated the NP got involved in the search, but they still could not obtain any. LVN B stated she begged the NP to send Resident #1 out to the hospital, and the NP told her they couldn't send someone to the hospital because they didn't have the proper supplies. She stated the NP did labs to try to find a reason to send Resident #1 out. She stated that the ADMD did not know the different between an [CONDITION(S)] and a [CONDITION(S)] and should not have made the decision to admit the resident. LVN B stated she has never seen an [CONDITION(S)] either but remembers from nursing school that the adhesive was different due to the acidity of the waste material. She stated the problem with the [CONDITION(S)] bag was they could not empty and continue to use them. She stated, instead, they had to take it all the way off, and then they would not be able to get it stuck again. She stated they continued to use [CONDITION(S)] bags because they did not have anything else. She stated she would have to use the bag, fold an ABD bandage in half, cut it in the middle, and put it underneath the [CONDITION(S)] bag, and then take a brief and put it on the side of the resident. She stated she would also put towels under the resident's side. She stated the MR/CS always made sure that he supplied her with [CONDITION(S)] bags, so there was never a time she had to only use towel until the day she came back to work on 1/24/2022. LVN B stated she came back to work on Sunday 1/23/2022 and saw Resident #1 with the [CONDITION(S)] waste all over her, and it went all the way to the vulva. She stated the next day, Monday 1/24/2022, the [CONDITION(S)] was even more horrible and leaking more. The stated the DON was not there that day on 1/24/2022, and it was one of the hardest days of her nursing career. She stated she was in tears asking the NP to help her help Resident #1. She stated she could not believe a human could go through that situation while she was there as her nurse. She stated she would have recommended to have the proper supplies before she came. She stated she doesn't know who assessed Resident #1. She stated Resident #1 was already fragile; she's 95, but what she looked like the day she discharged was not how she looked when she came to the facility. She stated if they had the proper supplies, they could have prevented Resident #1's injuries, pain, and suffering. During an interview on 1/26/2022 at 1:28 p.m., the NP stated she was familiar with Resident #1. She stated the resident was admitted on [DATE] and was a transfer from a short-term skilled facility. She stated the resident was a [AGE] year-old with multiple concerns: abdominal laparotomy, wound vac, [CONDITION(S)], sacral pressure ulcer. She stated the resident was doing okay in the beginning, and then there was an issue with the [CONDITION(S)] leaking because the ostomy bag was leaking and not fitting. She stated they tried to thicken the stool by adding [MEDICATION(S)], but because of her peg tube feeding, the stool remained mostly liquid and was going into the abdominal wound. She stated she sees her twice a week, and the wound care doctor was coming once per week. She stated, because the ostomy was leaking, she did labs to make sure the white count wasn't elevated, which would have indicated that she had an infection of some sort. She stated they drew the labs on 1/20/2022 and received results on 1/22/2022 that did not show signs of infection. She stated she was thinking if they could not get the right supplies, and the labs were bad, they would send her to the hospital., but since the lab results were okay, she chose not to send her out. She stated the stool from an [CONDITION(S)] is so acidic, and if it leaks for a day or two it can burn the skin. She stated that Tuesday 1/25/2022 when the WCD came, the [CONDITION(S)] was leaking and was burning her skin a lot, so they had to send her to the hospital. She stated the hospital NP was upset about the skin around the stoma. She stated the nurses tried their level best to protect Resident #1's skin, and it was an unfortunate situation. She stated she had visited her 1/12/2022, 1/18/2022, and 1/21/2022. She stated the resident record said Resident #1 had problems with leaking on 1/17/2022. She stated they had no [CONDITION(S)] bags and were using [CONDITION(S)] bags, instead, which were not working. She stated she made it a concern with the facility. The stated the admission coordinator was there and called all the facilities and even outside the state to get the supplies, and [CONDITION(S)] bags were on back order. She stated they were trying to use what they had and to manage the patient. She stated she hadn't seen Resident #1 crying in pain. She stated the [CONDITION(S)] was leaking but was not a bad situation when she saw the resident on 1/21/2022. She stated she was not informed of the skin irritation reflected in resident progress notes for 1/22/2022. She stated they told her that the wound was all dressed. She stated that when she assessed on 1/21/2022 and knew the product was on back order and the [CONDITION(S)] bag was still leaking, she figured that the wound care doctor would be coming and expected he would have supplies. She stated the nurses were the ones who are mostly taking care of the patient. She stated that after she saw the resident on 1/21/2022, she was always available on phone if It got worse. She stated there must have been a communication mistake, as no one at the facility asked to send Resident #1 out to the hospital or reached out to her on 1/24/2022. She stated she had no role in determining if a resident's needs could be met in the facility. She stated that, in other buildings it was usually the admission team and the ADON and DON. She stated if she had been asked about Resident #1 prior to admission, she would have said to hold the admission until they could get the proper supplies. She stated she was never informed that they only had a towel over the stoma. She said one could use a towel to cover the stoma for a brief time while it was being changed, but it should not have stayed like that. She stated that this was a very unfortunate even and should not have happened to the patient. She stated she knew how much Resident #1 was going through for something that should not have happened. An attempt was made on 1/26/2022 at 2:00 p.m. to contact the MD/Resident #1's PCP by telephone. A voicemail was left. During an interview on 1/26/2022 at 3:46 p.m., the DON stated that Resident #1 came to the facility on [DATE] with a deviated abdominal wound, [CONDITION(S)] and unstageable pressure wound to her coccyx. The DON stated the wound doctor ordered a wound vac, but they saw it was sucking up the [CONDITION(S)] waste. The WCD checked her once a week, and they got the NP to see her, so she ordered wet/dry dressings (dressing is placed on the site and allowed to dry so that it picks up dead tissue when removed) for the pressure ulcer in place of the wound vac. She was not in the building for those changes, as she was out on leave during this time and did not return until 1/24/2022. She stated at that time, the nurses told her there was no [CONDITION(S)] bag. She said they were using the supply in house and had run out of any extras and only had enough for the one other resident in the building with a [CONDITION(S)]. She stated she went to see Resident #1 and noticed irritation around the [CONDITION(S)] site and immediately called the administrator saying the [CONDITION(S)] site was not what it had been like when she left and was not good. They checked that the MR/CS had placed the order for the [CONDITION(S)] bags, but they were on back order. They checked everywhere they could think of but could get nothing. She stated they improvised with a wastebasket bag. She stated the fo

Based on observation, interview, and record reviews, the facility failed to ensure residents have the right to be free from neglect for one (Resident #1) of five residents reviewed for abuse and neglect, in that: The facility had no [CONDITION(S)] bags available when they admitted Resident #1, who had an [CONDITION(S)], to the facility. This resulted in her [CONDITION(S)] leaking waste for seven days before she was transported to the hospital, causing serious chemical [CONDITION(S)] to the surrounding skin. An Immediate Jeopardy (IJ) was identified on 1/27/2022 at 1:34 p.m. While the IJ was removed on 1/31/2022 at 12:30 p.m., the facility remained out of compliance at a scope of isolated and severity of actual harm due to the facility's need to evaluate the effectiveness of the corrective systems. This failure resulted in Resident #1 sustaining chemical [CONDITION(S)] on the skin around her [CONDITION(S)] which required hospitalization and caused substantial pain. It also placed other residents with [CONDITION(S)] and [CONDITION(S)] status at risk of skin breakdown, pain, and decreased quality of life. Findings included: Review of Resident #1's face sheet reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an admission MDS for Resident #1 dated 1/18/2022 reflected an ostomy status with a bowel continence rating of 9, indicating Resident had an ostomy (an opening in the abdominal wall that allows feces to pass) or did not have a bowel movement for the entire seven days. Review of a comprehensive care plan for Resident #1 reflected there was none entered in the EMR. Review of the baseline care plan for Resident #1 dated 1/11/2022 reflected that she was incontinent with an [CONDITION(S)] appliance (a bag that adheres to the skin to collect liquid acidic feces). It also reflected the use of a wound vac that had been discontinued. Review of updated admission packet from the referring nursing facility reflected wound care orders dated 12/5/2021 for the following: -Wound 1- mucocutaneous separation location peri-stoma (skin around an opening in the wall of the belly). Primary dressing is for stoma powder and thin [MEDICATION(S)] dressing; Wound 2- Unstageable, sacrum. Cleanse topically with normal saline. 4% topical [MEDICATION(S)] to be applied 10 minutes prior to wound care. Mesalt Sodium Chloride dressing calcium alginate [MEDICATION(S)] HCS island dressing; Wound 3- Middle abdominal, surgical, dehisced, skin intact 19.1 length/4 width/2.1 depth. -Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Patient apparently with same issues last year, colonic stent was placed for obstruction, she was not a surgical candidate, and conservative management was used. CT abdomen showed mechanical obstruction in the region of colonic stent, some pneumatosis of the bowel may represent ischemic [CONDITION(S)]. Surgery was consulted. She initially refused surgery but agreed after discussions. Emergency ex lap, subtotal colectomy, small bowel resection and an [CONDITION(S)] were performed on 11/24 and patient was admitted to ICU and remained intubated. Patient was extubated after 24 hours but her respiratory status declined and had hypercarbia and some respiratory distress. -Patient was on [CONDITION(S)] most of her hospital stay. Patient made DNI in the hospital. She is S/P course of [MEDICATION(S)] , [MEDICATION(S)] and [MEDICATION(S)]. She had a presumed ESBL infection and was switched to [MEDICATION(S)]. On 11/27 patient had DHT placed endoscopically and was noted to have esophagitis and gastric ulcers, that were bleeding and cauterized. Patient improved some being able to wean to nasal cannula. Patient on the day of discharge with significant congestion in her chest and had previously refused a NT suction with therapy. Family and patient made patient DNR/DNI discussed possibly making comfort care if continued decline. Patient transferred here to (short term NF) for further care and management. Patient seen today sleeping soundly in bed. Aroused some to voice and tactile stimulation. Patient only moans, didn't open her eyes. On NC. No signs of distress. No new issues per nursing. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Change [CONDITION(S)] bag as needed; Empty [CONDITION(S)] bag two times a day Clean wound to mid abdomen with NS, pat dry, apply wet to dry dressing and cover with ABD pad and secure with tape; Unstageable wound of the sacrum, cleanse with NS, pat dry, apply med honey with calcium alginate and cover with bordered foam dressing. Apply skin prep to peri-wound margins; ABD wound cleanse with NS, pat dry, apply negative pressure wound therapy wound VAC three times a week for 30 days continue wet to dry dressing for wound VAC malfunction and unable to apply NPWT. Review of the January 2022 TAR for Resident #1 reflected that staff had signed off twice daily for Empty [CONDITION(S)] bag 1/11/2022 at 9:00 p.m. it also reflected that no staff had signed off for treatment item Change [CONDITION(S)] bag as needed from 1/12/2022 to 1/25/2022. Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . [CONDITION(S)] of colon: laparotomy, subtotal colectomy, small bowel resection and [CONDITION(S)] placement on 11/24/21. Now having dehisced wound, followed by wound care team, wound bed with sutures visible to the base of the wound with additional granulation tissues. Wound bed is now covered with biofilm, slough and non-viable tissues, no foul odor or purulent exudate, peri-wound intact with no arrhythmia or maceration, S/P debridement and was using VAC therapy. Now using wet to dry dressing until seen by wound care and supplies available. Review of a NP progress note for Resident #1 dated 1/18/2022 reflected the following: Patient was seen in her room today, resting in bed. Awake and alert, oriented times 3 to 4. VSS, tolerate anything to feeding. Staff reports [CONDITION(S)] bag has been leaking and it's causing irritation to her abdominal wound, currently causing wet to dry dressing. Peri-wound is intact. She has liquid stool due to [CONDITION(S)], [MEDICATION(S)] added for BID for changing the stool consistency. Patient reports her pain is managed, she is afebrile (without fever). Labs ordered . issues with obtaining [CONDITION(S)] bag, currently using [CONDITION(S)] bag and noted leaking around and draining with wound VAC suction, using wet to dry dressing again, labs ordered. (A [CONDITION(S)] bag adheres to the skin to collect less acidic feces). Review of a wound care physician's notes for Resident #1 dated 1/14/2022 reflected the following: Recent [CONDITION(S)] and open ABD wound. [CONDITION(S)] adjacent to wound leaking. Discussed with nurse practitioner when [CONDITION(S)] output more solid will try NPWT. Review of a wound care physician's notes for Resident #1 dated 1/18/2022 reflected the following: Recent [CONDITION(S)] and open ABD wound. [CONDITION(S)] adjacent to wound leaking [CONDITION(S)] liquid, poor seal leaking into wound VAC. Discussed with nurse [CONDITION(S)] bag back order, discussed measures to seal bag. Discussed [CONDITION(S)] output/risks volume depletion, etc. with nurse practitioner increase meds hold NPWT for now. Review of a wound care physician notes for Resident #1 dated 1/25/2022 reflected the following: Out of ostomy bags and draining on ABD with extensive irritation, plan is for her to go to hospital today for ostomy complications. At risk for dehiscence. Review of nursing progress notes for Resident #1 reflected the following: 1/17/2022 7:02 p.m. Note Text: Resident's [CONDITION(S)] was leaking out and leaking into the wound vac and the wound vac was absorbing all the [CONDITION(S)] contents. Writer cleaned resident up and replaced the [CONDITION(S)] bag and changed the wound dressing. At the end of the shift the same thing happened again and the [CONDITION(S)] leaked to the wound vac all the way to resident's vulva area (the outer part of the female genitals). Writer and Night shift nurse cleaned resident up, changed the [CONDITION(S)] bag and removed wound vac after writer got approval from DON. Wound vac was removed, wound was cleaned and dressed with wet to dry dressing and ABD pad applied. Will continue to monitor. 1/18/2022 10:00 a.m. Late Entry: Note Text: Writer did rounds with wound care doctor to see if doctor would have any recommendations on what to do with wound since there no [CONDITION(S)] bags on site and the [CONDITION(S)] bags being used were causing the [CONDITION(S)] waste to leak out of the bag into resident's skin. Wound care DR assessed the wound and stated that there was nothing he could do until the facility can get the appropriate bag for the [CONDITION(S)] site. He stated to keep using wet to dry dressing and we can put the wound vac back after the [CONDITION(S)] problem is solved. Writer spoke to [NP]about the lack of [CONDITION(S)] bag supply in the building and she asked if I can speak to the supply manager and writer explained to NP that writer and supply manager already tried to order some [CONDITION(S)] but they were on back stock. Writer spoke to admissions coordinator to see if she could help to find the write supplies for the [CONDITION(S)]. [CONDITION(S)] bags were still being used with no s/s of infection. 1/20/2022 2:01 p.m. Late Entry: Note Text: Resident resting in bed. [CONDITION(S)] bag leaking. This nurse cleansed the site and applied new [CONDITION(S)] bag to site as we had no [CONDITION(S)] bags on site. I secured the [CONDITION(S)] bag in place tape. No redness noted to site. Illeostomy was not inflamed or irritated. Resident tolerated well. This nurse also cleansed wound site to abdomen. No s/s infection noted. No redness to site. New dressing applied. Resident tolerated well. Denies pain and discomfort, no distress noted. Respirations even and unlabored, no SOB. Call bell in reach. 1/21/2022 10:32 a.m. Late Entry: Note Text: Writer and RN training nurse cleaned wound to mid abdomen, no s/s of infection noted wet to dry dressing applied and covered with ABD pad. [CONDITION(S)] bag was used for [CONDITION(S)] site, no [CONDITION(S)] available and all waists from elliostomy were leaking out of the [CONDITION(S)] bag into the residents lower abdomen area. Cleaned and replaced the area with a new [CONDITION(S)] bag and applied ABD pad to absorb the waists from the [CONDITION(S)] and to prevent leaking to the abdominal wound. Resident was crying due to pain and was given PRN pain pill, was effective. 1/22/2022 2:43 p.m. Late Entry: Note Text: Writer went to do wound care and found resident wet in the abdomen area covered in waists from the [CONDITION(S)] area, writer and CNA gave resident a bed bath, changed sheets and did wound care to sacrum and changed [CONDITION(S)] and replaced it with another [CONDITION(S)] bag and used and used ABD pad for absorption of the leaking waits products and to prevent from getting into the abdominal wound. Resident was given PRN pain pill and routine meds before doing wound care. Very mild redness was noted to skin from removing [CONDITION(S)] bag and putting it back on. Resident was positioned in right lateral position to prevent leaking into the skin and the wound. Resident was monitored closely for any changes. 1/23/2022 3:13 p.m. Late Entry: Note Text: Writer changed [CONDITION(S)] and replaced it with another [CONDITION(S)] bag and used ABD pad for absorption of the leaking waits products and to prevent from getting into the abdominal wound. Resident was given PRN pain pill and routine meds before doing wound care. Very mild redness was noted to skin from removing [CONDITION(S)] bag and putting it back on. Resident was positioned in right lateral position to prevent leaking into the skin and the wound. Resident was monitored closely for any changes. 1/24/2022 2:30 p.m. Late Entry: Note Text: When this nurse came on to the floor after not being on this hall for 3 days I was informed by the night nurse that the facility was out of [CONDITION(S)] bags and that the staff was using towels to cover the [CONDITION(S)] site. This nurse asked about the bags and was informed that the [CONDITION(S)] bags were on back order and there were no bags in the surrounding facilities. This nurse and ADON went into resident's room to do wound care and evaluate [CONDITION(S)] site. Upon removing the towels from site the skin surrounding the [CONDITION(S)] was red and bleeding. It also was leaking bm and blood into to the abdominal wound. This nurse and ADON told DON about the situation and that we believed she needed to be sent out to the hospital. DON stated she would go evaluate resident shortly. This nurse had to leave and ADON resumed care of resident. 1/25/2022 10:29 a.m. Note Text: Wound doctor came to eval and treat resident. Illeostomy site inflamed and bleeding. He gave order to send to (Hospital) to eval and treat. This nurse also spoke with NP she states to send resident to (hospital) Resident was sent via EMS to hospital with copy of facesheet, orders and DNR. Resident son, POA, informed of resident transfer. He states he has no further concerns at this time. 1/25/2022 10:45 a.m. Note Text: Saw patient today during wound rounds with the wound doctor, noticed area around [CONDITION(S)] site is excoriated and bleeding, wound doctor suggest patient be sent out for expert care and since facility is out of [CONDITION(S)] care supply, and might not get one right now. Wound doctor tried to apply [MEDICATION(S)] but cream will not stay on skin, this writer suggested xerofrom gauze, which was applied, and a large tegarderm transparent dressing used to cover all affected areas including the ABD wound after a separate wound is dressing has been applied to the ABD wound, to keep xeroform gauze in place, a small opening created at the [CONDITION(S)] site to channel drainage away from patient skin to prevent further skin irritation. A glove was attached to the small open site as an improvise to collect drainage as patient is being transported to the hospital. Wound doctor inform NP and Charge nurse notified RP and called EMS to transport patient to (hospital). Review of hospital records for Resident #1 dated 1/25/2022 reflected the following: Patient came by EMS. She resides at a nursing home. She is leaking around her ostomy site. Noted patient arrived she had a clear glove over ostomy with drainage everywhere irritated skin and feces on abdomen . Ostomy site present but there is a glove as a bag with significant leakage all around it and leaking feces in her abdomen. Diffuse widespread [CONDITION(S)] was very angry red raw skin bleeding. Sutures present from prior surgery. Dobbhoff tube present . I talked with NP and notified her my concerns of possible lack of care, severe skin irritation and [CONDITION(S)] around the ostomy site with the presence of a clear glove over the ostomy. She tells me last time she saw the patient was over week ago. She said the wound care doctor came to see the patient and was upset about the physical exam and said to send her to the hospital. Also have a conversation with the Director the nursing home and nursing at the facility regarding my concerns. Observation on 1/26/2022 at 8:35 a.m. revealed Resident #1 laying in her hospital bed in the acute care department of the hospital while the department's wound care PT was in the room with her. She was calling out Oh, it [CONDITION(S)]! It [CONDITION(S)]! over and over. The physical therapist was reassuring her that it would stop hurting in a few minutes when the treatment took effect. During an interview on 1/26/2022 at 8:35 a.m., the hospital PT stated that Resident #1 had chemical [CONDITION(S)] from the [CONDITION(S)] waste in a huge circle around the stoma site. He stated he does her wound care daily and as needed, and she has been in a lot of pain every time he has performed it. He stated the skin is red and blistered on an area almost a foot in diameter. He stated that it is blistered all the way into her abdominal suture. During an interview on 1/26/2022 at 8:52 a.m., the director of acute care at the hospital stated that Resident #1 came from the facility to the hospital with a glove around the stoma. She stated that hospital NP called, and the facility told her they had been out of supplies. The Director stated that Resident #1 had been in the department after her [CONDITION(S)] procedure, and the only thing wrong with her skin at that time was that her buttocks were red when she left and discharged to the short-term nursing facility. She stated that the unstageable ulcer developed since then, but she stated that was not the primary concern. She stated that the main concern was that the resident's skin was so badly burned by the [CONDITION(S)] waste and that the second nursing facility she entered did not have the supplies to take care of her yet let her stay there with the waste spilling onto her skin. During an interview on 1/26/2022 at 10:09 a.m., the MR/CS stated that he was aware that Resident #1 had an [CONDITION(S)] that was leaking waste on her skin and had to be hospitalized . He stated he was told about Resident #1's [CONDITION(S)] status upon her arrival and not given any advance notice to obtain the [CONDITION(S)] bags. He stated he began trying to order the bags immediately but was told by all the regular medical supply companies they use, and several others that they have not used before, that it would be months before any could arrive, as they would be on back order. He stated he talked to charge nurse and administrator to try to solve the problem, but no one had any luck getting bags specifically for [CONDITION(S)]. He stated he did not know exactly why she didn't start leaking [CONDITION(S)] waste until she had been in the facility for a few days, but he assumed she had a bag on her from the facility she came. He stated when that bag ran out, they used what they had, and he only had [CONDITION(S)] bags available. He stated he was not asked to order any additional [CONDITION(S)] bags. During an interview on 1/26/2022 at 11:24 a.m., LVN A stated she worked regularly with Resident #1 while she was in the facility. LVN A stated the resident had been admitted with a wound vac. When they had to change the [CONDITION(S)] bag she came to the facility with, the [CONDITION(S)] bag they replaced it with began leaking. The wound vac was sucking up the waste from the ostomy. She stated they removed the wound vac. She stated they had been using [CONDITION(S)] bags on the resident starting her second week there. She stated the reason the [CONDITION(S)] bags were leaking was that the adhesive on the bags that were meant to keep a seal between the bag and the skin was eaten away by the acidic content of the [CONDITION(S)] waste. She stated that she worked with Resident #1 on the previous Thursday, 1/20/2022, and they had [CONDITION(S)] bags. She stated she had been going in three times a day to clean up the waste that was leaking all over her and trying to keep the waste off her skin, but when she came back to work on Monday 1/24/2022, there was only a towel on the [CONDITION(S)] site. She stated apparently there were no [CONDITION(S)] bags available. She stated she went in with the ADON to do wound care on the abdominal suture, and when they went to remove the suture bandage and the towels, Resident #1's skin started bleeding. She stated they went and told the DON that Resident #1 needed to go to the hospital because it looked really bad. LVN A stated the DON said she would check on Resident #1. She stated the ADON took over the situation, and then when she came back to work Tuesday 1/25/2022, Resident #1 was still in the facility. She stated that day the WCD came to the facility she asked if he was going to see Resident #1. LVN A stated they went to do Resident #1's wound care, and the WCD said he was going to send her to the hospital. LVN A stated she was not sure how many days the towel was on Resident #1, as she was not working those days. She stated that it was obvious the leaking [CONDITION(S)] waste had burned Resident #1's skin. She stated the resident never should have been admitted if they did not have the supplies needed to care for her. During an interview on 1/26/2022 at 11:28 am, the WCD stated he was familiar with Resident #1 as he saw her in the facility a few times. He stated his understanding is a [CONDITION(S)] bag will substitute for an [CONDITION(S)] bag, but the [CONDITION(S)] bags couldn't stick to her skin and would not stay on. He stated ultimately, he had to send her out to the hospital on 1/25/2022. He stated the time he saw her before on 1/18/2022, there was leakage going into the wound vac, so he called the NP and had her discontinue the wound vac until they could get the right supplies. He stated that [CONDITION(S)] waste is liquid, and they hoped if they could get it thickened up, it would not leak as much. They ordered the resident [MEDICATION(S)] which can thicken the waste. When he left on 1/18/2022, there was no skin breakdown, and he had no concerns. He stated that at some point the bag came off, and the facility left it off because they couldn't find a replacement bag. He stated he was not notified when they could not find any [CONDITION(S)] bags for her. He found when he arrived on 1/25/2022 that there was not a bag on it. He stated the waste had leaked all over her body, bed, and onto the abdominal wound. He stated that judging by the state of the skin it looked like it had been off for more than a day. He stated that ileostomies were very hard, and the surgeon put it right there by the abdominal wound. The WCD stated that his concern was that the abdominal wound might dehisce (gape or pop open) if waste continued to spill onto and into it. He stated that if it had been his decision, when he realized there were no [CONDITION(S)] bags, he would have said to send Resident #1 to the hospital. He stated he would not have let it just spill out of the ostomy. He stated he would not have admitted her if the decision had been his. He stated it is a big struggle with managing an [CONDITION(S)] even in the hospital, and he would not have advised they take on that hardship. During an interview on 1/26/2022 at 12:38 p.m., the ADMD stated that the process when she receives a referral is, she gives the referral to the nursing department, and if the nursing department thinks the facility can meet the resident's needs, then she notifies the referring facility that they will accept the referral. She stated the person who makes the final decision is usually either the DON or the MDSC. She stated she does not believe there were questions about Resident #1's admission. She stated that Resident #1 had a wound vac, so ADMD had to make sure they had the supplies for that. She stated if something like the [CONDITION(S)] or [CONDITION(S)] bag was needed, they would make sure the supplies were available. She stated she does not know why that process did not occur with Resident #1, as it is the nursing department's responsibility. An attempt was made on 1/26/2022 at 12:39 p.m. to interview the MDSC, and the ADM notified that the MDSC was on leave. During an interview on 1/26/2022 at 12:40 p.m., LVN B stated that she cared for Resident #1 on many of her days in the facility. She stated they were using [CONDITION(S)] bags for Resident #1's [CONDITION(S)] after the bag she came with needed to be replaced. She stated the [CONDITION(S)] bag the resident came with was sticking to her skin just fine, and LVN B had three days off, came back, and they only had [CONDITION(S)] bags, which were leaking. She stated the [CONDITION(S)] bag leaked while there had been no issues with the [CONDITION(S)]. She stated that when she first cared for Resident #1, she did rounds with the wound care doctor on 1/18/2022. She stated he told her there was nothing he could do about the leaking until the facility got the [CONDITION(S)] bags. She stated that she and the MR/CS went online and everywhere was out of stock. She stated she thought if the referring short-term facility had the correct supplies, she did not understand how they could not get the correct supplies. She stated the NP got involved in the search, but they still could not obtain any. LVN B stated she begged the NP to send Resident #1 out to the hospital, and the NP told her they could not send someone to the hospital because they did not have the proper supplies. She stated the NP did labs to try to find a reason to send Resident #1 out. She stated that the ADMD did not know the difference between an [CONDITION(S)] and a [CONDITION(S)] and should not have made the decision to admit the resident. LVN B stated she has never seen an [CONDITION(S)] either but remembers from nursing school that the adhesive was different due to the acidity of the waste material. She stated the problem with the [CONDITION(S)] bag was they could not empty and continue to use them. She stated, instead, they had to take it all the way off, and then they would not be able to get it stuck again. She stated they continued to use [CONDITION(S)] bags because they did not have anything else. She stated she would have to use the bag, fold an ABD bandage in half, cut it in the middle, put it underneath the [CONDITION(S)] bag, and then take a brief and put it on the side of the resident. She stated she would also put towels under the resident's side. She stated the MR/CS always made sure that he supplied her with [CONDITION(S)] bags, so there was never a time she had to only use a towel until the day she came back to work on 1/24/2022. LVN B stated she came back to work on Sunday 1/23/2022 and saw Resident #1 with the [CONDITION(S)] waste all over her, and it went all the way to the vulva. She stated the next day, Monday 1/24/2022, the [CONDITION(S)] was even more horrible and leaking more. She stated the DON was not there that day on 1/24/2022, and it was one of the hardest days of her nursing career. She stated she was in tears asking the NP to help her help Resident #1. She stated she could not believe a human could go through that situation while she was there as her nurse. She stated she would have recommended having the proper supplies before she came. She stated she does not know who assessed Resident #1. She stated Resident #1 was already fragile; she was 95, but what she looked like the day she was discharged was not how she looked when she came to the facility. She stated if they had the proper supplies, they could have prevented Resident #1's injuries, pain, and suffering. During an interview on 1/26/2022 at 1:28 p.m., the NP stated she was familiar with Resident #1. She stated the resident was admitted on [DATE] and was a transfer from a short-term skilled facility. She stated the resident was a [AGE] year-old with multiple concerns: abdominal laparotomy, wound vac, [CONDITION(S)], sacral pressure ulcer. She stated the resident was doing okay in the beginning, and then there was an issue with the [CONDITION(S)] leaking because the ostomy bag was leaking and not fitting. She stated they tried to thicken the stool by adding [MEDICATION(S)], but because of her peg tube feeding, the stool remained mostly liquid and was going into the abdominal wound. She stated she sees her twice a week, and the wound care doctor was coming once per week. She stated, because the ostomy was leaking, she did labs to make sure the white count was not elevated, which would have indicated that she had an infection of some sort. She stated they drew the labs on 1/20/2022 and received results on 1/22/2022 that did not show signs of infection. She stated she was thinking if they could not get the right supplies, and the labs were bad, they would send her to the hospital. Since the lab results were okay, she chose not to send her out. She stated the stool from an [CONDITION(S)] was so acidic, and if it leaks for a day or two it can burn the skin. She stated that Tuesday 1/25/2022 when the WCD came, the [CONDITION(S)] was leaking and was burning her skin a lot, so they had to send her to the hospital. She stated the hospital NP was upset about the skin around the stoma. She stated the nurses tried their level best to protect Resident #1's skin, and it was an unfortunate situation. She stated she had visited her 1/12/2022, 1/18/2022, and 1/21/2022. She stated the resident record said Resident #1 had problems with leaking on 1/17/2022. She stated they had no [CONDITION(S)] bags and were using [CONDITION(S)] bags, instead, which were not working. She stated she made it a concern with the facility. The stated the admission coordinator was there and called all the facilities and even outside the state to get the supplies, and [CONDITION(S)] bags were on back order. She stated they were trying to use what they had and to manage the patient. She stated she had not seen Resident #1 crying in pain. She stated the [CONDITION(S)] was leaking but was not a bad situation when she saw the resident on 1/21/2022. She stated she was not informed of the skin irritation reflected in resident progress notes for 1/22/2022. She stated they told her that the wound was all dressed. She stated that when she assessed on 1/21/2022 and knew the product was on back order and the [CONDITION(S)] bag was still leaking, she figured that the wound care doctor would be coming and expected he would have supplies. She stated that after she saw the resident on 1/21/2022, she was always available by phone if It got worse. She stated there must have been a communication mistake, as no one at the facility asked to send Resident #1 out to the hospital or reached out to her on 1/24/2022. She stated she had no role in determining if a resident's needs could be met in the facility. She stated that, in other buildings it was usually the admission team and the ADON and DON. She stated if she had been asked about Resident #1 prior to admission, she would have said to hold the admission until they could get the proper supplies. She stated she was never informed that they only had a towel over the stoma. She said one could use a towel to cover the stoma for a brief time while it was being changed, but it should not have stayed like that. She stated that this was a very unfortunate event and should not have happened to the patient. She stated she knew how much Resident #1 was going through for something that should not have happened. An attempt was made on 1/26/2022 at 2:00 p.m. to contact the MD/Resident #1's PCP by telephone. A voicemail was left. During an interview on 1/26/2022 at 3:46 p.m., the DON stated that Resident #1 came to the facility on [DATE] with a deviated abdominal wound, [CONDITION(S)] and unstageable pressure wound to her coccyx. The DON stated the wound doctor ordered a wound vac, but they saw it was sucking up the [CONDITION(S)] waste. The WCD checked her once a week, and they got the NP to see her, so she ordered wet/dry dressings (dressing is placed on the site and allowed to dry so that it picks up dead tissue when removed) for the pressure ulcer in place of the wound vac. She was not in the building for those changes, as she was out on leave during this time and did not return until 1/24/2022. She stated at that time, the nurses told her there was no [CONDITION(S)] bag. She said they were using the supply in house and had run out of any extras and only had enough for the one other resident in the building with a [CONDITION(S)]. She stated she went to see Resident #1 and noticed irritation around the [CONDITION(S)] site and immediately called the administrator saying the [CONDITION(S)] site wa

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 6 of 8 residents (Residents # 1-6 and Residents #8 and 9) and one of one hall (hall 300), in that: The facility failed to have dedicated staff working with COVID-positive residents and allowed staff to work with both the COVID-positive (Residents #1-3) and COVID-negative (Residents #4-6) residents on the same quarantine hall (hall 300). These failures resulted in an identification of an Immediate Jeopardy (IJ) on 11/12/2020. While the IJ was removed on 11/16/2020 at 3:27 pm, the facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of pattern due to staff needing more time to monitor the plan of removal for effectiveness. These failures could place residents at risk for extended discomfort, physical and psychosocial decline, and death. Findings include: Review of facility self-reported incidents reflected the following COVID-positive test results reported to the State Agency: 11/10/2020 one staff tested positive including the narrative All residents and staff members exposed to the staff member are been tested again for COVID-19. Review of face sheet for Resident #1 reflected an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of MDS assessments for Resident #1 reflected there was no assessment completed for her prior to her death in the facility on 11/12/2020. Review of progress notes for Resident #1 reflected a note posted on 11/11/2020 at 5:44 p.m. included the following: Note Text: (FM) about (Resident #1) positive COVID [MEDICATION NAME] test due to surveillance testing. Advised she will be tested for COVID via PCR and will notify of results and educated on infection control practices and measures. He verbalized understanding and grateful he was notified. Review of PCR test results received 11/15/2020 for Resident #1 reflected [DIAGNOSES REDACTED]-Cov-2 was detected in her sample. Observation on 11/12/2020 at 10:26 a.m. revealed Resident #1 was laying in her bed in room [ROOM NUMBER] with the door open, breathing heavily with her mouth open, with bed in lowest position. She did not respond to any attempt to communicate with her. Review of face sheet for Resident #2 reflected a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of admission MDS for Resident #2 dated 11/3/2020 reflected a BIMS score of 9, indicating a significant cognitive impairment. Review of progress notes for Resident #2 reflected a note posted on 11/11/2020 at 5:35 p.m. which included the following: (FM) about (Resident #2) positive COVID [MEDICATION NAME] test. Advised she will be tested for COVID via PCR and educated on infection control practices and measures. He verbalized understanding and grateful he was notified. Review of PCR test results received 11/15/2020 for Resident #2 reflected [DIAGNOSES REDACTED]-Cov-2 was detected in her sample. Observation on 11/12/2020 at 10:38 a.m. revealed Resident #2 reading in her bed in room [ROOM NUMBER], the door of which was open. She declined to be interviewed at this time. Review of face sheet for Resident #3 reflected a [AGE] year-old female admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]., heart failure, hypertension, [MEDICAL CONDITIONS], dysphasia, [MEDICAL CONDITION], gastro-[MEDICAL CONDITION] reflux disease, dementia, [MEDICAL CONDITION] stage four, age-related physical debility, and urinary tract infection. Review of admission MDS for Resident #3 dated 11/5/2020 reflected a BIMS score of 99, indicating she either could not or would not participate in the assessment. Review of progress notes for Resident #3 reflected a note posted on 11/11/2020 at 5:51 p.m. which included the following: (FM) about (Resident #3) positive COVID [MEDICATION NAME] test due to surveillance testing. Advised she will be tested for COVID via PCR and educated on infection control practices and measures. She verbalized understanding and grateful she was notified. Review of PCR test results received 11/15/2020 for Resident #3 reflected [DIAGNOSES REDACTED]-Cov-2 was detected in her sample. Observation on 11/12/2020 at 10:41 a.m. revealed Resident #3 asleep in her bed. She did not stir when addressed. Review of face sheet for Resident #8 reflected an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]., [MEDICATION NAME] degeneration, depression, [MEDICAL CONDITION], frequency of micturition, [MEDICAL CONDITION], malaise, wrist pain, and hypertension. Review of quarterly MDS for Resident #8 dated 10/1/2020 reflected a BIMS score of 6, indicating a significant cognitive impairment. Review of PCR test results received 11/15/2020 for Resident #8 reflected [DIAGNOSES REDACTED]-Cov-2 was detected in her sample. Observation on 10/15/2020 at 10:18 p.m. revealed that Resident #8 was asleep in her bed. Review of face sheet for Resident #9 reflected a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]., recurrent [MEDICAL CONDITION], fracture of carpal bone, spondylosis with [DIAGNOSES REDACTED], and Klippel-Feil syndrome. Review of quarterly MDS for Resident #9 dated 12/12/2020 reflected a BIMS score of 00, indicating that staff completed the assessment on her behalf. Review of PCR test results received 11/15/2020 for Resident #9 reflected [DIAGNOSES REDACTED]-Cov-2 was detected in her sample. Observation on 10/15/2020 at 10:19 p.m. revealed that Resident #9 was asleep in her bed. Review of face sheet for Resident #10 reflected an [AGE] year-old female admitted to the facility 7/16/2018 [MEDICAL CONDITION], dementia, hypertension, hyper glycemia, acute atopic [MEDICAL CONDITION], weakness, fatigue, muscle weakness, abnormalities of gate and mobility, [MEDICAL CONDITION] reflux disease, impulse disorder, constipation, and [MEDICAL CONDITION]. Review of quarterly MDS for Resident #10 dated 7/27/2020 reflected a BIMS score of 3, indicating a severe cognitive impairment. Review of PCR test results received 11/15/2020 for Resident #10 reflected [DIAGNOSES REDACTED]-Cov-2 was detected in her sample. Observation on 10/15/2020 at 10:20 p.m. revealed that Resident #10 was asleep in her bed. Review of face sheet for Resident #11 reflected a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. tract infection, overactive bladder, drug induced constipation, major [MEDICAL CONDITION], dementia without behavioral disturbance, altered mental status, and nausea. Review of admission MDS for Resident #11 dated 9/21/2020 reflected a BIMS score of 14, indicating little to no cognitive impairment. Review of PCR test results received 11/15/2020 for Resident #11 reflected [DIAGNOSES REDACTED]-Cov-2 was detected in her sample. Observation on 10/16/2020 at 2:35 p.m. revealed that Resident #11 was seated on her bed. She exhibited no signs of respiratory distress and was organizing her belongings. Review of face sheet for Resident #12 reflected a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of admission MDS for Resident #12 dated 9/29/2020 reflected a BIMS score of 15, indicating little to no cognitive impairment. Review of PCR test results received 11/15/2020 for Resident #12 reflected [DIAGNOSES REDACTED]-Cov-2 was detected in her sample. Observation on 10/15/2020 at 10:22 p.m. revealed that Resident #12 was awake in her bed and watching television. She said that the food has been warm, and she had no immediate complaints. During an interview on 11/12/2020 at 9:30 a.m., the DON stated the CNA who tested positive became symptomatic on 11/5/2020 midway through her shift on the 300 hall and was sent home. He stated her positive PCR test results were obtained on 11/10/2020. He stated the facility tested all residents on 11/5/2020 using their point of care rapid [MEDICATION NAME] testing machine and obtained negative results for all residents at that time. He stated when the CNA's PCR results became available, he had all residents in the facility tested again using the rapid [MEDICATION NAME] test, and that three of them were positive for [DIAGNOSES REDACTED]-Cov-2, [MEDICAL CONDITION] that causes COVID-19: Residents #1, 2, and 3. He stated he obtained samples for PCR tests for those three residents to confirm their positive status, and the facility was still waiting on those results. He stated those residents were isolated in their rooms on the 300 hall, and he thought they were all at one end of the hall. He stated all three positive residents were asymptomatic, but Resident #1 was admitted on hospice and was actively dying. Observation on 11/12/2020 at 10:18 a.m. revealed all residents on the 300 hall were on droplet precautions. There was no barrier present dividing this hall from the rest of the facility. Staff working on the hall were observed in full PPE: isolation gowns, N95s, face shields, and gloves. Each room had a small plastic chest of drawers containing unused PPE in its original packaging. Resident #1 was in room [ROOM NUMBER] (first room on the left when entering the hall from the common area/nurse's station), Resident #2 was in room [ROOM NUMBER] (third room on the left when entering from the common area/nurse's station), and Resident #3 was in room [ROOM NUMBER] (last room on the right when entering from the common area/nurse's station). The other rooms on the 300 hall were occupied by COVID-unknown residents (new or readmissions). CNA A was observed going in and out of all rooms on the 300 hall, donning and doffing PPE in each room, but caring both for the three COVID-positive residents and the other COVID-unknown residents on the hall. CNA B was also observed caring for both the three COVID-positive residents and the other COVID-unknown residents. During an interview on 11/12/2020 at 10:50 a.m., the NP stated she was part of the clinical decision to have the residents who tested positive with the rapid [MEDICATION NAME] testing stay in their rooms and wait to create a COVID-19 unit, because the rapid [MEDICATION NAME] testing is not reliable and can indicate the subject has been infected at any time within the past 90 days. She stated the test is not accurate enough to make a determination that the resident is COVID-positive, and they must wait for the results of a PCR test. Observation on 11/12/2020 at 10:58 a.m. revealed the NP was observed going into a COVID-unknown resident's room to assess her, doffing and donning PPE, and entering a COVID-positive resident's room. She was then observed doffing and donning PPE a second time and entering a COVID-unknown resident's room. Observation on 11/12/2020 at 11:52 a.m. revealed RN C was administering medication and moving in and out of resident rooms on the 300 hall. She entered Resident #1's room in full PPE, provided care, doffed her PPE, and exited the room. She then entered the room of a COVID-unknown resident on the hall, using the same procedure for donning and doffing PPE. She was then observed seated at the nurse's station in middle of all the halls, working on the computer, and also attending to her nurse's cart against the outside of the common nurse's station. During an interview on 11/12/2020 at 12:35 p.m., RN C stated she has been working with all residents on hall 300. She stated she has not worked with COVID-positive residents in previous outbreaks in the facility, and this is the first time she has worked with COVID-positive residents. When asked what she had been trained to do with regard to cohorting COVID positive residents, she shrugged and refused to elaborate on what her shrug meant. Observation on 11/12/2020 at 2:07 p.m. revealed CNA A was walking out of hall 100, no longer wearing PPE. She walked to the dining room, which was being used as an employee breakroom, and took a break. She also went to the common staff bathroom on hall 500. During an interview on 11/12/2020 at 2:52 p.m., the DON stated the facility COVID-response plan indicates they were to immediately create a COVID-19 unit with designated staff if residents test positive. When asked why they did not follow their facility protocol, he stated We base ourselves on the PCR guidelines for the positives. He stated they had isolated the residents in their rooms and placed them on isolation with full PPE while they wait for the PCR tests, which were taken and then sent out that morning. He stated it has been taking three to seven days to get PCR results back. He stated the flowchart from CDC they had been using said if the rapid [MEDICATION NAME] test was positive, but the residents were asymptomatic, it was a false positive. When asked who made the decision to treat the positive [MEDICATION NAME] tests as false positives and leave the COVID-positive residents in the same hall as the COVID-unknown residents, he did not have a clear answer but reiterated they had isolated the residents in their room and were waiting for the PCR results. He was asked to produce standing orders in place for the facility regarding COVID-19. During an interview on 11/12/2020 at 3:05 p.m., the RNC, when asked why a COVID-positive isolation wing with dedicated staff had not yet been created, stated the facility just got the [MEDICATION NAME] test results, so the COVID wing was about to be constructed. He stated they immediately did the PCR tests when they got the [MEDICATION NAME] results. He stated the time frame when they receive positive resident results to construct a designated unit should be to do it as soon as possible, but this time they had some hiccups. When asked what these hiccups were, he stated they were getting the roster to look at transferring the residents. He stated the [MEDICATION NAME] has a 90% false positive rate, and CDC says they should be treated as a false positive if there are no symptoms. He stated the CDC has a flowchart that explains when to treat an [MEDICATION NAME] test as a false positive and when to treat it as accurate. He stated the flowchart says when the patient is asymptomatic, it should be treated as a false positive until confirmed by PCR. He stated the CDC web page where this flow chart was obtained and from which they had been deriving their guidance on the [MEDICATION NAME] test results was titled Interim Guidance for Rapid [MEDICATION NAME] Testing for [DIAGNOSES REDACTED]-CoV-2. He stated the residents who tested positive were in rooms with roommates, and once they were positive they were placed in a room alone on isolation. He stated what should have happened is they should have immediately put up the COVID-positive unit. He stated the [MEDICATION NAME] results were obtained on 11/11/2020 kind of late in the day, and they planned on creating a unit, but they had not done it yet. He stated he understood there had been an additional 24 hours of the same staff working with positive and unknown residents and moving out from the quarantine area on hall 300 to the main area of the facility. He stated he saw how that increased the risk of transmission. He was asked to produce any standing orders currently in place regarding COVID-19. During an interview on 11/12/2020 at 5:40 p.m., the MD stated he wasn't aware residents had tested positive in the facility on the [MEDICATION NAME] tests. He stated he knew they were testing but didn't know the results. He reached out to everyone this morning and emailed them, but he does not think he heard back. He stated he put himself in as medical director a couple months ago to help improve the facility, which has had many problems. He stated he lives far away from the facility and is a full time hospitalist, so he does not round at the facility but has another doctor (DR) at his practice does the onsite visits. He stated they did weekly calls, and he shared all the regulations and expectations with them several times. He stated it is his expectation the facility would implement cohorting immediately for any positive residents. He stated these expectations apply to positive [MEDICATION NAME] tests as well as positive PCR tests. He stated he would never have said they couldn't trust an [MEDICATION NAME] test. He stated the testing itself has gotten better, and the false positive rate has gone down. He stated the protocol exists to prevent the spread of infection, and it does not delineate between [MEDICATION NAME] and PCR testing. During an interview on 11/16/2020 at 1:29 p.m., the DR stated she was not aware the facility had failed to immediately cohort the three positive residents with dedicated staff. She stated they didn't keep her in the loop on any of their decision making about it. She stated that, if they had called her, she would never have said just get the PCR and let the residents sit in their rooms on the hall with other COVID-unknown residents. She stated the facility called her and asked her for standing orders for COVID-19 protocol, and her response was disbelief that they were on their 4th outbreak and had no standing orders already. Observation on 11/12/2020 at 6:45 p.m. revealed LVN D was in the hall charting on residents and moving in and out of rooms on the 300 hall. She went into every room on the 300 hall, including the rooms of Residents #1, 2, and 3 and all the other residents on the hall. During an interview on 11/12/2020 at 6:45 p.m., LVN D stated she was working on the 300 hall with all the residents there. She stated she checks vital signs on the residents once during her shift. She stated the nurses are supposed to check for COVID-19 when it's in the MAR, but she always does it whether she sees it in the MAR indicated [REDACTED]. She stated she was only working on the 300 hall and not anywhere else that night. When asked if she had worked on both the 300 and 400 halls the night before, she shrugged and refused to answer. Review of the 24-hour report book for the 300 hall reflected no entries regarding COVID-19 signs or symptoms on any page in the seven day lookback period. Observation on 11/12/2020 at 6:54 p.m. revealed CNA G was in full PPE and assisting Resident #2 (COVID-positive resident) with clearing her dinner dishes and pouring water for her. She then doffed her PPE, donned new PPE, and entered the room next door and assisted Resident #4 (COVID-negative resident on quarantine) by repositioning her. During an interview on 11/12/2020 at 7:30 p.m., the RNC, ADM, and DON were all asked if any of them could explain who made the decision to wait to create the COVID-19 unit and dedicate staff. The DON stated again that he had sent out the PCR tests and had moved the roommates of the positive roommates out and put them on isolation. The RNC stated he understood what was being said about it but did not elaborate. The ADM did not reply. The RNC stated they got the test results late in the day the day before. When asked what time the results of the [MEDICATION NAME] tests were obtained, the DON stated he was at the facility testing residents until 8:30 p.m. the night before. When asked if that meant he received positive results on Residents #1, 2, and 3 at 8:30 p.m., he stated he thought that sounded about right. They were asked again to produce standing orders for the facility regarding COVID-19 and the pandemic response. The facility's standing orders were not provided prior to exit. Review of progress notes for Resident #2 reflected a note posted on 11/11/2020 at 5:35 p.m. that included the following: (FM) about (Resident #2) positive COVID [MEDICATION NAME] test. Advised she will be tested for COVID via PCR and educated on infection control practices and measures. He verbalized understanding and grateful he was notified. Review of progress notes for Resident #1 reflected a note posted on 11/11/2020 at 5:44 p.m. included the following: Note Text: (FM) about (Resident #1) positive COVID [MEDICATION NAME] test due to surveillance testing. Advised she will be tested for COVID via PCR and will notify of results and educated on infection control practices and measures. He verbalized understanding and grateful he was notified. Review of progress notes for Resident #3 reflected a note posted on 11/11/2020 at 5:51 p.m. included the following: (FM) about (Resident #3) positive COVID [MEDICATION NAME] test due to surveillance testing. Advised she will be tested for COVID via PCR and educated on infection control practices and measures. She verbalized understanding and grateful she was notified. Review of document provided by the RNC in response to his description of a CDC flowchart that explains when to treat an [MEDICATION NAME] test as a false positive and when to treat it as accurate reflected the flowchart referred to reporting guidelines to the Indiana State Department of Health as well as how to report public data regarding Point of Care laboratory data to the CDC. The flowchart did not refer to what clinical practices to put in place related to isolation or cohorting protocol anywhere on the document. Review of email from the MD to the surveyor on 11/12/2020 at 7:01 p.m. reflected the following: I immediately called both (the RNC) and (the NP), to educate and inquire as to what was actually going on. What they told me contrasted from what you had shared, and both of them readily confirmed the processes and protocols that I have put in place with and for them. Re: what they said they do/were doing and what our protocols are for PUI's and CV+ pts, this includes: Immediately quarantining CV+ staff away from work, do internal contract tracing of staff and residents, and perform widespread facility (staff and residents) [MEDICATION NAME] testing. Moving pts to the dedicated COVID wing as soon as their [MEDICATION NAME] test comes back positive. Having each PUI/+ pt have their own room, especially PUI's. (Confirmed positive pts can share if the need arises due to room/bed shortages). Immediately sending a PCR to confirm, since false positives do exist (although not anywhere near 90%.). Continue to treat per CDC guidelines as if they are positive unless PCR comes back negative. This includes all CDC protocols and guidance, including appropriate PPE usage, 1 dedicated staff member to the positive/PUI hall that does not also care for residents that are CV-, the quarantine process incl duration, methods, HCP and pt monitoring and surveillance, when to discontinue isolation, etc. I am concerned that they may have been caught off guard and either misspoke or things were miscommunicated to you or between you and them. They assured me that what was outlined above is what our policy was and what is actively going on. And if that is true, I stand by that process. Review of staffing sheets for the facility reflected the following: -LVN D on the 300 and 400 halls from 10:00 p.m. to 6:00 a.m. on 11/11/2020. This was signed by the LVN, indicating she worked the shift. -CNA E on the 300 and 400 halls from 10:00 p.m. to 6:00 a.m. on 11/11/2020. This was signed by the CNA, indicating she worked the shift. -MA F as a CNA on the 300 and 400 halls from 2:00 p.m. to 10:00 p.m. -CNA G on the 300 and 400 halls from 2:00 p.m. to 10:00 p.m. This was signed by the CNA, indicating she worked the shift. -LVN H on the 300 and 400 halls from 6:00 a.m. to 6:00 p.m. This was signed by the LVN, indicating she worked the shift. Review of a document titled Date Range Schedule reflected the following: -CNA A was scheduled for the 300/400 hall from 6:00 a.m. to 10:00 p.m. on 11/12/2020. - LVN D on the 300 and 400 halls from 10:00 p.m. to 6:00 a.m. on 11/12/2020. -MA F as med aide on the 300 and 400 halls from 2:00 p.m. to 10:00 p.m. on 11/12/2020. -RN C on the 300 and 400 halls of the facility from 6:00 a.m. to 6:00 p.m. on 11/12/2020. -MA I on the 300 and 400 halls of the facility from 6:00 a.m. to 2:00 p.m. on 11/12/2020. Review of a document dated May 2020 and titled Coronavirus (COVID-19) Isolation Plan reflected the following: In the event that a resident in our facility tested positive for COVID-19, these are steps will be taken to isolate the resident and minimize the risk of infection to other residents and staff: -The facility will designate the last four rooms in the 300 hall, as COVID-19 isolation rooms. -These rooms allow for the housing of eight residents in semi-private room setting. -These rooms are separated from the first half of the hall by both a community shower and soiled linen closet. -The separation between the first half of the hall and the last four rooms dedicated to COVID-19 isolation will be divided by a privacy screen that will clearly separate both halves of the hall. -The COVID-19 isolation rooms are adjacent to an emergency exit that faces the south side of the building. -In the event that these rooms have been used for COVID-19 isolation the therapy department will relocate to the activities room located on the first half of the 400 hall. -In the event that there are resident deaths in the facility has to provide a temporary morgue to store the bodies, the therapy gym at the end of the 300 hall will serve that purpose. -If there is a critical shortage of staff, the facility will utilize the contracted staffing agencies to meet those needs. -If the number of residents that are positive for COVID is greater than eight, and there is not enough room for them in the area outlined above, the facility will relocate the isolation area to a hall that can adequately house the number of positive residents and will follow the same isolation precautions aforementioned. The isolation area can be located in the 200, 300, or 500 halls. -Changes may be made this plan to meet safety and benefit of residents needs. Review of the CDC webpage titled Interim Guidance for Rapid [MEDICATION NAME] Testing for [DIAGNOSES REDACTED]-CoV-2 and found at the URL https://www.cdc.gov/coronavirus/2019-ncov/lab/resources/[MEDICATION NAME]-tests-guidelines.html#:~:text=CDC%20recommends%20that%20laboratory%20and%20testing%20professionals%20who,own%20[DIAGNOSES REDACTED]-CoV-2%20testing%20over%20the%20previous%207%E2%80%9310%20days reflected the following: When used for screening testing in congregate settings, test results for [DIAGNOSES REDACTED]-CoV-2 should be considered presumptive. Confirmatory nucleic acid testing following a positive [MEDICATION NAME] test may not be necessary when the pretest probability is high, especially if the person is symptomatic or has a known exposure. During an interview on 11/15/2020 at 10:10 p.m., the DON stated that the facility had tested all residents with PCR testing when they tested the three rapid [MEDICATION NAME] positive residents, and they have finally gotten all PCR results back earlier that evening. He stated that Residents #1, 2, and 3 had received confirmed positive PCR tests, but that five more residents throughout the other halls had also tested positive. He stated that the residents themselves had already been moved to the covid-positive unit, which had been expanded immediately to accommodate them. He stated that the staff was still working on moving the resident belongings. He stated that they had added a CNA to the unit in order that resident needs could be met. The ADM was notified on 11/12/2020 at 9:36 p.m. an Immediate Jeopardy situation had been identified due to the above failures. The IJ template was provided to the ADM on 11/12/2020 at 9:51 p.m. A Plan of Removal was first submitted by the RNC on 11/13/2020 at 2:17 p.m. and the following POR was accepted on 11/14/2020 at 6:27 p.m (Facility Name) Plan of Removal: The facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity. The facility failed to assess residents three times per day for signs and symptoms of COVID-19 (standing orders were 2x per day), but they also failed to begin assessing all new residents for signs and symptoms of COVID-19 even twice per day, in that: Two residents on the 300 quarantine hall (where the three COVID-positive residents are still living) currently do not have orders for COVID monitoring. Four residents on the quarantine hall, including two of the COVID-positive residents, only received orders to screen for COVID signs and symptoms at or after 1 pm on 11/12/20. Review of skilled evaluations, vital signs logs, progress notes, and the 24 hour book for the 300 hall all reflected that COVID assessments of the residents are not being conducted even once a day in some cases. Several of these residents also do not have MDS assessments completed and/or comprehensive person-centered care plans entered into the EMR. The facility did not implement any increased monitoring or specified assessments for the residents who tested positive for COVID-19.: All orders to assess for COVID-19 have been entered for 100% of the facility. All assessments that were entered for twice a day have all been changed to three times a day. Standing orders for three times a day have been created in Point Click Care. All Nurses will be re-in-service on imputing COVID-19 monitoring orders upon admission. This in-service will be conducted by Nurse manager or designee. This will begin today 11/13/2020. The in-servicing will be complete by 11/15/2020. Ongoing in-servicing will be initiated for new hires as well. Audit to ensure TID assessments are entered and completed will be done daily X one month, three times a week X one month and two times a week X one month. Official auditing for this plan will be comlete on January 13,2021. After this specific measurable auditing period, we will continue auditing all new admission charts the next business day for completeness with assessment and COVID-19 orders included. This review of charts will be completed by nursing management or designee. Standing orders initiated for residents who are positive for COVID-19 to reflect increased monitoring at every 6 hrs. A current audit is being conducted for residents with no MDS assessments completed and/or comprehensive person-centered care plans entered into the EMR. This is being done by MDS Nurse.(TRUNCATED)

Based on observation, interview, and record review, the facility failed to ensure the drug regimen was free from unnecessary medication for 1 of 7 residents reviewed for unnecessary medications.(Resident #4) The facility failed to determine an indication for the use of insulin for Resident #4. Resident #4 had a history of [REDACTED]. After receiving 2 doses of long-acting insulin Resident #4 was admitted to the hospital intensive care unit for [DIAGNOSES REDACTED] (abnormally low blood glucose (blood sugar) level). This failure contributed to the hospitalization of Resident #4 and could place the census of 88 residents at risk of adverse reactions to unnecessary medications. Findings included: A Face Sheet dated 12/11/14 indicated Resident #4 was [AGE] years old and admitted [DATE] at 4:30 p.m. The resident was listed as his own responsible party. The hospital Medication Administration Record [REDACTED]. The record indicated on 11/26/14 at 4:48 p.m. Resident #4 received [MEDICATION NAME] 50 percent in water for [DIAGNOSES REDACTED]. A History and Physical Report dated 12/10/14 indicated Resident #4 had a past medical history consistent with occasional [DIAGNOSES REDACTED]. The hospital chemistry report indicated the following glucose levels (reference range 70-110) for Resident #4: 11/25/14 74, 11/26/14 58, 11/27/14 98, 11/28/14 100, 11/29/14 96, 11/30/14 100, 12/1/14 112, 12/2/14 105, 12/3/14 97, 12/4/14 146, 12/5/14 107, 12/6/14 127, 12/7/14 124, 12/8/14 86, and 12/9/14 79. The hospital Patient Discharge Information report dated 12/10/14 timed 3:12 p.m. indicated Resident #4 had [DIAGNOSES REDACTED]. The report indicated his medications were to continue with no changes. The medications listed on the report did not include insulin. A laboratory report dated 12/10/14 indicated Resident #4 had a fasting glucose level of 98 (reference range 70-110). admission orders [REDACTED]. The orders did not include an order for [REDACTED]. During an interview on 12/16/14 at 2:23 p.m. LVN A said Resident #4 told her on admission he was diabetic and was not on any medication. LVN A said she took the resident's blood sugar and it was 179. LVN A said the resident was admitted with no orders for insulin. She said she contacted the nurse practitioner and obtained an order for [REDACTED]. A telephone order from the nurse practitioner dated 12/11/14 indicated Resident #4 was to receive accuchecks in the morning and at bedtime with a sliding scale of Humalog (insulin). The resident was to receive [MEDICATION NAME] 15 units every morning and every night. During an interview on 12/16/14 at 1:02 p.m. the nurse practitioner said she received a call from a nurse that Resident #4 had a blood sugar level of 200. The nurse practitioner said she put the resident on a low dose of insulin. She said she had never seen the resident and the physician she worked for had never seen the resident. She said she was not familiar with the resident's history. She indicated she did not have any documentation of the date of the call. The nurse practitioner reviewed the resident's chart and noted there was no documentation in the chart of the resident having a blood sugar level of 200. A Nursing MAR for December 2014 indicated Resident #4 had a blood sugar level of 128 on 12/11/14 at 4:30 p.m. and 183 at 8:00 p.m. Resident #4 received 2 units of Humalog (insulin). The resident's blood sugar level was 69 on 12/12/14 at 6:30 a.m. A Nursing MAR for December 2014 indicated Resident #4 received [MEDICATION NAME] 15 units on 12/11/14 at 8:00 p.m. and 12/12/14 at 6:30 a.m. Nursing notes dated 12/10-11/14 did not document blood sugar levels for Resident #4. A nursing note dated 12/12/14 indicated Resident #4 was unconscious and not responding. The resident's glucose level was documented at 69. The resident was transferred to the hospital. An undated Hypoglycemic Management Protocol indicated Resident #4 was unresponsive and had a glucose level of 69. An Emergency Physician Record dated 12/12/14 indicated Resident #4 had a decreased mental status and low blood sugar. The resident was unresponsive. The record indicated the emergency medical services documented the resident had a blood sugar of less than 20 and the resident received [MEDICATION NAME] 50 which brought the resident's blood sugar level up to the 80's. The hospital History and Physical Report dated 12/12/14 indicated Resident #4 was admitted to the hospital for altered mental status with [DIAGNOSES REDACTED]. The report documented the resident "was started on insulin the day prior at the nursing home, [MEDICATION NAME] 50 units twice a day, which is likely the etiology of the [DIAGNOSES REDACTED]." The report indicated the resident was admitted to the insensitive care unit for closer monitoring. The resident received multiple doses of [MEDICATION NAME] 50 and [MEDICATION NAME] 10 for [DIAGNOSES REDACTED]. The record indicated the resident was not on insulin prior to the nursing home admission and "was restarted on insulin for inexplicable reasons." During an interview on 12/16/14 at 4:43 p.m. RN B said Resident #4 was admitted to the hospital for [DIAGNOSES REDACTED]. RN B said since admission on 12/12/14 the resident had not received insulin. During an observation and interview and on 12/16/14 at 4:50 a.m. Resident #4 was in the hospital. The resident said he was discharged from the hospital on [DATE] to the nursing facility. Resident #4 said when he was discharged from the hospital he was not on insulin because he tended to have [DIAGNOSES REDACTED] episodes. He said he told the nurse at the facility that he did not receive medication for his diabetes. He said the nurse said that did not matter. Resident #4 said they gave him insulin anyway. He said the staff at the facility called him "crazy." The CMS 672 dated 12/16/14 indicated a census of 88.

Based on observation, interview and record review, the facility failed to implement written policies and procedures that prohibit neglect for one (1) of six (6) residents reviewed for abuse and neglect (Resident #3). The facility failed to ensure that Certified Nursing Assistant (CNA) B transferred Resident #3 properly. During care on 01/25/14 at 5:54 pm, Resident #3, who required a two person transfer, lost balance and was lowered to the floor by CNA B (the only CNA in the room). CNA B did not follow facility post fall procedures when she assisted Resident #3 off of the floor, by herself, before a nurse was notified of the fall. Resident #3 sustained an acute [MEDICAL CONDITION] humerus (a [MEDICAL CONDITION] of the upper arm bone, near the shoulder joint). This was determined to be a past non-compliance at the actual harm level that occurred on 01/25/14 through 01/27/14 for Resident #3. This deficient practice could place 63 residents who require the assistance of one or two staff members for transfers at risk for injury due to improper transfer technique and being moved post-fall prior to a nurse assessment. Findings include: Review of facility's abuse and neglect policy dated January 2007 reflected "Any facility staff member who has cause to believe that the physical or mental health or welfare of a resident has been, or may be adversely affected by abuse, neglect or exploitation caused by another person, is to report the abuse, neglect or exploitation immediately. Notification time frame: 1. For staff notify Administrator and DON immediately. 2. Administrator and DON notify your direct report/supervisor immediately to determine if event meets DADS current reportable criteria .... The following incidents of abuse and/or neglect must be reported to the DADS (Department of Aging and Disability Services)...immediately upon learning of the incident .... Neglect: The facility must determine if an injury, harm, or death of a resident was due to facility failure to provide services, treatment or care to a resident." Review of Resident Abuse Policy, undated, reflected " The resident has the right to be free from verbal, sexual, physical, or mental abuse, corporal punishment, and/or involuntary seclusion and/or injury from an unknown source. In the event of any evidence or cause to believe that a resident has suffered any of the above abuses, the employee, visitor, or family members are requested to report all allegations, suspicions, or incidents to the administrator of the facility or to State officials posted in the facility. " Review of Resident #3 ' s face sheet reflected she is a [AGE] year old female admitted to the facility on [DATE], and readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #3 ' s care plan dated 01/25/14 reflected that Resident #3 was care planned for pain related to her fracture. Review of the facility ' s incident report dated 1/25/14 at 4:00 pm reflected CNA B reported that while transferring Resident #3, she might have injured resident ' s right shoulder. The resident was assessed and the nurse practitioner was notified. A fractured humerus was revealed. During an interview on 02/11/14 at 1:59 pm, Licensed Vocational Nurse (LVN) A stated that she was working when the incident occurred with Resident #3 on 01/25/14 on the 2:00 pm to 10:00 pm shift. LVN A stated that CNA B came to the nurse ' s station and told LVN A that she lowered Resident #3 to the ground because the resident was about to fall. CNA B stated that she then tried to get Resident #3 up off of the floor and she thinks that she injured the resident ' s arm. LVN A stated that CNA B did not have a gait belt with her. CNA B told LVN A that she was attempting to transfer Resident #3 by herself, with no assistance from another staff member and without a gait belt. LVN A stated that CNA B told her that she knew that Resident #3 was a two person transfer but that she had transferred the resident by herself before. LVN A stated that when she got to Resident #3 ' s room, the resident was holding her arm close to her body and said that her shoulder was hurting. LVN A put a pillow under the residents arm for support and called the nurse practitioner (NP). The NP told LVN A to give Resident #3 some Tylenol for pain and to order a stat x-ray. The results were faxed back that Resident #3 had a fracture to her arm. LVN A stated that she called the NP back and an order was given to send Resident #3 to the emergency room (ER). LVN A stated that Resident #3 came back to the facility that same day with her arm in a sling. LVN A stated that after she called the NP, she also called the Assistant Director of Nurses (ADON) to report the incident to her. LVN A stated that the ADON told her that she was going to report the incident to the Director of Nurses (DON) and the Administrator. LVN A stated that after the incident, she confirmed that the dot system (an index card system that identified a resident ' s transfer type and other care information) was in place in Resident #3 ' s room. LVN A stated that Resident #3 ' s " dot system " index card was in place in the resident ' s closet and indicated that Resident #3 was a two person transfer. LVN A stated that CNA B worked the rest of the 2:00 pm to 10:00 pm shift after the incident occurred. During a telephone interview on 02/11/14 at 2:47 pm, CNA B stated that the incident involving Resident #3 was her " fault " and that she should have gotten help immediately when Resident #3 was on the floor instead of trying to get her up off of the floor by herself. CNA B stated that she had given Resident #3 a shower and she took Resident #3 back to her room where she was trying to put a brief on the resident while she was standing and holding on to a bar for support. CNA B stated that Resident #3 began to slide to the ground, so she lowered the resident to the floor. CNA B stated that she moved Resident #3 from the floor to her bed by herself and accidentally hurt her arm in the process. CNA B stated that she then went to tell the nurse what happened. CNA B stated that the resident was not yelling out, but when she asked her if she was in pain, the resident said yes. CNA B stated that the CNA flow-sheet said that Resident #3 was a one person transfer. CNA B stated that she did not know what the dot system index card in Resident #3 ' s room said regarding the transfer type. CNA B stated that the dot system index card " might say 2 " person transfer. Review of the CNA flow-sheet for Resident #3 dated 02/03/14 reflected that Resident #3 was a two person transfer. The CNA flow-sheet for Resident #3 dated 01/25/14 was not available. During an interview on 02/11/14 at 3:49 pm, the DON stated that the facility did not keep old CNA flow-sheets in medical records, so the flow-sheet from 01/25/14 was not available. Observation of Resident #3 ' s care card on the inside of the closet door revealed a white card with several colored paper dots and a green star. The white dot had the number 2 written on it. Review of Resident Care Identification System document reflected that a white dot with the number 2 written on it indicated a 2 person transfer. During an interview on 02/11/14 at 3:00 pm, CNA F stated that Resident #3 was a 2-person transfer at least since April of 2013. CNA F stated that she has worked in the facility on two different occasions and worked with Resident #3. The first employment time period was January 2012 to August 2012. CNA F stated that she remembered that Resident #3 was a one person transfer during that time period. CNA F stated that the second time she started back to work here was April of 2013. She noticed that Resident #3 was less steady on her feet and her DOT system had changed to a two person transfer. Observation of Resident #3 on 02/12/14 at 11:10 am revealed she was dressed appropriately, wearing a right arm sling and sitting in a wheelchair in the dining room and was observed to pick at her food with her left hand and was also assisted to eat by staff. During an interview on 02/11/14 at 10:30 am, Resident #3, who is unable to verbally communicate, used physical movement to nod her head for " yes " or shake her head for " no " during the interview. Resident #3 was asked if she remembered falling a while back and she shook her head no. Resident #3 was also asked if her arm hurt and she shook her head no. During an interview on 02/11/14 at 3:49 pm, the DON stated that she found out about the incident involving Resident #3 the same evening as the incident through a text message from the ADON. The DON stated that the Administrator responded saying that the incident needed to be investigated and that statements needed to be taken from the CNA and other staff members involved. The DON stated that CNA B was terminated (01/31/14). The DON stated that the dot system was in place in Resident #3 ' s room and that the CNAs have instructions on how to read the dot system index cards on the backs of their name badges. The DON stated that the dot system master sheet is reviewed during interdisciplinary team meetings and if any changes are made, the cards will be updated at that time. During an interview on 02/12/14 at 10:00 am, the Administrator/ Abuse Coordinator, stated that on Saturday night (01/25/14) there was a problem with a transfer; however, he was not aware that the resident went to the emergency room until Monday morning when he arrived at the facility. The Administrator stated he did not get a phone call regarding the resident ' s transfer to the hospital and it was Monday morning before he found out about the incident, started their investigation and reported it to the Texas Department of Aging and Disability (DADS). Review of Resident #3 ' s nurse ' s notes dated 01/25/14 at 3:45 pm (written by LVN A) reflected " CNA reported that she was getting resident dressed and possibly injured resident shoulder. Resident assessed for injuries. Resident stated that her right shoulder was hurting and appeared tearful ... Resident grimacing and guarding right side during ROM (range of motion). NP (nurse practitioner) notified. X-ray ordered of right shoulder. (Mobile x-ray company) called. " The nurse ' s note at 4:00 pm reflected " (Mobile x-ray company) in facility to do x-ray. RP (responsible party) notified. Resident medicated with 1000 mg APAP ([MEDICATION NAME]) for right shoulder pain. " At 5:15 pm, nurse ' s notes reflected " Received x-ray results from (mobile x-ray company). Called in to NP. NP gave order to send resident to ER (emergency room ). Ambulance called. Nurse to nurse called. Called and left message for RP to call facility. " At 5:45 pm, emergency medical services (EMS) arrived. At 5:55 pm, EMS left the facility with Resident #3 on a stretcher. At 6:00 pm, the nurse (LVN A) called the ADON and informed her of Resident #3 ' s injury. At 7:40 pm, Resident #3 ' s RP called back and was informed of the resident ' s status. At 7:50 pm, " Resident returned to facility with sling on right arm/shoulder with instructions to wear until released by physician. " Review of Mobilex Radiology Report dated 01/25/20 reflected an acute [MEDICAL CONDITION] humerus and moderate [MEDICAL CONDITION] joint disease of the right shoulder. Review of Provider Investigation Report, dated, 01/27/14, reflected a description of the allegations as: Abuse on 01/25/14 at 5:54 p.m. in the resident ' s room. (CNA B) was transferring resident from shower chair to wheel chair. She was going to put a brief on resident before she put her in wheel chair. Resident lost her balance and (CNA B) assisted resident to the floor. (CNA B) then transferred resident to bed prior to notifying charge nurse. There were no additional alleged perpetrator's and there were no witnesses to the incident. (CNA B) thought that resident's shoulder was injured in transfer from floor to bed. Resident was X-ray'd in house and diagnosed with [REDACTED]. Returned to facility with order for ice and a sling. Description of Assessment: Shoulder assessed immediately by Charge nurse. Resident complained of pain to shoulder. Nure Practitioner(NP) recommended x-ray to rule out fracture. X-ray revealed a fracture. NP then recommended to send to Emergency Department for evaluation and treatment. Provider Response: (CNA B) suspended pending investigation. All staff in-serviced on Abuse & Neglect, who the Abuse Coordinator is, and to report abuse immediately to the Abuse Coordinator. Direct care staff in-serviced on resident care identification system (DOT system), and resident care Activities of Daily Living(ADL) tool. Assistant Director ofNursing (ADON), Responsible party, and Nurse Practitioner notified. Investigation Summary: (CNA B) was transferring resident from shower chair to wheel chair. She was going to put a brief on resident before she put her in wheel chair. Resident lost her balance and (CNA B) assisted resident to the floor. (CNA B) then transferred resident to bed prior to notifying charge nurse. There were no additional alleged perpetrator ' s and there were no witnesses to the incident. (CNA B) thought that resident ' s shoulder was injured in transfer from floor to bed. Resident was X-ray'd in house and diagnosed with [REDACTED]. Returned to facility with order for ice and a sling. The resident is a 2 person transfer and (CNA B) also did not utilize a gait belt. (CNA B) had just recently been in-serviced on the use of gait belts. (CNA B) has been suspended pending investigation. (CNA B) stated that, "she wasn't thinking. That she should have gotten help. "All staff in-serviced on Abuse & Neglect, who the Abuse Coordinator is, and to report abuse &/or neglect immediately to the Abuse Coordinator. Direct care staff in-services on Resident Care Identification system (DOT system), and resident care ADL tool. Provider Action Taken Post-Investigation:(CNA B) was terminated based on the confirmation of the investigation. Social Worker interviewed resident. She was asked several questions that she could respond yes or no to. The only negative response from resident was that she felt AP handled her a little rough. Other residents on same hall interviewed and there was no negative response about care from (CNA B). Review of Witness statement written by CNA B dated 01/25/14 at 3:15 pm reflected, "After (Resident #3's) shower I try to transfer her from the shower chair to the W/C (wheelchair) trying to put her brief on as she stand. She couldn ' t hold her balance, I lightly lay her down on the floor without any help I lift her up from floor and somehow dislocated broken her arm." Review of statement of incident by LVN A charge nurse dated 01/25/14 reflected that "at 3:45 (pm) (CNA B) came to nurse station and asked that I come look at (Resident #3). I asked her why? She stated that she was trying to put brief on resident and had to lower her to the floor. As we were walking toward res room she stated , "I think I broke her arm. " I asked how? She stated that she was trying to put her into bed. I asked if she was by herself? She stated yes. I then asked, " Isn ' t she a 2 person lift? " She stated, " Yes but I can usually do her " I noted that (CNA B) didn ' t have a gait belt. I then stated, " you did this without help and without a gait belt? " She shook her head yes ... " Review of Director of Nurses written statement of her telepone interview with CNA B, undated, reflected CNA B stated, " I was putting her brief on, didn ' t call for help " her legs gave out and she was trying to lay on floor. Picked her up, under arms, didn ' t have gait belt put her on the bed. Right arm was flapping. Resident #3 denied pain. I told charge nurse after I had her in bed. Asked her did she use DOT card she stated, " No, I used that flow sheet we ' ve been writing on it said one (1) person. " Asked why she didn ' t call for help and charge nurse when resident was assisted to floor. " I wasn ' t thinking. I should have called for help. " During an interview on 02/11/14 at 3:35 pm, the ADON stated that the facility's post fall procedures included all serious injuries be reported to the DON and stated that the charge nurses were responsible for following the procedure. She gave investigator a copy of the procedure titled: When to Notify the Director of Nurses. The procedure titled: When to Notify Director of Nurses was dated 02/22/13 and verified by ADON as the implementation date of this facility procedure. Review of the When to Notify Director of Nurses procedure dated 02/22/13 reflected the following: " You need to notify your DON immediately if any of the following occur: 6. Any allegations of abuse or neglect both physical and verbal 9. Staff/Resident incident 10. Incidents resulting in hospital transfer, serious injury to resident, staff, or visitor Any other serious events/situations should be called to the nursing manager on duty ie: staffing issues, minor resident issues/concerns, etc. If you are unable to speak to the DON, leave a message on the answering machine/voice mail and then call the Administrator. " Review of Incident Reports/Investigations policy, undated, reflected " Use the investigation report, as needed, to successfully complete an Incident report and conduct a proper investigation. Incidents/Accidents leading to fractures, elopements, suspected abuse/neglect, medication administration complications, transfers to acute care hospital and staff injury require immediate notification of the DON and administrator." Review of the First Aid: Falls policy, undated, reflected " Procedure: When a resident falls, let him lie on floor and examine the resident carefully. If found on the floor do not move until charge nurse [MEDICATION NAME] the resident. Determine if emergency action is needed. " Review of the policy titled " When to Notify the Director of Nurses(DON)", undated, reflected " You need to notify your Director of Nurses immediately if any of the following occur: ...Any allegations of abuse or neglect both physical and verbal ....Incidents resulting in hospital transfer, serious injury to resident, staff, or visitor .... If you are unable to speak to the DON, leave a message on the answering machine/voice mails and then call the Administrator. " The facility Administrator was notified of the past non-compliance at an actual harm level on 02/12/14 at 3:10 pm. Record Review of the facility Staff Development /In-services reflected the following: DateTopic of Discussion09/06/2013Fall Prevention Evidence-Based Best Practice for Nursing Fall Risk Management (Attendance STAFF)09/27/2013Transfers-when transferring residents you must use a gait belt to support residents. Do not use residents extremities to support them ie. Arms, wrist, hands, etc. (Attendance STAFF)12/13/2013Mandatory to have gait belt with you when working the floor. This is a part of your uniform. (Attendance STAFF)01/14/2014If an issue is brought to your attention and you fail to correct the action and report the issue you will be held accountable as well. (Attendance Nursing)01/27/2014Abuse & Neglect, Abuse Coordinator, Reporting Abuse and Neglect (Attendance All Staff)01/27/2014CNA communications for Resident Care: 1. Resident care identifier system, 2. CNA communication form resident ' s needs and Improved understanding of resident ' s needs: 1. DOT training 2. Assignment sheet used daily for specific care needs. (Attendance ALL Nursing CNA,MA,NURSES) During an interview on 02/12/14 at 10:40 am, CNA G stated that Resident #3 was a 2 person transfer for at least the past year that she worked with Resident #3. CNA G stated that the DOT system and resident flow sheet was used by the CNAs to know the residents transfer status. During an interview on 02/11/14 at 1:46 pm, CNA K stated that CNAs use the CNA flow-sheets and the DOT system to find the transfer status of a resident. CNA K stated that after a fall, CNAs should not move the resident and should immediately notify a nurse. CNA K stated that the resident should never be moved after a fall before a nurse assessment. During an interview on 02/11/14 at 1:59 pm, LVN A stated that CNAs and nurses use the DOT system (that is posted in the resident's closet) to find the resident's transfer status. LVN A stated that CNAs should notify a nurse immediately after a resident falls and they should not move the resident until the nurse assesses the resident. During an interview on 02/12/14 at 1:45 pm the DON stated that she spoke to direct care staff about several ways that the facility ensures that direct care staff follow the Resident DOT System and individualized plan of care to meet Activities of Daily Living needs for the Residents. DON stated that her managers and staffing coordinator follow behind CNAs doing random checks during ADL care, they do skills check-off for competencies, and that they have a daily focus meeting Monday - Friday in which the DOT system and ADL care flow sheets are compared and updated for changes. Review of Provider Investigation Report, dated, 1/27/2014, reflected that all staff in-serviced on Abuse & Neglect, who the Abuse Coordinator is, and to report abuse &/or neglect immediately to the Abuse Coordinator. Direct care staff in-services on Resident Care Identification system (DOT system), and resident care ADL tool. Provider Action Taken Post-Investigation: AP was terminated based on the confirmation of the investigation. Social Worker interviewed resident. She was asked several questions that she could respond yes or no to. The only negative response from resident was that she felt AP handled her a little rough. Other residents on same hall interviewed and there was no negative response about care from AP. Review of the CMS-672 dated 02/11/14 reflected that 63 residents required assist of one or two staff members for transfers.

Based on observation, interview and record review, the facility failed to implement policies and procedures that prohibit neglect for one (1) of six (6) residents reviewed for abuse and neglect (Resident #3). The facility failed to ensure that Certified Nursing Assistant (CNA) B transferred Resident #3 properly. During care on 01/25/14 at 5:54 pm, Resident #3, who required a two person transfer, lost balance and was lowered to the floor by CNA B (the only CNA in the room). CNA B did not follow facility post fall procedures when she assisted Resident #3 off of the floor, by herself, before a nurse was notified of the fall. Resident #3 sustained an acute [MEDICAL CONDITION] humerus (a [MEDICAL CONDITION] of the upper arm bone, near the shoulder joint). This was determined to be a past non-compliance at the actual harm level that occurred on 01/25/14 through 01/27/14 for Resident #3. This deficient practice could place 63 residents who require the assistance of one or two staff members for transfers at risk for injury due to improper transfer technique and being moved post-fall prior to a nurse assessment. Findings include: Review of Resident #3 ' s face sheet reflected she is a [AGE] year old female admitted to the facility on [DATE], and readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #3 ' s care plan dated 01/25/14 reflected that Resident #3 was care planned for pain related to her fracture. Review of the facility ' s incident report dated 1/25/14 at 4:00 pm reflected CNA B reported that while transferring Resident #3, she might have injured resident ' s right shoulder. The resident was assessed and the nurse practitioner was notified. A fractured humerus was revealed. During an interview on 02/11/14 at 1:59 pm, Licensed Vocational Nurse (LVN) A stated that she was working when the incident occurred with Resident #3 on 01/25/14 on the 2:00 pm to 10:00 pm shift. LVN A stated that CNA B came to the nurse ' s station and told LVN A that she lowered Resident #3 to the ground because the resident was about to fall. CNA B stated that she then tried to get Resident #3 up off of the floor and she thinks that she injured the resident ' s arm. LVN A stated that CNA B did not have a gait belt with her. CNA B told LVN A that she was attempting to transfer Resident #3 by herself, with no assistance from another staff member and without a gait belt. LVN A stated that CNA B told her that she knew that Resident #3 was a two person transfer but that she had transferred the resident by herself before. LVN A stated that when she got to Resident #3 ' s room, the resident was holding her arm close to her body and said that her shoulder was hurting. LVN A put a pillow under the residents arm for support and called the nurse practitioner (NP). The NP told LVN A to give Resident #3 some Tylenol for pain and to order a stat x-ray. The results were faxed back that Resident #3 had a fracture to her arm. LVN A stated that she called the NP back and an order was given to send Resident #3 to the emergency room (ER). LVN A stated that Resident #3 came back to the facility that same day with her arm in a sling. LVN A stated that after she called the NP, she also called the Assistant Director of Nurses (ADON) to report the incident to her. LVN A stated that the ADON told her that she was going to report the incident to the Director of Nurses (DON) and the Administrator. LVN A stated that after the incident, she confirmed that the dot system (an index card system that identified a resident ' s transfer type and other care information) was in place in Resident #3 ' s room. LVN A stated that Resident #3 ' s " dot system " index card was in place in the resident ' s closet and indicated that Resident #3 was a two person transfer. LVN A stated that CNA B worked the rest of the 2:00 pm to 10:00 pm shift after the incident occurred. During a telephone interview on 02/11/14 at 2:47 pm, CNA B stated that the incident involving Resident #3 was her " fault " and that she should have gotten help immediately when Resident #3 was on the floor instead of trying to get her up off of the floor by herself. CNA B stated that she had given Resident #3 a shower and she took Resident #3 back to her room where she was trying to put a brief on the resident while she was standing and holding on to a bar for support. CNA B stated that Resident #3 began to slide to the ground, so she lowered the resident to the floor. CNA B stated that she moved Resident #3 from the floor to her bed by herself and accidentally hurt her arm in the process. CNA B stated that she then went to tell the nurse what happened. CNA B stated that the resident was not yelling out, but when she asked her if she was in pain, the resident said yes. CNA B stated that the CNA flow-sheet said that Resident #3 was a one person transfer. CNA B stated that she did not know what the dot system index card in Resident #3 ' s room said regarding the transfer type. CNA B stated that the dot system index card " might say 2 " person transfer. Review of the CNA flow-sheet for Resident #3 dated 02/03/14 reflected that Resident #3 was a two person transfer. The CNA flow-sheet for Resident #3 dated 01/25/14 was not available. During an interview on 02/11/14 at 3:49 pm, the DON stated that the facility did not keep old CNA flow-sheets in medical records, so the flow-sheet from 01/25/14 was not available. Observation of Resident #3 ' s care card on the inside of the closet door revealed a white card with several colored paper dots and a green star. The white dot had the number 2 written on it. Review of Resident Care Identification System document reflected that a white dot with the number 2 written on it indicated a 2 person transfer. During an interview on 02/11/14 at 3:00 pm, CNA F stated that Resident #3 was a 2-person transfer at least since April of 2013. CNA F stated that she has worked in the facility on two different occasions and worked with Resident #3. The first employment time period was January 2012 to August 2012. CNA F stated that she remembered that Resident #3 was a one person transfer during that time period. CNA F stated that the second time she started back to work here was April of 2013. She noticed that Resident #3 was less steady on her feet and her DOT system had changed to a two person transfer. Observation of Resident #3 on 02/12/14 at 11:10 am revealed she was dressed appropriately, wearing a right arm sling and sitting in a wheelchair in the dining room and was observed to pick at her food with her left hand and was also assisted to eat by staff. During an interview on 02/11/14 at 10:30 am, Resident #3, who is unable to verbally communicate, used physical movement to nod her head for " yes " or shake her head for " no " during the interview. Resident #3 was asked if she remembered falling a while back and she shook her head no. Resident #3 was also asked if her arm hurt and she shook her head no. During an interview on 02/11/14 at 3:49 pm, the DON stated that she found out about the incident involving Resident #3 the same evening as the incident through a text message from the ADON. The DON stated that the Administrator responded saying that the incident needed to be investigated and that statements needed to be taken from the CNA and other staff members involved. The DON stated that CNA B was terminated (01/31/14). The DON stated that the dot system was in place in Resident #3 ' s room and that the CNAs have instructions on how to read the dot system index cards on the backs of their name badges. The DON stated that the dot system master sheet is reviewed during interdisciplinary team meetings and if any changes are made, the cards will be updated at that time. During an interview on 02/12/14 at 10:00 am, the Administrator/ Abuse Coordinator, stated that on Saturday night (01/25/14) there was a problem with a transfer; however, he was not aware that the resident went to the emergency room until Monday morning when he arrived at the facility. The Administrator stated he did not get a phone call regarding the resident ' s transfer to the hospital and it was Monday morning before he found out about the incident, started their investigation and reported it to the Texas Department of Aging and Disability (DADS). Review of Resident #3 ' s nurse ' s notes dated 01/25/14 at 3:45 pm (written by LVN A) reflected " CNA reported that she was getting resident dressed and possibly injured resident shoulder. Resident assessed for injuries. Resident stated that her right shoulder was hurting and appeared tearful ... Resident grimacing and guarding right side during ROM (range of motion). NP (nurse practitioner) notified. X-ray ordered of right shoulder. (Mobile x-ray company) called. " The nurse ' s note at 4:00 pm reflected " (Mobile x-ray company) in facility to do x-ray. RP (responsible party) notified. Resident medicated with 1000 mg APAP ([MEDICATION NAME]) for right shoulder pain. " At 5:15 pm, nurse ' s notes reflected " Received x-ray results from (mobile x-ray company). Called in to NP. NP gave order to send resident to ER (emergency room ). Ambulance called. Nurse to nurse called. Called and left message for RP to call facility. " At 5:45 pm, emergency medical services (EMS) arrived. At 5:55 pm, EMS left the facility with Resident #3 on a stretcher. At 6:00 pm, the nurse (LVN A) called the ADON and informed her of Resident #3 ' s injury. At 7:40 pm, Resident #3 ' s RP called back and was informed of the resident ' s status. At 7:50 pm, " Resident returned to facility with sling on right arm/shoulder with instructions to wear until released by physician. " Review of Mobilex Radiology Report dated 01/25/20 reflected an acute [MEDICAL CONDITION] humerus and moderate [MEDICAL CONDITION] joint disease of the right shoulder. Review of Provider Investigation Report, dated, 01/27/14, reflected a description of the allegations as: Abuse on 01/25/14 at 5:54 p.m. in the resident ' s room. (CNA B) was transferring resident from shower chair to wheel chair. She was going to put a brief on resident before she put her in wheel chair. Resident lost her balance and (CNA B) assisted resident to the floor. (CNA B) then transferred resident to bed prior to notifying charge nurse. There were no additional alleged perpetrator's and there were no witnesses to the incident. (CNA B) thought that resident's shoulder was injured in transfer from floor to bed. Resident was X-ray'd in house and diagnosed with [REDACTED]. Returned to facility with order for ice and a sling. Description of Assessment: Shoulder assessed immediately by Charge nurse. Resident complained of pain to shoulder. Nure Practitioner(NP) recommended x-ray to rule out fracture. X-ray revealed a fracture. NP then recommended to send to Emergency Department for evaluation and treatment. Provider Response: (CNA B) suspended pending investigation. All staff in-serviced on Abuse & Neglect, who the Abuse Coordinator is, and to report abuse immediately to the Abuse Coordinator. Direct care staff in-serviced on resident care identification system (DOT system), and resident care Activities of Daily Living(ADL) tool. Assistant Director ofNursing (ADON), Responsible party, and Nurse Practitioner notified. Investigation Summary: (CNA B) was transferring resident from shower chair to wheel chair. She was going to put a brief on resident before she put her in wheel chair. Resident lost her balance and (CNA B) assisted resident to the floor. (CNA B) then transferred resident to bed prior to notifying charge nurse. There were no additional alleged perpetrator ' s and there were no witnesses to the incident. (CNA B) thought that resident ' s shoulder was injured in transfer from floor to bed. Resident was X-ray'd in house and diagnosed with [REDACTED]. Returned to facility with order for ice and a sling. The resident is a 2 person transfer and (CNA B) also did not utilize a gait belt. (CNA B) had just recently been in-serviced on the use of gait belts. (CNA B) has been suspended pending investigation. (CNA B) stated that, "she wasn't thinking. That she should have gotten help. "All staff in-serviced on Abuse & Neglect, who the Abuse Coordinator is, and to report abuse &/or neglect immediately to the Abuse Coordinator. Direct care staff in-services on Resident Care Identification system (DOT system), and resident care ADL tool. Provider Action Taken Post-Investigation:(CNA B) was terminated based on the confirmation of the investigation. Social Worker interviewed resident. She was asked several questions that she could respond yes or no to. The only negative response from resident was that she felt AP handled her a little rough. Other residents on same hall interviewed and there was no negative response about care from (CNA B). Review of Witness statement written by CNA B dated 01/25/14 at 3:15 pm reflected, "After (Resident #3's) shower I try to transfer her from the shower chair to the W/C (wheelchair) trying to put her brief on as she stand. She couldn ' t hold her balance, I lightly lay her down on the floor without any help I lift her up from floor and somehow dislocated broken her arm." Review of statement of incident by LVN A charge nurse dated 01/25/14 reflected that "at 3:45 (pm) (CNA B) came to nurse station and asked that I come look at (Resident #3). I asked her why? She stated that she was trying to put brief on resident and had to lower her to the floor. As we were walking toward res room she stated , "I think I broke her arm. " I asked how? She stated that she was trying to put her into bed. I asked if she was by herself? She stated yes. I then asked, " Isn ' t she a 2 person lift? " She stated, " Yes but I can usually do her " I noted that (CNA B) didn ' t have a gait belt. I then stated, " you did this without help and without a gait belt? " She shook her head yes ... " Review of Director of Nurses written statement of her telepone interview with CNA B, undated, reflected CNA B stated, " I was putting her brief on, didn ' t call for help " her legs gave out and she was trying to lay on floor. Picked her up, under arms, didn ' t have gait belt put her on the bed. Right arm was flapping. Resident #3 denied pain. I told charge nurse after I had her in bed. Asked her did she use DOT card she stated, " No, I used that flow sheet we ' ve been writing on it said one (1) person. " Asked why she didn ' t call for help and charge nurse when resident was assisted to floor. " I wasn ' t thinking. I should have called for help. " During an interview on 02/11/14 at 3:35 pm, the ADON stated that the facility's post fall procedures included all serious injuries be reported to the DON and stated that the charge nurses were responsible for following the procedure. She gave investigator a copy of the procedure titled: When to Notify the Director of Nurses. The procedure titled: When to Notify Director of Nurses was dated 02/22/13 and verified by ADON as the implementation date of this facility procedure. Review of the When to Notify Director of Nurses procedure dated 02/22/13 reflected the following: " You need to notify your DON immediately if any of the following occur: 6. Any allegations of abuse or neglect both physical and verbal 9. Staff/Resident incident 10. Incidents resulting in hospital transfer, serious injury to resident, staff, or visitor Any other serious events/situations should be called to the nursing manager on duty ie: staffing issues, minor resident issues/concerns, etc. If you are unable to speak to the DON, leave a message on the answering machine/voice mail and then call the Administrator. " Review of Incident Reports/Investigations policy, undated, reflected " Use the investigation report, as needed, to successfully complete an Incident report and conduct a proper investigation. Incidents/Accidents leading to fractures, elopements, suspected abuse/neglect, medication administration complications, transfers to acute care hospital and staff injury require immediate notification of the DON and administrator." Review of the First Aid: Falls policy, undated, reflected " Procedure: When a resident falls, let him lie on floor and examine the resident carefully. If found on the floor do not move until charge nurse [MEDICATION NAME] the resident. Determine if emergency action is needed. " Review of the policy titled " When to Notify the Director of Nurses(DON)", undated, reflected " You need to notify your Director of Nurses immediately if any of the following occur: ...Any allegations of abuse or neglect both physical and verbal ....Incidents resulting in hospital transfer, serious injury to resident, staff, or visitor .... If you are unable to speak to the DON, leave a message on the answering machine/voice mails and then call the Administrator. " Review of facility's abuse and neglect policy dated January 2007 reflected "Any facility staff member who has cause to believe that the physical or mental health or welfare of a resident has been, or may be adversely affected by abuse, neglect or exploitation caused by another person, is to report the abuse, neglect or exploitation immediately. Notification time frame: 1. For staff notify Administrator and DON immediately. 2. Administrator and DON notify your direct report/supervisor immediately to determine if event meets DADS current reportable criteria .... The following incidents of abuse and/or neglect must be reported to the DADS (Department of Aging and Disability Services)...immediately upon learning of the incident .... Neglect: The facility must determine if an injury, harm, or death of a resident was due to facility failure to provide services, treatment or care to a resident." Review of Resident Abuse Policy, undated, reflected " The resident has the right to be free from verbal, sexual, physical, or mental abuse, corporal punishment, and/or involuntary seclusion and/or injury from an unknown source. In the event of any evidence or cause to believe that a resident has suffered any of the above abuses, the employee, visitor, or family members are requested to report all allegations, suspicions, or incidents to the administrator of the facility or to State officials posted in the facility. " The facility Administrator was notified of the past non-compliance at an actual harm level on 02/12/14 at 3:10 pm. Record Review of the facility Staff Development /In-services reflected the following: DateTopic of Discussion09/06/2013Fall Prevention Evidence-Based Best Practice for Nursing Fall Risk Management (Attendance STAFF)09/27/2013Transfers-when transferring residents you must use a gait belt to support residents. Do not use residents extremities to support them ie. Arms, wrist, hands, etc. (Attendance STAFF)12/13/2013Mandatory to have gait belt with you when working the floor. This is a part of your uniform. (Attendance STAFF)01/14/2014If an issue is brought to your attention and you fail to correct the action and report the issue you will be held accountable as well. (Attendance Nursing)01/27/2014Abuse & Neglect, Abuse Coordinator, Reporting Abuse and Neglect (Attendance All Staff)01/27/2014CNA communications for Resident Care: 1. Resident care identifier system, 2. CNA communication form resident ' s needs and Improved understanding of resident ' s needs: 1. DOT training 2. Assignment sheet used daily for specific care needs. (Attendance ALL Nursing CNA,MA,NURSES) During an interview on 02/12/14 at 10:40 am, CNA G stated that Resident #3 was a 2 person transfer for at least the past year that she worked with Resident #3. CNA G stated that the DOT system and resident flow sheet was used by the CNAs to know the residents transfer status. During an interview on 02/11/14 at 1:46 pm, CNA K stated that CNAs use the CNA flow-sheets and the DOT system to find the transfer status of a resident. CNA K stated that after a fall, CNAs should not move the resident and should immediately notify a nurse. CNA K stated that the resident should never be moved after a fall before a nurse assessment. During an interview on 02/11/14 at 1:59 pm, LVN A stated that CNAs and nurses use the DOT system (that is posted in the resident's closet) to find the resident's transfer status. LVN A stated that CNAs should notify a nurse immediately after a resident falls and they should not move the resident until the nurse assesses the resident. During an interview on 02/12/14 at 1:45 pm the DON stated that she spoke to direct care staff about several ways that the facility ensures that direct care staff follow the Resident DOT System and individualized plan of care to meet Activities of Daily Living needs for the Residents. DON stated that her managers and staffing coordinator follow behind CNAs doing random checks during ADL care, they do skills check-off for competencies, and that they have a daily focus meeting Monday - Friday in which the DOT system and ADL care flow sheets are compared and updated for changes. Review of Provider Investigation Report, dated, 1/27/2014, reflected that all staff in-serviced on Abuse & Neglect, who the Abuse Coordinator is, and to report abuse &/or neglect immediately to the Abuse Coordinator. Direct care staff in-services on Resident Care Identification system (DOT system), and resident care ADL tool. Provider Action Taken Post-Investigation: AP was terminated based on the confirmation of the investigation. Social Worker interviewed resident. She was asked several questions that she could respond yes or no to. The only negative response from resident was that she felt AP handled her a little rough. Other residents on same hall interviewed and there was no negative response about care from AP. Review of the CMS-672 dated 02/11/14 reflected that 63 residents required assist of one or two staff members for transfers.

Based on interview and record review the facility failed to immediately consult with the physician for 1 of 6 sampled residents with swallowing difficulty (Resident #1) following an episode of vomiting and audible rattling noises in her chest. Resident #1 vomited and was having "rattling" in her chest at approximately 6:50 AM on [DATE]. Certified Nurse Aide (CNA A) brought her to the nurses' station after cleaning her and getting her out of bed. Licensed Vocational Nurse (LVN E) heard a "rattle" in Resident #1's chest. However, LVN E did not listen to the resident's lungs with a stethoscope, obtain oxygen saturation level or vital signs at that time and did not call and consult with the physician and/or Nurse Practitioner (NP). Resident #1 propelled herself away from the nurses' station and was found unresponsive on the floor at approximately 7:00 AM and expired in the facility at 7:09 AM. This deficient practice resulted in a delay in medical intervention and treatment for [REDACTED]. Findings include: Review of the Out of Hospital Do Not Resuscitate for Resident #1 reflected a signature date of [DATE]. Review of the face sheet reflected Resident #1 was a [AGE] year old non-verbal female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a progress notes dated [DATE] reflected Resident #1 had further [DIAGNOSES REDACTED]. She required a pureed diet with honey thickened liquids as a result of a swallowing study done in ,[DATE] which revealed severe Dysphagia (difficulty swallowing which may result in Aspiration, the inhalation of food or liquid into the lungs which could result in Aspiration Pneumonia) and " Silent Aspiration " which is the inhalation of food or liquids into the lungs without outward signs such as turning red or coughing. In an interview on [DATE] at 3:00 PM LVN E stated that on [DATE] at the beginning of the 6:00 AM to 2:00 PM shift CNA A found Resident #1 lying in bed in vomit. CNA A brought her to the nurses' station after cleaning her and getting her out of bed. He stated that CNA A told him that Resident #1 was making a weird noise that she had never heard before. He stated that what she was hearing was a rattling sound from Resident #1's chest. LVN E stated that he could hear a "rattle" in Resident #1's chest and thought that if she vomited, she may have aspirated. He stated that her finger nail beds were pink and her color was good and she wheeled herself off in her wheelchair as she always did. LVN E stated that she seemed to be her normal self. He stated that he did not use a Stethoscope to listen to Resident #1's lungs but he could hear an audible rattle and her breathing rate and rhythm were normal. She was showing no signs of distress. He stated, "My biggest fear at that point was Aspiration." He stated that she probably aspirated when she vomited. He stated that he did not instruct CNA A to check Resident #1's vital signs and did not ask her to put Resident #1 back to bed. He stated that he usually checked vital signs himself. He stated that he told CNA A that he would notify the NP and get an X-ray, but he did not have time to call the NP until after Resident #1 had passed away. He stated that after Resident #1 scooted away in her wheelchair, he went into the medication room and got the morning insulin and the treatment cart. He stated that he had six to eight insulin injections to give that morning. He stated that he then headed down the 500 hall with his treatment cart and at that point, he was just worried about getting out there with his insulins. He stated that he got just a little ways down the 500 hall near the water cooler and heard CNA B call out, "LVN E (by his name), come quick, she's fallen!" LVN E stated that he immediately followed CNA B around to the 400 hall. He didn't know who the CNA was talking about at first. He stated that Resident #1 was on the floor. LVN C was leaning directly over Resident #1 who was in a fetal position with her head on the floor, leaning slightly to her right side against a door. He stated that LVN C rolled Resident #1 to her side and maintained her airway. He noticed dark liquid coming from her nose and mouth. Resident #1 took a rapid shallow breath. He stated that her skin color had drastically changed from normal to a very dark dusky grey color. LVN E stated that he thought LVN D was also there assisting by that time. He stated that they placed Resident #1 in her wheelchair and he and LVN D quickly wheeled her to her room on the 500 hall. He stated that she was still alive and had taken a few more breaths as they wheeled down the hall. He stated that LVN D grabbed the oxygen saturation monitor from the nurses' station on the way and LVN F saw them go by her office and followed them to Resident #1's room. He stated that he and LVN F lifted Resident #1 into her bed, positioned her on her side in case of further emesis and maintained an open airway. He and LVN F stayed with Resident #1 while LVN D went to get oxygen, an oxygen mask and the vital sign machine. He stated she returned quickly and oxygen by face mask was placed on Resident #1 and the oxygen was turned "wide open" (15 liters/minute). He stated that as he and LVN F continued to work with Resident #1, LVN D went to the nurses' station to notify the NP, family and call EMS (Emergency Medical Services). He stated that they were never able to get a pulse, blood pressure or oxygen saturation on Resident #1 and as he was heading to the nurses' station to call the NP and inform her that Resident #1 had passed away. He stated that he looked at his watch and it was 7:09 AM. LVN E stated that LVN D had just gotten off the phone with EMS and told him that she was going to call [DATE] because EMS had an estimated time of arrival of 15 minutes. He stated that he informed LVN D that Resident #1 had passed away and she did not have to call [DATE]. He stated that he then called the NP at 7:11 AM and informed her that Resident #1 had passed away. He informed her that they were unable to get oxygen saturation on Resident #1 and that Resident #1 did not have a heart beat, blood pressure, pulse or respirations; her eyes were fixed and dilated and her skin was dark and dusky. He stated that the NP told him that Resident #1 had obviously expired and to call the family and release Resident #1's body to the Funeral Home of their choice. He stated that he attempted to call Resident #1's primary responsible party and was not able to reach her. LVN E stated that he reached Resident #1's secondary responsible party by telephone at approximately 7:15 AM. He stated that he briefly explained what had happened with Resident #1 to her secondary responsible party and informed her that Resident #1 had expired. He stated that Resident #1's secondary responsible party informed him that she would notify the responsible party. He stated that after some time went by (approximately an hour) and he had not heard from Resident #1's responsible party, he attempted to call her again and was not able to reach her. LVN E stated that about that time LVN D informed him that she had just gotten off of the phone with Resident #1's responsible party and that they were franticly looking for a Funeral Home. He stated that the Funeral Home called him at the facility at approximately 10:00 AM. He stated that the Funeral Home Attendant arrived and Resident #1's body was released at 10:30 AM. The Funeral Home Attendant did not ask questions of him and he did not volunteer information to her regarding Resident #1's death. LVN E stated that later in the day the Funeral Home Attendant called the facility and said that Resident #1's family was under the impression that Resident #1 had expired as a result of a fall. LVN E stated that when Resident #1 was brought to the nurses' station by CNA A that morning, he heard "rattling" in her chest but she was not in any distress at that time or he would have thoroughly assessed her right then with full vital signs. He probably would have listened to her lungs with a Stethoscope and called the NP right then. He stated that since she was not in any distress at that time and she wheeled herself away in her wheelchair as she always did, he went to administer insulin on the 500 hall. In an interview on [DATE] at 12:23 PM CNA A stated that she went to work at 6:00 AM on [DATE] and at 6:15 AM she went to check on Resident #1. Resident #1 had vomited in her bed. She stated that it was a large amount of dark brown vomit. CNA A stated that she cleaned Resident #1 up, changed her bed linens and transferred her from her bed to her wheelchair. She stated that Resident #1 was not verbal and was looking at her. She had made a "weird" moaning noise when CNA A sat her up. CNA A stated that as soon as she placed Resident #1 in her wheelchair, she started scooting away like she usually did. CNA A stated that as soon as she opened the door Resident #1 was scooting down the hallway in her wheelchair. CNA A stated that she caught up with Resident #1 and took her to the nurses' station to see the nurse. She stated that she informed LVN E that Resident #1 had vomited and was making a weird noise. She stated that LVN E heard a "rattle" in Resident #1's chest. She stated that she then left Resident #1 with LVN E and went to get other residents out of bed. She stated that after taking care of another resident, she came out of the room to see LVN E and LVN D wheeling Resident #1 in her wheelchair, down to her room, very quickly. She stated that she did not know what had happened. Review of nurses' notes dated [DATE] by LVN D reflected that she was called to the 400 hall by the 400 hall nurse. Resident #1 was lying face down on the floor, curled up in a ball and leaning against a door. She had dark liquid on her clothing and coming from her nose and mouth. She was rolled onto her left side to obtain a patent airway. The 500 hall nurse arrived and we transported Resident #1 to her room. The Minimum Data Set (MDS) nurse arrived in the room to assist. LVN D went to get an oxygen tank, an oxygen mask and the vital sign machine while the 500 hall nurse and MDS nurse remained with the resident. LVN D then went to notify Resident #1's Nurse Practitioner (NP) of Resident #1's change and transport. The NP gave orders to send Resident #1 to the emergency room (ER) for evaluation and treatment if the family is all right with hospitalization . A call was placed to Resident #1's responsible party. There was no answer and a message was left to call the facility as soon as possible (ASAP). A call was placed to Resident #1's second contact. She was informed of the changes and stated that the family would want her to go to the hospital for treatment. Emergency Medical Services (EMS) was contacted. They gave an estimated time of arrival of 15 minutes. LVN D informed EMS that she would contact [DATE]. Upon hanging up the telephone, the 500 hall nurse stated that Resident #1 had passed and not to call [DATE]. In an interview on [DATE] at 10:05 AM, the Nurse Practitioner (NP) stated that Resident #1 had been having a steady decline in her physical health over the past six months. She stated that Resident #1 had an episode of choking and [MEDICAL CONDITIONS] on [DATE]. She was having weight loss, not eating well and taking more rest periods during the day. She stated that as recently as [DATE], Resident #1 had a chest x-ray done due to a report that she was having a cough. she stated she placed Resident #1 on a cough medication and [MEDICATION NAME] tablets (a medication used to treat airway spasms). the NP added that Resident #1's x-ray was negative for Pneumonia or an Upper Respiratory Infection and she was not placed on Antibiotics. She stated that on [DATE] she was informed by LVN E that Resident #1 had fallen and that there was brown vomit surrounding the circumstances. She stated that she was not aware that Resident #1 was taken to the nurses' station after vomiting and had "rattling" in her chest. She stated she would be concerned that Resident #1 had aspirated after vomiting. She stated that Resident #1 had swallowing problems and no control over her airway. The NP stated that LVN E should have listened to her lungs with a stethoscope, obtained oxygen saturation and vital signs at that time and then called her. She would have had a better idea as to whether Resident #1 had aspirated and how much aspirate had he (LVN E) made that assessment and call. However, she stated that she would have ordered a chest x-ray and possibly some STAT (immediate) blood work but it would not have changed the outcome for Resident #1 in that short period of time. Review of a nurses' note dated [DATE] at 6:50 AM LVN E reflected that CNA A brought Resident #1 to the nurses' station and stated that Resident #1 had vomited and was "rattlely" when she breathed. LVN E squatted down to assess Resident #1 and immediately noted audible rattling. LVN E listened for gurgling sounds but none noted. Her nail beds were pink and her skin color was good. Her respirations were even and non-labored. She was in no respiratory distress. She rolled away in her wheelchair per self without difficulty. LVN E informed CNA A that he would notify the NP and get orders to obtain a chest X-ray, labs and whatever else the NP ordered. Review of nurses' notes dated [DATE] at 7:00 AM LVN E reflected that he was called to the 400 hall by CNA B who was yelling out "LVN E, come quick! Resident #1 is on the floor!" When LVN E got to Resident #1, LVN C and LVN D were working on Resident #1 to maintain a patient airway. Resident #1 had vomited approximately 40 to 50 milliliters of dark brown liquid. LVN E immediately noted a change in Resident #1's skin color to a dark dusky color. Her respirations were irregular and shallow. LVN C and this nurse assisted Resident #1 into her wheelchair. LVN D and this nurse quickly transported Resident #1 to her room. LVN D grabbed an oxygen saturation monitor and began trying to obtain an oxygen saturation level as we were going to her room. Resident #1 had been unresponsive since this nurse arrived on the scene on the 400 hall. When we arrived at Resident #1's room LVN F, the Minimum Data Set (MDS) coordinator was there and assisted this nurse in transferring Resident #1 to her bed. Resident #1 was positioned to maintain a patent airway. LVN D stated that she was going after an oxygen tank, oxygen mask and the vital sign machine while LVN F worked with Resident #1 to maintain a patent airway in case of more emesis. This nurse continued to attempt to obtain an oxygen saturation level. LVN D returned to Resident #1's room with oxygen, oxygen mask and the vital sign machine. LVN F and this nurse placed Resident #1 on oxygen. LVN D stated she was returning to the nurses' station to call the NP, family and transport if needed or ordered. LVN F began attempting to obtain a blood pressure and pulse while this nurse continued to attempt to obtain an oxygen saturation level using two different oxygen saturation monitors. LVN E observed Resident #1 take two short breaths and then rapidly exhaled. After no breathing was noted for a few seconds, a stethoscope was used to locate an apical heart beat. Neither LVN F nor LVN E could auscultate an apical heart beat. Resident #1 had no respirations, no blood pressure, no heart beat, and no oxygen saturation. Her skin was dark and mottled. Her nail beds were blue and her pupils were fixed and dilated. This nurse informed LVN F that he was going to the nurses' station to call the NP and notify her of our assessment. The time was 7:09 AM. LVN D, who was at the nurses' station had called EMS and was about to call [DATE]. She was informed not to call [DATE] due to the assessment by LVN E and LVN F's assessment. LVN E then placed a call to the Nurse Practitioner and received orders to release the body to the funeral home of the family's choice. In an interview on [DATE] at 9:30 AM CNA B stated that she was working the 6:00 AM to 2:00 PM shift on [DATE]. She stated that she went to answer a call light near the front of the 400 hall (room [ROOM NUMBER]). She stated she had not seen Resident #1 yet that day and she was not on the 400 hall when she went into room [ROOM NUMBER] to answer the call light. She stated that she was in the room for approximately five minutes and when she came out, Resident #1 was on the floor with her wheelchair behind her. She was face down, curled up like a ball. She stated that she saw LVN C at the end of the 400 hall with a meal tray in her hand. She called LVN C, who immediately put the food tray down and came up the hall. She stated that when LVN C got to Resident #1 she said to get the 500 hall nurse. CNA B stated that she ran around to the 500 hall where LVN E was standing at his treatment cart near the middle of the hall. She stated that LVN E ran to the 400 hall where Resident #1 was on the floor. She stated that LVN E and LVN C turned Resident #1 to her side, her skin was pale and there was a dark liquid stain on the floor that seemed to have come from her mouth. In an interview on [DATE] at 9:00 AM LVN C stated that she got to work around 6:00 AM on [DATE] and got busy on her assigned hall (400 hall). She stated that she was about in the middle of the 400 hall when CNA B, who was at the front of the 400 hall, yelled my name and waved me over. She said that Resident #1 was on the floor. LVN C stated that she ran to the front of the hall and saw Resident #1 on the floor. She had dark colored emesis coming from her nose and mouth that seemed to be blocking her airway. She stated that she sent CNA B to get LVN E from the 500 hall and that she saw LVN D at the nurses ' station and called her over. They rolled Resident #1 to her side and cleared her airway and Resident #1 was breathing. She stated that she assisted LVN E and LVN D took Resident #1 to her room in her wheelchair and she stayed on her assigned hall. In an interview on [DATE] at 2:35 PM LVN D stated that on the morning of [DATE] the 400 hall nurse, LVN C called me to the 400 hall where Resident #1 was on the floor. It appeared as if she had fallen from her wheelchair. She stated that they rolled Resident #1 to her side and she had what looked like emesis coming from her nose. She stated that the 500 hall nurse, LVN E arrived and they got Resident #1 into her wheelchair and wheeled her to her room, grabbing the oxygen saturation monitor off the nurses' station on the way. She stated that Resident #1 was breathing at that time but she could tell that her respirations had changed. She stated that LVN E and LVN F stayed with Resident #1 in her room while she went to get oxygen, an oxygen mask and the vital sign machine and took them to LVN E and F. She stated that she then went to the nurses' station to call the Nurse Practitioner, Resident #1's responsible party and EMS. She stated that the NP ordered to send Resident #1 to the ER if the family agreed to hospitalization . She stated that she called Resident #1's responsible party and did not get an answer so she left a message. She then called Resident #1's secondary contact and informed her that Resident #1 had vomited and fallen out of her wheelchair. Resident #1's secondary contact agreed to send Resident #1 to the ER. LVN D stated that she then called EMS who informed her that they would not be able to respond for approximately 15 minutes. She stated that she was about to call [DATE] when LVN E came to the nurses' station and informed her not to call [DATE] because Resident #1 had passed away. Review of consolidated physician's orders [REDACTED]. She had [MEDICATION NAME] Nebulizer treatment (breathing treatment used to decrease swelling of the airway passages to ease wheezing, difficulty breathing or coughing) ordered every six hours as needed (PRN) for shortness of breath or wheezing. However review of the Medication Administration Records (MAR) dated [DATE], [DATE] and [DATE] reflected Resident #1 had not received any [MEDICATION NAME] treatments in that three month period of time. Review of Weekly Nursing summaries from [DATE]/through [DATE] reflected Resident #1 had swallowing difficulty, her respirations were even and unlabored and she received no Nebulizer treatments or oxygen. Review of the Minimum Data Set ((MDS) dated [DATE] (Quarterly), [DATE] (Annual) and [DATE] (Quarterly) reflected Resident #1 had difficulty chewing and swallowing. Review of the current care plan dated [DATE] reflected Resident #1 was on a pureed diet with honey thickened liquids due to difficulty swallowing. Review of nurses' notes from [DATE] through [DATE] reflected Resident #1 had wheezing on [DATE], wheezing during dinner on [DATE], a cough on [DATE] and her lungs were clear to auscultation on [DATE]. There was no other documentation of wheezing or rattling in her chest until [DATE]. Review of the facility's undated policy and procedure for Significant Change in Resident Status reflected that as a significant change in the resident's condition occurs, the charge nurse will notify the physician, family or other appropriate person/agency of the significant change immediately. If a question about the seriousness of any significant change in condition exists, the operating philosophy of this facility is always to notify appropriate persons immediately. Review of " Prevention of Aspiration Pneumonia: A Research-Based Protocol reflected that Aspiration Pneumonia can progress to necrotizing lung infections, abscess formation and empyema (puss in the pleural space surrounding the lungs). Signs of Tachypnea (rapid respirations), cough, rales (a crackling or rattling noise in the lungs), cyanosis (blue or purple coloration of the skin due to a insufficient oxygen in the blood), wheezing, fever, Leukocytosis and occasionally apnea develop usually within two hours of the Aspiration. <http://www.pspinformation.com/disease/aspiration/pneu.shtml> Review of the facility's CMS form 802 reflected a facility census of 102. There were 26 residents in the facility with swallowing difficulty.