Every finding on record at Park View Nursing Care Center

Based on observations, interviews, and record reviews the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 2 (Resident #1 and Resident #2) of 5 residents reviewed for abuse/neglect policy implementation.The facility failed to implement their abuse policy and report to state within 2 hours when Resident #2's family member alleged to RN F that Resident #1 entered Resident #2's room and hit her in the face on the evening of 03/19/26.This failure could place residents at risk of abuse and neglect occurring and/or continuing.Findings Included:Record review of Resident #1's admission record dated 04/01/26 revealed an [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning) and pseudobulbar affect (inappropriate involuntary laughing and crying due to a nervous system disorder).Record review of Resident #1's quarterly MDS completed on 03/27/26 revealed a BIMS of 4 which indicated severely impaired cognition. Section E Behavior revealed Resident #1 had physical behavioral symptoms and verbal behavioral symptoms directed toward others 1-3 days of the look-back period.Record review of Resident #1's care plan completed on 02/02/26 revealed no mention of behaviors directed toward others. Resident #1 was noted to have wandering behavior.Record review of Resident #1's progress notes revealed a note by LVN A on 03/19/26 at 8:47 PM stating Resident #2's family member called RN F and stated Resident #1 was in Resident #2's room hitting Resident #2 in the face. LVN A noted CNA removed Resident #1 and Resident #1 was agitated and scratched the CNA. LVN A noted Resident #1 thought Resident #2's room was her room.Record review of Resident #2's admission record dated 04/01/26 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, chronic obstructive pulmonary disease (inflammation of lung tissue due to non-infectious causes, which results in cough without mucus or phlegm, shortness of breath, and fatigue), congestive heart failure (a progressive heart disease that affects the pumping action of the heart muscles resulting in shortness of breath and fatigue), and Parkinson's disease (chronic and progressive movement disorder that initially causes tremors in one hand and stiffness or slowing of movement).Record review of Resident #2's significant change MDS revealed a BIMS of 14 which indicated intact cognition.Record review of Resident #2's care plan completed on 03/25/26 revealed no mention of issues or conflict with Resident #1.Record review of Resident #2's progress notes revealed the following note with corresponding date and author:A note on 03/19/26 by LVN A This nurse was doing med pass, when Co-nurse from day shift came and was on the phone with Resident's family saying that they were stating that another resident was in [Resident #2]'s room hitting her in the face. Co-nurse and CNAs went to resident's room and got co-resident out of the room and laid her down in bed. Vital signs of resident receiving physical aggression assessed . Resident's skin assessed and no noted bruising or redness. When asked resident if she was having any pain resident stated no. During med pass resident refused sleeping pill because she stated that she did not want to sleep because she did not want the other resident to go in her room again. [Physician] notified of received physical aggression and family aware due to resident calling family during the incident. Resident is currently sitting in recliner awake in her room, even and unlabored breathing noted. No distress noted at this time. Call light is within reach.During an interview on 04/01/26 at 10:20 AM ADM stated she was in the facility on the evening of 03/19/26 when Resident #1 was alleged to have hit Resident #2 in the face. She stated CNA E walked into Resident #2's room and saw Resident #2 attempting to push Resident #1 in her wheelchair out of Resident #2's room.During an interview on 04/01/26 at 11:11 AM CNA H stated she was trained on facility policy to report suspected abuse immediately to ADM or DON.During an interview on 04/01/26 at 11:13 AM COTA stated she was trained on facility policy to report suspected abuse immediately to ADM or DON.During an interview on 04/01/26 at 11:15 AM CNA C stated she was trained on facility policy to report suspected abuse immediately to ADM or DON.During an observation on 04/01/26 at 11:21 AM Resident #1's room was noted to be directly across the hall from Resident #2's room. Resident #2's room had an approximately 7-inch-wide strip of netting hung approximately 3 feet high across the doorway with a stop sign in the middle of the netting. The door to her room was closed behind the netting.During an observation and interview on 04/01/26 at 11:22 AM Resident #2 was seated in the recliner in her room. She stated she had had issues with Resident #1 coming into her room. She stated the last time Resident #1 came into her room she (Resident #2) made the mistake of getting in front of Resident #1 and Resident #1 kicked her in the shins and hit her in the face. She stated it did not hurt. Resident #2 stated she got behind Resident #1 and started pushing her in her wheelchair toward the door of the room when Resident #1 caught the partially open door with her foot and kicked it closed. Resident #2 stated she reopened the door and was attempting to push Resident #1 out the door when CNAs came in and wheeled Resident #1 out of her room. Resident #2 stated after the incident staff offered to move her to a room on another hall, but she declined as she likes her current room.During an interview on 04/01/26 at 11:38 AM HSK stated she had been trained on facility's policy to report abuse immediately to ADM or DON.During an interview on 04/01/26 at 11:55 AM RN F stated Resident #1 had dementia and would frequently go into other residents' rooms and use their bathrooms. She stated Resident #1 had not been physically aggressive with other residents to her knowledge. RN F stated Resident #1 had difficulty hearing and seeing and those conditions combined with her dementia caused her to get resistive to care and occasionally physically aggressive with staff if they did not slowly explain to her what they were going to do when moving her in her wheelchair or providing care for her. RN F stated Resident #1 would hit and/or kick at staff when she became upset or confused. She stated she was trained on the facility policy to report abuse immediately at least weekly.During an observation and attempted interview on 04/01/26 at 01:40 PM Resident #1 was in the hospital in her bed with the head of the bed raised to seated position. She stated she was doing okay. Resident #1 appeared unable to hear questions regarding altercation with Resident #2 and/or unwilling to answer said questions.During an interview on 04/01/26 at 03:53 PM Resident #2's family member stated Resident #2 called her on 03/19/26 to say Resident #1 tried to get in her room again and hit her. Resident #2's family member stated she visited Resident #2 at the facility and Resident #2 seemed to be okay and not worried and there was not a mark on her. She stated that Resident #2 told her she wished she had not said anything because she did not want to get Resident #1 in trouble. Resident #2's family member stated she did not think Resident #1 hurt Resident #2 in the altercation. She stated the facility offered to move Resident #2 to a hall away from Resident #1 but Resident #2 was having enough trouble adjusting to being in the facility and the family agreed a room change was not a good idea at the time.During an interview on 04/01/26 at 04:24 PM DON stated she expected staff to report suspected abuse immediately to her and/or ADM. She stated a possible negative outcome of not reporting suspected abuse immediately was it would continue.During an interview on 04/01/26 at 04:48 PM ADM stated suspected abuse was to be reported immediately to her or DON and within 2 hours to the state, otherwise a resident would be negatively affected. She stated LVN A would be disciplined for not reporting the incident between Resident #1 and Resident #2 immediately. She stated she thought the timing was off, that the incident happened earlier in the day and not when Resident #2's family called RN F. She stated when the family called RN F and LVN A went to the doorway of Resident #2's room and spoke to her but Resident #1 was not in her room at that time.During an interview on 04/01/26 at 05:07 PM Resident #1's family member stated he was notified Resident #1 went into another resident's room and was physically aggressive. He stated, But I mean she's (Resident #1) got dementia, she doesn't know. She is not doing it on purpose.During an interview on 04/01/26 at 05:35 PM ADON stated she expected staff to report suspicion of abuse immediately to her, DON, or ADM. She stated she and DON had trained staff 'til we are blue in the face on reporting abuse and neglect. She stated a possible negative outcome of not reporting abuse immediately was more harm or damage could happen to a resident.During an interview on 04/01/26 at 06:02 PM RN F stated on 03/19/26 she was staying late in the facility to chart, and she answered the phone at the nurses' station. She stated it was Resident #2's family member calling to say another resident was in Resident #2's room hitting Resident #2. She stated she and LVN A ran down the hall to Resident #2's room and no one was in the room except Resident #2. She stated Resident #2 did not appear to be injured. She stated she told LVN A to report the allegation.During an interview on 04/01/26 at 06:12 PM CNA G stated she was trained regularly on the facility policy of reporting suspected abuse immediately to DON or ADM.During an interview on 04/01/26 at 06:33 PM CNA D stated she was trained regularly on the facility policy of reporting suspected abuse immediately to DON or ADM.During an interview on 04/01/26 at 06:46 PM DON stated LVN A texted the on-call phone which was in her (DON's) possession at 07:24 PM on 03/19/26 regarding the incident between Resident #1 and Resident #2. She stated she was already asleep and did not wake up to the text message. She stated she had a talk with LVN A and told her to call and not text in the future.During an interview on 04/01/26 at 07:35 PM LVN A stated she sent a text to the on-call phone regarding the incident between Resident #1 and Resident #2 on 03/19/26. She stated ADM was in the building at the time of the incident and she believed ADM went down the hall with her and RN F to check on Resident #2 when Resident #2's family member called. She stated when they got to Resident #2's room Resident #1 had already been removed from the room by a CNA. She stated she was trained on the facility policy of reporting suspected abuse immediately to DON or ADM.During an interview on 04/02/26 at 02:37 PM CNA E stated on the evening of 03/19/26 she was headed to Resident #1's room to put her to bed and she found Resident #1 across the hall in Resident #2's room. She stated she saw Resident #2 in her wheelchair behind Resident #1 who was in her wheelchair. CNA E stated Resident #2 was attempting to push Resident #1 out of her room. She stated she went in and wheeled Resident #1 out of Resident #2's room. CNA E stated when she entered Resident #2's room to retrieve Resident #1, Resident #2 said, Oh good, how did you know she (Resident #1) was in here (Resident #2's room)? CNA E stated, A little bit after that the nurse received a phone call from Resident #2's family member and they thought and incident occurred right then and there, but I had already put Resident #1 in her room. She stated she informed LVN A and RN F of finding Resident #1 in Resident #2's room earlier in the evening. She stated Resident #2 was shaken up that evening and kept calling staff until 10 (PM) or midnight to make sure Resident #1 was not in her room. She stated she was trained on the facility's policy of reporting suspected abuse immediately.Record review of facility policy titled Abuse and Neglect - Clinical Protocol and dated 2001 revealed the following, . The management and staff, with physician support, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations.Record review of an undated facility policy titled Abuse, Neglect, and Incident Reporting Requirement revealed the following: All staff are required to immediately report any suspected or alleged abuse, neglect, exploitation, misappropriation of resident property, or unusual incident to the Administrator and Director of Nursing (DON). All reports must remain confidential and only shared with appropriate leadership and regulatory authorities.Record review of an undated facility policy titled CMS F600/F609 Abuse Reporting revealed the following: All allegations must be reported immediately. Immediate reporting to Administrator/DON . Timely reporting to state authorities .Record review of an undated facility New Employee Orientation packet reveals the following: . Report and Investigate . The facility will put in place measures that facilitate and assure the reporting of abuse and neglect within 2 hours of identification or allegation .

Based on observation, interview, and record review the facility failed to, in response to allegations of abuse, neglect, exploitation, or mistreatment, to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 2 (Resident #1 and Resident #2) of 5 residents reviewed for reporting of abuse/neglect allegations.The facility failed to report to state within 2 hours when on 03/19/26 Resident #2's family member alleged to RN F that Resident #1 hit Resident #2 in the face.This failure could place residents at risk of continued abuse/neglect.Findings Included:Record review of Resident #1's admission record dated 04/01/26 revealed an [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning) and pseudobulbar affect (inappropriate involuntary laughing and crying due to a nervous system disorder).Record review of Resident #1's quarterly MDS completed on 03/27/26 revealed a BIMS of 4 which indicated severely impaired cognition. Section E Behavior revealed Resident #1 had physical behavioral symptoms and verbal behavioral symptoms directed toward others 1-3 days of the look-back period.Record review of Resident #1's care plan completed on 02/02/26 revealed no mention of behaviors directed toward others. Resident #1 was noted to have wandering behavior.Record review of Resident #1's progress notes revealed a note by LVN A on 03/19/26 at 8:47 PM stating Resident #2's family member called RN F and stated Resident #1 was in Resident #2's room hitting Resident #2 in the face. LVN A noted CNA removed Resident #1 and Resident #1 was agitated and scratched the CNA. LVN A noted Resident #1 thought Resident #2's room was her room.Record review of Resident #2's admission record dated 04/01/26 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, chronic obstructive pulmonary disease (inflammation of lung tissue due to non-infectious causes, which results in cough without mucus or phlegm, shortness of breath, and fatigue), congestive heart failure (a progressive heart disease that affects the pumping action of the heart muscles resulting in shortness of breath and fatigue), and Parkinson's disease (chronic and progressive movement disorder that initially causes tremors in one hand and stiffness or slowing of movement).Record review of Resident #2's significant change MDS revealed a BIMS of 14 which indicated intact cognition.Record review of Resident #2's care plan completed on 03/25/26 revealed no mention of issues or conflict with Resident #1.Record review of Resident #2's progress notes revealed the following note with corresponding date and author:A note on 03/19/26 by LVN A This nurse was doing med pass, when Co-nurse from day shift came and was on the phone with Resident's family saying that they were stating that another resident was in [Resident #2]'s room hitting her in the face. Co-nurse and CNAs went to resident's room and got co-resident out of the room and laid her down in bed. Vital signs of resident receiving physical aggression assessed . Resident's skin assessed and no noted bruising or redness. When asked resident if she was having any pain resident stated no. During med pass resident refused sleeping pill because she stated that she did not want to sleep because she did not want the other resident to go in her room again. [Physician] notified of received physical aggression and family aware due to resident calling family during the incident. Resident is currently sitting in recliner awake in her room, even and unlabored breathing noted. No distress noted at this time. Call light is within reach.During an interview on 04/01/26 at 10:20 AM ADM stated she was in the facility on the evening of 03/19/26 when Resident #1 was alleged to have hit Resident #2 in the face. She stated the CNA E walked into Resident #2's room and saw Resident #2 attempting to push Resident #1 in her wheelchair out of Resident #2's room. She stated Resident #2 was offered a room on another hall further away from Resident #1, but she declined. She stated Resident #1 was out of the facility at the hospital and when she returned the facility planned to move her into a room on a different hall.During an observation on 04/01/26 at 11:21 AM Resident #1's room was noted to be directly across the hall from Resident #2's room. Resident #2's room had an approximately 7-inch-wide strip of netting hung approximately 3 feet high across the doorway with a stop sign in the middle of the netting. The door to her room was closed behind the netting.During an observation and interview on 04/01/26 at 11:22 AM Resident #2 was seated in the recliner in her room. She stated she had had issues with Resident #1 coming into her room. She stated the last time Resident #1 came into her room she (Resident #2) made the mistake of getting in front of Resident #1 and Resident #1 kicked her in the shins and hit her in the face. She stated it did not hurt. Resident #2 stated she got behind Resident #1 and started pushing her in her wheelchair toward the door of the room when Resident #1 caught the partially open door with her foot and kicked it closed. Resident #2 stated she reopened the door and was attempting to push Resident #1 out the door when CNAs came in and wheeled Resident #1 out of her room. Resident #2 stated after the incident staff offered to move her to a room on another hall, but she declined as she likes her current room.During an interview on 04/01/26 at 11:55 AM RN F stated Resident #1 had dementia and would frequently go into other residents' rooms and use their bathrooms. She stated Resident #1 had not been physically aggressive with other residents to her knowledge. RN F stated Resident #1 had difficulty hearing and seeing and those conditions combined with her dementia caused her to get resistive to care and occasionally physically aggressive with staff if they did not slowly explain to her what they were going to do when moving her in her wheelchair or providing care for her. RN F stated Resident #1 would hit and/or kick at staff when she became upset or confused.During an observation and attempted interview on 04/01/26 at 01:40 PM Resident #1 was in the hospital in her bed with the head of the bed raised to seated position. She stated she was doing okay. Resident #1 appeared unable to hear questions regarding altercation with Resident #2 and/or unwilling to answer said questions.During an interview on 04/01/26 at 03:53 PM Resident #2's family member stated Resident #2 called her on 03/19/26 to say Resident #1 tried to get in her room again and hit her. Resident #2's family member stated she visited Resident #2 at the facility and Resident #2 seemed to be okay and not worried and there was not a mark on her. She stated that Resident #2 told her she wished she had not said anything because she did not want to get Resident #1 in trouble. Resident #2's family member stated she did not think Resident #1 hurt Resident #2 in the altercation.During an interview on 04/01/26 at 04:24 PM DON stated she expected staff to report suspected abuse immediately. She stated a possible negative outcome of not reporting suspected abuse immediately was it would continue.During an interview on 04/01/26 at 04:48 PM ADM stated suspected abuse was to be reported immediately to DON or ADM and within 2 hours to the state, otherwise a resident would be negatively affected. She stated LVN A would be disciplined for not reporting the incident between Resident #1 and Resident #2 immediately. She stated she thought the timing was off, that the incident happened earlier in the day and not when Resident #2's family called RN F. She stated when the family called RN F and LVN A went to the doorway of Resident #2's room and spoke to her but Resident #1 was not in her room at that time.During an interview on 04/01/26 at 05:07 PM Resident #1's family member stated he was notified Resident #1 went into another resident's room and was physically aggressive. He stated, But I mean she's (Resident #1) got dementia, she doesn't know. She is not doing it on purpose.During an interview on 04/01/26 at 05:35 PM ADON stated she expected staff to report suspicion of abuse immediately to her, DON, or ADM. She stated she and DON had trained staff 'til we are blue in the face on reporting abuse and neglect. She stated a possible negative outcome of not reporting abuse immediately was more harm or damage could happen to a resident.During an interview on 04/01/26 at 06:02 PM RN F stated on 03/19/26 she was staying late in the facility to chart, and she answered the phone at the nurses' station. She stated it was Resident #2's family member calling to say another resident was in Resident #2's room hitting Resident #2. She stated she and LVN A ran down the hall to Resident #2's room and no one was in the room except Resident #2. She stated Resident #2 did not appear to be injured. She stated she told LVN A to report the allegation.During an interview on 04/01/26 at 06:46 PM DON stated LVN A texted the on-call phone which was in her (DON's) possession at 07:24 PM on 03/19/26 regarding the incident between Resident #1 and Resident #2. She stated she was already asleep and did not wake up to the text message. She stated she had a talk with LVN A and told her to call and not text in the future.During an interview on 04/01/26 at 07:35 PM LVN A stated she sent a text to the on-call phone regarding the incident between Resident #1 and Resident #2 on 03/19/26. She stated ADM was in the building at the time of the incident and she believed ADM went down the hall with her and RN F to check on Resident #2 when Resident #2's family member called. She stated when they got to Resident #2's room Resident #1 had already been removed from the room by a CNA.During an interview on 04/02/26 at 02:37 PM CNA E stated on the evening of 03/19/26 she was headed to Resident #1's room to put her to bed and she found Resident #1 across the hall in Resident #2's room. She stated she saw Resident #2 in her wheelchair behind Resident #1 who was in her wheelchair. CNA E stated Resident #2 was attempting to push Resident #1 out of her room. She stated she went in and wheeled Resident #1 out of Resident #2's room. CNA E stated when she entered Resident #2's room to retrieve Resident #1, Resident #2 said, Oh good, how did you know she (Resident #1) was in here (Resident #2's room)? CNA E stated, A little bit after that the nurse received a phone call from Resident #2's family member and they thought and incident occurred right then and there, but I had already put Resident #1 in her room. She stated she informed LVN A and RN F of finding Resident #1 in Resident #2's room earlier in the evening. She stated Resident #2 was shaken up that evening and kept calling staff until 10 (PM) or midnight to make sure Resident #1 was not in her room.Record review of facility policy titled Abuse and Neglect - Clinical Protocol and dated 2001 revealed the following, . The management and staff, with physician support, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations.Record review of an undated facility policy titled Abuse, Neglect, and Incident Reporting Requirement revealed the following: All staff are required to immediately report any suspected or alleged abuse, neglect, exploitation, misappropriation of resident property, or unusual incident to the Administrator and Director of Nursing (DON). All reports must remain confidential and only shared with appropriate leadership and regulatory authorities.Record review of an undated facility policy titled CMS F600/F609 Abuse Reporting revealed the following: All allegations must be reported immediately. Immediate reporting to Administrator/DON . Timely reporting to state authorities .Record review of an undated facility New Employee Orientation packet reveals the following: . Report and Investigate . The facility will put in place measures that facilitate and assure the reporting of abuse and neglect within 2 hours of identification or allegation .

Based on interview, and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 (Resident #3) of 5 residents reviewed for medication administration.The facility failed to ensure LVN B administered Resident #3's morning medications within an hour of the ordered time on 03/29/26.This failure could place residents at risk of increased disease symptoms and/or diminished quality of life.Findings Included:Record review of Resident #3's admission record dated 04/01/26 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified focal traumatic brain injury with loss of consciousness of unspecified duration sequela (condition resulting from a head injury that leads to specific focal brain damage with long-term effects/complications), post traumatic seizures (seizures that result from a traumatic brain injury), anxiety disorder (a group of mental health conditions characterized by excessive and persistent worry, fear, and nervousness that can significantly interfere with daily life), and other muscle spasm (involuntary, sudden, and often painful contraction of a muscle that cannot relax immediately).Record review of Resident #3's quarterly MDS completed 01/15/26 revealed a BIMS of 3 which indicated severely impaired cognition. Section GG Functional Abilities revealed Resident #3 was dependent across all ADLs.Record review of Resident #3's care plan completed on 02/02/26 revealed the following: . Altered Comfort due to pain R/T bilateral upper and lower extremity contractures, a history of healed fractures and TBI . Analgesics (pain medications) as ordered. Tizanidine (muscle relaxer) as ordered . I have seizure disorder related to TBI . Give seizure medication as ordered by doctor. I am at risk for falls . ensure he is not at edge of bed, [Resident #3] will wiggle and wiggle out of bed to floor.Record review of Resident #33's Order Summary Report dated 04/01/26 revealed the following orders: Cholecalciferol Oral Tablet 25 MCG . Give 3 tablet via G-Tube one time a day related to VITAMIN D DEFICIENCY . Multivitamin Adult Oral Tablet (Multiple Vitamin) Give 1 tablet via G-Tube one time a day related to VITAMIN D DEFICIENCY . Chlorhexidine Gluconate Mouth/Throat Solution 0.12% . Give 15 ml by mouth two times a day for mouth wash twice a day . diazepam Oral Tablet 5 MG . give 1 tablet via G-Tube two times a day related to ANXIETY DISORDER. Docusate Sodium Oral Tablet 100 MG . Give 1 tablet via G-Tube two times a day . levetiracetam Oral Solution 500 MG/5ML . Give 5 ml via G-Tube two times a day related to UNSPECIFIED FOCAL TRAUMATIC BRAIN INJURY WITH LOSS OF CONCIOUSNESS OF UNSPECIFIED DURATION SEQUELA . Baclofen Oral Tablet 5 MG . Give 1 tablet via G-Tube three times a day . related to OTHER MUSCLE SPASM . Buspirone HCI Oral Tablet 10 MG . Give 1 tablet via PEG-Tube three times a day related to ANXIETY DISORDER . tizanidine HCI Oral Tablet 4 MG . Give 2 tablet via G-Tube three times a day related to OTHER MUSCLE SPASM . Enteral Feed Order four times a day Nutren 2.0 250 cc per g-tube 4 times per day .Record review of Resident #3's MAR for March 2026 revealed the following medications with corresponding order times were administered on the morning of 03/29/26 by LVN B.08:00 AM Cholecalciferol Oral Tablet 25 MCG . Give 3 tablet via G-Tube one time a day related to VITAMIN D DEFICIENCY .08:00 AM Multivitamin Adult Oral Tablet (Multiple Vitamin) Give 1 tablet via G-Tube one time a day related to VITAMIN D DEFICIENCY .08:00 AM Chlorhexidine Gluconate Mouth/Throat Solution 0.12% . Give 15 ml by mouth two times a day for mouth wash twice a day .08:00 AM diazepam Oral Tablet 5 MG . give 1 tablet via G-Tube two times a day related to ANXIETY DISORDER.08:00 AM Docusate Sodium Oral Tablet 100 MG . Give 1 tablet via G-Tube two times a day .08:00 AM levetiracetam Oral Solution 500 MG/5ML . Give 5 ml via G-Tube two times a day related to UNSPECIFIED FOCAL TRAUMATIC BRAIN INJURY WITH LOSS OF CONCIOUSNESS OF UNSPECIFIED DURATION SEQUELA .08:00 AM Baclofen Oral Tablet 5 MG . Give 1 tablet via G-Tube three times a day . related to OTHER MUSCLE SPASM .08:00 AM Buspirone HCI Oral Tablet 10 MG . Give 1 tablet via PEG-Tube three times a day related to ANXIETY DISORDER .08:00 AM tizanidine HCI Oral Tablet 4 MG . Give 2 tablet via G-Tube three times a day related to OTHER MUSCLE SPASM .09:00 AM Enteral Feed Order four times a day Nutren 2.0 250 cc per g-tube 4 times per day .Record review of Resident #3's progress notes revealed the following notes with corresponding date, time, and author:A note from 03/29/26 at 11:11 AM by LVN B Resident found by writer on the floor of his room. The resident was lying between the bed and the wall. Fall is unwitnessed. The bed was pushed away from the wall. It was noted by writer that the resident did not have any injuries and there was no noted distress. Resident assisted back to bed by writer and two CNAs. Family, physician, and on-call nurse notified via telephone.A note from 03/29/26 at 02:39 PM by DON Spoke with POA [Resident #3's family member] about resident [Resident #3's name]. [Family member] stated that she had received a phone call from charge nurse [LVN B], LVN that [Resident #3] had fallen between his bed and the wall. The nurse ask [sic] [Family member] to view footage from her camera to see how the fall had occurred as [Resident #3]'s roommate had been in the room and she was afraid he might have caused the fall. [Family member] said according to the camera footage which she started from the time the night CNA went in to change him which was a little before 5am until 10:50am no one entered the room. [Family member] was especially concerned that his 8:00am [sic] medications had no [sic] been given. [Family member] said [Resident #3]'s movements become exaggerated and squirmy when he does not get his medications on time. [Family member] called up here to ask the nurse (LVN B) why she had not given him his am (AM) medications and the nurse (LVN B) told [family member] that she had administered his medications. [Family member] stated that [Resident #3] had become so squirmy that he had literally squirmed himself off the bed.During an observation and interview on 04/01/26 at 10:04 AM Resident #3 was seated in his specialized wheelchair in the common area in front of the television. He had physical therapy carrots on both hands for his hand contractures. He was dressed neatly and his hair appeared to be recently combed. Resident #3 nodded his head indicating yes when asked if staff were kind to him and taking good care of him.During an interview on 04/01/26 at 11:15 AM CNA C stated she was working as a facility floater (someone who helps out the CNAs assigned to every hall as needed) on 03/29/26 when Resident #3 fell out of his bed. She stated the nurse found Resident #3 on the floor and asked for assistance putting him back to bed. CNA C stated, When I went in there he was between the bed and the wall on the floor. The bed was moved out. I think he kicked it and scooted it out from the wall. He was laughing about it. She stated the night CNA told her Resident #3 was moving around in his bed a lot that night.During an observation on 04/01/26 at 11:17 AM of Resident #3's room it was noted a person standing in the doorway of his room observing his bed would not be picked up by the camera in his room due to the position of the camera and the location of his television.During an interview on 04/01/26 at 11:55 AM RN F stated she was working on 03/29/26 but she was not assigned to Resident #3's hall. She was moved to his hall after his fall. RN F stated, I did go and check him out afterward (after the fall) and switched to his hall and he had no issues he was happy .During an interview on 04/01/26 at 03:40 PM Resident #3's family member stated on the morning of 03/29/26 around 11:00 AM LVN B called her and asked her to review the camera footage from Resident #3's room due to him falling out of bed. Resident #3's family member stated she reviewed the camera footage and noticed no staff member entered his room from approximately 05:00 AM until LVN B walked in and found him on the floor. She stated Resident #3's roommate appeared to find him on the floor and leave to alert LVN B. Resident #3's family member stated she called DON to tell her what she found during her review of the camera footage.During an interview on 04/01/26 at 04:24 PM DON stated on 03/29/26 she spoke to LVN B and LVN B told her she gave Resident #3 his medications at 10:50 AM. However, DON stated she had Resident #3's family member bring her the video footage to review. She stated according to the video footage at 10:53 AM Resident #3 fell on the floor and his roommate walked over and said something to him and left the room. At 11:09 LVN B entered the room for the first time followed by Resident #3's roommate and found Resident #3 on the floor. DON stated prior to falling, Resident #3 was moving around in his bed and was kicking the wall causing his bed to move away from the wall each time he kicked. DON stated it was absolutely an issue that the nurse did not see Resident #3 until 11:09 AM. She stated, Somebody should have checked on that poor boy. DON stated, If he doesn't get his meds all of his movements get exaggerated. She stated, He has a lot of spasticity and less ability to control that spasticity when his medications are not administered in a timely manner. DON stated staff have one hour before and one hour after the ordered time shown on the MAR to administer medications to residents and she expects them to do so. She stated any time after 09:00 AM was considered late administration for Resident #3 morning medications. She stated LVN B was an agency nurse, and she called the agency to say she did not want LVN B in her facility anymore. DON stated if a nurse administered medications late she was to note that on the MAR according to facility policy.During an interview on 04/01/26 at 04:48 PM ADM stated residents could be negatively impacted if their medications were not administered in a timely manner. She stated, Well, they need their meds for a reason, it might mess with their care.During an interview on 04/01/26 at 05:35 PM ADON stated she expected nurses to administer medications ordered at 08:00 AM on the MAR between 07:00 AM and 09:00 AM. She stated a resident's health could be negatively affected by late medication administration. She stated in Resident #3's case his muscle spasms could worsen if he did not receive his scheduled baclofen (muscle relaxer). During an interview on 04/01/26 at 06:12 PM CNA G stated she worked the night shift ending on 03/29/26 at 6 AM. She stated Resident #3 usually squirms and wiggles throughout the night. She stated his behavior on the night in question was not out of the ordinary.During an interview on 04/01/26 at 06:33 PM CNA D stated she was on the day shift on Resident #3's hall on 03/29/26. She stated she was getting residents up, dressed, and fed and she stopped by Resident #3's room several times and looked in on him and spoke to him. She stated when LVN B found Resident #3 on the floor she had just seen him in his bed approximately 10 minutes prior. CNA D stated when she, CNA C, and LVN B went in to put Resident #3 back in his bed he was laughing and smiling. She stated he did not seem to be in any pain or to be scared.During an interview on 04/02/26 at 10:01 AM LVN B stated she had her medication cart outside Resident #3's room the morning of 03/29/26 and was talking to him. She stated, He likes when you just chat with him. LVN B stated she had had some issues with other residents and when she went into Resident #3's room he was on the floor. She stated she called Resident #3's family member to ask her to review the camera footage and find out what happened. LVN B stated Resident #3's family member never said what happened because she was more concerned about Resident #3 getting his feeding and his medications late. (at this point the phone call cut off)During an interview on 04/02/26 at 10:26 AM LVN B stated she gave Resident #3 his medications late. She stated she was not sure what time she gave him his morning feed and medications, but she thought it was around 10:00 or 10:30 AM. She stated she was not sure what time he was supposed to get his morning medications off the top of her head because she did not work regularly in the facility as she was agency staff. LVN B stated she did not think Resident #3 was negatively impacted by receiving his medications late.Record review of facility policy titled Administering Medications and dated April 2019 revealed the following: . Medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with prescriber orders, including any required time frame. 5. Medication administration times are determined by resident need and benefit, not staff convenience. 7. Medications are administered within one 91) hour of their prescribed time .Record review of facility policy titled Administering Medications through an Enteral Tube and dated November 2018 revealed the following: . Follow medication administration guidelines in the policy entitled Administering Medications.

Based on interviews and record review, the facility failed to establish and maintain an effective system of accounting and record keeping according to generally accepted accounting systems, for 2 of 5 residents (Resident #1, 2) reviewed for trust fund accounting. The facility failed to: Ensure residents with a trust fund were given a full and complete recording of their trust fund transactions when requested (Resident #1)Maintain an accurate running ledger for each resident (Resident #1 and #2)Ensure residents were provided with a financial record of purchases and a quarterly statement at least quarterly or upon request.(Resident #1) These failures could place all residents who had a facility trust fund account at risk of financial misappropriation. Findings included: Findings included:Resident #1 was a 65-y o male admitted to the facility on [DATE] with diagnoses of dementia, Bell's Palsy, depressive disorders and Parkinson's disease. A Care Plan dated 12/23/25 documents resident had tremors, dental issues and was independent in ADLs. A Quarterly MDS dated [DATE] documented a BIMS score of 15 out of 15 which indicates cognition was intact. Resident #2 was a 52-y o female admitted to the facility on [DATE] with diagnoses of multiple sclerosis, congestive heart failure, heart failure and chronic pain. A Care Plan dated 12/9/25 documents resident is dependent on staff for some ADLs and was at risk for pain and falls. A Quarterly MDS dated [DATE] documented a BIMS score of 15 out of 15 which indicates cognition was intact. In an interview on 2/25/26 at 10:15 am, the ADM stated she was not aware of any issues with the resident trust fund accounts. She stated she had switched the shopping duties from the former AD to the former BOM. She stated she did not remember the date of the switch. She stated there were only 2 residents had trust fund accounts. In an interview and record review on 2/25/26 at 2:20 pm Resident #1 stated in December he requested the BOM purchase Christmas presents for various people. He stated he did not see the receipts and did not sign the receipts but stated the main things he wanted were purchased. He stated he was not given any receipts for purchases in Jan or Feb and he was not sure he got all of the items he ordered. He stated he had asked for cokes to be purchased and had not gotten any receipts for that purchase. He stated the BOM had purchased a phone for him as his phone had broken. He stated he did not get a receipt for the phone, and he did not know how much the phone cost. He stated he had to wait for 3 weeks after requesting a new phone and the BOM kept giving him excuses about why she could not get him a phone. He stated she finally did give him a phone, but he did not know where she got it or how much it cost. He stated he did not sign a receipt. He stated this week he had asked for an account statement but had not been provided with a statement since November 2025. He stated he had to ask for a statement from the BOM about his account. He stated he had to ask for the only one he had ever gotten was in November and he had to ask for it He stated he had not gotten any other statements for the trust fund account. He stated he had never seen any accounting of the purchases made or what the receipts said. In an interview on 2/26/26 at 9:00 am the former BOM stated it had been brought to her attention by Resident #1 that Resident #1 was missing cokes, and the AD had gone shopping for him. The BOM stated Resident #1 had asked for money to purchase several large cartons of cokes to be bought so it would last him all month. She stated Resident #1 had been keeping the Cokes in the activity director's office so the Cokes would not disappear from his room. She stated at some point during the month when Resident #1 asked the AD for a coke, the AD stated he did not have any cokes left. The BOM stated Resident #1 had not been made to sign a receipt and she was not given a receipt for the purchases. The former BOM stated when she gave money out, she had the resident sign a receipt. She stated she had always had the residents sign the receipts for purchases. She stated she did not know where the receipts were for the residents' trust fund accounts as she was no longer employed by the facility. In an interview on 2/26/26 at 11:00 am the former AD stated she had never bought items for Resident #1 and had not kept any receipts for any trust fund purchases. In an interview on 2/26/26 at 12:00 pm, Resident #2 stated she had a trust fund account. She stated she was aware she had money in her account and used it as needed but had never gotten an accounting of what was spent or a quarterly statement. In an interview on 2/26/26 at 2:50 pm, the Corporate CEO stated when the former BOM left there were several zippered pouches with random 10.00 bills and little notes. She stated there were no receipts other than the few she had furnished. She stated she did not feel like the BOM had stolen anything, but she did have sloppy documentation. She stated the residents should be able to get a balance and access their trust fund at any time. She stated the facility should be able to produce an accounting of residents' money and what was spent on o monthly basis. She stated she hand the ADM had looked and could not find any further information on trust fund accounts. Record review of the facility bank statement for the month of January 2026 did not reveal any separate purchases for residents with trust fund accounts. The facility trust fund account for Resident #1 for the month of December 2025 did not have receipts or itemized purchase information. Record review of the Resident receipts produced by the facility for Resident #1's purchases included 1 undated receipt for cell phone for 120.00 with no signature of resident, 1 receipt for 60.00 for prepaid phone dated 1/30/26 and one receipt for 66.00 for prepaid phone, dated 1/9/26, 1 receipt for snacks and cokes dated 1/8/26. Review of the signatures for the residents appeared to be different to this writer. Review of Resident Trust fund did not list these amounts in the trust fund paperwork from the facility.Record Review of the facility policy titled Management of Resident Personal Funds dated April 2017 revealed .Should the resident elect to have the facility manage his funds the facility will act as a fiduciary of the resident funds and hold safeguard manage and account for the personal funds of the resident.The resident will be informed in advance of any charges to his personal fund. A copy of all financial transactions will be filed in the resident's permanent record.

Based on interview and record review the facility failed to ensure conveyance of resident funds within 30 days of discharge for 1 of 1 resident (Resident #3) reviewed. The facility failed to ensure Resident #3's funds were conveyed after death within 30 days. This failure could affect residents by not giving them access to funds in a timely manner. Findings include: Resident #3 was an 87-y o female admitted to the facility on [DATE] with diagnoses of unspecified dementia, chronic kidney disease, convulsions, depression, atrial fibrillation and anemia. A Care Plan dated [DATE] documented resident was incontinent, at risk for falls, and had complaints of pain. A Quarterly MDS dated [DATE] documents a BIMS score of 8 out of 15 which indicates cognition was moderately impaired. Review of Resident #3's admission packet did not reveal any family members listed or a power of attorney. Nurse's notes dated [DATE] revealed Resident#3 had a seizure during peri care and was sent to the hospital. Hospital records reviewed indicated Resident #3 had a hemorrhagic stroke and expired in the hospital on [DATE]. In an interview on [DATE] at 2:50 pm the Corporate CEO stated she was aware Resident #3 had a balance in her account, and it had not been conveyed. She stated Resident#3 had not had any visitors and stated she had no family. At the time of her death on [DATE], the former BOM suddenly stated Resident #3 had family and the money needed to go to them. The Corporate CEO stated the facility had no information on the family and had decided to send the money back to the state. She stated the facility had not had time to send the money back. She stated she was aware there was a 30-day period of time in which to send the money back. When asked what the consequences would be she had no answer. Record review of Resident #3's trust fund account statement dated [DATE] revealed a balance of 13,946.81 in her account. Record review of the facility policy titled Refunds dated [DATE] revealed within 30 days of death or discharge, the facility will refund the residents personal funds and provide a final accounting of those funds to the resident, the residents representative or the residents estate.

Based on interviews and record reviews, the facility failed to ensure that residents received treatment and care in accordance with the professional standards of practice and comprehensive person-centered care plan for 1 of 5 residents (Resident #2) who were reviewed for quality of care. The facility failed to provide the care and services to Resident #2 when her physician was not contacted on 1/22/26 at approximately 4:30 a.m. when she was found in her bed unresponsive but still breathing. Because the physician was not contacted or included in Resident #2's change of condition, she did not receive the best care available. An IJ was identified on 2/5/26 at 4:00 p.m. While the IJ was removed on 2/6/26 at 1:57 p.m., the facility remained out of compliance at a scope of isolated with the severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy. This failure could place residents at risk for a delay in treatment or diagnosis, a decline in the resident's condition, the need for hospitalization or death.Findings include: Record review of Resident #2's face sheet revealed Resident #2 was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had the following diagnoses: dementia without behavioral disturbances (presently with signs and symptoms of dementia but lack behavioral symptoms), chronic kidney disease - Stage 4 (irreversible loss of kidney function often causing waste to build up in the blood), Atrial Fibrillation (irregular and often rapid heart rate causing the heart's upper chamber to quiver instead of contracting properly), Depressive episodes (persistent low mood, loss of interest, severe fatigue and difficulty concentrating), personal history of pulmonary embolism (sudden blockage in a lung artery), trigeminal neuralgia (chronic pain condition causing severe, sudden, electric shock-like facial pain), specified diseases of pancreas (diabetes), Fracture of lower end of right femur, cognitive communication deficit, Chronic Obstructive Pulmonary Disease (progressive, inflammatory lung disease), fracture of shaft of right tibia (break in lower leg bone), facture of shaft of right fibula (break in lower leg bone), hypertensive emergency (sudden, severe increase in blood pressure), chronic respiratory failure with hypoxia (respiratory failure with inadequate oxygen at the cellular level), obesity, fracture of lower end of left femur (break in leg), long term use of anticoagulants, macular degeneration (a progressive deterioration of the maculae of the retina and choroid of the eye), hypertension (high blood pressure), cerebrovascular disease (heart disease), spinal stenosis (herniated disks and bone spurs on spine). Resident #2 was the only person listed as the responsible party. Resident #2 was a DNR. Record review of Resident #2's annual MDS assessment, dated 10/14/25, documented the resident scored 12 of 15 on a BIMS for cognitive awareness which indicated moderately impaired cognition. Resident #2 had impairment of both lower extremities, used a wheelchair, substantial assistance with toileting, showering, dressing, personal hygiene, totally dependent on 2 staff for transfers, incontinent, frequent moderate pain, no falls, prescribed an antidepressant, anticoagulant, opioid, antiplatelet and an anticonvulsant. Record review of Resident #2's care plan, last reviewed 7/18/25, revealed Resident #2 was care-planned for:*Refuses to get out of bed for meals despite continuous education on risk of aspiration. Verbalizes understanding of risk of aspiration (when food or liquid is breathed into the airways and lungs instead of being swallowed) but states she knows her rights and has the right to lay in bed and eat if she wishes. Intervention: Continue to educate of the risk for aspiration, continue to encourage Resident #2 to attend meals in the dining room or to set up in chair or edge of bed for meals. Encourage Resident #2 to sit upright for meals, leave call light in reach and check on her frequently throughout meal. Ensure Resident #2 is sitting up in bed during meals, or positioned correctly in bed prior to eating, monitor skin for breakdown. *a seizure disorder related to resection of meningioma (surgical treatment for removing noncancerous tumors from the brain) in 1989. Interventions: Give Dilantin as ordered by doctor. Monitor labs and report any sub therapeutic or toxic results to physician. Dilantin level every 6 months. Post seizure treatment: turn on side with head back, hyper-extended to prevent aspiration, keep airway open, after seizure, take vital signs and neuro check, monitor for aphasia (impairment of ability to speak, understand, read and write), headache, altered level of consciousness, paralysis, weakness or pupillary changes. Seizure documentation: location of seizure activity, type of seizure activity, duration, level of consciousness, any incontinence, sleeping or dazed post-ictal state, after seizure activity. Seizure Precautions: Do not leave alone during a seizure. Protect from injury, if out of bed, help to the floor to prevent injury. Remove or loosen tight clothing. Don't attempt to restrain during a seizure as this could make the convulsions more severe. Protect my privacy. *An alteration of hematological status (overall health of an individual's blood, bone marrow and related components) related to use of Eliquis and NSAID aspirin. Interventions: administer ferrous sulfate and vitamin C as ordered. CBC blood test as ordered every 6 months, Give Eliquis as ordered, monitor for side effects, monitor for any signs or symptoms of bleeding, hard, raised, elevated bruising, hematuria, hematemesis, bleeding gums, bloody stools, notify doctor immediately of any abnormal findings. Monitor/document/report to physician as needed the following signs and symptoms of anemia, pallor (loss of color from skin), fatigue, dizziness, syncope, headache, palpitations, weakness, feeling of cold, low blood count, shortness of breath on exertion, sore tongue, chest pain, tinnitus (ringing in ears), changes in mental status. *Multiple cardiac issues: CAD, hyperlipidemia, atrial Fibrillation, CHF, anemia and HTN. Interventions: Administer oxygen as ordered, continuous oxygen via nasal cannula at 2 liters, ensure medications are given for treatments for conditions, monitor, document and report to physician any signs or symptoms of complications related to A-fib such as chest pain or pressure especially with activity, rapid heart rate, signs or symptoms of poor perfusion, shortness of breath, signs or symptoms of cerebral vascular accident (stroke). Obtain/monitor/report to physician lab work as ordered every 6 months, weights as ordered and as needed. *Altered respiratory status related to sleep apnea and chronic respiratory failure with hypoxia and had an order for CPAP at night but constantly refused to wear it and therefore the order for CPAP was discontinued but uses continuous O2 throughout the day. Interventions: administer inhaler as ordered, encourage resident to use her oxygen at bedtime, keep head of bed elevated. Monitor for signs and symptoms of respiratory distress and report to physician - increased respirations, decreased pulse oximetry, increased heart rate, restlessness, diaphoresis (soaking in a cold sweat not related to heat or exercise), headaches, lethargy, confusion, cough, pleuritic pain (painful inflammation of the lining of the lungs), accessory muscle usage, skin color changes to blue/grey. Record review of Resident #2's nurses notes documented the following:1/22/26 at 6:56 a.m. - documented by the DON - Resident continue follow-up for Nitrofurantoin (antibiotic) for UTI. Nurse was called to the resident's room by CNAs this morning due to resident being unresponsive. Nurse could not get the resident to respond. Vitals signs were WNL, and no distress was noted. Breathing was not labored, and the resident appeared to be resting comfortably with no distress. Told CNAs to increase monitoring and let me know of any changes.1/22/26 at 7:02 a.m. - documented by the DON - called back to resident's room at 4:40 a.m. due to blood in resident's mouth. After cleaning, it was apparent that resident had bitten her bottom lip. Lip and mouth were cleansed, and no further bleeding was noted. Resident #2 still sleeping very soundly and no distress is noted. 1/22/26 at 2:47 p.m. - documented by LVN A - At approximately 11:10 a.m. during peri care, the resident began having seizure activity that lasted approximately 30 seconds. Following seizure, Resident #2 noted to be unresponsive with shallow, labored respirations. Did not respond to tactile (the sense of touch) or painful stimuli. Vital signs - blood pressure 163/89, temperature 97.3 degrees Fahrenheit, respirations 79, pulse 20, oxygen saturation 93% on two liters per minute via nasal cannula. EMS called for transport to the ER at 11:15 a.m. and arrived at the facility at 11:22 a.m. The resident left facility via stretcher at 11:35 a.m. to be transported to hospital via ambulance. The doctor and Administration notified. 1/23/26 at 10:52 a.m. - documented by the DON - The DON got report from hospital that resident passed away in the hospital and was pronounced dead at 5:05 a.m. on 1/23/26. Record review of Hospital Records for Resident #2 documented the following:*A CT scan, dated 1/22/26 at 11:28 a.m., documented a large area of parenchymal hemorrhage (life-threatening type of stroke involving bleeding directly into the brain) within the left temporal frontal lobe (critical area for language comprehension and verbal memory). MRI would be recommended if there is concern for acute stroke.*A chest x-ray revealed slight basilar pneumonia (mild infection affecting the lower bases of both lungs).*1/22/26 at 11:58 a.m. - ED Provider Note: This [AGE] year-old female presents via EMS after seizure activity. Patient witnessed having a grand-mal type seizure. Patient stopped seizing but has yet to regain consciousness. Patient had a blood pressure of 209/119 prior to arrival per EMS. Patient is noted to have Cheyne-Stokes type respirations (dangerous, abnormal breathing pattern characterized by a cycle of shallow breaths that deepen, then shrink, and stop entirely, often lasting 4 seconds to 3 minutes) and is minimally responsive to verbal or painful stimuli.*1/22/26 at 12:17 p.m. - ED Provider Note: Called a larger hospital and spoke with staff on patient logistics line. Spoke with neurosurgery at the hospital after determining that the patient is a DNR/DNI. Neurosurgery agrees with keeping the patient here and providing comfort measures.*Death Summary Report dated 1/23/26 at 5:37 a.m. documented this [AGE] year-old female was admitted to in-patient for comfort care measures after she was found to have a large hemorrhagic stroke to the left side of her brain. Patient was noted to be minimally arousable to painful stimuli. Patient passed away at 5:09 a.m. The patient is DNI/DNR. Physical Exam: General: UnresponsiveEyes: Pupils are unreactiveHeart: No heart tones auscultatedProblems treated this visit: Nontraumatic intracerebral hemorrhage, intraventricular, convulsion disorder. During a telephone interview on 1/29/26 at 10:50 a.m., the DON stated she was working the night shift that night (1/22/26) and the girls (CNAs) were making their last rounds. The DON stated the CNAs called her down to Resident #2's room and she did not notice the resident in any distress. The DON stated Resident #2 seemed like she was sleeping soundly, she cracked her eyes a bit and she just seemed sleepy. The DON stated Resident #2 had blood around her mouth and she cleaned it up and she could see where Resident #2 had bitten her lip. The DON stated she told the day shift to monitor her closely and her vitals were normal, but she was still not responsive. The DON stated she probably should have called the doctor, as it was 4:00 a.m. in the morning, and she was not thinking too clearly. During a telephone interview on 1/29/26 at 1:22 p.m., LVN A stated she was taking care of Resident #2 the day she was sent to the hospital. LVN A stated she was told in report that Resident #2 had a bad night. LVN A stated that morning, she checked Resident #2's vitals when she came on duty and they were fine. LVN A stated after she got Resident #2's vital signs, she was more alert. LVN A stated she checked on Resident #2 later that morning and she was not as alert as she was and looked a little worrisome. LVN A stated she told the CNAs to get her ready to send out to the hospital. LVN A stated she was getting Resident #2's paperwork together and the CNAs came and got her because Resident #2 was having some seizure like activity. LVN A stated EMS was immediately called and Resident #2 was sent out to the hospital. During a follow-up interview on 2/5/26 at 10:15 a.m., the DON stated she was working the floor on the night shift on 1/22/26. The DON stated around 4:30 a.m., the CNAs asked her to go to Resident #2's room because they felt something was wrong. The DON stated Resident #2 was unresponsive but was still breathing without any distress. The DON stated Resident #2 was not acting right. The DON stated she did a sternal rub and Resident #2 opened her eyes slightly but other than that, Resident #2 there was no response when she was asked questions. The DON stated she did not call the doctor then because it was early in the morning, but that absolutely should have told her to call the doctor. The DON stated about 20 minutes later; Resident #2 had some blood on the side of her mouth and had a little bit on the outside of her lip. The DON stated she should have called the doctor then, but she did not. The DON stated she then gave report to LVN A and LVN B, told them that she thought Resident #2 was septic. The DON stated Resident #2's vitals were taken, and they were still normal at that time so the two LVNs thought they would monitor her. The DON stated she went home after that and went to bed During an interview on 2/5/26 at 11:05 a.m., LVN B stated he came on shift on 1/22/26 and Resident #2 was opening her eyes and was nodding her head and answered yes or no questions. LVN B stated later that morning, Resident #2 looked like she had taken a turn for the worse because she seemed less responsive. LVN B stated the doctor was called at that time to send Resident #2 to the hospital. LVN B stated the CNAs were cleaning Resident #2 up and she had seizure activity. LVN B stated when Resident #2 was sent out with EMS, she was unresponsive. During an interview on 2/5/26 at 11:20 a.m., CNA C stated she was taking care of Resident #2 the day she went to the hospital. CNA C stated LVN B told her to start getting Resident #2 cleaned up because she was going to be sent to the hospital. CNA C stated Resident #2 had her eyes closed and she was unresponsive. CNA C stated she turned Resident #2, and she opened her eyes, and she reported that to LVN B. CNA C stated she had another CNA helping her with Resident #2 to get her dressed. CNA C stated that was when Resident #2 had a seizure which was right before EMS got to the facility to take her to the hospital. During an interview on 2/5/26 at 11:50 a.m., Resident #2's physician stated if a resident of his was found to be unresponsive but still breathing, but not talking, even after having a sternal rub, he would want to be notified of that change in condition. Resident #2's physician stated if a resident was unresponsive and had bitten her lip, he would want to be notified. Resident #2's physician stated of the resident had possibly bitten her lip, she could have had a seizure and needed to be sent to out to the hospital. Resident #2's physician stated if he had known that Resident #2 was unresponsive that morning, he would have had her sent out to the hospital right then. Record review of the facility's policy titled, Acute Condition Changes - Clinical Protocol revealed the following:Assessment and Recognition: The physician will help identify, individuals with a significant risk for having acute changes of condition during their stay, for example, an individual with an indwelling urinary catheter who has had recurrent symptomatic urinary tract infections, or someone with unstable vital signs or recurrent pneumonia. In addition, the nurse shall assess and document/report the following baseline information.Vital signsNeurological statusLevel of consciousnessOnset, duration and severity.Direct care staff, including nursing assistants will be trained in recognizing subtle but significant changes in the resident (for example, a decrease in food intake, increased agitation, changes in skin color or condition) and how to communicate these changes to the Nurse.The physician and nursing staff will review the details of any recent hospitalization and will identify complications and problems that occurred during the hospital stay, that may indicate instability or the risk of having additional complications, for example, acute bronchitis or gastrointestinal bleeding in someone with advanced COPD who is receiving corticosteroids after a prolonged, complicated, recent hospitalization.The physician will help identify medications and mediation combinations that are associated with adverse consequences that could cause significant changes in condition.The nursing staff will contact the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response (within approximately one-half hour or less).The Nursing staff will contact the medical director for additional guidance and consultation if they do not receive a timely or appropriate response. The nurse and physician will discuss and evaluate the situation.Cause IdentificationThe staff and physician will discuss possible causes of the condition change based on factors including resident/patient history, current symptoms, mediation regimen and diagnostic test results.Treatment/ManagementThe physician will help identify and authorize appropriate treatments.This was determined to be an Immediate Jeopardy (IJ) on 2/5/26 at 4:00 p.m. The Administrator and DON were notified and were provided with the IJ Template on 2/5/26 at 4:00 p.m. via in person and email. The following Plan of Removal was submitted by the facility and accepted on 2/6/26 at 7:43 a.m.Plan of Removal Plan for F684On 2/5/26 at 4:00 p.m., an Immediate Jeopardy (IJ) was identified related to Tag F684. The facility took immediate action to remove the jeopardy and ensure resident health and safety.Immediate Actions Taken*In-services initiated immediately in relation to notifications of Quality of Care:-Identify changes-Report Immediately-Document thoroughly-Follow facility policy-All changes in conditions - not baseline, will be notified immediately to Administrator/DON/Medical director/Primary Care Physician.*All residents were assessed by nursing staff.Protection of all Residents*All residents were assessed for potential harm related to this IJ on 2/5/26.*Any identified concerns will be addressed immediately.Staff Education*On 2/5/26, the DON was in-serviced by the Corporate RN on Quality of Care and Neurological Assessment.*Staff education was initiated regarding Quality of Care and Neurological Assessment on 2/5/26 and will be completed on 2/6/26. Any staff who cannot be in-serviced by 2/6/26 will be in-serviced before their next shift.*Education included - see attachment.*Attendance was documented.Monitoring to Ensure Ongoing Compliance*The facility-initiated monitoring beginning 2/5/26.*Monitoring includes reviewing daily 24-hour reports and conducting daily resident rounds.*The Administrator/DON/Designee will review findings daily for two weeks, then 3 times weekly for one month.Date of Compliance: 2/6/26 Monitoring of the Plan of Removal included the following: During an interview on 2/6/26 at 10:30 a.m., the DON stated she had all the paperwork for the POR in a folder. The DON stated she had the 24-hour report for this morning, which was reviewed, and things were highlighted for the doctor to be notified. The DON stated that right after the medication passes in the morning, the nurses assess every resident daily Monday through Friday for 4 weeks, then 3 times a week for one month, then once a week for one month. The DON stated they had a base line in-service covering neurological assessments and Quality of Care, and then 43 pages of what was included, and they were working on that in-service right now. The DON stated the education was ongoing as not all staff were available, but would l be in-serviced before they were allowed to work. The DON stated she had a one-on-one directed education by the corporate representative which covered the following areas: changes in condition assessments which is required for traumatic events (fall, injury) and changes in resident's baseline assessment, DON doing daily rounds, including Glascow Coma Scale in assessments, notification of primary physician and emergency contact to determine plan of care, document findings of assessment and notification in medical record. Record Review on 2/6/26 at 10:43 a.m. of the daily assessment sheet which will be used daily to assess every resident in the facility to ensure Quality of Care revealed the nurses will check any physical, behavioral or neurological concerns observed for that day. All residents were assessed from 2/5/26 t0 2/6/26 by checking current vitals, any pain concerns, reviewed progress notes. The physician and family were notified timely of two falls with no injury Record Review of the in-service sheets reflected all staff were trained on the Facility's Plan of Removal, Daily Nurse Assessment Sheet, Change in Condition, Neurological Assessment and Change in Condition, What is a Change of Condition, 24-Hour Summary Reports and Seven Components of Prevention and Detection. Included with the In-service sheets, there was a Directed Education for the DON regarding change in condition assessments and Quality of Care which included: 1. Baseline assessments for each resident, 2. Use of nursing assessment with a change of condition, 3. Notification of primary physician and emergency contact to determine plan of care, and 4. Document findings of assessment and notification in medical record. Interviews on 2/6/26 starting at 11:05 a.m., the following interviews were conducted with staff working in the facility. All staff stated they have all been in-serviced over providing Quality Care to all residents. All nurses knew about daily assessments on all residents that need to be completed, also conducting neurological and behavioral assessments to ensure the residents did not have a change of condition that needed to be reported to the charge nurse or Don, what a change on condition could be and to know each residents baseline and what to look for and how to provide the care each resident needed.Interviews conducted included the following staff:Administrator and DONCNA D, F, GLVN B, EHousekeeping HCOTA IBOM/CMA/CNA JThe following interviews were conducted by telephone of all staff working all shifts, included the following: RNs - M, N, P, TLVNs - V, AA, BB, CCCNAs - K, L, O, Q, R, S, U, W, X, Y, Z The Administrator was informed the Immediate Jeopardy was removed on 2/6/26 at 1:57 p.m. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interviews and record reviews, the facility failed to consult with the resident's physician when there is a significant change in the resident's physical, mental, or psychosocial status: that is, a deterioration in mental health, or psychosocial status in either life-threatening conditions or clinical complications for 1 of 5 residents (Resident #2) for a change of condition. The DON failed to immediately consult with Resident #2's physician when she was found in her bed unresponsive but was still breathing on 1/22/26 at approximately 4:30 a.m. At approximately 11:10 a.m., Resident #2 had seizure like activity and was sent to the hospital. Resident #2 was diagnosed with a non-traumatic brain hemorrhage and subsequently died. An IJ was identified on 2/5/26. The IJ template was provided to the facility on 2/5/26 at 4:00 p.m. While the IJ was removed on 2/6/26 at 1:57 p.m., the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because all staff had not been trained on contacting the physician when a resident has a change of condition. This facility failure placed all residents at risk of serious harm or injury due to delaying possible life saving treatment and/or intervention, possible hospitalization or death.Findings Included: Record review of Resident #2's face sheet revealed Resident #2 was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had the following diagnoses: dementia without behavioral disturbances (presently with signs and symptoms of dementia but lack behavioral symptoms), chronic kidney disease - Stage 4 (irreversible loss of kidney function often causing waste to build up in the blood), Atrial Fibrillation (irregular and often rapid heart rate causing the heart's upper chamber to quiver instead of contracting properly), Depressive episodes (persistent low mood, loss of interest, severe fatigue and difficulty concentrating), personal history of pulmonary embolism (sudden blockage in a lung artery), trigeminal neuralgia (chronic pain condition causing severe, sudden, electric shock-like facial pain), specified diseases of pancreas (diabetes), acute pain due to trauma, Fracture of lower end of right femur, urinary tract infection, ESBL resistance, acute upper respiratory infection, hypocalcemia (low calcium levels in the blood), cognitive communication deficit, muscle weakness, lack of coordination, Chronic Obstructive Pulmonary Disease (progressive, inflammatory lung disease), fracture of shaft of right tibia (break in lower leg bone), facture of shaft of right fibula (break in lower leg bone), hypertensive emergency (sudden, severe increase in blood pressure), ill-defined heart disease, chronic respiratory failure with hypoxia (respiratory failure with inadequate oxygen at the cellular level), obesity, fracture of lower end of left femur (break in leg), long term use of anticoagulants, heart failure, macular degeneration (a progressive deterioration of the maculae of the retina and choroid of the eye), hypertension (high blood pressure), cerebrovascular disease (heart disease), spinal stenosis (herniated disks and bone spurs on spine) and retention of urine. Resident #2 was the only person listed as the responsible party. Resident #2 was a DNR. Record review of Resident #2's annual MDS assessment, dated 10/14/25, revealed the resident scored 12 of 15 on a BIMS for cognitive awareness which indicated she had moderately impaired cognition. Resident #2 had impairment of both lower extremities, used a wheelchair, substantial assistance with toileting, showering, dressing, personal hygiene, totally dependent on 2 staff for transfers, incontinent, frequent moderate pain, no falls, prescribed an antidepressant, anticoagulant, opioid, antiplatelet and an anticonvulsant. Record review of Resident #2's care plan, last reviewed 7/18/25, revealed Resident #2 was care-planned for:*Refuses to get out of bed for meals despite continuous education on risk of aspiration (when food or liquid is breathed into the airways and lungs instead of being swallowed). Verbalizes understanding of risk of aspiration but states she knows her rights and has the right to lay in bed and eat if she wishes. Intervention: Continue to educate of the risk for aspiration, continue to encourage Resident #2 to attend meals in the dining room or to set up in chair or edge of bed for meals. Encourage Resident #2 to sit upright for meals, leave call light in reach and check on her frequently throughout meal. Ensure Resident #2 is sitting up in bed during meals, or positioned correctly in bed prior to eating, monitor skin for breakdown. *a seizure disorder related to resection of meningioma (surgical treatment for removing noncancerous tumors from the brain) in 1989. Interventions: Give Dilantin as ordered by doctor. Monitor labs and report any sub therapeutic or toxic results to physician. Dilantin level every 6 months. Post seizure treatment: turn on side with head back, hyper-extended to prevent aspiration, keep airway open, after seizure, take vital signs and neuro check, monitor for aphasia (impairment of ability to speak, understand, read and write), headache, altered level of consciousness, paralysis, weakness or pupillary changes. Seizure documentation: location of seizure activity, type of seizure activity, duration, level of consciousness, any incontinence, sleeping or dazed post-ictal state, after seizure activity. Seizure Precautions: Do not leave alone during a seizure. Protect from injury, if out of bed, help to the floor to prevent injury. Remove or loosen tight clothing. Don't attempt to restrain during a seizure as this could make the convulsions more severe. Protect my privacy. *An alteration of hematological status (overall health of an individual's blood, bone marrow and related components) related to use of Eliquis and NSAID aspirin. Interventions: administer ferrous sulfate and vitamin C as ordered. CBC blood test as ordered every 6 months, Give Eliquis as ordered, monitor for side effects, monitor for any signs or symptoms of bleeding, hard, raised, elevated bruising, hematuria, hematemesis, bleeding gums, bloody stools, notify doctor immediately of any abnormal findings. Monitor/document/report to physician as needed the following signs and symptoms of anemia, pallor (loss of color from skin), fatigue, dizziness, syncope, headache, palpitations, weakness, feeling of cold, low blood count, shortness of breath on exertion, sore tongue, chest pain, tinnitus (ringing in the ears), changes in mental status. *Multiple cardiac issues: CAD, hyperlipidemia, atrial Fibrillation, CHF, anemia and HTN. Interventions: Administer oxygen as ordered, continuous oxygen via nasal cannula at 2 liters, ensure medications are given for treatments for conditions, monitor, document and report to physician any signs or symptoms of complications related to A-fib such as chest pain or pressure especially with activity, rapid heart rate, signs or symptoms of poor perfusion, shortness of breath, signs or symptoms of cerebral vascular accident (stroke). Obtain/monitor/report to physician lab work as ordered every 6 months, weights as ordered and as needed. *Altered respiratory status related to sleep apnea and chronic respiratory failure with hypoxia and had an order for CPAP at night but constantly refused to wear it and therefore the order for CPAP was discontinued but uses continuous O2 throughout the day. Interventions: administer inhaler as ordered, encourage resident to use her oxygen at bedtime, keep head of bed elevated. Monitor for signs and symptoms of respiratory distress and report to physician - increased respirations, decreased pulse oximetry, increased heart rate, restlessness, diaphoresis (soaking in a cold sweat not related to heat or exercise), headaches, lethargy, confusion, cough, pleuritic pain (painful inflammation of the lining of the lungs), accessory muscle usage, skin color changes to blue/grey. *Urinary incontinence and have a history of chronic urinary tract infections. Interventions: check and change brief at least every 2 - 3 hours for incontinence, wash, rinse and dry soiled areas, encourage adequate fluid intake. Moisture barrier cream/ointment to peri-area after each incontinent episode, monitor intake and output, obtain and monitor lab/diagnostic work as ordered, urinalysis with culture if indicated every month, report results to physician and follow up as indicted. May straight cath as needed. When/If urinary tract infection diagnosed - give antibiotic therapy as ordered. Monitor for side effects. *Renal insufficiency (Stage 4) and am at risk of fluid volume overload due to the decreased renal filtration rate. Interventions: assist with ADLs, watch for shortness of breath and match level of assistance to residents' current energy level. Auscultate (listen to) heart and lung sounds, notify physician of any noted abnormal findings. Elevate feet to help prevent dependent edema (swelling). Monitor and report changes in mental status, lethargy, tiredness, fatigue, tremors or confusion *Impaired cognitive function related to dementia. Interventions: identify yourself at each interaction, face resident when speaking and make eye contact. Reduce any distractions, provide resident with necessary cues - stop and return if agitated, provide a program of activities that accommodate resident's abilities *Impaired visual function related to macular degeneration (progressive eye disease causing central vision loss). Interventions: read and explain any written communication to resident. Resident does not use glasses and does not want them, states her vision cannot be corrected. Report to physician any signs or eye problems. *Potential for communication problems related to hearing deficit. Interventions: be conscious of my age-related hearing loss. Usually have television on very loud so she can hear it. She has headphones but doesn't like to use them. Face to face communication. *Chronic pain. Interventions: Administer medications for pain as ordered. Monitor for effectiveness and report to physician if needed. If pain is present, monitor and record characteristics - sharp or burning - severity from 0 - 10 on pain scale. Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decreased range of motion, withdrawal or resistance to care. Record review of Resident #2's nurses notes revealed the following:1/22/26 at 6:56 a.m. documented by the DON - Resident continue follow-up for Nitrofurantoin (antibiotic) for UTI. Nurse was called to the resident's room by CNAs this morning due to resident being unresponsive. Nurse could not get the resident to respond. Vitals signs were WNL, and no distress was noted. Breathing was not labored, and the resident appeared to be resting comfortably with no distress. Told CNAs to increase monitoring and let me know of any changes. 1/22/26 at 7:02 a.m. - documented by the DON - called back to the resident's room at 4:40 a.m. due to blood in resident's mouth. After cleaning, it was apparent that the resident had bitten her bottom lip. Lip and mouth were cleansed, and no further bleeding was noted. Resident #2 still sleeping very soundly and no distress is noted.1/22/26 at 2:47 p.m. - documented by LVN A - At approximately 11:10 a.m. during peri care, the resident began having seizure activity that lasted approximately 30 seconds. Following seizure, Resident #2 was noted to be unresponsive with shallow, labored respirations. Did not respond to tactile (the sense of touch) or painful stimuli. Vital signs - blood pressure 163/89, temperature 97.3 degrees Fahrenheit, respirations 79, pulse 20, oxygen saturation 93% on two liters per minute via nasal cannula. EMS was called for transport to the ER at 11:15 a.m. and arrived at facility at 11:22 a.m. The resident left facility via stretcher at 11:35 a.m. to be transported to hospital via ambulance. The doctor and Administration were notified. 1/23/26 at 10:52 a.m. - documented by the DON - the DON got report from the hospital the resident passed away in the hospital and was pronounced dead at 5:05 a.m. on 1/23/26. Record review of Hospital Records for Resident #2 documented the following:*A CT scan, dated 1/22/26 at 11:28 a.m., documented a large area of parenchymal hemorrhage (life-threatening type of stroke involving bleeding directly into the brain) within the left temporal frontal lobe (critical area for language comprehension and verbal memory). MRI would be recommended if there is concern for acute stroke.*A chest x-ray revealed slight basilar pneumonia (mild infection affecting the lower bases of both lungs).*1/22/26 at 11:58 a.m. - ED Provider Note: This [AGE] year-old female presents via EMS after seizure activity. Patient witnessed having a grand-mal type seizure. Patient stopped seizing but has yet to regain consciousness. Patient had a blood pressure of 209/119 prior to arrival per EMS. Patient is noted to have Cheyne-Stokes type respirations (dangerous, abnormal breathing pattern characterized by a cycle of shallow breaths that deepen, then shrink, and stop entirely, often lasting 45 seconds to 3 minutes) and is minimally responsive to verbal or painful stimuli.*1/22/26 at 12:17 p.m. - ED Provider Note: Called a larger hospital and spoke with staff on patient logistics line. Spoke with neurosurgery at the hospital after determining that the patient is a DNR/DNI. Neurosurgery agrees with keeping the patient here and providing comfort measures.*Death Summary Report dated 1/23/26 at 5:37 a.m. documented this [AGE] year-old female was admitted to in-patient for comfort care measures after she was found to have a large hemorrhagic stroke to the left side of her brain. Patient was noted to be minimally arousable to painful stimuli. Patient passed away at 5:09 a.m. The patient is DNI/DNR. Physical Exam: General: UnresponsiveEyes: Pupils are unreactiveHeart: No heart tones auscultatedProblems treated this visit: Nontraumatic intracerebral hemorrhage, intraventricular, convulsion disorder. During a telephone interview on 1/29/26 at 10:50 a.m., the DON stated she was working the night shift that night (1/22/26) and the girls (CNAs) were making their last rounds. The DON stated the CNAs called her down to Resident #2's room and she did not notice the resident in any distress. The DON stated Resident #2 seemed like she was sleeping soundly, she cracked her eyes a bit and she just seemed sleepy. The DON stated Resident #2 had been on an antibiotic and she thought Resident #2 might be going septic (severe life-threatening immune response to infection), but she was not sure. The DON stated Resident #2 had blood around her mouth and she cleaned it up and she could see where Resident #2 had bitten her lip. The DON stated she told the day shift to monitor her closely and her vitals were normal, but she was still not responsive. The DON stated the first report she received from the hospital was that Resident #2 had a hemorrhagic stroke (ruptured blood vessel in the brain) because she had bleeding in the brain. The DON stated Resident #2 passed away at the hospital maybe 48 hours after she was sent to the hospital. The DON stated she probably should have called the doctor, as it was 4:00 a.m. in the morning, and she was not thinking too clearly. The DON stated Resident #2 did not have any family, but she did have a family member that was in prison. The DON stated she did not think it was anything too serious with Resident #2 because she was not in distress, she had good color, her vitals were good, and her pupils were equal and reactive. The DON stated she was more concerned that Resident #2 bit her lip. The DON stated Resident #2 was obese and did not want to get out of bed. During a telephone interview on 1/29/26 at 1:22 p.m., LVN A stated she was taking care of Resident #2 the day she was sent to the hospital. LVN A stated she was told in report that Resident #2 had a bad night. LVN A stated that morning, she checked Resident #2's vitals when she came on duty at 6:00 a.m. and they were fine. LVN A stated after she got Resident #2's vital signs, she was more alert. LVN A stated she checked on Resident #2 later that morning and she was not as alert as she was and looked a little worrisome. LVN A stated she told the CNAs to get her ready to send out to the hospital. LVN A stated she was getting Resident #2's paperwork together and the CNAs came and got her because Resident #2 was having some seizure like activity. LVN A stated EMS was immediately called and Resident #2 was sent out to the hospital. LVN A stated she was off for a few days and when she came back to work, she was told Resident #2 had passed away a day or two after being sent to the hospital. During a follow-up interview on 2/5/26 at 10:15 a.m., the DON stated she was working the floor on the night shift on 1/22/26. The DON stated around 4:30 a.m., the CNAs asked her to go to Resident #2's room because they felt something was wrong. The DON stated Resident #2 was unresponsive but was still breathing without any distress. The DON stated Resident #2 was not acting right. The DON stated she did a sternal rub and Resident #2 opened her eyes slightly but other than that, there was no response when she was asked questions. The DON stated Resident #2's pupils were equal and reactive. The DON stated she told the CNAs to monitor Resident #2 closely and to let her know of any changes. The DON stated she did not call the doctor then because it was early in the morning, but she absolutely should have called the doctor. The DON stated about 20 minutes later; Resident #2 had some blood on the side of her mouth and had a little bit on the outside of her lip. The DON stated she cleaned up the blood and there was no further active bleeding. The DON stated she should have called the doctor then, but she did not. The DON stated she then gave report to LVN A and LVN B, told them that she thought Resident #2 was septic. The DON stated Resident #2's vitals were taken, and they were still normal at that time so the two LVNs thought they would monitor her. The DON stated she went home after that and went to bed. The DON stated she received a text later that day that they were sending Resident #2 to the hospital. The DON stated no formal education had been done about notifying doctors and family members of any changes the residents had but she had talked to the nurses about that. During an interview on 2/5/26 at 11:05 a.m., LVN B stated he came on shift on 1/22/26 at approximately 6:00 a.m. and Resident #2 was opening her eyes and was nodding her head and answered yes or no questions. LVN B stated later that morning, Resident #2 looked like she had taken a turn for the worse because she seemed less responsive. LVN B stated the doctor was called at that time to send Resident #2 to the hospital. LVN B stated the CNAs were cleaning Resident #2 up and she had seizure activity. LVN B stated when Resident #2 was sent out with EMS, she was unresponsive. LVN B stated that when there was a change of condition in a resident, he would call the doctor to let them know of the resident's condition. During an interview on 2/5/26 at 11:20 a.m., CNA C stated she was taking care of Resident #2 the day she went to the hospital. CNA C stated LVN B told her to start getting Resident #2 cleaned up because she was going to be sent to the hospital. CNA C stated Resident #2 had her eyes closed and she was unresponsive. CNA C stated she turned Resident #2, and she opened her eyes, and she reported that to LVN B. CNA C stated she had another CNA helping her with Resident #2 to get her dressed. CNA C stated that was when Resident #2 had a seizure which was right before EMS got to the facility to take her to the hospital. During an interview on 2/5/26 at 11:50 a.m., Resident #2's physician stated if a resident of his was found to be unresponsive but still breathing, but not talking, even after having a sternal rub, he would want to be notified of that change in condition. Resident #2's physician stated if a resident was unresponsive and had bitten her lip, he would want to be notified. Resident #2's physician stated of the resident had possibly bitten her lip, she could have had a seizure and needed to be sent to out to the hospital. Resident #2's physician stated if he had known that Resident #2 was unresponsive that morning, he would have had her sent out to the hospital right then. Record review of the facility's policy titled, Acute Condition Changes - Clinical Protocol revealed the following:Assessment and Recognition: The physician will help identify, individuals with a significant risk for having acute changes of condition during their stay, for example, an individual with an indwelling urinary catheter who has had recurrent symptomatic urinary tract infections, or someone with unstable vital signs or recurrent pneumonia. In addition, the nurse shall assess and document/report the following baseline information.Vital signsNeurological statusLevel of consciousnessOnset, duration and severity.Direct care staff, including nursing assistants will be trained in recognizing subtle but significant changes in the resident (for example, a decrease in food intake, increased agitation, changes in skin color or condition) and how to communicate these changes to the Nurse.The physician and nursing staff will review the details of any recent hospitalization and will identify complications and problems that occurred during the hospital stay, that may indicate instability or the risk of having additional complications, for example, acute bronchitis or gastrointestinal bleeding in someone with advanced COPD who is receiving corticosteroids after a prolonged, complicated, recent hospitalization.The physician will help identify medications and mediation combinations that are associated with adverse consequences that could cause significant changes in condition.The nursing staff will contact the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response (within approximately one-half hour or less).The Nursing staff will contact the medical director for additional guidance and consultation if they do not receive a timely or appropriate response. The nurse and physician will discuss and evaluate the situation.Cause IdentificationThe staff and physician will discuss possible causes of the condition change based on factors including resident/patient history, current symptoms, mediation regimen and diagnostic test results.Treatment/ManagementThe physician will help identify and authorize appropriate treatments. This was determined to be an Immediate Jeopardy (IJ) on 2/5/26 at 4:00 p.m. The Administrator and DON were notified and were provided with the IJ Template on 2/5/26 at 4:00 p.m. via in person and email. The following Plan of Removal was submitted by the facility and accepted on 2/6/26 at 7:43 a.m.Plan of Removal Plan for F580On 2/5/26 at 4:00 p.m., an Immediate Jeopardy (IJ) was identified related to Tag F580. The facility took immediate action to remove the jeopardy and ensure resident health and safety.Immediate Actions Taken*In-services initiated immediately in relation to notifications of Quality of Care:-Identify changes-Report Immediately-Document thoroughly-Follow facility policy-All changes in conditions - not baseline, will be notified immediately to Administrator/DON/Medical director/Primary Care Physician.*All residents were assessed by nursing staff.Protection of all Residents*All residents were assessed for potential harm related to this IJ on 2/5/26.*Any identified concerns will be addressed immediately.Staff Education*On 2/5/26, the DON was in-serviced by the Corporate RN on Notification of Change in Condition.*Staff education was initiated regarding Notification of change in conditions on 2/5/26 and will be completed on 2/6/26. Any staff who cannot be in-serviced by 2/6/26 will be in-serviced before their next shift.*Education included - see attachment.*Attendance was documented.Monitoring to Ensure Ongoing Compliance*The facility-initiated monitoring beginning 2/5/26.*Monitoring includes reviewing daily 24-hour reports and conducting daily resident rounds.*The Administrator/DON/Designee will review findings daily (M-F) for 4 weeks, then 3 x weekly for one month and then 1 x weekly for 1 month.Date of Compliance: 2/6/26 Monitoring of the Plan of Removal included the following: During an interview on 2/6/26 at 10:30 a.m., the DON stated she had all the paperwork for the POR in a folder. The DON stated she had the 24-hour report for this morning, which was reviewed, and things were highlighted for the doctor to be notified. The DON stated that right after the medication passes in the morning, the nurses assess every resident daily Monday through Friday for 4 weeks, then 3 times a week for one month, then once a week for one month. The DON stated they had a base line in-service covering neurological assessments, and then 43 pages of what was included, and they were working on that in-service right now. The DON stated the education was ongoing as not all staff were available but would be in-serviced before they were allowed to work. The DON stated she had a one-on-one directed education by the corporate representative which covered the following areas: changes in condition assessments which is required for traumatic events (fall, injury) and changes in resident's baseline assessment, DON doing daily rounds, including Glascow Coma Scale in assessments, notification of primary physician and emergency contact to determine plan of care, document findings of assessment and notification in medical record. Record Review on 2/6/26 at 10:43 a.m. of the daily assessment sheet which will be used daily to assess every resident in the facility revealed the nurses will check any physical, behavioral or neurological concerns observed for that day. All residents were assessed from 2/5/26 t0 2/6/26 by checking current vitals, any pain concerns, reviewed progress notes. The physician and family were notified timely of two falls with no injury. Record Review of the in-service sheets reflected all staff were trained on the Facility's Plan of Removal, Daily Nurse Assessment Sheet, Change in Condition, Neurological Assessment and Change in Condition, What is a Change of Condition, 24-Hour Summary Reports and Seven Components of Prevention and Detection. Included with the In-service sheets, there was a Directed Education for the DON regarding change in condition assessments which included: 1. Baseline assessments for each resident, 2. Use of nursing assessment with a change of condition, 3. Notification of primary physician and emergency contact to determine plan of care, and 4. Document findings of assessment and notification in medical record. Interviews on 2/6/26 starting at 11:05 a.m., were conducted with staff working in the facility. All staff stated they had all been in-serviced over when a resident had a change of condition and who to report it to, if the nurse seemed uninterested or did not pay attention, report it to the DON or the Administrator. All nurses knew about daily assessments on all residents that need to be completed, also conducting neurological and behavioral assessments to ensure the residents did not have a change of condition that needed to be reported to the charge nurse or DON, what a change on condition could be and to know each residents baseline and what to look for.Interviews conducted included the following staff:Administrator and DONCNA D, F, GLVN B, EHousekeeping HCOTA IBOM/CMA/CNA JThe following interviews were conducted by telephone of all staff working all shifts, included the following: RNs - M, N, P, TLVNs - V, AA, BB, CCCNAs - K, L, O, Q, R, S, U, W, X, Y, Z The Administrator was informed the Immediate Jeopardy was removed on 2/6/26 at 1:57 p.m. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1of 1 kitchen when they failed to: A. Ensure facility staff wore hair restraints and beard guards while in the kitchen.B. Ensure stored and cooked food was properly labeled, dated and covered.C. Ensure hand hygiene and use of proper serving utensils was maintained during serving a mealD. Ensure menu substitutions were documented. These failures placed all residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. Findings included: In an observation of the walk-in freezer on 1/13/26 at 10:40 am revealed the following:opened box of biscuits, open to air and unsecured.15 bags of waffles, not in original box, no label or date3 bags of hamburger patties, not in original box, no label or date6 bags of pancakes, not in original box, no label or date3 bags of chicken strips, not in original box, no label or date In an observation and interview on 1/13/26 at 11:20 am revealed [NAME] C had touched various kitchen surfaces with her gloved hands, walked to the serving table, picked up a serving dish and tongs and placed sausage in a pan. [NAME] C then took the sausage to the puree station and picked up the sausage links with her gloved hands and tore the sausage links into pieces with her gloved hands and proceeded to put the lid on the blender and puree the meat. When asked about touching the meat, [NAME] C stated, I am not supposed to to do that. She stated it could cause food borne illness. In an observation and interview of the kitchen prep table on 10/13/26 from 11:30 am to 12: 05 pm, revealed 6 individual plates sitting on the counter uncovered. As the remaining foods were pureed the plates of meat sat on the counter with no covering. [NAME] F stated the meat was for the noon meal for residents with pureed food. The pureed meat was plated at 11:25 am and the first plate went out at 12:15. The remaining 5 plates continued to sit on the counter uncovered until 12:16 pm when the plates were covered and put into the warmer. In an observation and interview on 1/13/26 at 11:50 am revealed the DM was in the kitchen with her hair in 2 braids on each side of her head not contained by a hairnet, TA B in the kitchen with no beard covering on his face, TA A in the kitchen with no beard cover. In a group interview the Cooks A and B both stated they should have had beard coverings but there were no beard coverings. The DM stated the staff should have beard covers but the kitchen had none. TA A stated they had masks from covid they could put on for beard guards until the beard covers came in. The DM stated she had forgotten her braids were not contained in the hairnet. She stated all hair should be covered with a hairnet and beards must be covered or shaved off. The DM stated the consequences of not having hair nets containing all hair would be food borne illness. In an observation and interview on 1/13/26 at 12:26 pm [NAME] C was observed plating food for the noon meal. [NAME] C touched plates tray cards, the counter and serving utensils with her gloved hands. [NAME] C picked up a plate, plated the food then picked up a dinner roll with her gloved hand. [NAME] C placed the plate on the tray then picked up another plate, picked up utensils and plated the meal. [NAME] C picked up a roll with her gloved hand and placed the roll on the plate. The DM was also present and stated [NAME] C should have used tongs for the bread. The DM went to [NAME] C and stated she needed to use the tongs sitting on the bread to serve bread. [NAME] C stated she had forgotten. The DM stated food borne illness would be the result of improper hand hygiene and touching food. In a record review of the facility menu substitution list for the past 4 months, there were no listed meal items for January. The substitution list did not have the substitute of carrots for onions and peppers for residents on a pureed diet for the lunch meal on 1/13/26. In an interview on 1/15/26 at 1:50 pm, the DM stated she had trained staff to put the receiving date on food when it is received, the open date when opened and the use by date when taken out of a box. She stated she had not been aware this had not been done. The DM stated she was not aware the temperature of foods was supposed to be taken at the time of the meal service. She stated she and the staff had been taking the temperatures of the food after the food had been prepared and when it was first put on the steam table after preparing. She stated the times food was put on the table were at different times before the meal service and was not right before serving. She stated she had not been aware the foods temperatures needed to be done just before service began. She confirmed the food sometimes sat on the tray line for over an hour at times. The DM stated she was aware the pureed meats had been sitting on the counter for over 30 minutes and were uncovered. She stated that food borne illness could result from all these issues. Record review of the facility policy titled ' Preventing Foodborne Illness- Employee Hygiene and Sanitary Practices' dated 2001 documented: Employees must wash hands before coming into contact with any food surfaces, after handling soiled equipment or utensils, during food preparations as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks Contact between food and bare hands is prohibited. Gloves are considered single use items and must be discarded after completing the task for which they are used. Gloves are removed abd hands are washed and gloves are replaced. The use of disposable gloves does not replace proper handwashing.Food Service employees are trained in the proper use of tongs, gloves and spatulas in order to prevent food borne illness. Hairnets and beard restraints are worn when cooking, preparing or assembling food to keep hair from contacting exposed food, clean equipment, utensils and linens. Record review of the facility's policy titled, 'Food Receiving and Storage' dated 2001, documented: All foods must be covered, labeled and dated (use by date)Wrappers of frozen foods must stay intact until thawing. Record review of the facility's policy titled, ' Nutrient Retention of Foods' dated 2001, documented: Food will not be held for more than one hour before service, preparation, thawing or reheating.Staff will work to minimize holding time as much as possible. Record review of the facility's policy titled, ' Menus ' dated 2001, documented: Deviations from posted menu are recorded including the reason for the substitution and/ or deviation and archived.

Based on observation the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles to include the appropriate accessory and cautionary instructions, and the expiration date when applicable on 2 (Hall 100 and Hall 200) of 2 medication carts. -1 bottle of Probiotic had an expiration date of 11/2025.-1 bottle of Tylenol had an expiration date of 10/2019.-Resident #1's Novolog did not have an open date on the medication.-Resident #36's Novolog and Lantus did not have open dates on the medications.-Resident #37 had 2 Wexela inhalers that did not have open dates written on the medications-Resident #37's 2-Wexela inhalers had expiration dates of 07/2023 and 10/2023.-2 loose pills were in the bottom of Medication cart for Hall 200. -Half of a loose pill was in the bottom of the narcotic drawer of Medication cart for Hall 100.The facility's failure could place residents at risk for not receiving the intended therapeutic action of the medication.Findings included:During an observation on 01/13/2026 at 10:19 AM of the Hall 200 medication cart with LVN D revealed the following: 1 bottle of Probiotic with an expiration date of 11/2025 and a bottle of Tylenol with the expiration date of 10/2019. 2 loose pills were discovered in the bottom of the medication cart drawers and Resident #1's Novolog flex pen did not have an open date on it. Resident #36's Novolog and Lantus insulin pens did not have open dates. During an interview on 01/13/2026 at 10:35 AM LVN D stated the negative outcome for not having open dates on insulin could be the medication could be expired and not as effective for the resident. LVN D stated the negative outcome of having loose pills could lead to a possible missed dose of medication for the residents. During an observation on 01/13/2026 at 11:49 AM of the Hall 100 medication cart with LVN E revealed the following:a half of a pill loose in the bottom of the narcotic medication drawer, and 2 inhalers of Wexela for Resident #37 with no open dates written on the inhalers and expiration dates for 10/2023 and 07/2023. During an interview on 01/13/2026 at 12:01 PM LVN E stated the negative outcome for not having open dates on medications could lead to the medication being expired the medication having a decreased effectiveness for the resident. LVN E stated that negative outcome for having loose pills in the medication cart could lead to a missed dose of medication for the resident. During an interview on 01/15/2026 at 1:44 PM DON stated a negative outcome for not having open dates on medications that required one could lead to residents receiving expired medications. DON stated the negative outcome for loose pills was that the residents could be missing doses.Record review of policy titled, Medication Labeling and Storage, undated, revealed the following: .Medication Storage.2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.5. Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems.Medication Labeling.2. The medication label includes, at a minimum: .d. expiration date, when applicable; . 5. Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded withing 28 days unless the manufacturer specifies a shorter or longer date for the open vial.Record review of policy titled, Administering Medication, revised April 2019, revealed the following: .12. The expiration/beyond use date on the medication label is checked before administering. When opening a multi-dose container, the date opened is recorded on the container. Record review of policy titled, Insulin Administration, September 2014, revealed the following: .Steps in the Procedure (Insulin Injections via Syringe).4. Check expiration date, if drawing from an opened multi-dose vial. If opening a new vial, record expiration date and time on the vial (follow manufacturer recommendations for expiration after opening).

Based on observation, interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #2) of 13 residents reviewed for accuracy of assessment.The facility coded Resident #2 as receiving insulin when she did not receive insulin.This failure could place residents at risk of receiving unnecessary care/medication.Findings Included:Record review of Resident #2's admission record dated 01/13/26 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning), chronic kidney disease (longstanding disease of the kidneys leading to kidney failure), and unspecified atrial fibrillation (irregular heart rhythm).Record review of Resident #2's annual MDS with ARD of 10/14/25 revealed a BIMS score of 12 which indicated moderately impaired cognition. Section N Medications revealed the following: . N0350 Insulin A. Insulin injections Record the number of days that insulin injections were received during the last 7 days or since admission/entry or reentry if less than 7 days. The numeral one was entered into the box suppled to record the number of days, which indicated Resident #2 received insulin one day from 10/07/25 to 10/14/25.Record review of Resident #2's care plan completed on 11/19/25 revealed no mention of insulin.Record review of Resident #2's active orders revealed no order for insulin.Record review of Resident #2's discontinued, struck out, and completed orders revealed no order for insulin.Record review of Resident #2's MAR for October 2025 revealed no insulin was administered to Resident #2 at any time during the month.During an observation on 01/14/26 at 08:30 AM LVN F was administering medication to Resident #2 at her bedside.During an interview on 01/14/26 at 08:35 AM LVN F stated she had worked for the facility for 6 months and Resident #2 had not received insulin during that time.During an interview on 01/15/26 at 10:17 AM CNA H stated she did not know if having an inaccurate MDS would negatively impact the resident.During an interview on 01/15/26 at 10:20 AM LVN F stated she did know if having an inaccurate MDS would negatively impact the resident.During an interview on 01/15/26 at 10:35 AM RN G stated an inaccurate MDS assessment could possibly impact the resident negatively. She stated Resident #2 did not receive insulin.During an interview on 01/15/26 at 10:59 AM ADON stated a corporate staff member had been responsible for MDS assessments until 01/01/26 when MDS LVN took over the responsibility. She stated a resident could be negatively impacted by an inaccurate MDS assessment. She stated the resident might not get the care they need and the MDS assessment affected funding so the facility might not get needed funding to provide care to residents. She stated Resident #2 did not receive insulin.During an interview on 01/15/26 at 11:11 AM DON stated corporate staff had been doing MDS assessments, but MDS LVN was taking over the responsibility. She stated an inaccurate MDS assessment could absolutely negatively impact the resident.During an interview on 01/15/26 at 11:25 AM ADM stated MDS LVN was responsible for completing MDS assessments. She stated the facility would not be able to provide the correct care to a resident if the MDS assessment was inaccurate.During an interview on 01/15/26 at 11:32 AM MDS LVN stated she began taking over responsibility for MDS assessments on 01/01/26. She stated she had noticed several areas where there appeared to be data entry errors or clerical errors on the MDS assessments for the facility. MDS LVN stated she used the RAI as her policy when completing MDS assessments. MDS LVN stated an inaccurate MDS assessment could negatively impact the resident's care. She stated, It depends on how it is inaccurate and what the error was. MDS LVN stated the MDS assessment directly affected the funding the facility received to provide care to the residents.During an interview on 01/15/26 at 12:08 PM CEO stated the MDS assessments were typically done by different individuals. The social worker has been doing BIMS and depression. The other MDS assessments are assigned to the nurses for example. Now that we have MDS LVN here onsite she will be handling that. When asked if there was a possible negative outcome to a resident of an inaccurate MDS assessment CEO stated, That would be concerning.Record review of the Long-Term Care Facility RAI 3.0 User's Manual Version 1.18.11 dated October 2023 revealed the following: . SECTION N: MEDICATIONS Intent: The intent of the items in this section is to record the number of days, during the last 7 days (or since admission/entry or reentry if less than 7 days) that any type of injection, insulin, and/or select medications were received by the resident. N0350: Insulin . Steps for Assessment 1. Review the resident's medication administration records for the 7-day look-back period . 2. Determine if the resident received insulin injections during the look-back period. 4. Count the number of days insulin injections were received . Coding Instructions for N0350A Enter in Item N0350A, the number of days during the 7-day look-back period . that insulin injections were received.

Based on interviews and record reviews the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care within 48 hours of a resident's admission for 1 (Resident #28) of 13 residents reviewed for care planning.The facility failed to develop a baseline care plan for Resident #28 within 48 hours of his admission on [DATE].This failure could place newly admitted residents at risk of not receiving effective, person-centered care.Findings Included:Record review of Resident #28's admission record dated 01/14/26 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Parkinson's disease (chronic and progressive movement disorder that initially causes tremors in one hand and stiffness or slowing of movement), type 2 diabetes mellitus (insufficient production of insulin, causing high blood sugar), atherosclerotic heart disease of native coronary artery without angina pectoris (fats, cholesterols, and other substances collected on the inner walls of heart arteries without chest pain), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and rash and other nonspecific skin eruption.Record review of Resident #28's admission MDS completed on 12/31/25 revealed a BIMS of 7 which indicated severely impaired cognition.Record review of Resident #28's EHR under the Assessments and the Miscellaneous tabs revealed no baseline care plan.Record review of Resident #28's care plan revealed it was initiated/created on 12/31/25 by CEO.During an observation and interview on 01/13/26 at 11:26 PM Resident #28 was seated in his recliner with his legs elevated. He stated staff were trying to find out what was wrong with his legs, why they were red. During an interview on 01/13/26 at 06:58 PM Resident #28's family member stated, He (Resident #28) had a rash that he left the hospital with, and it has gotten worse. They (the facility) just started antibiotics this week hoping that will take care of the issue. During an interview on 01/15/26 at 10:17 AM CNA H stated a resident could be negatively affected by not having a baseline care plan.During an interview on 01/15/26 at 10:20 AM LVN F stated she was not sure who was responsible for completing baseline care plans. She stated a resident could be negatively impacted if staff did not know their (residents') baselines we won't know if they are improving or getting worse.During an interview on 01/15/26 at 10:35 AM RN G stated she was not sure who was responsible for completing baseline care plans. She stated residents were supposed to have a baseline care plan within 24 hours of admission. RN G stated if a resident did not have a baseline care plan direct care staff might not know why the resident was in the facility and how to address that problem.During an interview on 01/15/26 at 10:59 AM ADON stated CEO was responsible for completing baseline care plans. She stated the facility is going to switch that responsibility to nurses. She stated the purpose of a baseline care plan was to get how they (residents) are functioning at the beginning and to get all of their (residents') likes and dislikes and then track changes from there. She stated a resident could be negatively impacted by having no baseline care plan because staff would not know where they started.During an interview on 01/15/26 at 11:11 AM DON stated admitting or charge nurse should be responsible for completing a baseline care plan. She stated, To be honest with you, until just recently it has almost always been [ADON] or [CEO] doing almost all of the assessments. DON stated the purpose of a baseline care plan was, So that you have a basic knowledge when the resident is admitted to the facility of what mobility issues will be needs regarding transfers, diet, psychotropic medication, dental, hearing, vision issues. She stated, It (baseline care plan) should give you the base to begin with and then you build from that. DON stated not having a baseline care plan could negatively impact resident care.During an interview on 01/15/26 at 11:25 AM ADM stated she did not know who was responsible for completing baseline care plans. She stated the baseline care plan was to show staff where the resident was initially and where we are headed. ADM stated not having a baseline care plan could negatively impact resident care because staff would not know where the resident started.During an interview on 01/15/26 at 11:32 AM MDS LVN stated the facility was transitioning to having the admitting nurse be responsible for completing the baseline care plan. She stated the purpose of the baseline care plan was to start the resident's plan of care from the day of admission. She stated without a baseline care plan staff would not know the plan of care.During an interview on 01/15/26 at 12:08 PM CEO stated the RN was responsible for completing baseline care plans. She stated, Ideally it would be the RN that is admitting the patient. CEO stated the purpose of the baseline care plan was, To provide basic care as we are getting to know the resident more in depth. It would provide safe care. She stated a possible negative outcome of not having a baseline care plan was, The baseline care plan guides the care for the resident. CEO stated a resident could be negatively affected by not having a baseline care plan.Record review of facility policy titled Care Plans - Baseline and dated December 2016 revealed the following: . A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. 1. To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission. 2. The Interdisciplinary Team will review the healthcare practitioner's orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care needs . 3. The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan.

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights and that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 (Resident #2 and Resident #28) of 13 residents reviewed for comprehensive care plans.1. The facility failed to include Resident #2's antidepressant medication in her care plan.2. The facility failed to include Resident #28's rash in his care plan.These failures could lead to residents not receiving needed care and or symptom monitoring.Findings Included:1. Record review of Resident #2's admission record dated 01/13/26 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning) and other specified depressive episodes (significant clinical impairment that does not meet standard criteria of a depressive disorder).Record review of Resident #2's annual MDS completed on 10/28/25 revealed a BIMS score of 12 which indicated moderately impaired cognition. Section N Medications revealed Resident #2 received antidepressant medication.Record review of Resident #2's care plan completed on 11/19/25 revealed no mention of depression or antidepressant medication. The care plan was revised by CEO.Record review of Resident #2's active orders revealed the following orders with corresponding order start dates:07/02/25 Anti-depressant medication Paroxetine behavior monitoring.07/02/25 Anti-depressant Paroxetine S/E monitoring.01/13/26 Paroxetine HCI Oral Tablet 10 MG (Paroxetine HCI) Give 5 mg by mouth one time a day related to OTHER SPECIFIED DEPRESSIVE EPISODES .Record review of Resident #2's GDR tracking report dated 12/26/25 revealed she had been receiving Paroxetine since 03/26/25.During an observation and interview on 01/13/26 at 11:05 AM Resident #2 was in her bed with the head of her bed raised to a seated position. She stated she had no issue with anxiety or depression.2. Record review of Resident #28's admission record dated 01/14/26 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Parkinson's disease (chronic and progressive movement disorder that initially causes tremors in one hand and stiffness or slowing of movement), type 2 diabetes mellitus (insufficient production of insulin, causing high blood sugar), and rash and other nonspecific skin eruption.Record review of Resident #28's admission MDS completed on 12/31/25 revealed a BIMS of 7 which indicated severely impaired cognition. Section M Skin Conditions revealed Resident #28 was having ointments/medications applied to his skin.Record review of Resident #28's care plan revealed it was initiated/created on 12/31/25 by CEO. The care plan did not include any mention of a rash or skin issueRecord review of Resident #28's active orders dated 01/14/26 revealed the following orders with corresponding order start dates:01/08/26 [Brand name of allergy medication] Oral Tablet 25 MG (Diphenhydramine HCI) Give 1 tablet by mouth at bedtime for rash/itching01/10/26 Cephalexin Oral Tablet 500 MG (Cephalexin) Give 1 tablet by mouth three times a day for give TID rash related to RASH AND OHER NONSPECIFIC SKIN ERUPTION.for 7 Days until finished12/19/25 Hydrocortisone External Cream 1% (Hydrocortisone (Topical)) Apply to groin every 4 hours as needed for itchingRecord review of Resident #28's struck out, completed, and discontinued orders revealed the following order with corresponding start and end date:12/23/25-12/28/25 Please apply Hydrocortisone cream to affected area on back TID for 5 days until healed three times a day for 5 DaysRecord review of Resident #28's progress notes from 12/19/25 to 01/14/25 revealed 55 total entries. The following 13 entries mentioned Resident #28's rash:A note by RN G on 12/22/25 at 04:20 PM Resident . c/o some itchiness to back at end of shift-lotion applied at that time for dry skin.A note by RN G on 12/23/25 at 04:22 PM Resident still c/o itchiness to back today even after shower and lotion application. [name of physician] notified and new order to apply hydrocortisone tid for 5 days rec'd.A note by LVN E on 12/25/25 at 02:18 PM . Hydrocortisone cream applied to affected area on upper back. Skin to area dry, flaky, and slightly red. [Resident #28] reports that area is itchy but itching improves when cream is applied.A note by LVN F on 12/26/25 at 06:16 PM Resident is on follow for hydrocortisone cream to the back x5 days for rash. Day 3/5, skin to the area is dry and slightly red. After application of cream, resident voices relief.A note by RN J on 12/29/25 at 05:53 AM Continues with improvement to rash to his back, anterior upper thighs, and abdomen. Rash noted less reddened and resident states it not [sic] longer itches. He completed hydrocortisone cream TID yesterday and presents with no adverse reactions and voices relief.A note by LVN E on 12/30/25 at 02:47 PM Resident has completed hydrocortisone cream. No adverse reactions noted. Continues with slight redness to back and ABD but denies itching or discomfort.A note by LVN E on 01/07/26 at 06:40 PM Resident noted with red rash to bilateral forearms and shins as well as on back and abdomen. [physician] notified and telephone order received for Benadryl 25 MG one tablet by mouth QHS.A note by LVN K on 01/08/26 at 04:11 AM Resident f/u new order for [brand name of allergy medication] 25mg PO Q daily. resident cont with red rash to bilateral forearms and shines [sic] .A note by LVN K on 01/09/26 at 04:28 AM Resident f/u new order for [brand name of allergy medication] 25mg PO Q daily. resident cont with red rash to bilateral forearms and shines [sic] .A note by RN G on 01/10/26 at 05:49 PM Resident still with rash to legs, arms and back- states his itching comes and goes but seems to be worse today. family concerned that rash is worse. RN notified [physician] of the rash and worsening of symptoms. New order rec'd for cephalexin 500 mg TID for 7 days .A note by LVN K on 01/11/26 at 04:06 AM Is taking [name of allergy medication] 25mg PO q hs in treatment for the itching and started [brand name of cephalexin] 500mg PO TID x 7 days in treatment for the rash also (initial dosed last night per orders).An infection note by ADON on 01/13/26 at 07:13 AM Type (topical, respiratory, etc) : topical rash Signs and Symptoms (temp, swelling, pain) : rash to BUE,BLE and torso. reports discomfort at times but denies pain. Agrees to notify staff if intervention is needed Diagnostic testing (cultures, labs, type of organism, results, etc) : n/a Treatments (antibiotic, other treatments) : hydrocortisone cream x5 days-treatment complete, [brand name of allergy medication] po at hs, cephalexin 500 mg po tid x7 days Adverse Reactions (hives, respiratory problems) : none noted at this time, resident is able to make needs known and is aware of possible risk An infection note by LVN E on 01/13/26 at 04:02 PM Type (topical, respiratory, etc) : Topical rash Signs and Symptoms (temp, swelling, pain) : Resident continues with slight redness to bilateral elbows and forearms. Skin temperature is normal. Denies itching or discomfort. Temp: 97.9 Diagnostic testing (cultures, labs, type of organism, results, etc) : N/A Treatments (antibiotic, other treatments) : Continues on [brand name of cephalexin] 500 MG TID Adverse Reactions (hives, respiratory problems) : Denies nausea, vomiting, diarrhea, or GI upset.During an observation and interview on 01/13/26 at 11:26 PM Resident #28 was seated in his recliner with his legs elevated. He was wearing shorts, and his lower legs appeared to be red and his lower right leg appeared to be swollen. When asked about his legs, Resident #28 stated he did not know why they were red, but staff were trying to find out why. He stated his legs did not hurt.During an interview and observation on 01/13/26 at 11:58 AM an RN surveyor accompanied this surveyor to look at Resident #28's legs. RN surveyor asked Resident #28 if he had a skin graft on his right leg and he stated he did due to sarcoma.During an interview on 01/13/26 at 06:58 PM Resident #28's family member stated, He (Resident #28) had a rash that he left the hospital with, and it has gotten worse. They (the facility) just started antibiotics this week hoping that will take care of the issue. His right leg is swollen too because years ago he had cancer, and they put a muscle flap there.During an interview on 01/15/26 at 10:17 AM CNA H stated an inaccurate/incomplete care plan could negatively impact the resident's care.During an interview on 01/15/26 at 10:20 AM LVN F stated an inaccurate/incomplete care plan could negatively impact a resident's ability to meet their goals.During an interview on 01/15/26 at 10:35 AM RN G stated staff needed to follow the resident's care plan so a resident could be negatively affected by an inaccurate/incomplete care plan.During an interview on 01/15/26 at 10:59 AM ADON stated CEO was responsible for completing care plans, but the facility was working on transitioning the responsibility to MDS LVN and someone in the corporate office. She stated resident #28's rash should have been included in his care plan. ADON stated Resident #2's antidepressant should have been included in her care plan. She stated residents could be negatively impacted by inaccurate/incomplete care plans because CNAs would not know which symptoms to monitor the residents for, and families would not be informed about the concerns during care plan meetings.During an interview on 01/15/26 at 11:11 AM DON stated CEO was responsible for completing care plans. She stated Resident #28's rash should absolutely be included in his care plan. She stated Resident #2's antidepressant should of course be included in her care plan. DON stated staff are supposed to be using the care plan as a guide to know what to monitor for. So, they [residents] can suffer a lack of monitoring for symptoms if a care plan was inaccurate/incomplete. DON stated the care plan also aides with family notification and participation in resident care.During an interview on 01/15/26 at 11:25 AM ADM stated MDS LVN was responsible for completing care plans. She stated if a resident's care plan was inaccurate/incomplete staff might not provide what is needed for the resident.During an interview on 01/15/26 at 11:32 AM MDS LVN stated CEO was responsible for care plans. She stated Resident #28's rash and Resident #2's antidepressant should have been included in their respective care plans. MDS LVN stated an inaccurate/incomplete care plan could negatively impact resident care because not everybody would know the plan of care for that resident.During an interview on 01/15/26 at 12:08 PM CEO was asked who was responsible for completing care plans and stated, Um, so the opening of a care plan is required by an RN. She stated the RN completed the care plan. CEO stated Resident #28's rash would generally be included in his care plan. She stated, regarding Resident #2's antidepressant, Normally depression should be included in the care plan. CEO stated an inaccurate/incomplete care plan would impact the provision of care.Record review of facility policy titled Care Plans, Comprehensive Person-Centered and dated March 2022 revealed the following: . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 7. The comprehensive, person-centered care plan: . b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, . e. reflects currently recognized standards of practice for problem areas and conditions. 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communication diseases and infections for 2 (Resident #1 and Resident #37) of 13 residents reviewed for infection control. -LVN F failed to use proper hand hygiene techniques when preparing and administering medications to Resident #1.-LVN F failed to clean glucometer before and after performing glucose check for Resident #1.-Facility failed to have proper EBP signage on Resident #37 who had a foley catheter. These failures had the potential to affect residents by placing them at risk of contracting, spreading, and/or exposing them to bacterial or viral infections that could lead to the spread of communicable diseases.Findings Included: During an observation on 01/13/2026 at 11:19 AM revealed no signage for enhanced barrier precautions on Resident #37's door. During an interview on 01/13/2026 at 11:19 AM a family member of Resident #37 revealed that the staff have never put on PPE to come in and assist Resident #37 with any care areas. During this interview staff entered the room with PPE on and the family member asked the investigator why are they putting on all that garb? Investigator stated that the staff was supposed to be doing that every time. Family member stated, this was the first time they have ever done it. During an observation on 01/14/2026 at 11:41 AM LVN F did not perform hand hygiene before donning gloves to perform blood glucose check and insulin administration of insulin to Resident #1. LVN F did not clean glucometer before LVN F performed glucose check for Resident #1. During an interview on 01/14/2026 at 2:18 PM LVN F stated a negative outcome for not performing hand hygiene and not cleaning the glucometer could lead to infection for the residents. Interview on 01/15/2026 at 1:44 PM DON stated a negative outcome for not performing HH at the appropriate times and not utilizing PPE for resident on EBPs, could lead to an infection control issue. Record review of policy titled, Enhanced Barrier Precautions, revised March 2024, revealed the following: Policy StatementEnhanced barrier precautions (EBPS) are utilized to reduce the transmission of multi-drug-resistant organisms (MDROs) to residents.Policy Interpretation and Implementation.3. Examples of high-contact resident cared activities requiring the use of gown and gloves for EBP's include: .g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and .5. EBPs are indicated ( when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization.b. Indwelling medical devices include central lines, urinary catheters, . Record review of policy titled, Handwashing/Hand Hygiene, revised October 2023, revealed the following: Policy StatementThis facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections.Indications for Hand HygieneHand Hygiene is indicated:Immediately before touching a resident;Before performing an aseptic task .After contact with blood, body fluids, or contaminated surfaces;After touching a resident; . Applying and removing GlovesPerform hand hygiene before applying non-sterile gloves. Record review of policy titled, Insulin Administration, revised September 2014, revealed the following: .Steps in the Procedure (insulin Injections via syringe)Wash hands.

Based on observation, interview, and record review, the facility failed to ensure the meals served reflected the nutritional needs of residents in accordance with established national guidelines for all residents when the facility failed to ensure menus were followed by 6 of 6 residents who received pureed meals. A. The facility did not serve onions and peppers to residents with a pureed meal for the lunch meal on 1/13/26 as directed by the menu. These failures could place all residents who received food from the kitchen at risk of decreased meal satisfaction, potential weight loss due to poor meal intake, not having their nutritional needs met, and a decline in health status. Findings included: In an observation and interview on 1/13/26, at 12:40 pm, 6 residents on a pureed diet did not receive onions and peppers on their meal tray. The residents were given carrots instead. In an interview the DM stated the residents with pureed meals had not received onions and peppers from the posted menu because you could not puree them. She stated the residents received carrots instead. This writer reviewed the recipe book and pointed out to the DM there was a recipe for pureed onions and peppers. The DM stated she did not know the recipe had been in the book. She stated she had never tried to puree onions and peppers. The DM stated the consequences of not serving all the menu items to residents on pureed diets could be dissatisfaction with meals and poor nutrition. Record Review of the facility lunch menu for Cycle 11, Week 1 Tuesday 1/13/26, revealed all residents were to be served: Bratwurst Links, [NAME] Noodles, Sauteed onions and peppers, Wheat dinner roll and chocolate cheesecake. Record review of the facility recipes in the facility recipe book revealed a recipe for pureed onions and peppers.

Based on observation, interview, and record review; it was determined the facility failed to ensure each resident was provided with the right to have personal privacy during medical treatments, for 1 (Resident #8) of 13 residents reviewed for privacy. -RN G and CNA I did not close the window blinds to provide privacy for Resident #8 during wound care. This failure could place residents at risk of feeling shame or embarrassment, lowered self-esteem, and a lack of a dignified existence.Findings Included:Resident #8Record review of Resident #8's clinical record revealed a [AGE] year-old male, who was admitted to the facility on [DATE] with diagnoses of myelodysplastic syndrome (the bone marrow produces faulty, immature blood cells that don't mature properly, leading to too few healthy red cells (anemia), white cells (infections), and platelets (bleeding)), schizoaffective disorder (a serious mental illness blending symptoms of schizophrenia (psychosis like hallucinations/delusions) with a mood disorder (major depression or bipolar mania), characterized by psychosis occurring for at least two weeks without mood symptoms), bipolar disorder (a serious mental illness blending symptoms of schizophrenia (psychosis like hallucinations/delusions) with a mood disorder (major depression or bipolar mania), characterized by psychosis occurring for at least two weeks without mood symptoms), and pain. Record review of Resident #8's most recent MDS assessment, dated 10/03/2025, indicated Resident #8 had a BIMS of 13, indicated no cognitive impairment and a functionality of total dependency assistance was required with showering/bathing, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. Maximal assistance was required with toileting hygiene, supervision or touching assistance was required with oral hygiene, and set-up or clean-up assistance was required for eating. During an observation on 01/14/2026 at 11:52 AM, RN G and CNA I provided Resident #8 with wound care, they did not close the window blinds. During an interview on 01/14/2026 at 12:03 PM RN G stated a negative outcome for the blinds not being closed was someone could walk by the window and see the residents bloody wound. During an interview on 01/15/2026 at 1:44 PM 01/15/2026 DON stated a negative outcome for not closing blinds during wound care could lead to someone walking by and seeing the resident in a compromising situation, plus it is a dignity issue. Record review of policy titled, Residents Rights, revised December 2016, revealed the following: Policy StatementEmployees shall treat all residents with kindness, respect, and dignity.Policy Interpretation and ImplementationFederal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:a dignified existence;be treated with respect, kindness, and dignity; . t. privacy and confidentiality;. Record review of policy titled, Confidentiality of Information and Personal Privacy, revised October 2017, revealed the following: Policy StatementOur facility will protect and safeguard resident confidentiality and personal privacy.Policy Interpretation and Implementation .2. The facility will strive to protect the resident's privacy regarding his or her: .b. medical treatment; .

Based on interview and record review, the facility failed to ensure the governing body of the facility appointed an administrator, who was licensed by the state, to be responsible for the management of the facility and reported to the governing body for 1 of 1 facility reviewed for governing body.The facility had not had an administrator since 09/02/2025.This could place residents at risk of decreased quality of life and quality of care due to lack of staff oversight and monitoring of care. The findings included: Record review on 12/16/25, of the former Administrator's undated Disciplinary Action Form revealed that the ADM was terminated on 09/02/25 due to violation of personnel policies. During an interview on 12/16/25 at 9:49 a.m., an entrance conference was conducted with the Corporate RN who stated there was not a full time ADM for the facility at this time. She stated she fired the full-time ADM on 09/02/25 for not having a current license and was currently acting on behalf of the facility to hire a new ADM. The Corporate RN stated there was an interim ADM in October 2025, who stayed about two weeks, and they recently offered the position to a new ADM starting on 01/05/26. She stated she is currently the Abuse Coordinator for the facility. The Corporate RN stated she is not the facility Administrator. During an interview on 12/16/25 at 10:49 a.m. CNA A stated the facility did not have a full-time administrator. She stated a possible negative outcome for not having an ADM could be that nobody would be in charge and staff would not know who to report things to. During an interview on 12/16/25 at 10:52 a.m. LVN B stated he worked at the facility for three days. He stated that there was not a full time ADM working at the facility at this time. LVN B stated a possible negative outcome for not having an ADM could be that there would be lack of leadership and staff would not know who to report issues to. During an interview on 12/16/25 at 11:26 a.m. the BOM stated there was no full-time ADM for the facility. She stated there was an Interim who worked for a couple weeks in October. The BOM stated that she heard that a new ADM was hired and supposed to start on 01/06/26, but she had not seen any paperwork for this new ADM or had not performed any background checks for this person. She stated a possible negative outcome for not having a full-time ADM could be that there would be no oversight for all the departments. During an interview on 12/16/25 at 11:32 a.m. The DON stated she worked at the facility for four weeks. She stated there was not a full-time ADM working at the facility. The DON stated she thought the last time they had an ADM was in September 2025. She stated a possible negative outcome for not having a full-time ADM could be no oversight of everything from maintenance staff to nursing. The DON stated that the biggest issue with not having an ADM was that there was no oversight concerning regulations. Record review of facility's Job Description for Title: Administrator, not dated, revealed . Qualifications: 2. Must have a current Texas Administrator's License. Record review of a facility policy titled Administrator with revised date of March 2021 revealed the following. A licensed Administrator is responsible for the day-to-day functions of the facility. 1. The governing board of this facility has appointed an Administrator who is duly licensed in accordance with current federal and state requirements i. Maintaining his/her license on a current status as required by law, and maintaining a copy of such license or registration on premises.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services that assure the accurate dispensing and administering of all drugs for two (Resident #1, #2) of five residents reviewed for pharmacy services. Resident #1 who was nonverbal and bedridden and dependent on staff for all care needs, tested positive for barbiturates on 11/14/2025. The medical record did not contain documentation of a current barbiturate prescription. Resident #2's was prescribed Primidone 50mg, a medication that metabolizes in the body as a barbiturate was missed per the MAR on 11/08/2025 and 11/09/2025. These failures could place residents in the facility at risk of adverse drug reactions, untreated or uncontrolled medical conditions and a decline in health status.Record review of Resident #1's face sheet dated 11/15/2025 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included but not limited to Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), unspecified, Dementia with other behavioral disturbances(impaired judgement with agitation), dysphagia, oropharyngeal phase (impaired ability to safely swallow foods or liquids) and muscle weakness.Record review of Resident #1's quarterly MDS dated [DATE] listed her with a BIMS of 00 of 15 indicating she was severely cognitively impaired. The MDS further reflected that she required total assistance from staff for all activities of daily living. Record review of Resident #1's care plan with date of 11/6/2025 revealed Resident #1 had an ADL self-care deficit due to weakness, loss of muscle mass, movement and impaired cognition with interventions require extensive assistance from staff.Record review of Resident #1's active and discontinued physician orders revealed she did not have any prescribed medications that would result in a positive test for barbiturates. Record review of Resident #1's progress notes revealed on 11/13/2025 resident went to emergency room due to not feeling well on the afternoon of 11/13/2025.Record review of Resident #1's hospital notes for 11/13/2025 revealed resident had a UTI and lab test resulting in a positive lab test for barbiturates. Record review of Resident #2's Face Sheet dated 11/15/2025 revealed he was a [AGE] year-old male admitted on [DATE] with diagnoses that included but not limited to Bell's Palsy (paralysis of muscles on one side of face), Parkison's disease with dyskinesia (neurological disorder that affects movement), essential tremor (uncontrollable movement), muscle weakness.Record review of Resident #2's quarterly MDS dated [DATE] revealed Resident #2 had a BIMS of 15 out of 15 indication cognition was intact and his functionality was independent with most of his daily activities.Record review of Resident #2's care plan dated 11/09/2025 revealed Resident #2 is a risk for falls due to tremors related to Parkinson's Disease.Record review of Resident #2's active physician orders revealed he takes Primidone Oral Tablet 50 mg. with orders to Give 1.5 tablet by mouth at bedtime related to Parkinson's disease with dyskinesia order dated 07/07/2025.Record review of Resident #2's MAR for November 2025 revealed resident did not receive his Primidone Oral Tablet 50 mg on 11/08/2025 or 11/09/2025.In an interview and observation on 11/15/2025 beginning at 7:37 AM, LVN C said she worked 11/13/2025. LVN C said Resident #1 was observed doing her normal behaviors on 11/13/2025 but in the afternoon was observed not doing her normal behavior moving her arms and legs when engaged with staff so the DON was informed, and she was evaluated by the DON and sent to the ER. LVN C said she was questioned about giving Resident #1 the Primidone but stated she checks three times between the medication and resident before giving the medication. LVN C said a possible negative outcome for giving a resident medication that did not belong to them could be that they could become sick. On observation of the med cart, revealed Resident #1's medication behind her card and Resident #2's medication behind his card, including the Primidone. The medications belonging to each resident were behind the card that displayed their name.In an interview on 11/15/2025 at 9:30 AM, The DON stated she assessed Resident #1 on 11/13/2025 during afternoon rounds when staff informed her that Resident #1 was not moving her arms and legs as she normally did, since Resident #1 was nonverbal that was how staff identified the concern. The DON called the physician, and he ordered her to send Resident #1 to the hospital for evaluation. The DON stated she returned on 11/14/2025 and the discharge paperwork from the hospital revealed she had a UTI and was prescribed an antibiotic but that she also tested positive for barbiturates. The DON said there were no barbiturates in the facility and did not know how she could test positive for such so she called the pharmacist, and the pharmacist said the drug Primidone metabolizes as a barbiturate and would come up in lab work as a barbiturate. The DON said the only resident in the facility that received Primidone was Resident #2. The DON said she observed the med cart and Resident #1 and Resident #2's prescriptions were next to each other, Resident #1's medication was behind the card that displayed her name and Resident #2's medication was behind the card that displayed his name. The DON said that she doesn't know how Resident #1 tested positive for barbiturates and felt the only possible way was if Resident #2's medication was inaccurately given to Resident #1. The DON said nurses were responsible for ensuring medication was given accurately but she was also responsible. The DON said she in-serviced her staff about the drug Primidone and medication administration on 11/14/2025.In an interview on 11/15/2025 at 10:09 AM, The Medical Director said he had received a phone call from the DON about Resident #1, and he had ordered her to go to the hospital for an evaluation as she has had UTIs in the past and he thought her behavior was a result of a UTI. The MD said when the DON called him and told him about the positive barbiturate test, he agreed that the Primidone does metabolize as a barbiturate. The MD said Resident #2's dose was a low dose taking only 75mg. and the negative outcome of having taken that medication without a prescription was not life threatening, but it could cause some drowsiness. The MD said Resident #1's symptoms on 11/13/2025 aligned with the positive UTI. In an interview on 11/15/2025 at 10:36 AM, a family member to Resident #1 stated no one in his family would have barbiturates or would give Resident #1 barbiturates.In an interview on 11/15/2025 at 10:57 AM, LVN A who worked on 11/08/2025 said she believed she gave Resident #2 his primidone and said she was doing something and forgot to sign his medication off after task was completed.Attempted interview with LVN B on 11/15/2025 at 11:05 AM about medication administration the day she worked on 11/09/2025 was unsuccessful.In an interview and observation on 11/15/2025 at 11:20 AM, Resident #2 was dressed for the day, clean and groomed, he stated he has not missed his medication for his tremors (Primidone). When asked about specific dates he said he could not be for sure but thought he had not missed his tremor medication.Observation on 11/15/2025 at 11:30 AM, Resident #1 was in a Geri chair in the common area, she was not interview able. She was clean and neatly groomed.Record review of In-services completed on 11/15/2025 revealed the DON educated her staff on medication administration and the drug Primidone.Record review of Adverse Consequences and Medication Errors Policy dated April 2014 revealed the following:A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professionals' providing services. Examples of medication errors include:a. Omission (a drug is ordered but not administered)b. Unauthorized drug (drug is administered without a physician's order)

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety for 1 of 1 kitchen reviewed for food safety. The facility failed to ensure all food in the dry pantry and cold storage were properly sealed, labeled and dated. The facility failed to ensure all foods in the dry pantry were at least 18 inches off the floor as required by facility policy for dry pantry storage. These failures could place residents at risk of residents at risk of food-borne illness and a diminished quality of life. Findings included: On [DATE] at 10:04AM an initial observation of the kitchen was conducted, and the following was noted: Dry Pantry: (3) partial 5lb. bags corn tortillas with no received date and one bag open to air. (1) partial 10lb. bag elbow macaroni with no received date and open to air. (1) partial 50lb. bag white rice with no received date and open to air. (2) 3oz. boxes dry raspberry gelatin with no received date. (1) partial 2lb. 3oz. bag frosted flake cereal with no received date and open to air. (1) 1gal. zip top bag crisp rice cereal with no received date and open to air. (1) partial 16oz. bag mini marshmallows open to air. (1) 1lb. box corn starch with no received date. (17) 3.2oz. packages dry Ranch dressing with no received date. (44) 4oz. cans pineapple juice with no received date. (36) 4oz. cans vegetable juice with no received date. (19) 4oz. cans chicken noodle soup with no received date. (4) 4oz. containers Thick-n-Easy Clear, Cranberry Flavored Drink with no received date. (10) 4oz containers Thick-n-Easy Clear, Orange flavored drink with no received date (12) 4oz. containers Thick-n-Easy Clear, Red Tea Flavored Drink with no received date. Dry pantry foods were not stored at least 18-inches above the floor as required by facility policy. Cold Storage Unit: ,d+[DATE] fresh tomato in a bowl with no label, no use by date and open to air. (3) 6oz. cups prepared thickened drink mix with no label, no use by date and open to air. 1qt. enchilada sauce with no received date. (4) 5lb. bags chicken breasts with no received date. 2 fresh cantaloupes with no received date. (1) 50lb. box fresh potatoes with no received date. (1) 1gal. container barbeque sauce with no received date. (1) 9lb 14oz box individual serving margarine cups with no received date. (4) 48-count fresh eggs in cardboard pallets with no received date. An interview with the Head [NAME] [DATE] at 11:12AM revealed there was no Dietary Manager working for the facility at that time. She stated the negative outcome of residents eating foods which were not labeled and dated was they could become sick if they ate foods which were expired. She stated there was no facility policy regarding Recommended Maximum Storage Periods for dry or cold storage foods. Review of facility policy for Food Receiving and Storage dated [DATE] revealed the following: (6.) Food stored in designated dry storage areas shall be kept off the floor (at least 18 inches) and clear of sprinkler heads, sewage/waste disposal pipes and vents. (8.) All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date) (14.) d. Beverages must be dated when opened and discarded after twenty-four (24) hours. e. Other opened containers must be dated and sealed or covered during storage.

48491 Based on observation, interview and record review, the facility failed to ensure that all allegations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, and misappropriation of resident property are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury to the administrator of the facility and to other officials (including the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 2 of 16 residents (Residents #5 and #27) reviewed for abuse and neglect. The facility failed to report to the Administrator and State Survey Agency an allegation of abuse involving Residents #5 and #27 within 2 hours of the allegation. This failure could place residents at risk of not having incidents of abuse, neglect, exploitation, and misappropriation of resident property being reviewed and investigated in a timely manner by the facility and state survey agency. Findings included: 1. Record review of Resident # 5's face sheet dated 10/23/2024, revealed that the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses, included but not limited to, Neurocognitive Disorder with Lewy Bodies (cognitive decline in thinking abilities, visual perception, and visual hallucinations), Dementia (cognitive loss) with anxiety and agitation, Parkinsonism (slowness of movement, tremor, difficulty walking, or rigidity). Record review of Resident # 5's significant change of status MDS, dated [DATE], revealed a BIMS score of 2 out of 15 which indicated his cognition was severely impaired and he required substantial/maximal physical assistance from 1 staff member in most ADLs including moving between surface to and from bed, chair, and wheelchair. Record review of Resident #5's Care Plan dated 09/09/2024 revealed that resident was care planned for falls with an intervention that stated to keep resident in line of sight, because he will try to try to constantly stand. Record review of Resident #5's progress notes dated 10/16/2024 revealed that at approximately 7:00 PM on 10/15/2024 agency staff reported to nursing staff that Resident #5 was noted on the floor in the dining room on his belly with left side of face on the floor and w/c beside him. Upon assessment resident noted with small skin tear to bridge of nose and superficial abrasion to left side of forehead. Minimal bleeding noted to skin tear on bridge of nose. Resident assisted back to w/c with assistance x 2 and was not able to move all extremities without complaint of pain or discomfort. Unable to provide description of fall due to cognitive status. POA, physician, RN, and ADM notified of resident's fall. 2. Record review of Resident #27's face sheet dated 10/24/2024 revealed that the resident was an [AGE] year-old female admitted to the facility on [DATE] with an original admitted [DATE] with diagnoses, included but not limited to, Alzheimer's disease (memory loss). Record review of Resident #27's quarterly MDS, dated [DATE], revealed a BIMS score of 99 which revealed that the resident was unable to complete the interview and she required complete dependence on 2 or more helpers in most ADLs including toileting and personal hygiene. Record review of Resident #27's progress notes dated 9/1/2024 at 7:45 AM fell while eating breakfast in dining room and was found lying on her left side with blood coming out of her head. EMS was called and resident transported to ER, POA, physician, and ADM notified of fall. During an observation on 10/23/2024 at 9:21 AM, Resident #27 had stiches to the head and leg. Resident was non interview able. Interview with Resident's family member on 10/23/2024 at 9:22 AM, stated that she had an unwitnessed fall on 09/01/2024 which resulted in a laceration to the head and required a hospital visit. During an observation on 10/23/2024 at 11:08 AM, Resident #5 was sitting in w/c in common area with 2 wounds on his arms, both had bandages on arms with dates of 10/21/2024 on them. Resident was observed to have wounds on cheeks and nose, neither were bandaged. Resident was non interview able. During a phone interview on 10/23/2024 at 6:40 PM, Resident #5's family member stated that the resident fell on [DATE] because he was left alone and was always supposed to have someone with him or be in their line of sight. Resident's family member did not think this incident was investigated or reported to the state. During an interview on 10/24/2024 at 9:14 AM, the ADON revealed to surveyor that falls were not investigated and/or reported to the state for investigation. During an observation on 10/24/2024 at 11:45 AM, CE showed surveyor video footage of a fall for Resident #27 on 09/01/2024 around 8:11 AM. No witnesses were observed in footage. During an observation on 10/24/2024 at 12:18 PM, CE showed surveyor video footage of Resident #5 without staff present. Video footage revealed at 7:06 PM on 10/15/2024 that Resident #5 fell from chair to his left side. Further footage of the video revealed at 7:08 PM on 10/15/2024, 2 unidentified staff walked away from Resident #5. During an interview on 10/24/2024 at 2:10 PM, the ADM stated that a negative outcome for not investigating a fall would be that they would not be able to find the root cause of the incident and to prevent future incidents of the same nature from happening and a negative outcome for failing to report a fall would be that it is required and expected . Record review of facility provided policy titled Abuse and Neglect - Clinical Protocol, dated 2001 and revised November 2018 , revealed the following in part: Assessment and Recognition, #4. Significant injuries in physically dependent individuals. Cause Identification, #1. The staff, with the physician's input as needed, will investigate alleged abuse and neglect to clarify what happened and identify possible causes. Record review of facility provided policy title Accidents and Incidents - Investigating and Reporting, dated 2001 and revised July 2017, revealed the following in part: Policy Statement. All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. Record review of facility employee in service training records revealed Falls-Prevention of Falls and Interventions training was conducted 08/09/2024 and 10/21/2024. Record Review of Tulip for intakes for this facility, revealed no incidents reported on either fall for Resident #5 or Resident #27.

Based on observation, interview, and record review, the facility failed to have evidence that all alleged violations were thoroughly investigated for 2 of 16 (Residents #5 & #27) residents reviewed for abuse and neglect. The facility failed to conduct a thorough investigation when Resident #5 fell from his wheelchair unobserved and obtained a skin tear to the bridge of nose and abrasion to left side of forehead. The facility failed to conduct a thorough investigation when Resident #27 fall leading to a head wound on her left side. This failure could place residents at risk of abuse and neglect. Findings included: Record review of Resident # 5's face sheet dated 10/23/2024, revealed that the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses, included but not limited to, Neurocognitive Disorder with Lewy Bodies (cognitive decline in thinking abilities, visual perception, and visual hallucinations), Dementia (cognitive loss) with anxiety and agitation, Parkinsonism (slowness of movement, tremor, difficulty walking, or rigidity). Record review of Resident # 5's significant change of status MDS, dated [DATE], revealed a BIMS score of 2 out of 15 which indicated his cognition was severely impaired and he required substantial/maximal physical assistance from 1 staff member in most ADLs including moving between surface to and from bed, chair, and wheelchair. Record review of Resident #5's Care Plan dated 09/09/2024 revealed that resident was care planned for falls with an intervention that stated to keep resident in line of sight, because he will try to try to constantly stand. Record review of Resident #5's progress notes dated 10/16/2024 revealed that at approximately 7:00 PM on 10/15/2024 agency staff reported to nursing staff that Resident #5 was noted on the floor in the dining room on his belly with left side of face on the floor and w/c beside him. Upon assessment resident noted with small skin tear to bridge of nose and superficial abrasion to left side of forehead. Minimal bleeding noted to skin tear on bridge of nose. Resident assisted back to w/c with assistance x 2 and was not able to move all extremities without complaint of pain or discomfort. Unable to provide description of fall due to cognitive status. POA, physician, RN, and ADM notified of resident's fall. Record review of Resident #27's face sheet dated 10/24/2024 revealed that the resident was an [AGE] year-old female admitted to the facility on [DATE] with an original admitted [DATE] with diagnoses, included but not limited to, Alzheimer's disease (memory loss). Record review of Resident #27's quarterly MDS, dated [DATE], revealed a BIMS score of 99 which revealed that the resident was unable to complete the interview and she required complete dependence on 2 or more helpers in most ADLs including toileting and personal hygiene. Record review of Resident #27's progress notes dated 9/1/2024 at 7:45 AM, fell while eating breakfast in dining room and was found lying on her left side with blood coming out of her head. EMS was called and resident transported to ER, POA, physician, and ADM notified of fall. During an observation on 10/23/2024 at 9:21 AM, Resident #27 had stiches to the head and leg. Resident was non interview able. Interview with Resident's family member on 10/23/2024 at 9:22 AM stated that she had an unwitnessed fall on 09/01/2024 which resulted in a laceration to the head and required a hospital visit. During an observation on 10/23/2024 at 11:08 AM, Resident #5 was sitting in w/c in common area with 2 wounds on his arms, both had bandages on arms with dates of 10/21/2024 on them. Resident was observed to have wounds on cheeks and nose, neither were bandaged. Resident was non interview able. During a phone interview on 10/23/2024 at 6:40 PM, Resident #5's family member stated that the resident fell on [DATE] because he was left alone and was always supposed to have someone with him or be in their line of sight. Resident's family member did not think this incident was investigated or reported to the state. During an interview on 10/24/2024 at 9:14 AM, the ADON revealed to surveyor that falls were not investigated and/or reported to the state for investigation. Footage of the falls were reviewed but that is the extent of the investigation. During an observation on 10/24/2024 at 11:45 AM, CE showed surveyor video footage of a fall for Resident #27 that happened on 09/01/2024 around 8:11 AM. No witnesses were observed in footage . During an observation on 10/24/2024 at 12:18 PM, CE showed surveyor video footage of Resident #5 without staff present. Video footage revealed at 7:06 PM on 10/15/2024 that Resident #5 fell from chair to his left side. Further footage of the video revealed at 7:08 PM on 10/15/2024, 2 unidentified staff walked away from Resident #5. During an interview on 10/24/2024 at 2:10 PM, ADM stated that a negative outcome for not investigating a fall would be that they would not be able to find the root cause of the incident and to prevent future incidents of the same nature from happening and a negative outcome for failing to report a fall would be that it is required and expected . Record review of facility provided policy titled Abuse and Neglect - Clinical Protocol, dated 2001 and revised November 2018, revealed the following in part: Assessment and Recognition, #4. Significant injuries in physically dependent individuals. Cause Identification, #1. The staff, with the physician's input as needed, will investigate alleged abuse and neglect to clarify what happened and identify possible causes. Record review of facility provided policy title Accidents and Incidents - Investigating and Reporting, dated 2001 and revised July 2017, revealed the following in part: Policy Statement. All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. Record review of facility employee in service training records revealed Falls-Prevention of Falls and Interventions training was conducted 08/09/2024 and 10/21/2024. Record review of Tulip for intakes for this facility, revealed no incidents reported on either fall for Resident #5 or Resident #27.

Based on interviews and record reviews, the facility failed to comply with the directive statement for 1 of 12 residents whose records were reviewed for advanced directive status. The facility staff failed to initiate CPR and call EMS on [DATE] around 4:20 AM when staff found resident #8 cyanotic (blue), unresponsive and without vital signs. The resident died in the facility and was pronounced at 5:07 AM. An IJ was identified on [DATE]. It was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure affected 1 of 12 sampled residents (#8). The findings include: 1. Review of resident #8's closed record revealed he was admitted to the facility on [DATE]. He was [AGE] years old at the time of his death. He had multiple [DIAGNOSES REDACTED]. The [DATE] through [DATE] physician orders [REDACTED]. The ,[DATE] MAR indicated [REDACTED]. Review of the [DATE] Advance Directive Treatment Choices Sheet revealed resident #8 wanted Heart-Lung Resuscitation (CPR), along with other life prolonging choices, such as artificial nutrition, pain medications, oxygen, etc. The document was signed by his son on [DATE]. Review of resident #8's [DATE] Care Plan (updated on [DATE]) revealed that "resident wishes to be Full Code in case of [MEDICAL CONDITION] Arrest, with Advance Directives specifying specific treatments." Review of the [DATE] through [DATE] (updated on [DATE]) Care Plan revealed "resident requests a Code Status of Full Code." Review of the [DATE] Resident Transfer Form revealed resident #8 was sent to the emergency room with the primary [DIAGNOSES REDACTED]. On the Resident Information section of the Transfer Sheet symptoms of unable to catch breath, lung sounds diminished, periods of apnea, respirations 14, and weakness unable to hold himself up in the chair were documented. Full Code was documented. Resident #8 returned to the facility on [DATE]. 2. During an interview on [DATE] at 8:50 AM, with CNA #2, she identified that she and CNA #3 had been working on the night shift when resident #8 died in the early morning of [DATE]. She stated that he was alert around 3:45 AM. Around 4:20 AM, she and CNA #3 found resident #8 sideways on the bed and his face was purple. CNA #2 called LVN #5 to resident #8's room. CNA #2 stated LVN #5 asked her to get the stethoscope. LVN #5 assessed the resident by listening for breathing and checking for a pulse. LVN #5 left the room to call RN #1. 3. A phone interview with LVN #5 on [DATE] at 4:15 PM revealed that she did not initiate CPR because resident #8 was unresponsive, pooling of blood had occurred, there were no vital signs, no pulse or blood pressure, no respirations, his color was ashen, his eyes were rolled back and fixed, the body was cool to the touch, and had no signs of life. LVN #5 stated she immediately called RN #1 and did not reach her. At 4:35 AM she called the ADON. The ADON called her back and reported that RN #1 was on her way. It was about 30 to 45 minutes before RN #1 got to the facility. The Administrator was notified at 4:38 AM by leaving a message on the answering machine. RN #1 left a message for the doctor. The doctor called back and RN #1 talked to him. LVN #5 stated RN #1 told the doctor resident #8 had died and she had pronounced him. LVN #5 stated that resident #8's ex-wife was called and came to the facility. RN #1 spoke with her. LVN #5 stated there was no indication to her that anything was going on with the resident prior to being found unresponsive. LVN #5 stated it happened so quickly, he was fine when the CNAs were in his room and in a short time they went in and he was unresponsive and without vital signs. 4. A phone interview with RN #1 on [DATE] at 4:10 PM revealed that she was not aware of resident #8's code status when she went to his room but was told he was a Full Code when she went back to the nurses' station. RN #1 stated that when she arrived to the building, it had already been about 45 minutes since resident #8 was found. RN #1 stated the body was already in rigor, there was pooling of blood, he was unresponsive, had no vital signs, and she pronounced him. RN #1 stated that an inservice was given within a day or two on death and calling 911. 5. It was determined this failure placed resident #8 in an IJ situation on [DATE]. The facility took the following actions to correct the non-compliance on [DATE]. At the facility morning meeting on [DATE] RN #1 informed the department heads (members of the QA committee) that LVN #5 had not initiated any interventions in compliance with resident #8's wishes. The QA committee notified the Medical Director who concurred with the committee's assessment a deficient practice existed. The QA committee directed RN #1 to notify the state agency and immediately begin corrective action. The timely response factor was met by the facility gathering the required information for the investigation and immediately suspending LVN #5. To prevent any future occurrences of similar events, the facility inserviced all charge nurses, including the weekend RN on [DATE]. The inservice covered the steps to be taken when there is an unresponsive resident in the facility. First the staff is to determine whether the resident had a DNR or are they a Full Code. If the resident is a DNR: Full assessment - Call the DON (ADON if DON is unavailable) to pronounce. If a Full Code: Have someone call 911 - Initiate CPR until EMS arrives. When charting the events of a death in the facility make sure to document all events leading up to the death including times, assessment of resident including vital signs or lack there of and was CPR initiated and if not why. (EX: CPR not initiated due to resident being a DNR.) It was signed by 13 nurses and was given by RN #1. All facility staff was inserviced on [DATE] about their role in the event of a resident being found unresponsive. All the resident records were reviewed for their advance directive status. A single page document denoting Full Code or DNR was placed in the front of all charts. At the conclusion of the facility investigation when LVN #5 was not able to satisfactorily explain why she had not initiated any life sustaining procedures for resident #8 she was terminated from employment by the facility. As part of the on-going monitoring process carried out by the QA committee and the Medical Director to ensure continued compliance, the facility reviews every subsequent death to ensure appropriate interventions were initiated. Three resident deaths since [DATE] have been found to be in compliance with the resident directives. Every new nursing employee is trained by a tenured staff member who reviews the resident's chart for the Full Code/DNR document and advanced directives section. Nursing employees are given an explanation of Full Code. All employees are given orientation upon hire and annually about the facility policies. 6. The administrator was notified of the past non-compliance IJ on [DATE] since the facility had taken corrective action on [DATE] to ensure staff would begin CPR immediately for residents wishing to be a Full Code. The administrator stated she had believed nurses would know what they were supposed to do up until the incident with resident #8. Interviews conducted with charge nurses on [DATE] and [DATE] confirmed they were all aware of the facility policy regarding initiating CPR for residents documented as Full Code and were confident in their abilities to carry out the resident's wishes. LVN #8 who was employed by the facility at the time of the incident had not signed the [DATE] inservice sheet. LVN #8 stated she was off on medical leave at the time of the incident. LVN #8 stated she was inserviced about the facility policy before beginning her first shift after returning from medical leave.

Based on observation, interview, and record review, the facility failed to implement its policies and procedures to prohibit neglect for 2 of 14 residents (#1, 3, 5, 10, 11, 17, 21, 23, 26, 27, 28, 29, 30, 31) by securing them while they were transported in their wheelchairs in the facility minivan and facility coach. The facility failed to train 5 of 5 staff (CNA #4, CNA #5, HR #1, DM/HS #1, MS #1) who transported residents in wheelchairs to appointments outside the facility in how to use the seat belt restraint systems installed in the facility vehicles. This lack of training caused 3 of the 5 staff (CNA #4, CNA #5, HR #1) not to use any seat belt restraint system on the residents in wheelchairs and 1 of the 5 staff (DM/HS #1) not to use the seat belt restraint system correctly. The last staff member's (MS #1) technique of applying the seat belts was not evaluated prior to the facility locating manufacturer training material. An IJ was identified on 3/16/11. While the IJ was removed on 3/16/11 when the facility immediately stopped using the facility transportation, the facility remained out of compliance at a severity of potential for more than minimal harm and a pattern scope because all staff had not been trained on how to use the seat belt system. This practice affected the 14 residents transported in wheelchairs in the facility minivan and facility coach. Failure to provide effective seat belt restraints during transportation could result in increased risk of injury or death in the event of a transportation accident. The findings include: 1. Review of the 5/27/10 updated Abuse Prevention, Reporting, and Discipline policy revealed the definitions section documented neglect as "a failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness." The policy had the required sections addressing screening potential new employees, training for employees, prevention methods, identification of possible incidents, investigation of incidents, protection of residents during investigations and reporting of incidents. The policy was informative about situations involving possible abuse and the response by the facility. The policy did not have information on neglect other than definition. Review of other facility policies and procedures and interview with the administrator on 3/16/11 at 5:19 PM revealed the facility policies were not current when she was hired on 5/10/10. There was not a policy addressing resident transportation needs until the administrator created one as part of the plan of action necessary to lift the IJ. 2. Observation on 3/14/11 in the large dining room at 5:44 PM revealed resident #5 in a power wheelchair. ~Review of the 4/22/10 MDS and 1/20/11 quarterly review MDS revealed resident #5 was assessed as requiring extensive assistance with transfers. ~During an interview on 3/16/11 at 8:07 AM resident #5 revealed staff secured her power chair when she was transported in the facility van and facility coach, however, staff did not secure her to the power chair. Resident #5 reported that one time when the facility coach went over a rough spot in the road she bounced and nearly fell out of her chair. Resident #5 demonstrated the bounce to the surveyor by leaning forward from her hips with her head close to her knees. When resident #5 was asked how she stayed secure in her chair, she replied "I hold on for dear life" and grasped the arms of the chair to demonstrate. Resident #5 was observed at this time to have her index finger on her left hand contracted totally against her palm. The contracture kept resident #5 from being able to have a firm grasp on the chair arm. 3. Observation on 3/16/11 at 9:53 AM revealed CNA #5 had loaded resident #10 in the facility coach. Resident #10 was sitting in her wheelchair next to the folding seat. Resident #10's wheelchair was strapped to the floor of the coach; however, resident #10 did not have on any type of body restraint securing her to the wheelchair. CNA #5 loaded resident #5 in her power chair into the coach. Once in the coach, resident #5's power chair was facing the lift platform so her body was perpendicular to the side wall of the coach and parallel to the back wall of the coach. After CNA #5 strapped resident #5's power chair to the floor of the coach, CNA #5 walked to the front of the coach. When the surveyor asked CNA #5 if she was done, she said "seat belts" and walked to the back of the coach. CNA #5 grasped seat belt strapping mounted to the back wall of the coach above the window and pulled it across resident #5's upper body from high above her right shoulder down to her left hip. CNA #5 held the end of the strap looking perplexed as to where she was going to attach it and what she was going to attach it with. The strap was very close to being across resident #5's neck looking like it would be a risk of causing strangulation. CNA #5 did not know how she would seat belt resident #10 since the wall mounted strap was behind the folded bench seat. CNA #5 went and got the administrator who stated she was unfamiliar with the correct application of the coach seat belts and would have to get the instructions. The administrator directed CNA #5 to use the abdominal seat belt on resident #5's power chair to secure her to the chair. The administrator directed CNA #5 to transfer resident #10 to a fixed seat with a built-in seat belt so that she would be secured during the transportation. 4. On 3/16/11 at 1:06 PM when the administrator provided the information she had on the facility coach, there was not any information about the correct application of the seat belt restraints. The CFR Title 49 Volume 1 (Revise as of October 1, 2003) ADA Requirements documented "Seat belt and Shoulder Harness-For each wheelchair or mobility aid securement device provided, a passenger seat belt and shoulder harness shall also be provided for use by wheelchair or mobility aide users. Such seat belts and shoulder harnesses shall not be used in lieu of a device, which secures the wheelchair or mobility aid itself." The administrator stated she did not have any information on the seat belt system in the minivan because it had been donated to the facility. 5. Observations on 3/16/11 at 1:32 PM revealed the minivan had the front passenger seat removed. There were 2 floor tracks, 1 in front of the seating area and the other behind the seating area. The tracks were perpendicular to the passenger door. CNA #5 demonstrated how residents in wheelchairs were secured while being transported. The combination shoulder and lap belt mounted on the door jam (original to the vehicle) was fastened to the latching device connected to the driver's seat since the latching device that went with the passenger seat had been removed with the seat. CNA #5 confirmed there was not any way to secure the driver with a seat belt when a resident in a wheelchair was being transported because there was only 1 latch available. It could not be determined due to lack of instructions whether this application method met safety standards for the resident or not. 6. On 3/16/11 at 2:24 PM, the administrator and DON were notified that an IJ existed due to the failure to safely secure residents during transport in facility vehicles. During an interview on 3/16/11 at 2:24 PM, the administrator and DON confirmed 5 staff drove the facility minivan and facility coach when transporting residents to appointments. ~Interview with MS #1 on 3/16/11 at 2:35 PM revealed he had driven the minivan and coach in the past. He stated he did not receive any training at this facility regarding the use of the seat belts. He stated he had not driven the vehicles with residents in several months. He stated he had been trained at another facility on their van and seat belt system. ~Interview with staff HR #1 on 3/16/11 at 2:55 PM revealed that she does drive residents to appointments in town and to other towns. She stated that she secures the wheelchairs but has never used seat belts with the residents in wheelchairs. She remembered that one time the facility insurance company sent out a video and a short test for people driving facility vehicles but that everyone that took that test doesn't work in the facility now. HR #1 stated the video and test were about defensive driving and not specifically about resident safety. She stated that she had transported more than one resident at a time and that they were without seat belts and in wheelchairs. ~Interview and observation with DM/HS #1 at 2:58 PM in the facility coach revealed she had not ever received any training on how to use the seat belt restraint in the coach. DM/HS #1 stated she figured out how to use the seat belt restraints on her own. DM/HS #1 demonstrated how she applied the seat belts to residents by strapping the surveyor in a wheelchair. DM/HS #1 attached the front tie-down straps to the folding cross-bar under the wheelchair. (Not the approved location of attachment) The shoulder strap was applied across the wheelchair arms and secured somewhere behind the wheelchair. The lap belt was not used. The surveyor straightened her legs and slid out of the wheelchair from under the strap resulting in the strap being across her neck, a risk of possible strangulation. During an interview on 3/16/11 at 5:10 PM, with CNA #4, she stated that she had been driving the people (residents) for a long time. She stated that she knew how to lock the resident wheelchairs down but had never used seat belts for the residents. She stated that she had not used seat belts in either the minivan or the big van (coach). She stated that she didn't think that there were seat belts for either of the vans. Interview with the administrator on 3/16/11 at 5:19 PM revealed none of the staff had ever brought up the issue that residents in wheelchairs were not being seat belted in the coach. The administrator stated none of the staff driving the minivan had mentioned not being able to secure a driver's seat belt due to the latch being used by the resident's seat belt. 7. On 3/16/11 at 5:19 PM, the administrator presented the facility's Plan of Action to remove the IJ. The IJ was removed. The plan documented the following: "All transportation of residents that is not medically necessary will be postponed until appropriate training for secure transportation can be provided. All medically necessary transportations will be deferred to Wheel Care Transportation until adequate transportation training can be provided. All staff not certified as a nurses aides will be removed from the facility insurance and will not transport residents. All transportation personnel will watch a training video provided online from the wheel chair passenger safety manufacture. (The facility prepared a handout "How to Guide Using Q'Straint Safety System. The handout had screen shots from the online video.) This video expressly defines how to use the bus's seatbelt system in the manner that provides the highest possible level of safety. Transportation Specialist through the company Wheel Care Transportation will provide an in-service to all drivers, who are also certified nurse's aides on the week of March 21-25, 2011. This in-service will be a tool to further support the education received through the transportation training video. After this in-service, facility administrator, maintenance director, and Wheel Care transportation specialist will require each transportation trainee do a thorough return demonstration to ensure competence regarding the operation of the vehicles' wheelchair restraint and seat belts. This competency training will be documented and kept on file in each driver's employee record. Transportation proficiency training will be done on an annual basis for each driver and all new drivers will be required to watch the manufactures training video and perform competency training through a return demonstration. The facility environmental services director who is also a certified nurses aide will manage the training for any new drivers. Social Services will interview Park View residents regarding their experiences with being transported. Manufacturer's Instructions for the large bus are included: the green van will not be used until the manufacturer's instructions can be located. The green van will be taken out of operation until the driver and all passengers could be safely transported with proper seatbelt restraints. Incidents and accidents for the past year have been reviewed. There were not any incidents or accidents related to the use of facility seatbelts in the facility vehicles. Policy and Procedure for Transportation is as follows: Description of service-Park View Nursing Care Center transportation vehicles are specially equipped and designed to be capable of transporting individuals with medical conditions and non-emergency conditions. Transportation is provided by Park View Nursing Care Center to the nearest medical facility for non-emergency situations and physicians offices for scheduled and non-scheduled visits within a 100 mile radius of the facility. Policy-Coverage will be provided for medical transport services when it is determined to be medically necessary, as outlined in the below guidelines and medical criteria. Transportation will be provided by designated vehicles of Park View Nursing Care Center. Designated vehicles to be maintained by facility according to recommended standard servicing. Transportation will be provided by designated drivers of Park View Nursing Care Center. Drivers will be provided with documented training in vehicle operation and resident safety. This training will be detailed in regards to the safety features such as seatbelts, vehicle wheelchair restraints and rules regarding driver safety. All designated facility drivers will be required to undergo an annual license verification, insurance acceptance, and drug testing. All new drivers will have their drivers' license verified upon hire for the position, drivers license verification will be done annually when the facility automobile insurance is renewed. When coverage will not be approved- Routine transportation when no medical attention is required is not covered. Transportation from one institution to another for the member's or family's convenience is not covered. Transportation for the purpose of receiving an excluded service is not covered. There is not a charge to the resident for this service. Disclaimer: This policy is not all inclusive and may be subject to change by the Muleshoe Area Hospital District: Park View Nursing Care Center. Maintenance for Vans: Attached is the information we have been able to locate in regards to the maintenance of facility vehicles. Policy and Procedure defines that the vehicles will be maintained in accordance with recommended standards for services. No staff has used personal vehicles for transportation since May of 2010 this is also included in our policy and procedure." 8. Interview with CNA #5 on 3/17/11 at 10:30 AM revealed that she had been driving the transportation vans for the facility residents for over 2 years. She identified that she is considered "in charge" of transportation. She stated that she transported up to 15 people in the big van (coach), usually 11 residents plus staff. She stated that you could fit 2 electric wheelchairs and 1 wheelchair in the back of the coach. She stated that the electric wheelchairs have their own seat belts but that the wheelchairs can be locked down but that they don't have seat belts. She stated she had never used a shoulder harness on anyone in the coach. She stated that she was trained by a former maintenance man to lock the wheelchairs down but was never trained to use any seat belts in the coach. CNA #5 stated that she drives the minivan, about 90% of the time. She identified that she would put residents in wheelchairs in the front space next to her. She would use the shoulder strap, pulling across the resident and buckling it into her own seat latch. When asked how she secured herself, as the driver? CNA #5 stated that she would pull the driver's shoulder harness across and hold it under her leg. She stated that she was more concerned about the resident's safety than her own. CNA #5 stated that she watched the video concerning seat belt use in the coach today (3/17/11). She stated that she realized that there were shoulder harnesses and extra buckles in the van after seeing the video. She stated that after watching the video she would be able to seat belt residents in the coach. 9. Interview with resident #10 on 3/17/11 at 11:25 AM revealed the staff had not ever used a shoulder seat belt on her in the facility coach. Resident #10 stated sometimes they moved her to a bench seat with a seat belt and sometimes she stayed in her wheelchair which did not have a seat belt leaving her unsecured during transport. 10. The facility provided a roster on 3/18/11 documenting 12 residents who were transported in their wheelchairs and power chairs in the minivan and coach. Residents #5 and #10 were not included in the 12 residents marked as being transported in wheelchairs, although they were observed and confirmed through interview they had been transported without seat belts, thus bringing the total of residents to 14.

Based on observation, interview, and record review, the facility failed to implement its policies and procedures to prohibit neglect for 2 of 14 residents (#1, 3, 5, 10, 11, 17, 21, 23, 26, 27, 28, 29, 30, 31) by securing them while they were transported in their wheelchairs in the facility minivan and facility coach. The facility failed to train 5 of 5 staff (CNA #4, CNA #5, HR #1, DM/HS #1, MS #1) who transported residents in wheelchairs to appointments outside the facility in how to use the seat belt restraint systems installed in the facility vehicles. This lack of training caused 3 of the 5 staff (CNA #4, CNA #5, HR #1) not to use any seat belt restraint system on the residents in wheelchairs and 1 of the 5 staff (DM/HS #1) not to use the seat belt restraint system correctly. The last staff member's (MS #1) technique of applying the seat belts was not evaluated prior to the facility locating manufacturer training material. An IJ was identified on 3/16/11. While the IJ was removed on 3/16/11 when the facility immediately stopped using the facility transportation, the facility remained out of compliance at a severity of potential for more than minimal harm and a pattern scope because all staff had not been trained on how to use the seat belt system. This practice affected the 14 residents transported in wheelchairs in the facility minivan and facility coach. Failure to provide effective seat belt restraints during transportation could result in increased risk of injury or death in the event of a transportation accident. The findings include: 1. Observation on 3/14/11 in the large dining room at 5:44 PM revealed resident #5 in a power wheelchair. ~Review of the 4/22/10 MDS and 1/20/11 quarterly review MDS revealed resident #5 was assessed as requiring extensive assistance with transfers. ~During an interview on 3/16/11 at 8:07 AM resident #5 revealed staff secured her power chair when she was transported in the facility van and facility coach, however, staff did not secure her to the power chair. Resident #5 reported that one time when the facility coach went over a rough spot in the road she bounced and nearly fell out of her chair. Resident #5 demonstrated the bounce to the surveyor by leaning forward from her hips with her head close to her knees. When resident #5 was asked how she stayed secure in her chair, she replied "I hold on for dear life" and grasped the arms of the chair to demonstrate. Resident #5 was observed at this time to have her index finger on her left hand contracted totally against her palm. The contracture kept resident #5 from being able to have a firm grasp on the chair arm. 2. Observation on 3/16/11 at 9:53 AM revealed CNA #5 had loaded resident #10 in the facility coach. Resident #10 was sitting in her wheelchair next to the folding seat. Resident #10's wheelchair was strapped to the floor of the coach; however, resident #10 did not have on any type of body restraint securing her to the wheelchair. CNA #5 loaded resident #5 in her power chair into the coach. Once in the coach, resident #5's power chair was facing the lift platform so her body was perpendicular to the side wall of the coach and parallel to the back wall of the coach. After CNA #5 strapped resident #5's power chair to the floor of the coach, CNA #5 walked to the front of the coach. When the surveyor asked CNA #5 if she was done, she said "seat belts" and walked to the back of the coach. CNA #5 grasped seat belt strapping mounted to the back wall of the coach above the window and pulled it across resident #5's upper body from high above her right shoulder down to her left hip. CNA #5 held the end of the strap looking perplexed as to where she was going to attach it and what she was going to attach it with. The strap was very close to being across resident #5's neck looking like it would be a risk of causing strangulation. CNA #5 did not know how she would seat belt resident #10 since the wall mounted strap was behind the folded bench seat. CNA #5 went and got the administrator who stated she was unfamiliar with the correct application of the coach seat belts and would have to get the instructions. The administrator directed CNA #5 to use the abdominal seat belt on resident #5's power chair to secure her to the chair. The administrator directed CNA #5 to transfer resident #10 to a fixed seat with a built-in seat belt so that she would be secured during the transportation. 3. On 3/16/11 at 1:06 PM when the administrator provided the information she had on the facility coach, there was not any information about the correct application of the seat belt restraints. The CFR Title 49 Volume 1 (Revise as of October 1, 2003) ADA Requirements documented "Seat belt and Shoulder Harness-For each wheelchair or mobility aid securement device provided, a passenger seat belt and shoulder harness shall also be provided for use by wheelchair or mobility aide users. Such seat belts and shoulder harnesses shall not be used in lieu of a device, which secures the wheelchair or mobility aid itself." The administrator stated she did not have any information on the seat belt system in the minivan because it had been donated to the facility. 4. Observations on 3/16/11 at 1:32 PM revealed the minivan had the front passenger seat removed. There were 2 floor tracks, 1 in front of the seating area and the other behind the seating area. The tracks were perpendicular to the passenger door. CNA #5 demonstrated how residents in wheelchairs were secured while being transported. The combination shoulder and lap belt mounted on the door jam (original to the vehicle) was fastened to the latching device connected to the driver's seat since the latching device that went with the passenger seat had been removed with the seat. CNA #5 confirmed there was not any way to secure the driver with a seat belt when a resident in a wheelchair was being transported because there was only 1 latch available. It could not be determined due to lack of instructions whether this application method met safety standards for the resident or not. 5. On 3/16/11 at 2:24 PM, the administrator and DON were notified that an IJ existed due to the failure to safely secure residents during transport in facility vehicles. During an interview on 3/16/11 at 2:24 PM, the administrator and DON confirmed 5 staff drove the facility minivan and facility coach when transporting residents to appointments. ~Interview with MS #1 on 3/16/11 at 2:35 PM revealed he had driven the minivan and coach in the past. He stated he did not receive any training at this facility regarding the use of the seat belts. He stated he had not driven the vehicles with residents in several months. He stated he had been trained at another facility on their van and seat belt system. ~Interview with staff HR #1 on 3/16/11 at 2:55 PM revealed that she does drive residents to appointments in town and to other towns. She stated that she secures the wheelchairs but has never used seat belts with the residents in wheelchairs. She remembered that one time the facility insurance company sent out a video and a short test for people driving facility vehicles but that everyone that took that test doesn't work in the facility now. HR #1 stated the video and test were about defensive driving and not specifically about resident safety. She stated that she had transported more than one resident at a time and that they were without seat belts and in wheelchairs. ~Interview and observation with DM/HS #1 at 2:58 PM in the facility coach revealed she had not ever received any training on how to use the seat belt restraint in the coach. DM/HS #1 stated she figured out how to use the seat belt restraints on her own. DM/HS #1 demonstrated how she applied the seat belts to residents by strapping the surveyor in a wheelchair. DM/HS #1 attached the front tie-down straps to the folding cross-bar under the wheelchair. (Not the approved location of attachment) The shoulder strap was applied across the wheelchair arms and secured somewhere behind the wheelchair. The lap belt was not used. The surveyor straightened her legs and slid out of the wheelchair from under the strap resulting in the strap being across her neck, a risk of possible strangulation. During an interview on 3/16/11 at 5:10 PM, with CNA #4, she stated that she had been driving the people (residents) for a long time. She stated that she knew how to lock the resident wheelchairs down but had never used seat belts for the residents. She stated that she had not used seat belts in either the minivan or the big van (coach). She stated that she didn't think that there were seat belts for either of the vans. 6. Interview with the administrator on 3/16/11 at 5:19 PM revealed none of the staff had ever brought up the issue that residents in wheelchairs were not being seat belted in the coach. The administrator stated none of the staff driving the minivan had mentioned not being able to secure a driver's seat belt due to the latch being used by the resident's seat belt. Review of the facility policies and procedures and interview with the administrator on 3/16/11 at 5:19 PM revealed the facility policies were not current when she was hired on 5/10/10. There was not a policy addressing resident transportation needs until the administrator created one as part of the plan of action necessary to lift the IJ. The 5/27/10 updated policy regarding abuse, neglect, and misappropriation revealed neglect is defined as "a failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness." 7. On 3/16/11 at 5:19 PM, the administrator presented the facility's Plan of Action to remove the IJ. The IJ was removed. The plan documented the following: "All transportation of residents that is not medically necessary will be postponed until appropriate training for secure transportation can be provided. All medically necessary transportations will be deferred to Wheel Care Transportation until adequate transportation training can be provided. All staff not certified as a nurses aides will be removed from the facility insurance and will not transport residents. All transportation personnel will watch a training video provided online from the wheel chair passenger safety manufacture. (The facility prepared a handout "How to Guide Using Q'Straint Safety System. The handout had screen shots from the online video.) This video expressly defines how to use the bus's seatbelt system in the manner that provides the highest possible level of safety. Transportation Specialist through the company Wheel Care Transportation will provide an in-service to all drivers, who are also certified nurse's aides on the week of March 21-25, 2011. This in-service will be a tool to further support the education received through the transportation training video. After this in-service, facility administrator, maintenance director, and Wheel Care transportation specialist will require each transportation trainee do a thorough return demonstration to ensure competence regarding the operation of the vehicles' wheelchair restraint and seat belts. This competency training will be documented and kept on file in each driver's employee record. Transportation proficiency training will be done on an annual basis for each driver and all new drivers will be required to watch the manufactures training video and perform competency training through a return demonstration. The facility environmental services director who is also a certified nurses aide will manage the training for any new drivers. Social Services will interview Park View residents regarding their experiences with being transported. Manufacturer's Instructions for the large bus are included: the green van will not be used until the manufacturer's instructions can be located. The green van will be taken out of operation until the driver and all passengers could be safely transported with proper seatbelt restraints. Incidents and accidents for the past year have been reviewed. There were not any incidents or accidents related to the use of facility seatbelts in the facility vehicles. Policy and Procedure for Transportation is as follows: Description of service-Park View Nursing Care Center transportation vehicles are specially equipped and designed to be capable of transporting individuals with medical conditions and non-emergency conditions. Transportation is provided by Park View Nursing Care Center to the nearest medical facility for non-emergency situations and physicians offices for scheduled and non-scheduled visits within a 100 mile radius of the facility. Policy-Coverage will be provided for medical transport services when it is determined to be medically necessary, as outlined in the below guidelines and medical criteria. Transportation will be provided by designated vehicles of Park View Nursing Care Center. Designated vehicles to be maintained by facility according to recommended standard servicing. Transportation will be provided by designated drivers of Park View Nursing Care Center. Drivers will be provided with documented training in vehicle operation and resident safety. This training will be detailed in regards to the safety features such as seatbelts, vehicle wheelchair restraints and rules regarding driver safety. All designated facility drivers will be required to undergo an annual license verification, insurance acceptance, and drug testing. All new drivers will have their drivers' license verified upon hire for the position, drivers license verification will be done annually when the facility automobile insurance is renewed. When coverage will not be approved- Routine transportation when no medical attention is required is not covered. Transportation from one institution to another for the member's or family's convenience is not covered. Transportation for the purpose of receiving an excluded service is not covered. There is not a charge to the resident for this service. Disclaimer: This policy is not all inclusive and may be subject to change by the Muleshoe Area Hospital District: Park View Nursing Care Center. Maintenance for Vans: Attached is the information we have been able to locate in regards to the maintenance of facility vehicles. Policy and Procedure defines that the vehicles will be maintained in accordance with recommended standards for services. No staff has used personal vehicles for transportation since May of 2010 this is also included in our policy and procedure." 7. Interview with CNA #5 on 3/17/11 at 10:30 AM revealed that she had been driving the transportation vans for the facility residents for over 2 years. She identified that she is considered "in charge" of transportation. She stated that she transported up to 15 people in the big van (coach), usually 11 residents plus staff. She stated that you could fit 2 electric wheelchairs and 1 wheelchair in the back of the coach. She stated that the electric wheelchairs have their own seat belts but that the wheelchairs can be locked down but that they don't have seat belts. She stated she had never used a shoulder harness on anyone in the coach. She stated that she was trained by a former maintenance man to lock the wheelchairs down but was never trained to use any seat belts in the coach. CNA #5 stated that she drives the minivan, about 90% of the time. She identified that she would put residents in wheelchairs in the front space next to her. She would use the shoulder strap, pulling across the resident and buckling it into her own seat latch. When asked how she secured herself, as the driver? CNA #5 stated that she would pull the driver's shoulder harness across and hold it under her leg. She stated that she was more concerned about the resident's safety than her own. CNA #5 stated that she watched the video concerning seat belt use in the coach today (3/17/11). She stated that she realized that there were shoulder harnesses and extra buckles in the van after seeing the video. She stated that after watching the video she would be able to seat belt residents in the coach. 8. Interview with resident #10 on 3/17/11 at 11:25 AM revealed the staff had not ever used a shoulder seat belt on her in the facility coach. Resident #10 stated sometimes they moved her to a bench seat with a seat belt and sometimes she stayed in her wheelchair which did not have a seat belt leaving her unsecured during transport. 9. The facility provided a roster on 3/18/11 documenting 12 residents who were transported in their wheelchairs and power chairs in the minivan and coach. Residents #5 and #10 were not included in the 12 residents marked as being transported in wheelchairs, although they were observed and confirmed through interview they had been transported without seat belts, thus bringing the total of residents to 14.

Based on interview and record review, the facility was not administered in a manner that enabled it to use its resources effectively to attain or maintain the highest practicable physical, mental, psychosocial well-being for 2 of 14 residents (#1, 3, 5, 10, 11, 17, 21, 23, 26, 27, 28, 29, 30, 31) who were transported in their wheelchairs in facility transportation. The administrator failed to ensure the facility trained 5 of 5 staff (CNA #4, CNA #5, HR #1, DM/HS #1, MS #1) who transported residents in wheelchairs to appointments outside the facility in how to use the seat belt restraint systems. This lack of training caused 3 of the 5 staff (CNA #4, CNA #5, HR #1) not to use any seat belt restraint system on the residents in wheelchairs and 1 of the 5 staff (DM/HS #1) not to use the seat belt restraint system correctly. The last staff member's (MS #1) technique of applying the seat belts was not evaluated prior to the facility locating manufacturer training material. This practice affected the 14 residents transported in wheelchairs in the facility minivan and facility coach. Failure to provide effective seat belt restraints during transportation could result in increased risk of injury or death in the event of a transportation accident. The findings include: 1. Observation on 3/14/11 in the large dining room at 5:44 PM revealed resident #5 in a power wheelchair. ~Review of the 4/22/10 MDS and 1/20/11 quarterly review MDS revealed resident #5 was assessed as requiring extensive assistance with transfers. ~During an interview on 3/16/11 at 8:07 AM resident #5 revealed staff secured her power chair when she was transported in the facility van and facility coach, however, staff did not secure her to the power chair. Resident #5 reported that one time when the facility coach went over a rough spot in the road she bounced and nearly fell out of her chair. Resident #5 demonstrated the bounce to the surveyor by leaning forward from her hips with her head close to her knees. When resident #5 was asked how she stayed secure in her chair, she replied "I hold on for dear life" and grasped the arms of the chair to demonstrate. Resident #5 was observed at this time to have her index finger on her left hand contracted totally against her palm. The contracture kept resident #5 from being able to have a firm grasp on the chair arm. 2. Observation on 3/16/11 at 9:53 AM revealed CNA #5 had loaded resident #10 in the facility coach. Resident #10 was sitting in her wheelchair next to the folding seat. Resident #10's wheelchair was strapped to the floor of the coach; however, resident #10 did not have on any type of body restraint securing her to the wheelchair. CNA #5 loaded resident #5 in her power chair into the coach. Once in the coach, resident #5's power chair was facing the lift platform so her body was perpendicular to the side wall of the coach and parallel to the back wall of the coach. After CNA #5 strapped resident #5's power chair to the floor of the coach, CNA #5 walked to the front of the coach. When the surveyor asked CNA #5 if she was done, she said "seat belts" and walked to the back of the coach. CNA #5 grasped seat belt strapping mounted to the back wall of the coach above the window and pulled it across resident #5's upper body from high above her right shoulder down to her left hip. CNA #5 held the end of the strap looking perplexed as to where she was going to attach it and what she was going to attach it with. The strap was very close to being across resident #5's neck looking like it would be a risk of causing strangulation. CNA #5 did not know how she would seat belt resident #10 since the wall mounted strap was behind the folded bench seat. CNA #5 went and got the administrator who stated she was unfamiliar with the correct application of the coach seat belts and would have to get the instructions. The administrator directed CNA #5 to use the abdominal seat belt on resident #5's power chair to secure her to the chair. The administrator directed CNA #5 to transfer resident #10 to a fixed seat with a built-in seat belt so that she would be secured during the transportation. 3. On 3/16/11 at 1:06 PM when the administrator provided the information she had on the facility coach, there was not any information about the correct application of the seat belt restraints. The CFR Title 49 Volume 1 (Revise as of October 1, 2003) ADA Requirements documented "Seat belt and Shoulder Harness-For each wheelchair or mobility aid securement device provided, a passenger seat belt and shoulder harness shall also be provided for use by wheelchair or mobility aide users. Such seat belts and shoulder harnesses shall not be used in lieu of a device, which secures the wheelchair or mobility aid itself." The administrator stated she did not have any information on the seat belt system in the minivan because it had been donated to the facility. 4. Observations on 3/16/11 at 1:32 PM revealed the minivan had the front passenger seat removed. There were 2 floor tracks, 1 in front of the seating area and the other behind the seating area. The tracks were perpendicular to the passenger door. CNA #5 demonstrated how residents in wheelchairs were secured while being transported. The combination shoulder and lap belt mounted on the door jam (original to the vehicle) was fastened to the latching device connected to the driver's seat since the latching device that went with the passenger seat had been removed with the seat. CNA #5 confirmed there was not any way to secure the driver with a seat belt when a resident in a wheelchair was being transported because there was only 1 latch available. It could not be determined due to lack of instructions whether this application method met safety standards for the resident or not. 5. On 3/16/11 at 2:24 PM, the administrator and DON were notified that an IJ existed due to the failure to safely secure residents during transport in facility vehicles. During an interview on 3/16/11 at 2:24 PM, the administrator and DON confirmed 5 staff drove the facility minivan and facility coach when transporting residents to appointments. ~Interview with MS #1 on 3/16/11 at 2:35 PM revealed he had driven the minivan and coach in the past. He stated he did not receive any training at this facility regarding the use of the seat belts. He stated he had not driven the vehicles with residents in several months. He stated he had been trained at another facility on their van and seat belt system. ~Interview with staff HR #1 on 3/16/11 at 2:55 PM revealed that she does drive residents to appointments in town and to other towns. She stated that she secures the wheelchairs but has never used seat belts with the residents in wheelchairs. She remembered that one time the facility insurance company sent out a video and a short test for people driving facility vehicles but that everyone that took that test doesn't work in the facility now. HR #1 stated the video and test were about defensive driving and not specifically about resident safety. She stated that she had transported more than one resident at a time and that they were without seat belts and in wheelchairs. ~Interview and observation with DM/HS #1 at 2:58 PM in the facility coach revealed she had not ever received any training on how to use the seat belt restraint in the coach. DM/HS #1 stated she figured out how to use the seat belt restraints on her own. DM/HS #1 demonstrated how she applied the seat belts to residents by strapping the surveyor in a wheelchair. DM/HS #1 attached the front tie-down straps to the folding cross-bar under the wheelchair. (Not the approved location of attachment) The shoulder strap was applied across the wheelchair arms and secured somewhere behind the wheelchair. The lap belt was not used. The surveyor straightened her legs and slid out of the wheelchair from under the strap resulting in the strap being across her neck, a risk of possible strangulation. During an interview on 3/16/11 at 5:10 PM, with CNA #4, she stated that she had been driving the people (residents) for a long time. She stated that she knew how to lock the resident wheelchairs down but had never used seat belts for the residents. She stated that she had not used seat belts in either the minivan or the big van (coach). She stated that she didn't think that there were seat belts for either of the vans. 6. Interview with the administrator on 3/16/11 at 5:19 PM revealed none of the staff had ever brought up the issue that residents in wheelchairs were not being seat belted in the coach. The administrator stated none of the staff driving the minivan had mentioned not being able to secure a driver's seat belt due to the latch being used by the resident's seat belt. Review of the facility policies and procedures and interview with the administrator on 3/16/11 at 5:19 PM revealed the facility policies were not current when she was hired on 5/10/10. There was not a policy addressing resident transportation needs until the administrator created one as part of the plan of action necessary to lift the IJ. The 5/27/10 updated policy regarding abuse, neglect, and misappropriation revealed neglect is defined as "a failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness." 7. On 3/16/11 at 5:19 PM, the administrator presented the facility's Plan of Action to remove the IJ. The IJ was removed. The plan documented the following: "All transportation of residents that is not medically necessary will be postponed until appropriate training for secure transportation can be provided. All medically necessary transportations will be deferred to Wheel Care Transportation until adequate transportation training can be provided. All staff not certified as a nurses aides will be removed from the facility insurance and will not transport residents. All transportation personnel will watch a training video provided online from the wheel chair passenger safety manufacture. (The facility prepared a handout "How to Guide Using Q'Straint Safety System. The handout had screen shots from the online video.) This video expressly defines how to use the bus's seatbelt system in the manner that provides the highest possible level of safety. Transportation Specialist through the company Wheel Care Transportation will provide an in-service to all drivers, who are also certified nurse's aides on the week of March 21-25, 2011. This in-service will be a tool to further support the education received through the transportation training video. After this in-service, facility administrator, maintenance director, and Wheel Care transportation specialist will require each transportation trainee do a thorough return demonstration to ensure competence regarding the operation of the vehicles' wheelchair restraint and seat belts. This competency training will be documented and kept on file in each driver's employee record. Transportation proficiency training will be done on an annual basis for each driver and all new drivers will be required to watch the manufactures training video and perform competency training through a return demonstration. The facility environmental services director who is also a certified nurses aide will manage the training for any new drivers. Social Services will interview Park View residents regarding their experiences with being transported. Manufacturer's Instructions for the large bus are included: the green van will not be used until the manufacturer's instructions can be located. The green van will be taken out of operation until the driver and all passengers could be safely transported with proper seatbelt restraints. Incidents and accidents for the past year have been reviewed. There were not any incidents or accidents related to the use of facility seatbelts in the facility vehicles. Policy and Procedure for Transportation is as follows: Description of service-Park View Nursing Care Center transportation vehicles are specially equipped and designed to be capable of transporting individuals with medical conditions and non-emergency conditions. Transportation is provided by Park View Nursing Care Center to the nearest medical facility for non-emergency situations and physicians offices for scheduled and non-scheduled visits within a 100 mile radius of the facility. Policy-Coverage will be provided for medical transport services when it is determined to be medically necessary, as outlined in the below guidelines and medical criteria. Transportation will be provided by designated vehicles of Park View Nursing Care Center. Designated vehicles to be maintained by facility according to recommended standard servicing. Transportation will be provided by designated drivers of Park View Nursing Care Center. Drivers will be provided with documented training in vehicle operation and resident safety. This training will be detailed in regards to the safety features such as seatbelts, vehicle wheelchair restraints and rules regarding driver safety. All designated facility drivers will be required to undergo an annual license verification, insurance acceptance, and drug testing. All new drivers will have their drivers' license verified upon hire for the position, drivers license verification will be done annually when the facility automobile insurance is renewed. When coverage will not be approved- Routine transportation when no medical attention is required is not covered. Transportation from one institution to another for the member's or family's convenience is not covered. Transportation for the purpose of receiving an excluded service is not covered. There is not a charge to the resident for this service. Disclaimer: This policy is not all inclusive and may be subject to change by the Muleshoe Area Hospital District: Park View Nursing Care Center. Maintenance for Vans: Attached is the information we have been able to locate in regards to the maintenance of facility vehicles. Policy and Procedure defines that the vehicles will be maintained in accordance with recommended standards for services. No staff has used personal vehicles for transportation since May of 2010 this is also included in our policy and procedure." 7. Interview with CNA #5 on 3/17/11 at 10:30 AM revealed that she had been driving the transportation vans for the facility residents for over 2 years. She identified that she is considered "in charge" of transportation. She stated that she transported up to 15 people in the big van (coach), usually 11 residents plus staff. She stated that you could fit 2 electric wheelchairs and 1 wheelchair in the back of the coach. She stated that the electric wheelchairs have their own seat belts but that the wheelchairs can be locked down but that they don't have seat belts. She stated she had never used a shoulder harness on anyone in the coach. She stated that she was trained by a former maintenance man to lock the wheelchairs down but was never trained to use any seat belts in the coach. CNA #5 stated that she drives the minivan, about 90% of the time. She identified that she would put residents in wheelchairs in the front space next to her. She would use the shoulder strap, pulling across the resident and buckling it into her own seat latch. When asked how she secured herself, as the driver? CNA #5 stated that she would pull the driver's shoulder harness across and hold it under her leg. She stated that she was more concerned about the resident's safety than her own. CNA #5 stated that she watched the video concerning seat belt use in the coach today (3/17/11). She stated that she realized that there were shoulder harnesses and extra buckles in the van after seeing the video. She stated that after watching the video she would be able to seat belt residents in the coach. 8. Interview with resident #10 on 3/17/11 at 11:25 AM revealed the staff had not ever used a shoulder seat belt on her in the facility coach. Resident #10 stated sometimes they moved her to a bench seat with a seat belt and sometimes she stayed in her wheelchair which did not have a seat belt leaving her unsecured during transport. 9. The facility provided a roster on 3/18/11 documenting 12 residents who were transported in their wheelchairs and power chairs in the minivan and coach. Residents #5 and #10 were not included in the 12 residents marked as being transported in wheelchairs, although they were observed and confirmed through interview they had been transported without seat belts, thus bringing the total of residents to 14.