Every finding on record at Pleasanton South Nursing and Rehabilitation

Based on observations, interviews, and record reviews, the facility failed to protect the confidentiality of personal and medical records for one (1) of three (3) staff (MA A) observed for confidentiality of records. The facility failed to ensure MA A locked her computer on the medication cart, which exposed Resident #1's electronic medication administration record, so the resident's information could be seen and/or accessed by someone walking by on 06/18/2026 at 12:36 p.m. This failure could place residents at risk of having medical information exposed to others and cause residents to feel uncomfortable and disrespected.The findings included: Record review of Resident #1's admission Record, dated 06/18/2026, reflected a [AGE] year-old female. She was admitted to the facility on [DATE]. Record review of Resident #1's Diagnosis Report, dated 06/18/2026, reflected diagnoses included multiple fractures (breaks) of ribs on the right side, hypertension (condition of high pressure in the vessels that carry blood from the heart to the rest of the body), acute sinusitis (inflammation of the sinuses), and hypothyroidism (when the thyroid does not produce enough hormones). Record review of Resident #1's Quarterly MDS Assessment, dated 06/09/2026, reflected the resident had a BIMS score of 14, which indicated she was cognitively intact. She had hypertension, fractures (other than hip), and had received both scheduled and as needed pain medications in the last 5 days. She had occasional pain in the last five (5) days. She was taking an opioid (used to control pain). Record review of Resident #1's Order Summary Report, dated 06/18/2026, reflected the following order summaries with order status, order date, start date, and end date if available: - amlodipine besylate oral tablet 5 MG (Amlodipine Besylate) Give 1 tablet by mouth one time a day for HTN Hold if SBP < 110, DBP <60, or HR <60, order noted as active, order date 10/17/2024, start date 10/18/20264, and an end date was not entered. - Levocetirizine Dihydrochloride Oral Tablet 5 MG (Levocetirizine Dihydrochloride) Give 1 tablet by mouth as needed for allergies, order noted as active, order and start date 04/24/2025, and an end date was not entered.- Levothyroxine Sodium Oral Tablet 75 MCG (Levothyroxine Sodium) Give 1 tablet by mouth one time a day for thyroid, order noted as active, order date 10/17/2024, start date 10/18/2024, and an end date was not entered.- Tramadol HCl Tablet 50 MG Give 1 tablet by mouth every 12 hours as needed for Pain, order noted as active, order and start date 11/27/2024, and an end date was not entered. During an observation on 06/18/2026 at 12:36 p.m., a medication cart, parked next to the centrally located nurses' station, revealed a computer screen on a medication cart, with the computer facing away from the nurses' station and down a resident hallway, was unlocked and unsupervised with Resident #1's medication orders and administration schedule visible and accessible. There were no residents or visitors in the immediate area. At 12:38 p.m., MA A was observed to approach the medication cart and computer from a resident hall and immediately locked the computer screen. During an interview on 06/18/2026 at 12:38 p.m., MA A stated she did notice she left her computer open. She stated she got distracted. She stated the facility did provide training on the expectation for staff to secure the computers. She stated leaving the computer screen open was a HIPAA violation, exposing patient information. During an interview on 06/18/2026 at 04:33 p.m., Resident #1 stated she would not care if anyone saw what type of medications she took. She stated she only regularly took thyroid, blood pressure, and allergy medications with the occasional tramadol (an opioid) when needed. She stated it did not bother her if anyone knew. During an interview on 06/18/2026 at 06:41 p.m., the DON stated her expectation for staff was to lock the electronic medical record by putting on a lock screen or closing the computer when walking away. She stated the impact of a computer screen being left open and visible was that it was a HIPAA violation and residents with an adequate cognitive status could see the screen and know about another resident's medications and possibly their health conditions. During an interview on 06/18/2026 at 07:09 p.m., the ADMIN stated the impact of an open and unattended computer was that there was the potential that a resident's private information could be exposed to people that should not have access to it. Record review of the facility's policy titled, Electronic Security, dated copyright 2026, revealed, Policy: It is the policy of this company to keep all intellectual property (electronic data) and its electronic resources (printers, networks, servers, laptops, desktops, storage, etc .) secure from any unauthorized use.Policy Explanation and Compliance Guidelines:1. Access to all resources is to be restrictive in nature and only authorized users may access these resources. Record review of the facility's policy titled, Resident Rights, dated copyright 2026, revealed, 7. Privacy and confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records. b. The resident has a right to secure and confidential personal and medical records.

Based on observation and interview, the facility failed to post on a daily basis information that included the facility name, current date, total number and actual hours worked by registered nurses, licensed practical or licensed vocational nurses, certified nurse aides directly responsible for resident care per shift and the resident census for two (2) of two (2) days (06/17/2026 and 06/18/2026) reviewed for posting of required information. 1. The facility failed to post the correct date on the required current nurse staffing and census information on 06/17/2026. 2. The facility failed to post the required current nurse staffing and census information at the beginning of each shift on 06/18/2026. These failures could place all residents, their families, and facility visitors at risk of not having access to information regarding staffing data and the facility census. The findings included: During an observation on 06/18/2026 at 12:05 p.m., a document labeled [facility name] Staffing Report, dated 06/16/2026, was posted on a wall of the front lobby. The document included the following information: census and the scheduled number and hours worked of registered nurses, licensed practical nurses, medication technicians, certified nurse aides, and nurse aides for the eight (8) noted nursing department 24-hour coverage shift times: 06:00 a.m.- 02:00 p.m., 02:00 p.m.- 06:00 p.m., 06:00 a.m.- 06:00 p.m., 07:00 a.m.- 03:00 p.m., 02:00 p.m.- 10:00 p.m., 06:00 p.m.- 10:00 p.m., 06:00 p.m.- 06:00 a.m., and 10:00 p.m.- 06:00 a.m. During an interview on 06/18/2026 at 06:41 p.m., the DON stated the HR was normally responsible for posting the daily census and nurse staffing document. She stated she checked the posting after lunch and it was dated for today, 06/18/2026, so it was possible the HR got caught up. She stated the posting was to let residents' families know what the daily census was and who was on the floor working. She stated it let facility visitors know what to expect on how many nursing staff were working on the floor. During an interview on 06/18/2026 at 07:00 p.m., the HR stated she had an appointment this morning, 06/18/2026, and when she returned at 12:30 p.m., she posted the daily census and nurse staffing posting for the day, 06/18/2026. She stated she worked this morning but was still filling the document out prior to her leaving for her appointment and therefore did not post it at that time. She stated she got side tracked. She stated she did post the document yesterday, 06/17/2026 after the morning meeting at 09:00 a.m. She stated she did not know why the posted document at 12:05 p.m. was dated 06/16/2026. She stated she thought she might have mis-dated the document. She stated she believed she posted the correct information for yesterday's census and nurse staffing but put the wrong date. She stated the impact of the document not being posted would be that for anyone that comes into the facility, not knowing the hours of staff working on the floor. During an interview on 06/18/2026 at 07:09 p.m., the ADMIN stated normally the HR posted the daily census and nurse staffing posting in the morning, no later than 09:30 a.m. She stated she did not believe there would be any type of resident impact from the document having not been posted but there was an impact on a regulatory standpoint. The ADMIN stated she knew the HR was going to be out of the building for part of the day, on 06/18/2026. Record review of the facility's policy titled, Nurse Staffing Posting Information, dated copyright 2025, revealed, Policy: It is the policy of this facility to make nurse staffing information readily available in a readable format to residents, staff, and visitors at any given time.Policy Explanation and Compliance Guidelines:1. The Nurse Staffing Sheet will be posted on a daily basis and will contain the following information: . b. The current date .2. The facility will post the Nurse Staffing Sheet at the beginning of each shift.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 facility kitchen in that: 1. A 40-ounce package of honey ham was undated. 2. A 32-ounce container of liquid eggs was undated. 3. A clear carafe of yellow liquid was uncovered, unlabeled, and undated. 4. A 6-ounce container of raspberries was undated. 5. An open 16-ounce can of energy drink was on the table where residents' food was prepared. 6. The plate warmer was not plugged-in during lunch service. 7. A 1 pound block of margarine was undated. 8. A tray of approximately 24 cups of liquid was unlabeled and undated. 9. Two 3-quart containers of apple juice were undated. 10. A 5-pound container of sour cream was undated. 11. A tray of approximately 24 cups of milk was unlabeled and undated. 12. A 16-ounce bottle of soda and a plastic bag with two 24-ounces cans of energy drink were located in the refrigerator where food for resident meals was stored. 13. Personal belongings of kitchen staff were hanging on the side of the pantry shelves and touching food items intended for resident meals. 14. The small kitchen sink was stained with brown liquid. 15. A plastic container of food thickener was unlabeled and undated. 16. The dish sanitation machine had a sand-like residue on the top and sides. 17. A 12-ounce container of caramel sauce, labeled refrigerate after opening was open and not refrigerated.18. The microwave door was soiled on the inside. These deficient practices could place residents who consume meals and snacks from the kitchen at risk for food borne illness. The findings were: Observations on 12/07/2025 between 12:15 p.m. and 12:30 p.m. revealed: 1. A 40-ounce package of honey ham in the three-door refrigerator was undated. 2. A 32-ounce container of liquid eggs in the three-door refrigerator was undated. 3. A clear carafe of yellow liquid in the three-door refrigerator was uncovered, unlabeled, and undated. 4. A 6-ounce container of raspberries in the three-door refrigerator was undated. 5. An open 16-ounce can of energy drink was on the table where residents' food was prepared. 6. The plate warmer was not plugged-in during lunch service. During an interview with Dietary Aide C on 12/07/2025 at 12:32 p.m., Dietary Aide C confirmed the three-door refrigerator contained a 40-ounce package of honey ham, 32-ounce container of liquid eggs, and a 6-ounce container of raspberries which were undated. Dietary Aide C also confirmed that the three-door refrigerator contained a clear carafe of yellow liquid which was uncovered, unlabeled, and undated, an open energy drink was located on the food preparation table, and the plate warmer was unplugged during lunch service. Observations on 12/10/2025 between 6:15 a.m. and 7:00 a.m. revealed: 7. A 1-pound block of margarine in the three-door refrigerator was undated. 8. A tray of approximately 24 cups of liquid in the three-door refrigerator was unlabeled and undated. 9. Two 3-quart containers of apple juice in the three-door refrigerator were undated. 10. A 5-pound container of sour cream in the three-door refrigerator was undated. 11. A tray of approximately 24 cups of milk in the three-door refrigerator was unlabeled and undated. 12. A 16-ounce bottle of soda and a plastic bag with two 24-ounces cans of energy drink were located in the three-door refrigerator where food for residents' meals was stored. 13. Personal belongings of kitchen staff were hanging on the side of the pantry shelves and touching food items intended for resident meals. 14. The small kitchen sink was stained with brown liquid. 15. A plastic container of food thickener was unlabeled and undated. 16. The dish sanitation machine had a sand-like residue on the top and sides. 17. A 12-ounce container of caramel sauce, labeled refrigerate after opening was open and not refrigerated.18. The microwave door was soiled on the inside. During an interview with the Dietary Manager on 12/10/2025 at 7:20 a.m., confirmed the three-door refrigerator contained a 1-pound block of margarine, two 3-quart containers of apple juice, and a 5-pound container of sour cream which were undated. The Dietary Manager also confirmed the three-door refrigerator contained tray of approximately 24 cups of liquid and a tray of approximately 24 cups of milk which were unlabeled and undated. The Dietary Manager also confirmed a bottle of soda and two energy drinks were located in the three-door refrigerator and personal belongings of two staff members were hanging on the side of the pantry shelves and touching food items intended for resident meals. The Dietary Manager confirmed that the small kitchen sink was stained with brown liquid, a plastic container of food thickener was unlabeled and undated, the dish sanitation machine had a sand-like residue on the top and sides, a 12-ounce container of caramel sauce, labeled refrigerate after opening was open and not refrigerated, and the microwave was soiled inside the door. The Dietary Manager stated all food items should have been labeled and dated, staff personal belongings and their personal drinks should not be found in the refrigerator or pantry, and the sink, microwave, and dish machine should be unsoiled. The Dietary Manager stated it was the responsibility of all kitchen staff to ensure resident food was stored and prepared in a sanitary and safe manner. Record review of the facility policy, Sanitation Inspection, undated, revealed, All food service areas shall be kept clean, sanitary, free from litter.

Based on observation, interview, and record review, the facility failed to ensure the resident environment was as free of accident hazards as possible for two (Hall E and Hall F) of four resident hallways, in that: Supply closets on resident Hall E and Hall F were open and unlocked and contained potentially hazardous materials. This deficient practice could result in residents coming into contact with, and being harmed by, hazardous materials. The findings were: Observation on 12/07/2025 at 11:46 a.m. of the supply closet located at the front of resident Hall F revealed it was unlocked and contained hand sanitizing wipes, 160 count, labeled Flammable Keep Out of Reach of Children and two containers of germicidal wipes, 160 count each, labeled Hazardous to Humans and Domestic Animals. During an interview with LVN A on 12/07/2025 at 11:48 a.m., LVN A confirmed the supply closet was unlocked and accessible to residents and contained the above listed potentially hazardous materials. LVN A stated the closet was usually locked and should have been secure. Observation on 12/07/2025 at 2:10 p.m. of the supply closet next to the Administrator's office and across the hall from the dining room on Hall E revealed it was unlocked and contained germicidal wipes, 160 count, labeled Hazardous to Humans and Domestic Animals.During an interview with the Maintenance Director on 12/07/2025 at 2:12 p.m., the Maintenance Director confirmed the supply closet was unlocked and accessible to residents and contained the above listed potentially hazardous materials. The Maintenance Director stated the closet was usually locked and should have been secure.During an interview with the DON on 12/10/2025 at 9:30 a.m., the DON stated her expectation was for all staff to assist in ensuring potentially hazardous materials were stored securely so that residents would not come into contact with them. Record review of the facility policy, Safe and Homelike Environment, undated, revealed, In accordance with residents' rights, the facility will provide a safe, clean, comfortable, and homelike environment.

Based on interview and record review, the facility failed to maintain medical records for each resident that were complete and accurately documented for 2 (Resident #27 and Resident #28) of 25 residents reviewed for clinical records, in that: Resident #27's diagnoses of Adjustment Disorder Unspecified and Other Specified Persistent Mood Disorders were not included on his list of diagnoses. Residents #28's diagnoses of Pain, Bilateral Cataracts, Poor Visual Acuity, and Adjustment Disorder with Mixed Disturbance of Emotions and Conduct were not included on his list of diagnoses. This failure could result in inadequate care due to incomplete and inaccurate medical records. The findings were:1) Record review of Resident #27's facesheet, dated 12/09/2025, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Nondisplaced Simple Supracondylar Fracture Without Intercondylar Fracture of Right Humerus (a break to the lower part of the humerus just above the elbow joint), Subsequent Encounter for Fracture with Routine Healing, Major Depressive Disorder, and Iron Deficiency Anemia Secondary to Blood Loss. Record review of Resident #27's admission MDS, dated [DATE], revealed a BIMS score of 9 which indicated moderate cognitive impairment. Record review of Resident #27's care plan, revised 12/08/2025, revealed [Resident #27] has a psychosocial well-being problem (potential) [related to] Recent Admission, [diagnoses]: Major Depression, restlessness. Further review revealed, [Resident #27] can become agitated, yelling, cursing, refusing care. Record review of Resident #27's psychological provider note, dated 12/03/2025, revealed diagnoses of adjustment disorder and Other specified persistent mood disorders, along with the prescription medication the resident was receiving for these diagnoses. Further review of Resident #27's clinical record and facesheet, dated 12/09/2025, revealed the resident's diagnoses of adjustment disorder and Other specified persistent mood disorders were not included in the list of diagnoses, and therefore were not populated onto the resident's facesheet. 2) Record review of Resident #28's facesheet, dated 12/09/2025, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Hemiplegia and hemiparesis following cerebral infarction (paralysis and weakness on one side of the body after a stroke), Malignant neoplasm of brain (brain tumor), and Type 2 diabetes mellitus. Record review of Resident #28's Quarterly MDS, dated [DATE], revealed a BIMS score of 9 which indicated moderately impaired cognition. Record review of Resident #28's care plan, revised 03/30/2025, revealed, [Resident #28] is resistive/noncompliant with care [related to] refuses medications and at times demonstrates verbally aggressive behaviors. Record review of Resident #28's physician note, dated 09/17/2025 revealed diagnoses of Pain, Bilateral cataracts, and Poor visual acuity. Record review of Resident #28's psychological provider note, dated 11/18/2025 revealed a diagnosis of adjustment disorder with mixed disturbance of emotions and conduct. Further review of Resident #28's clinical record and facesheet, dated 12/09/2025, revealed the resident's diagnoses of Pain, Bilateral cataracts, Poor visual acuity, and adjustment disorder with mixed disturbance of emotions and conduct were not included in the list of diagnoses, and therefore were not populated onto the resident's facesheet. During an interview with the DON on 12/09/2025 at 5:15 p.m., the DON confirmed that facility's medical records system populated the resident's facesheet from the list of diagnoses and confirmed that the facesheet was the primary mechanism by which information about the residents was conveyed to outside providers such as hospitals and medical specialists. The DON confirmed Resident #27 and Resident #28 facesheets were missing diagnoses and confirmed that they should have been included due to the importance of providing an accurate and complete record of the resident's health. Record review of the facility policy, Maintenance of Electronic Clinical Records, undated, revealed, This facility will maintain electronic medical records for each resident in accordance with acceptable standards of practice. A complete and accurate electronic clinical record will be maintained on each resident.

Based on interview, and record review, the facility failed to ensure the resident assessment accurately reflected the resident's status for 6 of 7 residents (Resident #7, Resident #10, Resident #47, Resident #53, Resident #54, and Resident #63) who were reviewed for resident assessments. 1.The facility failed to document Resident #7's use of anticoagulant medication on the quarterly MDS (Minimum Data Set) assessment. 2.The facility failed to document Resident #10's use of scheduled (routine) pain medication on the admission MDS assessment.3.The facility failed to document Resident #47's use of hypoglycemic medication and lack of use of scheduled pain medication on the quarterly MDS assessment.4.The facility failed to document Resident #53's lack of use of PRN (as needed) pain medication on the quarterly MDS assessment. 5.The facility failed to document Resident #54's use of anticoagulant and antiplatelet medication on the quarterly MDS assessment.6.The facility failed to document Resident #63's use of antidepressant medication and lack of use of scheduled and PRN pain medication on the quarterly MDS assessment.This failure could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being.The findings included:1.Record review of Resident #7's admission sheet dated 11/25/2025 with an original admission date of 10/20/2025 documented an [AGE] year-old male resident with diagnoses including chronic respiratory failure, hypertension (high blood pressure), type 2 diabetes mellitus, high cholesterol, and Alzheimer's dementia.Record review of Resident #7's MDS dated [DATE] documented a BIMS score of 3 indicating severe cognitive impairment and recorded the use of diuretics (medications which reduce the amount of fluid buildup in the body) and hypoglycemics (medications which reduce the amount of glucose in the blood). Further review of Resident #7's MDS revealed the assessment did not include the use of anticoagulant (blood thinner) medication, despite the resident receiving Apixaban (an oral anticoagulant medication).Record review of Resident #7's order summary documented an active order for the anticoagulant medication Apixaban with an order date of 11/25/2025.Record review of Resident #7's November 2025 MAR (medication administration record) documented the resident had been receiving Apixaban as prescribed. Further review of the November MAR recorded Apixaban was ordered as Apixaban 2.5mg, give 1 tablet via G-Tube two times a day related to paroxysmal atrial fibrillation (irregular heartbeat).Record review of Resident #7's care plan with an initiation date of 10/29/2025 documented the resident is at risk for complications related to use of anticoagulant medication for Dx A-fib, and the resident will remain without complications from bleeding or injury through next review date. The care plan further documented interventions including apply prolonged pressure to venipuncture sites, and observe for S/S of bleeding i.e. tarry stools, blood in urine, bruising, petechia (tiny spots of bleeding under the skin).2. Record review of Resident #10's admission sheet dated 11/08/2025 documented a [AGE] year-old female resident with diagnoses including type 2 diabetes mellitus, hyperlipidemia (high cholesterol), epilepsy (seizure disorder), hypertension, and down syndrome (a genetic condition where a person is born with an extra chromosome).Record review of Resident #10's MDS dated [DATE] documented a code of 3 under section C1000. Cognitive Skills for Daily Decision Making, with a code of 3 indicating Severely impaired-never/rarely made decisions and recorded the use of antibiotic, opioid, and anticonvulsant medication. Further review of the MDS revealed the assessment did not include the resident's use of scheduled pain medication in the last five days of the assessment, despite the resident receiving pain medication daily during the five day look back period between 11/10/2025 to 11/14/2025.Record review of Resident #10's order summary documented an active order for the analgesic medication Acetaminophen-Codeine with an order date of 11/10/2025.Record review of Resident #10's November 2025 MAR documented the resident had been receiving Acetaminophen-Codeine as prescribed. Further review of the November MAR recorded Acetaminophen-Codeine was ordered as Acetaminophen-Codeine 300-30mg, give 1 tablet by mouth every 6 hours for Wound.Record review of Resident #10's care plan with an initiation date of 11/10/2025 documented the resident has a need for pain management and monitoring related to sacral wound, urinary catheter, with a goal of will maintain adequate level of comfort as evidenced by no s/sx of unrelieved pain or distress, or verbalizing satisfaction with level of comfort through next review date. The care plan further documented the interventions including administer pain medication as ordered, evaluate need for routinely scheduled medications rather than PRN pain med administration, and evaluate need to provide medications prior to treatment or therapy.3. Record review of Resident #47's admission sheet dated 4/14/2025 with an original admission date of 11/28/2024 documented an [AGE] year old female resident with diagnoses including dementia, hypertension, acquired absence of right leg below knee, type 2 diabetes mellitus, chronic kidney disease and insomnia. Record review of Resident #47's MDS assessment dated [DATE] documented a BIMS of 14 indicating intact cognition and recorded the use of antibiotic, diuretic, antiplatelet, and anticonvulsant medication. Further review of Resident #47's MDS revealed the assessment documented the resident had received scheduled pain medication in the last 5 days of the assessment date, despite the resident having no order for scheduled pain medication. The resident's MDS did not document the use of hypoglycemic medication, despite the resident receiving Ozempic.Record review of Resident #47's order summary included an active order for the hypoglycemic medication Ozempic with an order date of 4/14/2025. Further review of the order summary did not include an active order for routinely scheduled pain medication.Record review of Resident #47's October 2025 MAR documented the resident had been receiving Ozempic as prescribed and had not been receiving a scheduled pain medication. Ozempic was ordered as Ozempic Subcutaneous Solution Pen-Injector 4mg/3mL, inject 1mg subcutaneously one time a day every Fri related to type 2 diabetes mellitus.Record review of Resident #47's care plan with an initiation date of 11/28/2024 documented the resident has alteration in Blood Glucose due to hyper/hypoglycemia r/t DMT2, CKD3, HX of infection, with a goal of will experience minimal signs and symptoms associated with hyperglycemia/hypoglycemia through next review date. Further review of the care plan documented interventions including administer medications as ordered, and monitor blood glucose levels per MD orders and report abnormal results per Physician parameters/guideline.4. Record review of Resident #53's admission sheet dated 12/08/2020 with an original admission date of 10/28/2018 documented a [AGE] year-old female resident with diagnoses including cerebral infarction (stroke), hypertension, depression, and cognitive impairment.Record review of Resident #53's MDS assessment dated [DATE] documented a BIMS of 10 indicating moderate cognitive impairment and recorded the use of anticoagulant and opioid medications. Further review of Resident #53's MDS documented the use of PRN pain medication during the five day look back period of the assessment, however the resident did not receive any PRN pain medication from 9/07/2025 to 9/11/2025.Record review of Resident #53's order summary included an active order for the analgesic Acetaminophen with an order date of 8/30/2023 and an active order for the analgesic Acetaminophen-Codeine with an order date of 9/21/2021. Record review of Resident #53's September MAR documented the resident was receiving Acetaminophen and Acetaminophen-Codeine as prescribed. Acetaminophen was ordered as Acetaminophen 325mg, give 650mg by mouth every 4 hours as needed for Moderate Pain. Acetaminophen-Codeine was ordered as Acetaminophen-Codeine 300-30mg, give 1 tablet by mouth every 6 hours as needed for Pain-Moderate. Further review of the September MAR revealed no doses of PRN Acetaminophen or PRN Acetaminophen-Codeine were administered or refused from 9/07/2025 to 9/11/2025.Record review of Resident #53's care plan with an initiation date of 1/11/2021 documented the resident has osteoporosis increasing her risk for spontaneous fractures, with interventions including give analgesics PRN for pain, resident may complain of pain, stiffness or weakness, and give medications as ordered, observe/document for side effects and effectiveness.5. Record review of Resident #54's admission sheet dated 3/05/2025 documented a [AGE] year-old male resident with diagnoses including cerebral infarction, diabetes, hyperlipidemia (high cholesterol), anxiety, and hypertension.Record review of Resident #54's MDS assessment dated [DATE] documented a BIMS of 11 indicating moderate cognitive impairment and recorded the use of hypoglycemic medication. Further review of the assessment revealed the document did not record the use of anticoagulant or antiplatelet medication. Record review of Resident #54's order summary included an active order for the anticoagulant Xarelto with an order date of 3/05/2025 and an active order for the antiplatelet Clopidogrel with an order date of 3/05/2025. Record review of Resident #54's September 2025 MAR documented the resident was receiving Clopidogrel and Xarelto as prescribed. Clopidogrel was ordered as Clopidogrel 75mg, give 1 tablet by mouth one time a day for anticoagulant. Xarelto was ordered as Xarelto 10mg, give 1 tablet by mouth one time a day for anticoagulant.Record review of Resident #54's care plan with an initiation date of 3/06/2025 documented the resident is at risk for complications related to anticoagulant or antiplatelet medication r/t CAD, CVA, HLD with a goal of the resident will remain without complications from bleeding or injury through next review date. Further review of the care plan documented interventions including Apply prolonged pressure to venipuncture sites, monitor medication regime for medications which increase effects, and observe for adverse reaction: fever, skin lesions, anorexia, nausea, vomiting, cramps, diarrhea, hemorrhage, hemoptysis.6. Record review of Resident #63's admission sheet dated 11/26/2025, with an original date of 12/13/2022 documented a [AGE] year-old female resident with diagnoses including dementia, type 2 diabetes mellitus, cerebral infarction, hypertension, depression, and anxiety.Record review of Resident #63's MDS assessment dated [DATE] documented a BIMS of 12 indicating moderate cognitive impairment and recorded the use of scheduled and PRN pain medications in the last five days since the assessment date. Further review of the MDS revealed the assessment recorded the use of antianxiety, diuretic, antiplatelet, and anticonvulsant medications. The assessment did not record the use of antidepressant medication. Record review of Resident #63's order summary included an active order for the antidepressant Prozac with an order date of 01/27/2025 and an active order for the analgesic Tylenol with an order date of 6/05/2023. Further review of the order summary revealed the summary did not include an active order for scheduled pain medication.Record review of Resident #63's September 2025 MAR documented the resident had been receiving Prozac and Tylenol as prescribed. Prozac was ordered as Prozac 20mg, give 1 capsule by mouth two times a day. Tylenol was ordered as Tylenol 325mg give 2 tablets by mouth every 4 hours as needed. Further review of the September MAR revealed no doses of PRN Tylenol had been administered or refused during the five day look back period between 9/04/2025 through 9/08/2025 of the MDS assessment.During an interview with the Regional Support Nurse on 12/09/2025 at 2:37 PM, the Regional Support Nurse stated each staff member who inputs their section of the MDS assessment signs their section for accuracy, and an RN (registered nurse) must sign the MDS for completion. The Regional Support nurse further stated, if the MDS coordinator is also an RN, that individual is responsible for signing for both completion and accuracy. The Regional Support Nurse went on to state her expectation is for all sections of the MDS assessment to be accurate, and that accuracy was important because the MDS paints a clear picture of a resident and the care they are providing.During an interview with the DON (director of nursing) on 12/9/25 at 2:49 PM, the DON stated her expectation for the MDS assessments is that they be accurate, and that it is the responsibility of the MDS coordinator to check the assessments for accuracy. The DON further stated it is important for the MDS assessment to be accurate, because it gives an updated picture of a resident for a particular quarter, and if a resident needs assistance or has a change in condition, or needs services, they want to be able to provide the care the resident requires.Review of the facility policy titled Resident Assessment - RAI, with a revised date of 5/05/2025 noted 1. The current version of the RAI (MDS 3.0) will be utilized when conducting a comprehensive assessment of each resident in accordance with the instructions found in the RAI Manual. 2. The assessment will include at least the following: n. Medications.

Based on observation, interview, and record review, the facility failed to ensure the residents could call for staff assistance for 1 (Resident # 60) of 25 residents reviewed in that: Resident #60's call light was out of reach under the resident's bed. This deficient practice could result in delay of needed care and assistance. The findings were: The findings were: Record review of Resident #60's facesheet, dated 12/09/2025, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Unspecified sequelae of cerebral infarction (residual effects lasting from a stroke), Hemiplegia and hemiparesis following cerebral infarction (paralysis and weakness on one side of the body after a stroke), and Chronic obstructive pulmonary disorder (a condition involving constriction of the airways and difficulty or discomfort in breathing).Record review of Resident #60's Quarterly MDS, dated [DATE], revealed a BIMS score of 4 which indicated severe cognitive impairment. Record review of Resident #60's care plan, revised 01/11/2021, revealed [Resident #60] has an [activities of daily living self-care performance deficit [related to] Hemiplegia, Limited Mobility, Limited [range of motion], Musculoskeletal impairment, Stroke. The resident requires [extensive] assistance by 1 staff to turn and reposition in bed. The resident requires [extensive] assistance by 1 staff with personal hygiene and oral care. The resident requires [extensive] assistance by 1 staff for toileting.and Encourage the resident to use bell to call for assistance. Observation on 12/07/2025 at 11:50 a.m., revealed Resident #60 was in her bed, leaning with the top half of her body out of the bed, and her call bell was in the floor under the bed and out of reach. During an interview with Resident #60 on 12/07/2025 at 11:50 a.m., Resident #60 stated she wanted to get up and could not reach her call bell. During an interview with Medication Aide B on 12/07/2025 at 11:50 a.m., Medication Aide B confirmed that Resident #60's call bell was in the floor under the bed and out of reach. During an interview with the DON on 12/10/2025 at 9:30 a.m., the DON stated her expectation was for all staff to assist in ensuring resident call bells were within the resident's reach at all times so that residents may call for assistance when needed. Record review of the facility policy, Call Lights: Accessibility and Timely Response, undated, revealed, The purpose of this policy is to ensure the facility is adequately equipped with a call light at each resident's bedside.

Based on interview and record review, the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 2 of 6 residents (Resident's #5 and #6) reviewed for clinical records. The facility failed to document Resident #6's and Resident #5's death, pronouncement of death, and details of notifications. This failure could place residents at risk of not receiving the care and services needed due to inaccurate or incomplete clinical records. The findings included: Record review of Resident #6's face sheet, dated [DATE], revealed a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses including malignant neoplasm of the brain (cancerous tumor of the brain), epilepsy (seizures), and altered mental status. The face sheet indicated Resident #6 was discharged on [DATE] (location not documented). Record review of Resident #6's death MDS assessment, dated [DATE], revealed she was discharged due to death in the facility. Record review of Resident #6's care plan, dated [DATE] revealed the resident was on hospice care with interventions to encourage visitors and notify hospice at time of death. Record review of Resident #6's progress notes, dated [DATE] at 9:41 p.m. documented by LVN A, revealed, .while making rounds resident noted without respirations, hospice notified .hospice nurse stated not to call family until they got there. There were no further entries on the progress notes. Record review of Resident #6's medical record revealed the physician discharge summary, notes/documentation on pronouncement of death, notification of local law enforcement for death, and disposition of the body were not documented in the medical record. During an interview on [DATE] at 4:32 p.m., LVN A stated he was trained and would normally document notifications including notification of the police of a death in the facility, pronouncement of death and disposition of the body but he did not because the hospice company stated they would take care of everything. He stated this was the first time this had happened because normally he could document these things. 2. Record review of Resident #5's face sheet, dated [DATE], revealed a [AGE] year-old male admitted on [DATE] with diagnoses including senile degeneration of brain, chronic respiratory failure and anxiety disorder. The face sheet indicated the resident was discharged on [DATE] to a local funeral home. Record review of Resident #5's discharge MDS assessment, dated [DATE], revealed the resident died in the facility. Record review of Resident #5's progress notes, dated [DATE], revealed RN documented Resident #5 was moved into a private room for a continued decline and that family was at bedside. The next entry was [DATE] when RN B documented the DME company picked up Resident #5's equipment and supplies. Record review of Resident #5's medical record revealed there was no documentation of the resident's death, pronouncement of death, notification of required entities, or disposition of the body. During an interview on [DATE] at 4:45 p.m., RN B stated she documented Resident #5's move to a private room because she was declining on hospice. She stated this occurred on a Friday. She stated the family was with the resident when she left and the resident was still alive. RN B stated when she returned the following Monday, she learned the resident died. During an interview on [DATE] at 4:58 p.m., RN C stated on an unknown date right after change of shift, Resident #5 passed away. She stated a CNA (unknown) told her the resident passed. RN C stated the resident was on hospice and had a DNR order. She stated she went to the room and listened for heart and breath sounds and verified the resident had expired. RN C stated she was the RN on duty, so she pronounced the death. RN C stated she then called the DON, the family, hospice, and the funeral home once the family decided. She stated the police came to the facility and she received a case number. She stated the family came and spent a long time with the resident. RN C stated she could not believe she failed to document the events. She stated she did not know what happened. She stated she did not save the note. She stated she messed up. RN C stated she should have documented it directly into the progress notes. She stated she was aware the facility policy required documentation of events of the death. She stated it was important to document, so the resident's medical records were accurate. During an interview on [DATE] at 5:15 p.m., the DON stated staff were expected to document family, hospice and other notifications. She stated the staff should clean and make the resident presentable so the family could spend time with them. She stated the staff should document the decline and the expiration. They should document vital signs that were assessed, and if appropriate, contact hospice or palliate care or the physician. She stated they should document how they find the resident, notification of local police, whether the JP responded and pronouncement of death. The DON stated this documentation was important because it painted the picture of what occurred so anyone could easily review the medical record and see what occurred. The DON stated the facility did not experience a lot of deaths and she was aware the facility was lacking in documentation. Record review of the facility's policy titled Documentation in Medical Record, last revised [DATE], revealed: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. 1. Licensed staff and the interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy.

Based on interview and record review, the facility failed to notify, consistent with his or her authority, the resident representative(s) when there was a significant change in the resident's physical, mental, or psychosocial status for one (Resident #6) of six residents reviewed for notification of changes. The facility failed to notify Resident #6's family when she expired (died) on [DATE]. This failure could place residents at risk of their family/RP not being aware of the residents' condition. The findings included: Record review of Resident #6's face sheet, dated [DATE], revealed a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses including: malignant neoplasm of the brain (cancerous tumor of the brain), epilepsy (seizures), and altered mental status. The face sheet indicated Resident #6 was discharged on [DATE] (location not documented). Record review of Resident #6's death MDS assessment, dated [DATE], revealed she was discharged due to death in the facility. Record review of Resident #6's care plan, dated [DATE], revealed the resident was on hospice care with interventions to encourage visitors and notify hospice at time of death. Record review of Resident #6's progress notes, dated [DATE] at 9:41 p.m. documented by LVN A, revealed, .while making rounds resident noted without respirations, hospice notified .hospice nurse stated not to call family until they got there. There were no further entries on the progress notes. Record review of Resident #6's hospice visit note, dated [DATE], revealed the hospice company confirmed time of death on [DATE] at 11:20 p.m. The note revealed the local police were notified, the local funeral home was notified and the residents family member was notified (unknown time) with note: unable to determine if patients {family member} is grieving appropriately. During an attempted interview on [DATE] at 4:18 p.m., Resident #6's family member declined to be interviewed and ended the call. During an interview on [DATE] at 4:32 p.m., LVN A stated when Resident #6 expired he did not notify the family of her death. He stated when a resident passes away the first thing he would do was notify the family. He stated he wanted to notify the family. He stated his normal procedure was to notify family, call hospice, call the police, and call the DON. LVN A stated when he notified the hospice RN, she told him not to notify the family. He stated he could not remember the hospice RN's name or who exactly it was that told him. He stated he just remembered hospice said they would take care of everything (after death details). He stated that was the first time that had happened (where he was asked not to make notifications). LVN A stated he told someone in the facility management that hospice said not to notify Resident #6's family but he could not remember who and he could not remember how they responded. LVN A stated he did not follow up with the hospice company to ensure the resident's family was notified. He stated family was not present at the time of Resident #6's death. During an interview on [DATE] at 5:15 p.m., the DON stated Resident #6 was a super sweet lady whose family member was having a hard time with her death. She stated the family member was upset Resident #6 was dying. She stated she assumed hospice did not want the facility to notify Resident #6's family member because he would get loud. The DON stated on a normal death, they should notify family, hospice, physician and facility management. She stated each hospice company was different and had their own preferences. The DON stated she was not sure what the facility policy was for family notification upon death when hospice was involved. The DON stated accurate documentation and notification were important because they wanted to make sure the family had a good death experience. She stated the facility did not have many deaths and did not have much practice. During an interview on [DATE] at 12:03 p.m., a hospice representative stated he attended to Resident #6 as an RN but was not present on the date of her death. He stated hospice coordinated care with the nursing facility. He stated the facility nurse would contact hospice at the time of death. He stated the hospice company would then offer to send a nurse to assist with the death details. He stated the hospice company would never tell a facility not to notify next of kin. He stated he considered it callous not to notify family immediately. The hospice representative stated he was aware of some dynamics between the family and the facility but was not aware of any directives from hospice not to notify next of kin. Record review of the facilities policy titled Notification of Changes, last revised [DATE], revealed: The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification included: 2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include: a. Life-threatening conditions, or b. clinical complications 4. a transfer or discharge of the resident from the facility. Record review of the facility's policy titled Coordination of Hospice Services, last revised [DATE], revealed, 10. The facility will immediately contact and communicate with the hospice staff, attending physician/practitioner and the family resident representative regarding any significant changes in the resident's status, clinical complications or emergent situations.

Based on interview and record review the facility failed to incorporate the recommendations from the PASARR Level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care for 1 of 2 residents (Resident #1) reviewed for PASARR. The facility failed to initiate an NFSS within 20 business days following the date the services was agreed upon in the IDT meeting. This failure could cause residents with mental health disorders and psychiatric conditions to have a delay in services or not receive specialized services or equipment that may be needed. Findings included: Record review of the Admission Record for Resident #1 documented a [AGE] year old female admitted to the facility 09/27/24 with a diagnoses of cerebral palsy (a group of neurological disorders that affect movement, balance, and posture often due to brain damage before, during or shortly after birth), major depressive disorder (a mental health condition characterized by persistent feelings of sadness and a loss of interest or pleasure), and anxiety disorder (a group of mental health conditions characterized by excessive worry, fear, and avoidance behaviors that significantly interfere with daily life). Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 12 indicating moderate cognitive impairment. During an interview on 04/30/25 at 2:27 p.m., Resident #1, was asked how she liked therapy. Resident #1 was in the therapy room laying on a mat during the conversation after giving approval to talk with surveyor. Resident #1 stated it was OK but felt that life was generally boring since everything here is for old people. Resident #1 acknowledged that she was getting a new wheelchair. When asked if anyone from the PASARR local office ever took her out of the facility, she said no but stated she might like to go out. During an interview on 04/29/25 at 3:02 p.m., the MDS Coordinator stated they had the required IDT meetings with the local authority. There was a delay in getting Resident #1 started on therapy services and getting a new wheelchair since she had not been approved by Medicaid. The MDS Coordinator stated the facility was in contact with the case manager but her case was considered pending until her Medicaid was approved. The PASARR person in State Office was in contact with the Administrator and Director of Nurses but told them she would report the issue to regulatory since they did not start services within 20 days of the IDT meeting. During an interview with the Director of Rehabilitation (DOR) on 04/29/25 at 3:15 p.m., he stated that Resident #1 is now on all 3 therapies which included Physical therapy, Occupational therapy, and Speech therapy. The DOR stated they were going to start in October 2024 but had to wait until Resident #1's Medicaid was approved so she started services in February. During an interview with the Administrator on 4/29/25 at 3:45 p.m., she stated she was communicating with the PASARR office until a new MDS Coordinator was hired in December. The ADM stated she tried to tell the PASARR office that they could not start services until Resident #1's LTCMI was showing that resident was approved for long term care Medicaid since PASARR is a Medicaid service. ADM stated that the MDS Coordinator who is now working will ensure that communication is maintained with the PASARR office. During an interview with the BOM on 4/30/25 at 11:25 a.m., the BOM stated the facility was waiting for Resident #1's Medicaid to be transferred from community Medicaid to Long Term Care Medicaid. Resident #1 was finally eligible for Medicaid in February 2025 so they were able to bill for Medicaid services including the custom wheelchair. During an interview with the LIDDA case manager on 04/30/25 at 3:56 p.m., stated if the facility is aware that Medicaid is not started, then we shouldn't put it in the system. When asked how a facility could prevent this situation which is resulting in a citation, the case manager said the service should have been put in TMHP as discontinued or pending until Medicaid was started. The case manager said they had offered ILS and Day Hab services to Resident #1 but so far she had refused. The case manager said they would continue to encourage her to take advantage of these services. The Administrator provided the Admission Criteria policy dated March 2019 that included: 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders per the Medicaid Pre-Admission Screening and Resident Review (PASARR) process. c. Upon completion of the Level II evaluation, the State PASARR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in the facility is appropriate. d. The State PASARR representative provides a copy of the report to the facility. e. The interdisciplinary team determines whether the facility is capable of meeting the needs and services of the potential resident that are outlined in the evaluation.

Based on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 5 residents (Resident #25) reviewed for pharmacy services. Resident #25's tube feeding bag was not labeled with the correct date, did not have the resident's name, time hung, or date and time to be taken down. This failure could put residents at risk of not receiving the correct tube feeding and could result in decreased continuity of care, and a general decline in health. The findings were: Record review of Resident #25's face sheet dated, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with hospice care. Her diagnoses included other cerebral infarction (also known as a stroke-refers to damage to tissues in the brain due to a loss of oxygen to the area, adult failure to thrive (a state of decline that is multifactorial and may be caused by chronic concurrent diseases and functional impairments. Manifestations of this condition include weight loss, decreased appetite, poor nutrition, and inactivity), moderate protein calorie malnutrition (a disorder caused by a lack of proper nutrition or an inability to absorb nutrients from food), and cachexia (weakness and wasting of the body due to severe chronic illness). Record review of Resident #25's admission MDS dated [DATE] revealed the resident the resident was unable to complete the BIMS and her cognitive skills were severely impaired. The resident was unable to respond and was dependent on staff for all turning and positioning, and the resident had a gastrostomy feeding tube. Record review of Resident #25's undated care plan revealed a focus initiated on 7/29/24 and revised on 8/14/24 for alteration in diet for gastrostomy feedings. Interventions included to give diet as ordered of Jevity 1.5 cal at 40ml/hour for 22 hours with 120ml flushes every 4 hours. Record review of Resident #25's physician orders revealed an order with a start date of 8/5/24 for Jevity 1.5 cal at 40ml/hour x 22 hours with 120ml flushes every 4 hours. During an observation on 9/3/24 at 11:30 a.m. Resident #25's the tube feeding was running via a pump at 40ml/hr, the feeding bag was clear and had blue ball point pen writing on it 9/8/23 Jevity 1.5 and the room # next to the room number on the feeding bag was a possible cursive capital G but unable to read. Record review of Resident #25's EMAR for September 2024 revealed the Jevity feeding was hung as ordered on 9/3/24 at 6:00 a.m. In an observation and interview on 9/3/24 at 11:40am, the ADON stated the bags were not labeled correctly and it should be dated for 9/3/24 not 9/8/23 and she would be correcting it as soon as possible. The ADON was unsure of how the bags were not labeled correctly and stated they should have the correct date, resident, formula, and rate it was to be administered. The ADON returned with new bags with proper labels with the correct date and information. Review of the facility policy on enteral feedings revised November 2018 indicated . h. Check the enteral nutrition label against the order before administration. Check the following information: resident name, ID and room number; type of formula; date and time formula was prepared; route of delivery; access site; method (pump, gravity, syringe); and rate of administration(ml/hr). 2. On the formula label document initials, date, and time the formula was hung.

Based on observation, interview, and record review the facility failed to provide routine drugs and biologicals to its residents or obtain them under an agreement and 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 3 of 7 residents (Residents #44, #51, and #52) reviewed for pharmacy services. 1. Resident #44 was administered her ordered supplement and shared it with Resident #52 while the nurse was not present. 2. Resident #51 did not receive her ordered doses of Velphoro (A medication used for people receiving dialysis to bind phosphates in the blood for excretion to prevent excess build up, the chewable tablets are 500mg) from 8/26/24 to 8/30/24, 9/3/24, and 9/4/24. These failures could put residents at risk of not receiving the therapeutic effects of their ordered medications and supplements, adverse reactions, exacerbation of illness, and a general decline in health. The findings were: 1. Record review of Resident #44's face sheet dated 9/6/24 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included unspecified dementia, moderate with other behavioral disturbance (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), anemia unspecified (condition of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues.), and unspecified protein-calorie malnutrition (a disorder caused by a lack of proper nutrition or an inability to absorb nutrients from food). Record review of Resident #44's quarterly MDS assessment dated [DATE] revealed the resident had a BIMS score of 2 indicating the resident had severe cognitive impairment. The resident had unclear speech and was able to be understood only sometimes and was only sometimes able to understand. The resident only required set-up or clean up assistance with eating and had malnutrition but no significant weight gain or loss. Record review of Resident #44's care plan undated revealed a focus initiated on 2/2/21 and revised on 1/19/24 for nutritional problem and included shake supplements with lunch and dinner interventions were to administer medications as ordered and to observe and document effectiveness and to observe diet and intake and to record the amount consumed. Record review of Resident #52's face sheet dated 9/6/24 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included unspecified dementia, and cognitive communication deficit. Record review of Resident #52's Physician orders revealed no order for 2cal supplement. During an observation and interview on 9/3/24 at 12:50 p.m. Resident #44 was seated at a table in the dining room and had a clear plastic cup with measurements on it with a thicker brown liquid (appeared to be a shake supplement. unable to read the measurement but was approximately 100ml). The resident took two sips from the cup and set it on the table and slid it across the table towards a resident sitting directly across from her. Resident #52 picked up the cup, took a drink and set it down, picked it back up and took another drink then set it back on the table and slid it back towards Resident #44. Resident #44 took another drink and slid it back towards the other resident who took another drink and slid it back towards Resident #44 who then finished it. The nurse was not present with Resident #44. LVN A did arrive and witnessed the residents sharing the supplement and stated it was Resident #44's ordered supplement and she had given it Resident #44. Record review of Resident #44's physician orders revealed an order with a start date of 2/26/24 for 2 cal supplement (high calorie-480 calories per 8 ounces and high protein- 20grams per 8 ounces of supplement) 90ml three times daily. Record review of Resident #44's EMAR for September 2024 revealed 2 cal supplement was administered to the resident by LVN A for both the 9 a.m. and 1 p.m. doses on 9/2/24 and 9/3/24. Record review of Resident #44's EHR revealed no significant weight loss or ill effects from not drinking all her supplement. Record review of the Resident #52's EHR revealed no allergies to the supplement, no significant weight losses or gains, and no ill effects from the sharing of the supplement. In an interview on 9/3/24 at 1:15 p.m. LVN A stated possible consequences of the residents sharing the supplement was a possible infection control issue. LVN A stated she was familiar with both residents and there were no allergies or ill side effects from the sharing. LVN A further stated she usually stays and watches Resident #44 drink her supplement and further stated Resident #44 does not usually sit at a table with other residents. In an interview on 9/6/24 at 10:40 a.m. LVN A stated she had never witnessed Resident #44 share her supplement or attempt to and Resident #52 did not usually sit at that table and Resident #44 usually finished all her supplement. 2. Record review of Resident #51's face sheet dated, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with readmissions on 12/16/23 and latest readmission on 7/11/24. Her diagnoses included End Stage Renal Disease (ESRD- medical condition in which the kidneys cease functioning on a permanent basis leading to the need for long-term dialysis or a kidney transplant to maintain life), and dependence on renal dialysis (treatment for people whose kidneys are failing to remove waste products and excess fluid from the blood). Record review of Resident #51's admission MDS assessment dated [DATE] revealed the resident had a BIMS score of 8 indicating the resident had moderate cognitive impairment. The resident had clear speech and was usually understood by others and usually understood others. The resident had ESRD and was dependent on renal dialysis. Record review of Resident #51's undated care plan revealed a focus for alteration in kidney function, ESRD, dialysis initiated on 12/17/23 and revised on 8/28/24 with interventions that included resident was on a renal diet and 1 liter fluid restriction, as ordered by Physician and to encourage patient to follow nutritional and hydration program. interventions. Record review of Resident #51's physician orders revealed an order with a start date of 8/26/24 for velphoro chewable tablet. Give 1 tablet by mouth before meals related to ESRD. Record review of Resident #51's EMAR for August 2024 revealed velphoro chewable tablet to be given before meals at 6:30 a.m., 11:30 a.m., and 4:30 p.m. was documented as not administered on 8/26/24 at 4:30 p.m., and on 8/27/24, 8/28/24, 8/29/24and 8/30/24 for all three doses on those days. Further review revealed it was documented as given to the resident for all three doses on 8/31/24. Record review of Resident #51's EMAR for September 2024 revealed velphoro chewable tablet to be given before meals at 6:30 a.m., 11:30 a.m., and 4:30 p.m. was documented as not administered on 9/3/24 at 4:30 p.m. and not administered on 9/4/24 at 6:30 a.m. Further review revealed it was documented as on hold from 9/4/24 at 11:30 a.m. to 9/7/24 at 6:30 a.m. Record review of Resident #51's progress notes revealed EMAR linked notes for velphoro were dated 8/26/24 at 7:54 p.m. the velphoro was pending delivery. On 8/27/24 at 9:00 a.m. medication on order, 8/27/24 12:43 p.m. pending arrival from pharmacy, 8/27/24 4:08 p.m. pending arrival from pharmacy. On 8/28/24 at 7:36 a.m. medication on order, pending arrival, charge nurse will call today on medication, 8/28/24 at 7:53 p.m. medication pending arrival, 8/29/24 at 8:35 a.m. and 12:14 p.m. medication n/a (not applicable) at this time, pending approval through pharmacy, DON, and charge nurse aware. On 8/30/24 at 10:00 a.m., 4:06 p.m., and 6:08 p.m. medication pending arrival from pharmacy. On 9/3/24 at 3:33 p.m. reordered medication, pending arrival from pharmacy. On 9/4/at 6:53 a.m. medication on order, pending arrival, charge nurse aware. Record review of Resident #51's physician orders revealed an order with a start date of 9/4/24 to hold velphoro. Record review of Resident #51's EHR revealed no abnormal lab work or other effects from not receiving her Velphoro phosphorous binder. In an interview on 9/6/24 at 10:40 a.m. LVN A stated Resident #51's velphoro was waiting on insurance approval through the pharmacy and when it was delivered, only 9 tablets were delivered and waiting on insurance approval again. But the pharmacy had delivered again. LVN A stated the physician had been contacted and the dialysis center and physician as well. LVN A stated there had been no ill effects of the resident not receiving doses of the ordered medication. In an interview on 9/6/24 at 10:45 a.m. the DON stated she was aware of Resident #51's velphoro not being available .The DON stated Resident #51's primary care physician had ordered Velphoro but a delay occurred because she was waiting on the resident's renal dialysis physician's approval to use the medication. Then there was an issue with the resident's insurance, but the facility did receive a partial order from the pharmacy . The DON stated a different phosphate binder had been approved through the insurance and pharmacy, but they were waiting on the approval of the resident's renal physician along with the proper dosage for the medication as the dosages were not interchangeable. The DON stated the resident was being monitored and the dialysis center was also aware, and the facility had received another partial order and the resident would be getting that until they received new orders. Review of the facility policy on administering medications revised April 2019 indicated . 4. Medications are administered in accordance with prescriber orders .26. Medications ordered for a particular resident may not be administered to another resident, unless permitted by state law and facility policy, and approved by the Director of Nursing Services. Review of the facility policy on pharmacy services revised April 2019 indicated . The provider pharmacy shall agree to provide services that comply with applicable facility policies and procedures; accepted professional standards of practice, and laws and regulations, including but not limited to . a help the facility identify needed supplies and services related to medications; c. Help the facility comply with its legal and regulatory requirements related to medications and medication management . h. Establish a reliable way to notify the facility in a timely fashion of issues and concerns related to medications and prescriptions; Review of the National Library of Medicine website accessed 9/10/24 at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10695651/#:~:text=Most%20patients%20receiving%20dialysis%20rely,is%20associated%20with%20increased%20mortality published online October 23, 2023, revealed . Most patients receiving dialysis rely on dietary restriction and phosphate binders to minimize the risk of hyperphosphatemia (high phosphorous blood level), which is associated with increased mortality. However, dietary restriction is difficult because of hidden phosphate additives in processed foods and medications.

Based on interview and record review the facility failed to provide a minimum of 80 square feet per resident in 43 of 43 resident rooms (A2 through A8, A10, B3 through B11, C2 through C5, C7, C9, C10, D2 through D7, E2 through E4, E6 through E8, and F1 through F8) reviewed for minimum for square footage per resident, in that: Resident rooms A2 through A8, A10, B3 through B11, C2 through C5, C7, C9, C10, D2 through D7, E3 through E6 through E8, and F1 through F8 did not have a minimum of 80 square feet per resident. This deficient practice could affect residents residing in rooms due to the reduced living space for the residents and could pose problems in the residents' activities of daily living. The findings were: Record review of previous room waiver, dated 09/06/2024,revealed the following: Resident rooms A2, A3, A5 through A8, and A10 measured 13 feet 7 inches by 11 feet 5 inches which provided 157.55 square feet of floor space. Dividing the 157.55 square feet of usable floor space by 2 resulted in 78.77 square feet of floor space per resident in these rooms. Room A4 measured 13 feet 6 inches by 11 feet 7 inches which provided 159.12 square feet of usable floor space. Dividing the 159.12 square feet of usable floor space by 2 resulted in 79.56 square feet of floor space per resident in this room. Room B3 measured 13 feet 6 inches by 11 feet 10 inches which provided 150.96 square feet of floor space. Dividing the 150.96 square feet of usable floor space by 2 resulted in 75.48 square feet of floor space per resident in this room. Rooms B4 through B6, B8 through B11, C7, C9, D4, E4, E7 and E8 measured 13 feet 6 inches by 11 feet 5 inches which provided 156.4 square feet of floor space. Dividing the 156.4 square feet of usable floor space by 2 resulted in 78.2 square feet of floor space per resident in these rooms. Room B7, C4, D3, and F7 measured 13 feet 6 inches by 11 feet 6 inches which provided 157.76 square feet of floor space. Dividing the 157.76 square feet of usable floor space by 2 resulted in 78.88 square feet of floor space per resident in these rooms. Room C2, C3, and C5 measured 13 feet 5 inches by 11 feet 5 inches which provided 155.25 square feet of floor space. Dividing the 155.25 square feet of usable floor space by 2 resulted in 77.63 square feet of floor space per resident in these rooms. Room C10, E5, F2, F3, F5, F6. and F8 measured 13 feet 7 inches by 11 feet 5 inches which provided 158.92 square feet of floor space. Dividing the 158.92 square feet of usable floor space by 2 resulted in 79.46 square feet of floor space per resident in these rooms. Room D2, D5 through D7, E3. and E6 measured 13 feet 7 inches by 11 feet 6 inches which provided 157.55 square feet of floor space. Dividing the 157.55 square feet of usable floor space by 2 resulted in 78.77 square feet of floor space per resident in these rooms. Room F4 measured 13 feet 4 inches by 11 feet 4 inches which provided 152.76 square feet of floor space. Dividing the 152.76 square feet of usable floor space by 2 resulted in 76.38 square feet of floor space per resident in this room. An interview with Administrator on 09/06/2024 at 11:02 a.m., revealed Administrator would be requesting a room waiver on the same rooms from last year which did not provide residents with 80 square feet of floor space. Record review of Form 3740, Bed Classifications, provided by the Administrator on 09/03/2024 revealed that all resident rooms were double occupancy.

Based on observation, interview, and record review, the facility failed to ensure the environment was as free of accident hazards as is possible and each resident receives adequate supervision to prevent accidents for 1 of 1 resident (Resident #1) reviewed for accidents and hazards, in that: Resident #1 was able to exit the facility without staff knowing on 08/13/2024. Staff were unaware that Resident #1 had walked out of the facility until they received a call from local police informing them Resident #1 was with the Police at a restaurant located .3 miles from the facility. An IJ was identified on 08/27/2024. The IJ template was provided to the facility on [DATE] at 06:45 PM. While the IJ was removed on 08/29/2024, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because the facility needed to evaluate the effectiveness of their corrective actions. This failure could place residents at risk of accidents that could result in serious injury, harm, impairment, or death. Findings were: Record review of Resident #1's face sheet, dated 08/27/24, revealed Resident #1 was a [AGE] year-old female diagnosed with dementia originally admitted to the facility 03/01/2021. Record review of Resident #1's MDS assessment, dated 08/08/2024, revealed Resident #1 had a BIMS score of 5. Resident #1 used a walker when ambulating. Record review of Resident #1's care plan, dated 06/03/2024, revealed Resident #1 was identified as an elopement risk with no exit seeking behaviors. One intervention was identified as involve resident in group activities. Record Review of Resident #1's Elopement Risk Assessment, dated 06/12/2024, revealed Resident #1 was identified as At Risk for elopement with a score of 5. Resident #1's Elopement Risk Assessment was marked Yes for questions 1. Does the resident have a diagnosis of Dementia, OBS, Alzheimer's, Intellectual/ Developmental Disability, Delusions, Hallucinations, Anxiety Disorder, Depression, Bipolar, and/or Schizophrenia?, 2.Does the resident ambulate independently, with or without the use of an assistive device? (i.e. walker, cane or wheelchair)?, 3. Does the resident have any hearing, vision or communication problems?, 7. Is the resident cognitively impaired with poor decision-making skills (i.e. disorientation, cognitive deficits, disorganized thinking)?, 10. Does the resident display wandering without a sense of purpose (i.e. going in and out of other resident's rooms and explore their belongings, confused, aimless movements)?. The incident Record review of facility in-service training named Abuse & Neglect, Elopement/Wandering, and ensuring doors closed after letting visitors in/out, dated 8/13/2024, revealed 67 staff had signed the in-service. Record review of facility's employee roster revealed the facility had 75 employees. Record review of staff's clock-ins revealed 68 staff had worked from the time Resident #1 eloped from the facility on 08/13/2024 (around 9:00 PM) to morning shift (6 AM to 2 PM) on 08/27/2024. Out of the 68 staff who worked, 16 staff had not signed the in-service. Interview with DON on 08/27/2024 at 10:24 AM revealed Resident #1 eloped from the facility on 08/13/2024. DON stated that the medication aide passed Resident #1's medications about 9:00 PM and then asked resident if she wanted to go lay down. Resident #1 then walked to her room and entered. DON stated that Resident #1 was not seen leaving the facility and the staff were unaware that Resident #1 had left until the local police called the facility. Local police informed the facility that Resident #1 was with them at a restaurant .3 miles from the facility. Local police returned Resident #1 to the facility around 9:30 PM. DON stated that she completed a head-to-toe assessment on Resident #1 and then started to in-service on Abuse/Neglect, Elopement/wandering and ensuring doors are closed with all staff that were on shift. Interview with Administrator on 08/27/2024 at 10:34 AM revealed Resident #1 eloped from the facility on 08/13/2024 after receiving her 9:00 PM medications. Administrator stated the facility received a call from the local police informing them Resident #1 was at a restaurant .3 miles from the facility and would be escorted back to the facility. Administrator stated that resident was returned to the facility about 9:30 PM by local police. Administrator stated she was unsure how resident was able to elope from the facility but speculated that Resident #1 followed another resident's family out of the facility. Administrator stated that resident did not have exit seeking behaviors prior to her elopement. Interview with Resident #1's responsible party on 08/27/2024 at 11:30 AM revealed Resident #1 had been at the facility since 2021. Resident #1's responsible party stated Resident #1 had never had exit seeking behaviors. Resident #1's responsible party stated that Resident #1 was happy at the facility and had never expressed concerns with her care. Observation of all facility exit doors on 08/27/2024 starting at 11:45 AM revealed all exit doors were locked and unlocked with a keypad. All exit door alarms were working properly. Observation of Resident #1 on 08/27/2024 at 12:15 PM revealed resident sitting in the living room close to nursing station. Resident had a small band with a white square (wander guard) on her left ankle. Interview attempted with Resident #1 on 08/27/2024 at 12:16 PM revealed resident was confused and unable to answer surveyor's questions. Resident #1 was unable to tell surveyor the day of the week or what she had for breakfast. Interview with MA D on 08/27/2024 at 2:17 PM revealed Resident #1 received her medications on 08/13/2024 just after 9 PM and then went back to her room. MA D stated she did not see Resident #1 leave her room or the facility the night she eloped. Resident #1 was returned to the facility by local police around 9:30 PM. MA D stated the facility exit doors are locked and have an alarm when opened without being unlocked. MA D stated resident had no exit seeking behaviors prior to her elopement. This was determined to be an Immediate Jeopardy (IJ) on 08/27/2024 at 6:45 PM. Administrator was provided with the IJ template on 08/27/2024. The following Plan of Removal was accepted on 08/28/2024 at 1:13 PM. Plan of Removal: PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it May Concern, Summary of details which leads to outcomes. On August 27, 2024 an investigation was initiated at [facility name and address]. At approximately 6:45p.m on August 27, 2024 a surveyor provided verbal notification that Texas Health and Human Services had determined the conditions at [the facility] constitute immediate jeopardy to resident health and safety. The Immediate Jeopardy findings were identified in the following areas: F-0689 - Free of Accident Hazards/Supervision/Devices Immediate Corrections Implemented for Removal of Immediate Jeopardy. On August 13,2024 at approximately 9:20pm Resident#1 returned to the facility from the Emergency Department. Action: Resident #1 is a current resident and was brought back to facility on 8/13/2024. The director of nursing reassessed Resident #1 for Elopement risk and Wander guard was placed 8/15/2024 to monitor for resident exiting facility. IDT reviewed and interventions initiated, and care plan updated reflect elopement risk. On August 27, 2024, at approximately 7:00pm the following actions were taken; Action: Education initiated Elopement risk, Abuse/Neglect/Exploitation, Signs to watch for with residents exhibiting potential for elopement, increased wandering, exit seeking, increased behaviors. Education will be completed prior to staff working the next scheduled shift, and ongoing with general orientation for all new hires. Start Date: 8/27/2024 Completion Date: 8/27/2024 Responsible: Director of Nursing/designee Action: Administrator validated that exit doors are functioning with wander guard system for notification of opening doors and residents attempting to exit that have been identified as High risk of elopement. Start Date: 8/27/2024 Completion Date: 8/27/2024 Responsible: Administrator/Designee IDENTIFICATION OF OTHER AFFECTED: All residents have the potential to be affected. Action: Completed Elopement Risk Assessment on all residents and validated all residents at risk of elopement, score of 3 or greater, have appropriate interventions and plan of care in place per risk assessment. Start Date: 8/27/2024 Completion Date: 8/27/2024 Responsible: Director of nursing/designee SYSTEMIC CHANGES AND/OR MEASURES: Action: In-service and education was provided to facility staff regarding the process for residents who have been identified as an elopement risk and proper steps to take to assure residents remain safe without risk for elopement, including monitoring, care plan updates, wander guards as indicated. Start Date: 8/27/2024 Completion Date: Ongoing until all staff have received education prior to their next scheduled shift. Responsible Party: Director of Nursing/Designee Action: Signage to be placed at exit door to notify all persons exiting to watch for residents to assure they are not followed out by potentially wandering or unsafe residents. Start Date: 8/28/2024 Completion Date: 8/28/2024 Responsible Party: Administrator Action: Education was provided to all staff on Elopement policy, Abuse/Neglect/Exploitation. Start Date: 8/27/2024 Completion Date: 8/27/2024 and Ongoing until staff have received training prior to the start of their next shift. Responsible Party: Director of Nursing/Designee Action: Ad hoc QAPI meeting held with IDT team and MD to review policy on Elopement, Abuse and neglect, and Plan of removal/response to Immediate Jeopardy Citation on 8/27/2024 Start Date: 8/27/2024 Completion Date: 8/27/2024 Responsible: Administrator/Designee Tracking and Monitoring Director of Nursing/Designee will review residents with At Risk for wandering or elopement identified or newly admitted with history of elopements to assure appropriate interventions and plan of care are in place 5 times per week beginning 8/28/2024 for 12 weeks or until sufficient compliance if found. This will be documented in daily clinical meeting with use of electronic log and reviewed monthly in QAPI meeting. Director of Nursing/Designee will complete audits for those residents who wear a wander guard to ensure electronic monitoring device is functioning every shift for 7 days beginning 8/28/2024 then will monitor electronic monitoring devices daily 5 times per week for 12 weeks or until sufficient compliance if found. This will be documented in daily clinical meeting with use of electronic log and reviewed monthly in QAPI meeting. Administrator/designee will complete random audit every shift for 7 days, beginning 8/28/2024 for appropriate staff response to wandering or potentially exit seeking residents, immediate education will be provided, if necessary, then will monitor random shifts, 5 times a week for 12 weeks or until sufficient compliance if found. This will be documented on log to be reviewed in QAPI Meeting Monthly. Administrator/designee will complete audit of exits for proper functioning of doors, alarms and wander guard system for proper functioning every shift for 7 days, beginning 8/28/2024 then will monitor random shifts, 5 times a week for 12 weeks or until sufficient compliance if found. This will be documented on log to be reviewed monthly in QAPI. Any trends or concerns were/will be addressed with Quality Assurance Performance Committee and continue until a lessor frequency deemed appropriate through QAPI review Verification: Interview with Administrator on 08/28/2024 at 1:25 PM revealed the facility started in-servicing its staff on 08/27/24. Administrator stated the facility would continue to in-service its staff prior to the start of their shifts until all staff have been in-serviced. Administrator also stated the DON started to re-assess all residents on their elopement risk and would be complete on 08/29/2024. Administrator stated she hung signs on all exit doors instructing anyone exiting to ensure that residents do not follow them out. Administrator stated she tested all exit doors to ensure the alarms and wander guards worked properly. Observation of the facility's exit doors on 08/28/2024 starting at 1:45 PM revealed all 8 exit doors had a sign that read Caution For the safety of our residents please ensure doors properly close behind you. All exit doors were locked, and alarm sounded when release bar was pressed. Interview with Administrator on 08/29/2024 at 9:54 AM revealed DON and Administrator worked on re-assessing the residents to identify those at risk for elopement. Administrator stated she was reviewing care plans for residents identified as at risk for elopement and ensuring care plans included interventions to prevent elopement. Interview with LPN A on 08/29/2024 at 9:24 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. LPN A was able to demonstrate an understanding of the in-service materials. Interview with RN B on 08/29/2024 at 9:35 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. RN B was able to demonstrate an understanding of the in-service materials. Interview with CNA C on 08/29/2024 at 9:52 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. CNA C was able to demonstrate an understanding of the in-service materials. Interview with MA D on 08/29/2024 at 10:17 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. MA D was able to demonstrate an understanding of the in-service materials. Interview with CNA E on 08/29/2024 at 10:32 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. CNA E was able to demonstrate an understanding of the in-service materials. Interview with LPN F on 08/29/2024 at 10:36 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. LPN F was able to demonstrate an understanding of the in-service materials. Interview with LPN G on 08/29/2024 at 10:52 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. LPN G was able to demonstrate an understanding of the in-service materials. Interview with MA H on 08/29/2024 at 11:08 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. MA H was able to demonstrate an understanding of the in-service materials. Interview with RN I on 08/29/2024 at 11:17 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. RN I was able to demonstrate an understanding of the in-service materials. Interview with CNA J on 08/29/2024 at 11:22 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. CNA J was able to demonstrate an understanding of the in-service materials. Interview with CNA K on 08/29/2024 at 11:22 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. CNA K was able to demonstrate an understanding of the in-service materials. Interview with CNA L on 08/29/2024 at 11:28 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. CNA L was able to demonstrate an understanding of the in-service materials. Interview with CNA M on 08/29/2024 at 11:31 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. CNA M was able to demonstrate an understanding of the in-service materials. Interview with Housekeeping N on 08/29/2024 at 11:32 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. Housekeeping N was able to demonstrate an understanding of the in-service materials. Interview with Housekeeping O on 08/29/2024 at 11:36 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. Housekeeping O was able to demonstrate an understanding of the in-service materials. Interview with DA P on 08/29/2024 at 11:42 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. DA P was able to demonstrate an understanding of the in-service materials. Interview with [NAME] Q on 08/29/2024 at 11:42 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. [NAME] Q was able to demonstrate an understanding of the in-service materials. Interview with DS R on 08/29/2024 at 11:43 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. DS R was able to demonstrate an understanding of the in-service materials. Interview with [NAME] S on 08/29/2024 at 11:46 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. [NAME] S was able to demonstrate an understanding of the in-service materials. Interview with Housekeeping T on 08/29/2024 at 11:48 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. Housekeeping T was able to demonstrate an understanding of the in-service materials. Interview with Human Resources Director U on 08/29/2024 at 11:50 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. Human Resources Director U was able to demonstrate an understanding of the in-service materials. Interview with CNA V on 08/29/2024 at 11:52 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. CNA V was able to demonstrate an understanding of the in-service materials. Interview with LPN W on 08/29/2024 at 11:54 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. LPN W was able to demonstrate an understanding of the in-service materials. Interview with Activities Director X on 08/29/2024 at 11:57 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. Activities Director X was able to demonstrate an understanding of the in-service materials. Interview with PT Assistant Y on 08/29/2024 at 12:00 PM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. PT Assistant Y was able to demonstrate an understanding of the in-service materials. Interview with [NAME] Z on 08/29/2024 at 12:04 PM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. [NAME] Z was able to demonstrate an understanding of the in-service materials. Interview with LPN AA on 08/29/2024 at 12:10 PM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. LPN AA was able to demonstrate an understanding of the in-service materials. Observation of the facility's wander guard system on 08/29/2024 at 3:02 PM revealed alarm sounds when resident got about 5 feet from the front door in the living room. The alarm turned off when resident moved closer to the nurse's station at the end of the living room. Record review of in-service training on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out, dated 08/27/2024, on 08/29/2024 revealed 63 out of 69 staff have signed the in-service training. Record review of all resident's Elopement Risk assessments on 08/29/2024 revealed the facility re-assessed each resident's risk of eloping starting 08/27/2024. The facility completed the re-assessments on 08/29/2024. Record review of facility's monitoring logs on 08/29/2024 revealed DON/Designee reviewed resident's identified as elopement risk care plans for appropriate interventions on 08/28/2024 and 08/29/224. Record review of facility's monitoring logs on 08/29/2024 revealed DON/Designee completed audits for residents wearing wander guards on 08/28/2024 on all shifts and 08/29/2024 6 AM-2 PM shift. Record review of facility's monitoring logs on 08/29/2024 revealed Administrator/Designee completed random audits of staff's response to resident's wandering on 08/28/24 on each shift and on 08/29/2024 on the 6 AM-2 PM shift as well as the 2 PM- 10 PM shift. Record review of facility's monitoring logs on 08/29/2024 revealed Administrator/Designee reviewed completed audits of exit for proper functioning of door alarms and wander guard system on 08/28/2024 and 08/29/2024. The Administrator was informed the Immediate Jeopardy was removed on 08/29/2024 at 3:29 PM. The facility remained out of compliance at a severity level of potential for more than minimal harm that was not Immediate Jeopardy and a scope of isolated due to the facility's need to monitor the implementation of the plan of removal.

Based on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #2) reviewed for infection control. CNA-AB failed to follow EBP by not wearing a gown while providing incontinent care for Resident #2 on 08/27/2024 This failure could place residents at risk for cross contamination and infection. Findings: Record review of Resident #2's face sheet dated 08//27/2024 revealed Resident #2 was a 76- year-old female who had an initial admitted [DATE] and a re-admitted [DATE] with diagnoses that included: MRSA (a bacterial infection that is resistant to certain antibiotics) as cause of disease classified elsewhere; Fracture of unspecified part of neck of right femur (region just below the ball of the hip joint); unspecified dislocation of unspecified hip; dementia; functional urinary incontinence; pressure ulcer of sacral region (portion of spine between lower back and tailbone) - stage 3; pressure ulcer of right buttock - stage2; and pressure ulcer of left buttock - stage 2. Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed Resident #2 had a BIMS of 6, suggesting severe cognitive impairment and was coded under assistance needed for toileting as a 1, indicating total dependence on others. Record review of Resident #2's Physician Orders dated 08/27/24 revealed an order to Initiate isolation and educate resident/family and staff on handwashing, meals and activities and therapy in room while on isolation every shift r/t MRSA effective 07/23/2024. Record review of Resident #2's Care Plan dated 06/23/3034 revealed a focus area for .enhanced barrier precaution r/t pressure ulcer of sacral and buttocks, has surgical incision to right hip, with date initiated of 07/05/2024, and interventions which included: [NAME] [put on] gown and gloves during high-contact resident care activities and Enhanced Barrier Precautions. Observation on 08/27/2024 at 11:08 a.m. in the hallway outside Resident #2's room, revealed a Contact Precautions sign posted on the door, and a small PPE supply storage unit outside the door. Observation of the contents inside this PPE supply storage unit revealed there were no gowns available. During an observation on 08/27/2024 at 11:11 a.m., CNA- AB was observed in Resident #2's room, in the process of tying a plastic trash bag, wearing gloves, but no gown. During an interview with CNA-AB at 08/27/2024 at 11:11a.m., CNA-AB stated she had just finished providing incontinent care to Resident #2 , and that she did not wear a gown while providing this incontinent care because there were no gowns available in the PPE supply drawer. CNA-AB further stated that she was aware that Resident #2 was on contact precautions and that she should have worn both a gown and gloves to provide the incontinence care. CNA-AB stated there were additional gowns available in the medical supply closet, but she did not go to supply closet to get a gown before entering Resident #2's room, because Resident #2 was asking to be changed and she did not want to make her upset by making her wait while she went to go get more gowns. CNA-AB stated that by not wearing both gown and gloves when she provided incontinent care to Resident #2, she could catch what she has. During an interview the DON on 08/28/2024 at 1:16 p.m., the DON confirmed that Resident #2 was on Enhanced Barrier Precautions due to MRSA, and that the sign posted outside of Resident #2 's room on 08/27/2024 should have been for EBP and not contact precautions. The DON noted that the correct EBP sign has now been placed on Resident #2's room, but also stated that both EBP and Contact precautions required use of both gown and gloves for high-contact activities such as incontinence care. The DON stated that adequate supply of PPE should be maintained in the PPE supply units outside rooms requiring enhanced-barrier precautions and that it was the responsibility of all the staff to ensure they were kept stocked. The DON stated that failure to use the correct PPE during high-contact activities could result in the spread of infection. The DON confirmed CNA-AB had received training in infection control procedures. Record review of CNA-AB's facility training record dated 06/17/2024 revealed CNA-AB had initialed her training record next to infection control, indicating she had receiving training on infection control procedures. Record review of the facility Enhanced Barrier Precautions policy dated August 2022 revealed EBP's employ targeted gown and glove use during high contact resident care activities and gloves and gown are applied prior to performing the high contact resident care activity . The policy further includes examples of high-contact activities including .providing hygiene and changing briefs or assisting with toileting.

Based on observation, interview, and record review, the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs and preferences for 1 of 25 residents (Resident #20) reviewed for administration. The facility failed to ensure all staff providing direct care to residents in the facility identify themselves by name and job title. This failure could affect resident in the facility by placing them at risk of not having needs met. Findings included: During and observation upon entrance to the facility on [DATE] at 9:28 a.m. LVN F was not wearing a name tag while in a resident care area. During and observation upon entrance to the facility on [DATE] at 9:40 a.m CNA B was not wearing a name tag while in a resident care area. During and observation upon entrance to the facility on [DATE] at 9:45 a.m. MA C was not wearing a name tag while in a resident care area. During and observation upon entrance to the facility on [DATE] at 9:50 a.m. NA-A was not wearing a name tag while in a resident care area. During and observation upon entrance to the facility on [DATE] at 10:30 a.m. the DON was not wearing a name tag that identified her current role while in a resident care area. During an interview with Resident #1 on 10/21/2023 at 11:56 a.m., Resident #1 said she had a hard time hearing some staff and understanding them. She described a staff member providing care to her and said she did not know their name at first and then after seeing the staff member she learned their name after having several interactions while the staff member assisted her in her room. Resident #1 said she was finally able to remember the staff members name because when she was younger her brother had a dog with the same name. Resident #1 explained being hard of hearing made it difficult for her to understand staff sometimes so being able to see a name and their title helps. Record review of Resident #1's face sheet, dated 10/22/2023, revealed an [AGE] year-old with diagnoses that included: bilateral hearing loss (hearing loss in both ears), Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness and difficulty with balance and coordination), need for personal assistance with personal care, and cognitive communication disorder. During an interview with LVN F on 10/21/2023 at 3:55 p.m. LVN F said she did not have a name tag on this morning when she opened the door for this surveyor to enter the facility, she said this was her second time to work at this facility and she had not been given a name tag. During an interview with CNA B on 10/21/2023 at 2:40 p.m. CNA B stated they were supposed to wear name tags but no one had given her one but sometimes the facility would give a name tag to staff if they forget their name tag and then explained the staff that did that before is not at the facility on the weekends. During an interview with MA C on 10/21/2023 at 3:01 p.m., MA C stated she had never been given a name tag by this facility but did have one that could be worn and went on to say everyone should wear name tags so the residents know who was providing care to them. During an interview with NA-A on 10/21/2023 at 3:50 p.m., NA-A said she was not wearing a name tag but she was supposed to wear a name tag, so the residents know who people are and what they do. During an interview with the DON on 10/21/2023 at 4:00 p.m., the DON had a name tag with her name and ADON on the name tag beside her name. When asked if she was the DON or the ADON, she said the DON and had not received a new name tag with DON. The DON said she had been the DON for over 6 months. During an interview with the Administrator on 10/21/2023 at 4:15 p.m., the Administrator said all staff are required to wear name tags. The Administrator went on to say the facility does have a policy on staff wearing name tags the staff are expected to follow the policy, so residents and families know who they are and what their roles are. The Administrator did have a plastic name tag sleeve on with her standard business card identifying her within the plastic sleeve and clipped to her shirt. The Administrator provided a policy, Identification Name Badges, with the following Policy Statement: In order to promote safety and security measures established by our facility, each employee must wear his/her identification name badge at all times while on duty. Policy revised January 2008.

Based on interview and record review the facility filed to ensure 1(NA A) of 3 Nurses' Aides were not working in the facility longer than four months without being enrolled in or having completed an approved training course. The facility failed to ensure NA A was certifed within the required time frame. This failure place residents at risk for receiving care from an individual whose skill level was not known. Findings include: Record review of the facility staff roster provided upon entrance revealed: Nurses' Aide A was listed at a Nursing Assistant with an 08/01/2022 hire date. During an interview with Nurses' Aide A on 10/21/2023 at 3:50 p.m. Nurses' Aide A explained previously taking the CNA written portion of the exam and not passing it. Nurses' Aide A explained she had not rescheduled the test since taking it in May 2022 and was waiting on the facility to register her for a CNA class. Nurses' Aide A explained she completes all services a Certified Nurses' Aide did in the facility. During an interview with HR specialist on 10/21/2023 at 4:40 p.m., HR specialist stated the Nurses' Aide did have a start date of employment at the facility on 03/01/ 2022 and did not know if she had taken any type of CNA test for certification but did know Nurses' Aide was listed on the staff list and in the facility records as a Nursing Assistant and not a CNA. During an interview with the DON on 10/21/2023 at 4:54 p.m., the DON said she did not think Nurses' Aide A was a CNA at this time and was not aware when or if Nurses' Aide previously took any type of CNA test. The DON explained the facility continued to allow Nurses' Aide because they had been given information on a PL that have approval for staff who had not completed a CNA course or testing an extension on the initial grace period granted during COVID- 19 (COVID-19- Corona Virus Disease- A severe acute respiratory syndrome aka SARS-COV-2). During an interview with the Administrator at 5:10 p.m. on 10/21/2023, the Administrator said Nurses' Aide A was a CNA at this time and was not aware when or if Nurses' Aide A previously took any type of CNA test or scheduled for any type of testing at this time. The Administrator explained the facility continued to allow the Nurses' Aide because they had been given information on a PL that have approval for staff who had not completed a CNA course or testing an extension on the initial grace period granted during COVID- 19. The Administrator provided an email on 10/22/2023 containing the following information: Work Experience and Training Requirements for Existing Temporary Nurse Aides Temporary nurse aides hired during the COVID-19 public health emergency were allowed under state regulations to use work experience and training obtained at a nursing facility to satisfy the 100-hour training requirement needed in order to take the exam for full certification. Per 26 TAC S556.100, these temporary nurse aides were required to test and become fully certified by Oct. 15, 2023 (four months following the end of the COVID-19 public health emergency). Beginning July 5, 2023, the online portal used by nurse aide applicants to request testing for certification has experienced some technical issues. Due to the delays caused by these unforeseen issues, HHSC will not enforce the Oct. 15, 2023, deadline but instead require certification before May 1, 2024. Until this date, a facility may continue to use temporary nurse aides who were hired and who completed their 100-hour training requirement before Oct. 15, 2023. Note: Federal regulations require that temporary nurse aides become certified within four months of their hire date. So, there may be some individuals who can apply the 100-hour work experience and training obtained while working as a temporary nurse aide towards the certification requirements but who still may be prohibited from working in a facility until they become certified. Nursing facilities must ensure that their temporary nurse aides register for testing and maintain documentation of registration and test dates on file. Any existing temporary nurse aides not certified before May 1, 2024, must complete a traditional Nurse Aide Training and Competency Evaluation Program (NATCEP) to be approved to take an exam and become certified.

Based on observation, interviews and record reviews the facility failed to ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 3 of 29 (Resident #61) residents reviewed for CPR care and 2 of 21 nurses (LVN A and RN C) reviewed for competencies and skill sets for CPR care to include an AED, in that; The facility failed to ensure all nursing staff had competent skills in performing actual CPR, to include using the AED, as a result of Resident #61 being found unresponsive on [DATE] and the responding nurse staff (LVN A and RN C) not using the AED during the actual CPR process for this resident. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 4:10 pm. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of actual harm that was not Immediate Jeopardy because the facility is still monitoring the effectiveness of their Plan of Removal. This failure placed residents at risk for harm up to and including death by the denial of all life saving measures as trained. The findings included: A record review of Resident #1's admission record dated, [DATE], revealed an admitted [DATE] and a death discharge date of [DATE], with diagnoses which included altered mental status, extended spectrum beta lactamase resistance [a bacteria that can't be killed by many of the antibiotics that doctors use to treat infections, like penicillin's and some cephalosporins for urinary tract infections], and urinary tract infection. A record review of Resident #1's admission MDS dated [DATE] revealed Resident #61 was an [AGE] year-old male admitted from an acute care hospital for support and rehabilitation related to a urinary tract infection. A record review of Resident #61's physician's order dated [DATE] revealed RN R documented a physician's order for Resident #61 to receive care as Full Code. A record review of Resident #61's care plan dated [DATE], revealed, [Resident #61] has an advance Directive as evidenced by: Full code status Date Initiated: [DATE] [ .] wishes will be honored, Date Initiated: [DATE] [ .] CPR will be performed as ordered A record review of Resident #61's SBAR document dated [DATE] revealed, Situation [ .] the change in condition, symptoms, or signs observed, and evaluated is/are: cardiac arrest, respiratory arrest. This started on: [DATE]. Since this started it has gotten: stayed the same [ .] Resident/Patient Evaluation [ .] mental status evaluation: unresponsiveness [ .] Code Status: Full Code [ .] Appearance, summarize your observations and evaluation: CNA notified this nurse of resident being unresponsive assessed resident not responsive no pulse RN supervisor notified initiated CPR crash cart access notified 911 CPR performed until paramedics arrived emergency medical technicians continued with CPR resident transfers out with Pulse unconscious accompanied by three emergency medical technicians [ .]. A record review of the EMS TripTix EMS Patient Care Record dated [DATE] revealed, CPR was performed by the facility staff for 9 minutes from 09:38 AM to 09:47 AM as evidenced by, Incident Date / Times [ .] unit notified by dispatch [DATE] 09:41 [AM] [ .] Unit En Route [DATE] 09:43 [AM] [ .] Unit Arrived on Scene [DATE] 09:45 [AM] [ .] Arrived at patient [DATE] 09:47 [AM] [ .] Unit left scene [DATE] 10:04 [AM] [ .] complaints and impressions; cardiac arrest, onset date and time [DATE] 09:38 [AM], [ .] AED used prior to EMS NO [ .] Further review revealed a summary which reflected the facility had performed CPR chest compressions and oxygenated rescue breathing but had not used the AED. The EMTs provided medications and applied the EMS AED and revealed Resident #61 had regained an irregular heartbeat after EMS care and medications administered intraosseous [directly into the bone marrow]. During an interview and observation on [DATE] at 02:28 PM the DON stated sometime in [DATE] Resident #61 was discovered unresponsive and was provided emergency CPR care. The DON stated she was not certain if the AED used. The DON proceeded to demonstrate the AED to the surveyor. The AED was stored on the facility's emergency crash cart along with CPR equipment such as an oxygen tank, and oxygen delivery equipment and included a suction pump with accessories. The DON demonstrated the AED as functional and stated the AED had not been used and could not recall the last time it had been used. The DON stated she believed LVN A, LVN B, and RN C were directly involved with Resident #1's CPR care. During an interview on [DATE] at 07:10 PM the DON provided updated information and stated she recalled the [DATE] CPR event for Resident #61 and stated the AED was not utilized, and EMS services arrived at the facility after the 911 call, approximately ,d+[DATE] minutes. The DON stated she did not know why the AED was not utilized and further stated EMS arrived quickly. The DON was asked to provide any further documentation to the event and did not provide further documentation. The DON stated LVN A, LVN B, and RN C were involved in the CPR event for Resident #61 AND reported to her Resident #61 was unresponsive. LVN A stated she told the CNAs to get RN C and immediately arrived at Resident #61's bed side. LVN A stated she assessed Resident #61 as a full code and without a pulse and not breathing. LVN A stated she began emergency CPR with chest compressions and RN C arrived at the bedside quickly. LVN A stated RN C assumed chest compressions and told her to get the crash cart and call 911. LVN A stated she ran to retrieve the crash cart and along the way told LVN B to call 911. LVN A stated she returned to Resident #61 with the crash cart and resumed chest compressions while RN C administered oxygen with rescue breaths. LVN A stated 911 EMTs were at the bedside quickly around ,d+[DATE] minutes maybe. LVN A stated EMS took over and Resident #61 was assessed with a pulse and left for the hospital with EMS. LVN A stated she was trained for CPR by the American Heart Association. LVN A stated the AED was stored on the crash cart and was immediately available upon arrival at Resident #61's bedside. LVN A stated the AED was never opened, removed from the case, or from the crash cart. LVN A stated she was so involved in providing CPR chest compressions and rescue breaths she did not think about the AED. LVN A stated her training included the use of an AED during CPR as soon as the AED was available. During an interview on [DATE] at 06:00 AM RN C stated on [DATE] she worked from 06:00 AM to 02:00 PM. RN C stated she was providing patient care when CNAs AB and AC told her LVN A needed her, and Resident #61 was unresponsive. RN C stated she ran to Resident #61's bedside and assessed Resident #61 as unresponsive and told LVN A to get the crash cart and call 911. RN C stated she began CPR chest compressions. RN C stated LVN A returned with the crash-cart, and they switched CPR roles and LVN A continued chest compressions while RN C administered oxygenated rescue breaths. RN C stated 911 EMS arrived quickly and continued CPR. RN C stated the facility's AED was stored on the facility's crash-cart and was immediately available when the crash-cart arrived but she nor LVN A gave it a thought due to the high stress of providing CPR. RN C stated she and LVN A provided CPR for maybe 5 minutes and 911 arrived quickly. RN C stated she was CPR trained by the American Heart Association. RN C stated her training included the use of an AED during CPR as soon as the AED is available. RN C stated she had not documented her role in Resident #61's CPR care to include times and details of care such as the use of an AED, RN C stated she believed the DON and / or LVN A had documented the CPR care. A record review of the facility's Emergency Procedure Cardiopulmonary Resuscitation policy dated February 2018, revealed, Policy Statement; personnel have completed training on the initiation of cardiopulmonary resuscitation and basic life support including Defibrillation for victims of sudden cardiac arrest; general guidelines; the chances of surviving sudden cardiac arrest may be increased if CPR is initiated immediately upon collapse. Early delivery of a shock with a defibrillator plus CPR within 3 to 5 minutes of collapse can further increase chances of survival [ .] emergency procedure; cardiopulmonary resuscitation; [ .] when the AED arrives assess for need and follow AED protocol as indicated [ .]. A record review of the American Heart Association's website Part 3: Adult Basic and Advanced Life Support; 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/adult-basic-and-advanced-life-support, accessed [DATE], revealed, Top 10 take home messages for adult cardiovascular life support: [ .] On recognition of a cardiac arrest event, a layperson should simultaneously and promptly activate the emergency response system and initiate cardiopulmonary resuscitation (CPR). Performance of high-quality CPR includes adequate compression depth and rate while minimizing pauses in compressions. Early defibrillation with concurrent high-quality CPR is critical to survival when sudden cardiac arrest [ .] Defibrillation is most successful when administered as soon as possible [ .]. A record review of the facility's in-service train the trainer, revealed, In-service Description: Rapid Response Policy, date: [DATE], Instructor Corp RN, in-service time: 1 hour.; the Administrator; the DON received CPR / AED training. Further review of the attached printed training revealed, [ .] the chances of surviving a sudden cardiac arrest maybe increased if CPR is initiated immediately upon collapse [ .] Early delivery of a shock with a defibrillator plus CPR within ,d+[DATE] minutes of collapse can further increase chances of survival [ .] Provide periodic mock codes for training purposes [ .] instruct a staff member to retrieve the automatic external defibrillators [ .] when the AED arrives, assess for need and followed protocols as indicated [ .] continue with CPR/BLS until emergency medical personnel arrive [ .] This was determined to be an Immediate Jeopardy (IJ) on ,d+[DATE] at 4:10 p.m. The Administrator was notified. The Administrator was provided with the IJ template on [DATE]. The following Plan of Removal was accepted on [DATE] at 2:10 p.m. Plan of Removal Verification Date [DATE] PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it May Concern, POR - Plan of Removal for Immediate Jeopardy dated [DATE] at 12:32 PM with the DON and ADMN Y: Summary of details which leads to outcomes. On [DATE] an annual survey was initiated at the Facility. On [DATE], a surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. The notification of the alleged immediate jeopardy states as follows: F726 COMPETENT NURSING STAFF The facility failed to have sufficient nursing staff with the appropriate competencies and skills set to provide nursing and related services to assure resident and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident Problem The Facility's Deficient practice revealed facility staff failed to demonstrate competency related to providing basic life support, including CPR including the timely application and use of an AED to a resident requiring emergency care prior to the arrival of emergency medical personnel. Immediate Corrections Implemented for Removal of Immediate Jeopardy. o Once the facility was made aware of the deficient practice, the Director of Nursing/ designee conducted an in-service with all staff on Mock Code, Rapid Response, AED, and CPR Training with emphasis on staff competencies to include all licensed staff all shifts, with return demonstration. The facility Director of Nursing/designee completed a 100% training in person with return demonstration of all licensed staff began on [DATE] and completed on [DATE] o Director of Nursing/Designee initiated education with clinical staff on [DATE] on proper protocol and procedure during a rapid response event and including timely retrieval and proper use of AED. This education was completed on [DATE]. The education was completed as a mock drill and monitored with DONs direct supervision and guidance to validate staff competency and understanding completed began mock code Competency in-service training sheet. Identification of Others: o Residents identified with full code status have the potential to be impacted by the alleged deficient practice. o Director of nursing/designee completed mock code reviews with clinical staff to ensure adequate knowledge of resuscitation protocol. Systemic Changes o the DON/designee initiated immediate training on Mock Codes, Rapid Response, AED, CPR and documentation of code process training to nursing staff on [DATE]. All education is at 100% completion as of [DATE]. o the DON/designee completed all education and training to all clinical staff and all clinical staff upon hire and added to new hire checklist. o the facility DON, Corporate Clinical Director and Administrator met on [DATE] to evaluate the facility policy and procedures regarding Quality of Life and staff competencies. o the DON/designee will complete education and training with all clinical staff on [DATE] and newly hired clinical staff over Mock Codes, Rapid Response, AED, CPR protocols and documentation of code process. The education will be provided by DON or designee with the necessary skill set related to CPR/ Rapid Response, including AED use and proper documentation. Education will include return demonstration and routine mocks to validate understanding and competency of all clinical staff. o The Administrator, DON/designee will develop and ensure an ongoing long-term monitoring and oversight system is in place by [DATE] to review and address concerns related to the deficient practices identified in F726. Monitoring will include a system to ensure deficient practice is prevented. The monitoring and oversight system will ensure clinical staff are adequately trained to meet requirements of safe practice. Concerns identified will be provided by the DON or designee to the QAPI committee monthly, for a minimum of 6 months, for the discussion of sustaining compliance or correction of concerns identified. Monitoring o The DON or designee will develop a short-term monitoring system for all areas of deficient practice identified for this deficiency by [DATE]. Monitoring will include a system to observe all clinical staff's verbalization of comprehension and return demonstration of rapid response protocols on all shifts through return demonstration q month for 3 months and quarterly for 12 months. o Monitoring will be completed through direct observation, when possible, and observation of mock codes. DON/Designee will retain record of all written mock competencies' routine and PRN. Mock codes will be run monthly for all clinical staff q month for 3 months on various shifts, then quarterly for 12 months. The monitoring will be documented on educational in-service forms and mock drills with staff's acknowledgment. o The Administrator/ designee will develop or ensure an ongoing long-term monitoring and oversight system is in place by [DATE] to review and address concerns related to the deficient practices identified in F726 o The QAPI committee will meet monthly, and facility interdisciplinary team will meet daily to review the ongoing status of the corrections for this deficiency with the purpose to identify, evaluate, plan, implement, and address concerns or deficient practices identified as it relates, or to determine if compliance is being sustained. All corrections or steps taken and identified by QAPI will be documented and addressed immediately. o An Ad Hoc QAPI meeting was held on [DATE] with the Medical Director, Administrator, Director of Nursing, and IDT to review and validate the plan of removal. Involvement of Medical Director The DON notified the facility's Medical Director, of the Immediate Jeopardy tag on [DATE]. The Administrator will be responsible for implementation of ensuring the adequate process regarding Monitoring of staff competency related to the provision of CPR including the use of an AED. The new process/system was initiated on [DATE]. Please accept this letter as our plan of removal for determination of the alleged Immediate Jeopardy issued [DATE]. Plan of Removal Verification Once the facility was made aware of the deficient practice, the DON/designee conducted an in-service with all staff on Mock Code, Rapid Response, AED, and CPR Training with emphasis on staff competencies to include all licensed staff all shifts, with return demonstration. The facility Director of Nursing/designee completed a 100% training in person with return demonstration of all licensed staff began on [DATE] and completed on [DATE] DON/Designee initiated education with clinical staff on [DATE] on proper protocol and procedure during a rapid response event and including timely retrieval and proper use of AED. This education was completed on [DATE]. The education was completed as a mock drill and monitored with DON's direct supervision and guidance to validate staff competency and understanding completed began mock code Competency in-service training sheet. Identification of Others: Residents identified with full code status have the potential to be impacted by the alleged deficient practice. Director of nursing/designee completed mock code reviews with clinical staff to ensure adequate knowledge of resuscitation protocol. Systemic Changes The DON/designee initiated immediate training on Mock Codes, Rapid Response, AED, CPR, and documentation of code process training to nursing staff on [DATE]. All education is at 100% completion as of [DATE]. The DON/designee completed all education and training to all clinical staff and all clinical staff upon hire and added to new hire checklist. The facility DON, Corporate Clinical Director and Administrator met on [DATE] to evaluate the facility policy and procedures regarding Quality of Life and staff competencies. The DON/designee will complete education and training with all clinical staff on [DATE] and newly hired clinical staff over Mock Codes, Rapid Response, AED, CPR protocols and documentation of code process. The education will be provided by DON or designee with the necessary skill set related to CPR/ Rapid Response, including AED use and proper documentation. Education will include return demonstration and routine mocks to validate understanding and competency of all clinical staff. During and observation of a mock CPR AED event on [DATE] at 01:51 p.m., revealed the DON called out to that a resident was unresponsive. The DON yelled out Code Blue and instructed RN O, RN K, RN N and LVN P to follow her to the unresponsive mock-Resident's room. The DON then delegated responsibilities to each nurse and one nurse to go get the crash cart. DON then proceeded to place a backboard under mock resident while communicating out load the importance of this backboard and if no backboard to then place the Unresponsive resident on the floor. The DON began compressions while counting outloud to 30, followed by using the AMBU bag for the two breaths. The crash cart arrived during this time. The DON showed staff, while doing it, how to remove the AED from its case, open the AED cover, which automatically begins the verbal AED Prompts protocols, the DON removed the AED pads from the case, attached the electrical pad leads to the AED, and placed the pads on the CPR mannequin, and continued to follow the AED verbal Prompts. The DON stated to the Mock CPR AED participants, continue CPR with the AED until EMS arrives. Interview on [DATE] at 2PM the DON stated 2 nurses, LVN M and LVN J were called at first and came in for mock CPR code training. Interview on [DATE] at 2:13 PM with LVN P, T, TH doubles, Fridays ,d+[DATE]PM, worked for SNF for 8 yrs. Worked all halls. DON -over weekend had a mock code, in-service, documentations, designate duties, implement AED, can participate call 911, call family, Call MD, give report to ER implement skills and continue use of AED. Interview on [DATE] at 2:18 PM- ADON K, worked for [DATE], works the floor if coverage is needed, all shifts -Did mock codes- 6 time, staff that would work different shifts, she made sure to cover all component, directed staff to do different task, call 911, call family, call MD, give report to ER, especially documentation, QAPI- monthly-don't recall talking about Resident #61, had 2 ADHOC mtg- nursing competency, areas of improvement all related to investigations management team DM, pharmacies, DON, Admin. Interview on [DATE] at 2:23 PM with RN O, ADON, m-f ,d+[DATE], prn, worked the floor, worked all halls, worked as LVN, trained on Mock code by DON-process and delegate task, call 911, family, MD and DON. Learned the delegating of task. QAPI-not sure if it was brought up, recent member to QAPI, had a emergency QAPI mtg, called MD, pharmacist, Admin, DON, department heads-discussed the incident with resident and interventions and POR. Interview on [DATE] at 2:33 PM with RN N, worked for 7 yrs. ago, worked all halls, worked days and evenings, DON mock codes-2nd, refreshes CPR training, CPR certified, process- go to resident, assess, pulse, delegate, check if resident code status, work as a team to assist resident. Make sure to sue board or on floor, make sure resident is positioned and can with out with other team member, utilize ED, document, wait for EMS. Did go to QAPI trainings. Interview on [DATE] at 2:46 PM with LVN J, worked the prn, all shifts, all halls, (nights) worked for 2 yrs., was out of town, called her on phone, yesterday did demonstration - DON in-service, CPR, all staff have a role, check pt., make sure environment after, assess, check code status, process, CNA can be involved- calling 911, family, DON explained for nursed and CNA in detail of training, CPR, AED, QAPI-not sure. Interview on [DATE] at 2:51 PM with LVN M, night shift, worked here for 1 yr., DON-called first, then came in yesterday for mock code-going over code and procedures and react to situation, go to room, res not breathing, initiated emergency response, call 911, cart c rt, AED, document time, delegate task, document on PCC. QAPI-had training. Interview on [DATE] at 2:57 PM with LVN F, Med nurse Charge nurse, m-f ,d+[DATE], worked for 2 yrs., worked all halls, in-service - was at SNF, mock code and in-service-find resident responsive, if code does not get verbal, check pulse, assess, delegate task, check res code status, crash cart, back board, AED, start on CPR and wait for EMS to come, QAPI-not sure. Interview on [DATE] at 3:16 PM with LVN E, shifts doubles ,d+[DATE]pm, worked for 3 months, worked E, F B hall (left side), -DON in-service mock code-demonstrated mock code, trained, res assesses, get res code status, 30 compressions to 2 rest, AED, call 911, etc, documentation and who helped you and wait for EMS. QAPI- no A record review of the facility's nursing roster revealed 21 nurses were employed by the facility over all 3 shifts, 06:00 AM to 02:00 PM, 02:00 PM to 10:00 PM, and 10:00 PM to 06:00 AM. 21 of the 21 nurses were interviewed for AED CPR training. A record review of the facility's nursing roster revealed 2 nurses, LVN J and LVN M were not in serviced in person as of [DATE] and have since [DATE] received in person CPR, AED, Documentation, training. During an interview on [DATE] at 02:13 PM LVN P stated she had received in person training for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED is presented. LVN P stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. LVN P stated the training was documented on a training competency checkoff form which she signed, and the DON signed. LVN P stated she currently works ,d+[DATE] time a week doubles from 06:00 AM to 02:00 PM and continues on 02:00 PM to 10:00 PM. During an interview on [DATE] at 02:18 PM RN K stated she had received training on [DATE] to include instructions for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED is presented. RN K stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. RN K stated her training with return demonstration was recorded on a CRP AED competency checkoff form signed by the DON and herself. RN K stated she had attended the QAPI meeting on [DATE]. RN K stated she works Monday thru Friday 06:00 AM to 06:00 PM. During an interview on [DATE] at 02:23 PM RN O stated she had received in-person training for CPR with the use of an AED during a Mock CPR code event on [DATE]. RN O stated the training included the immediate use of an AED as soon as the AED was presented on the crash cart. RN O stated the training also focused on post documentation for the CPR event to include event time, description details, such as time CPR started, time AED used. RN O stated the DON signed her CPR AED competency checkoff list in approval of her CPR AED competency training. RN O stated she works Monday thru Friday 06:00 AM to 06:00 PM. During an interview on [DATE] at 02:33 PM RN N stated she had received in person training for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED is presented. RN N stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. RN N stated the training was documented on a training competency checkoff form which she signed, and the DON signed. RN N stated she received in-service training for QAPI reporting. RN N stated she currently works ,d+[DATE] time a week doubles from 06:00 AM to 02:00 PM and continues on 02:00 PM to 10:00 PM. During an interview on [DATE] at 02:50 PM LVN J stated she had received training on [DATE] to include instructions for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED is presented. LVN J stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. LVN J stated her training with return demonstration was recorded on a CRP AED competency checkoff form signed by the DON and herself. LVN J stated she was in serviced on the QAPI review process. LVN J stated she is PRN and works all shifts. During an interview on [DATE] at 02:51 PM LVN M stated she had received in-person training for CPR with the use of an AED during a Mock CPR code event on [DATE]. LVN M stated the training included the immediate use of an AED as soon as the AED was presented on the crash cart. LVN M stated the training also focused on post documentation for the CPR event to include event time, description details, such as time CPR started, time AED used. LVN M stated the DON signed her CPR AED competency checkoff list in approval of her CPR AED competency training. LVN M stated she works the night shift 10:00 PM to 06:00 AM. During an interview on [DATE] at 02:57 PM LVN F stated she had received in person training for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED is presented. LVN F stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. LVN F stated the training was documented on a training competency checkoff form which she signed, and the DON signed. LVN F stated she received in-service training for QAPI reporting. LVN F stated she worked the 06:00 AM to 02:00 PM shift. During an interview on [DATE] at 03:16 PM LVN E stated she had received training on [DATE] to include instructions for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED is presented. LVN E stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. LVN E stated her training with return demonstration was recorded on a CPR AED competency checkoff form signed by the DON and herself. LVN E stated she had attended the QAPI meeting on [DATE]. LVN E stated she works Monday thru Friday 06:00 AM to 06:00 PM. LVN E stated she currently works ,d+[DATE] time a week doubles from 06:00 AM to 02:00 PM and continued 02:00 PM to 10:00 PM. Identification of Others: Residents identified with full code status have the potential to be impacted by the alleged deficient practice. A record review of the facility census revealed 29 residents requested they receive CPR care and had Full Code orders signed by a physician. A record review of Resident #2's code status revealed Resident #2 was a full code. A record review of Resident #7's code status revealed Resident #7 was a full code. A record review of Resident #33's code status revealed Resident #33 was a full code. A record review of Resident #53's code status revealed Resident #53 was a full code. A record review of Resident #257's code status revealed Resident #257 was a full code. Monitoring The DON or designee will develop a short-term monitoring system for all areas of deficient practice identified for this deficiency by [DATE]. Monitoring will include a system to observe all clinical staff's verbalization of comprehension and return demonstration of rapid response protocols on all shifts through return demonstration q month for 3 months and quarterly for 12 months. Monitoring will be completed through direct observation, when possible, and observation of mock codes. DON/Designee will retain record of all written mock competencies' routine and PRN. Mock codes will be run monthly for all clinical staff q month for 3 months on various shifts, then quarterly for 12 months. The monitoring will be documented on educational in-service forms and mock drills with staff's acknowledgment. The Administrator/ designee will develop or ensure an ongoing long-term monitoring and oversight system is in place by [DATE] to review and address concerns related to the deficient practices identified in F726 A record review of the facility's, F726 Staffing, Sufficient and Competent Nursing policy, dated [DATE] revealed, Policy Statement: Our Facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. policy interpretation and implementation: . competent staff: competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by state law. staff must demonstrate the skills and techniques necessary to care for residents needs including but not limited to the following areas: . resident rights; person centered care; basic nursing skills; basic restorative services; identification of changes in condition . licensed n [TRUNCATED]

Based on observation, interviews and record reviews the facility failed to provide basic life support, including CPR to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 (Resident #61) of 29 residents reviewed for CPR, in that; Resident #61 was discovered unresponsive, assessed as full code, and provided CPR for 9 minutes without the use of an available an AED prior to 911 EMS's arrival at the resident's side. An IJ was identified on [DATE]. The IJ template was provided on [DATE] at 11:05 am. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of actual harm that was not Immediate Jeopardy because the facility is still monitoring their effectiveness of their plan of removal. This failure placed residents at risk for harm up to and including death by the denial of all life saving measures as trained. The findings included: A record review of Resident #1's admission record dated, [DATE], revealed an admitted [DATE] and a death discharge date of [DATE], with diagnoses which included altered mental status, extended spectrum beta lactamase resistance [a bacteria that can't be killed by many of the antibiotics that doctors use to treat infections, like penicillin's and some cephalosporins for urinary tract infections], and urinary tract infection. A record review of Resident #1's admission MDS dated [DATE] revealed Resident #61 was an [AGE] year-old male admitted from an acute care hospital for support and rehabilitation related to a urinary tract infection. A record review of Resident #61's physician's order dated [DATE] revealed RN R documented a physician's order for Resident #61 to receive care as Full Code. A record review of Resident #61's care plan dated [DATE], revealed, [Resident #61] has an advance Directive as evidenced by: Full code status Date Initiated: [DATE] [ .] wishes will be honored, Date Initiated: [DATE] [ .] CPR will be performed as ordered. A record review of Resident #61's SBAR document dated [DATE] revealed, Situation [ .] the change in condition, symptoms, or signs observed, and evaluated is/are: cardiac arrest, respiratory arrest. This started on: [DATE]. Since this started it has gotten: stayed the same [ .] Resident/Patient Evaluation [ .] mental status evaluation: unresponsiveness [ .] Code Status: Full Code [ .] Appearance, summarize your observations and evaluation: CNA notified this nurse of resident being unresponsive assessed resident not responsive no pulse RN supervisor notified initiated CPR crash cart access notified 911 CPR performed until paramedics arrived emergency medical technicians continued with CPR resident transfers out with Pulse unconscious accompanied by three emergency medical technicians [ .]. A record review of the EMS TripTix EMS Patient Care Record dated [DATE] revealed, CPR was performed by the facility staff for 9 minutes from 09:38 AM to 09:47 AM as evidenced by, Incident Date / Times [ .] unit notified by dispatch [DATE] 09:41 [AM] [ .] Unit En Route [DATE] 09:43 [AM] [ .] Unit Arrived on Scene [DATE] 09:45 [AM] [ .] Arrived at patient [DATE] 09:47 [AM] [ .] Unit left scene [DATE] 10:04 [AM] [ .] complaints and impressions; cardiac arrest, onset date and time [DATE] 09:38 [AM], [ .] AED used prior to EMS NO [ .] Further review revealed a summary which reflected the facility had performed CPR chest compressions and oxygenated rescue breathing but had not used the AED. The EMTs provided medications and applied the EMS AED and revealed Resident #61 had regained an irregular heartbeat after EMS care and medications administered intraosseous [directly into the bone marrow]. During an interview and observation on [DATE] at 02:28 PM the DON stated sometime in [DATE] Resident #61 was discovered unresponsive and was provided emergency CPR care. The DON stated she was not certain if the AED used. The DON proceeded to demonstrate the AED to the surveyor. The AED was stored on the facility's emergency crash cart along with CPR equipment such as an oxygen tank, and oxygen delivery equipment and included a suction pump with accessories. The DON demonstrated the AED as functional and stated the AED had not been used and could not recall the last time it had been used. The DON stated she believed LVN A, LVN B, and RN C were directly involved with Resident #1's CPR care. During an interview on [DATE] at 07:10 PM the DON provided updated information and stated she recalled the [DATE] CPR event for Resident #61 and stated the AED was not utilized, and EMS services arrived at the facility after the 911 call, approximately ,d+[DATE] minutes. The DON stated she did not know why the AED was not utilized and further stated EMS arrived quickly. The DON was asked to provide any further documentation to the event and did not provide further documentation. The DON stated LVN A, LVN B , and RN C were involved in the CPR event for Resident #61. During an interview on [DATE] at 07:40 PM LVN A stated on [DATE] around 09:30 AM to 10:00 AM CNAs AB and AC reported to her Resident #61 was unresponsive. LVN A stated she told the CNAs to get RN C and immediately arrived at Resident #61's bed side. LVN A stated she assessed Resident #61 as a full code and without a pulse and not breathing. LVN A stated she began emergency CPR with chest compressions and RN C arrived at the bedside quickly. LVN A stated RN C assumed chest compressions and told her to get the crash cart and call 911. LVN A stated she ran to retrieve the crash cart and along the way told LVN B to call 911. LVN A stated she returned to Resident #61 with the crash cart and resumed chest compressions while RN C administered oxygen with rescue breaths. LVN A stated 911 EMTs were at the bedside quickly around ,d+[DATE] minutes maybe. LVN A stated EMS took over and Resident #61 was assessed with a pulse and left for the hospital with EMS. LVN A stated she was trained for CPR by the American Heart Association . LVN A stated the AED was stored on the crash cart and was immediately available upon arrival at Resident #61's bedside. LVN A stated the AED was never opened, removed from the case, or from the crash cart. LVN A stated she was so involved in providing CPR chest compressions and rescue breaths she did not think about the AED. LVN A stated her training included the use of an AED during CPR as soon as the AED was available. During an interview on [DATE] at 06:00 AM RN C stated on [DATE] she worked from 06:00 AM to 02:00 PM. RN C stated she was providing patient care when CNAs AB and AC told her LVN A needed her, and Resident #61 was unresponsive. RN C stated she ran to Resident #61's bedside and assessed Resident #61 as unresponsive and told LVN A to get the crash cart and call 911. RN C stated she began CPR chest compressions. RN C stated LVN A returned with the crash-cart, and they switched CPR roles and LVN A continued chest compressions while RN C administered oxygenated rescue breaths. RN C stated 911 EMS arrived quickly and continued CPR. RN C stated the facility's AED was stored on the facility's crash-cart and was immediately available when the crash-cart arrived but she nor LVN A gave it a thought due to the high stress of providing CPR. RN C stated she and LVN A provided CPR for maybe 5 minutes and 911 arrived quickly. RN C stated she was CPR trained by the American Heart Association . RN C stated her training included the use of an AED during CPR as soon as the AED is available. A record review of the facility's Emergency Procedure Cardiopulmonary Resuscitation policy dated February 2018, revealed, Policy Statement; personnel have completed training on the initiation of cardiopulmonary resuscitation and basic life support including Defibrillation for victims of sudden cardiac arrest; general guidelines; the chances of surviving sudden cardiac arrest may be increased if CPR is initiated immediately upon collapse. Early delivery of a shock with a defibrillator plus CPR within 3 to 5 minutes of collapse can further increase chances of survival [ .] emergency procedure; cardiopulmonary resuscitation; [ .] when the AED arrives assess for need and follow AED protocol as indicated [ .]. A record review of the facility's Automatic External Defibrillator, Use and Care of, dated [DATE], revealed, Policy Interpretation and Implementation: The automatic external defibrillator (AED) will be used to try to restore normal cardiac rhythm when arrhythmia is strongly suspected .remove the device from its case .check the battery cartridge to ensure it is in place .remove the film seals from the pads .turn on the device and follow the prompts . A record review of the American Heart Association's website Part 3: Adult Basic and Advanced Life Support; 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/adult-basic-and-advanced-life-support, accessed [DATE], revealed, Top 10 take home messages for adult cardiovascular life support: [ .] On recognition of a cardiac arrest event, a layperson should simultaneously and promptly activate the emergency response system and initiate cardiopulmonary resuscitation (CPR). Performance of high-quality CPR includes adequate compression depth and rate while minimizing pauses in compressions. Early defibrillation with concurrent high-quality CPR is critical to survival when sudden cardiac arrest [ .] Defibrillation is most successful when administered as soon as possible [ .]. A record review of the facility's in-service train the trainer, revealed, In-service Description: Rapid Response Policy, date: [DATE], Instructor Corp RN, in-service time: 1 hour.; the Administrator; the DON received CPR / AED training. Further review of the attached printed training revealed, [ .] the chances of surviving a sudden cardiac arrest maybe increased if CPR is initiated immediately upon collapse [ .] Early delivery of a shock with a defibrillator plus CPR within ,d+[DATE] minutes of collapse can further increase chances of survival [ .] Provide periodic mock codes for training purposes [ .] instruct a staff member to retrieve the automatic external defibrillators [ .] when the AED arrives, assess for need and followed protocols as indicated [ .] continue with CPR/BLS until emergency medical personnel arrive [ .] This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 11:05 AM. ADMN AA was notified. ADMN AA was provided with the IJ template on [DATE]. The following Plan of Removal was accepted on [DATE] at 10:27 AM. Plan of Removal Date [DATE] PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it May Concern, Summary of details which leads to outcomes. On [DATE] an annual survey was initiated at [Facility name and address]. On [DATE], a surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. The notification of the alleged immediate jeopardy states as follows: F678 Quality of Life CPR The facility failed to provide Quality of life CPR care for Resident #61 in that it did not follow and provide basic life support, including CPR, to a resident requiring such emergency care prior to arrival of emergency medical personnel. Problem The Facility's Deficient practice revealed facility failed to provide basic life support, including CPR, to a resident requiring emergency care prior to the arrival of emergency medical personnel. Immediate Corrections Implemented for Removal of Immediate Jeopardy. Once the facility was made aware of the deficient practice, the Director of Nursing/designee conducted an in-service with all staff on Mock Code, Rapid Response, AED, and CPR Training with emphasis on the expectation that the AED is retrieved immediately after checking for pulse and respirations. Residents identified at risk are those with Advanced Directives of Full Code status. The facility Director of Nursing/designee completed a 100% audit of residents advanced directive. This audit was completed on [DATE]. Residents who did not have a proper advanced directive were corrected immediately. Director of Nursing/Designee initiated education with clinical staff on [DATE] on proper protocol and procedure during a rapid response event and including timely retrieval and proper use of AED. This education was completed on [DATE]. The education was completed as a mock drill and monitored with DONs direct supervision and guidance to validate staff competency and understanding. Staff completed in-service training sheet. Identification of Others: Residents identified with full code status have the potential to be impacted by the alleged deficient practice. Director of nursing/designee completed mock code reviews with clinical staff to ensure adequate knowledge of resuscitation protocol. Systemic Changes The Director of Nursing/ designee initiated immediate training on Mock Codes, Rapid Response, AED, CPR and documentation of code process training to nursing staff on [DATE]. All education is at 100% completion as of [DATE]. The Director of Nursing/designee completed all education and training was started on [DATE] and will continue until all clinical staff have received training prior to the start of their work shift. The facility Director of Nursing, Corporate Clinical Director and Administrator met on [DATE] to evaluate the facility policy and procedures regarding Quality of Life and CPR Care. The Director of nursing/designee will complete education and training with all clinical staff on [DATE] and newly hired clinical staff over Mock Codes, Rapid Response, AED, CPR protocols and documentation of code process. The education will be provided by DON or designee with the necessary skill set related to CPR/ Rapid Response and proper documentation. The Administrator, DON, and designee will develop and ensure an ongoing long-term monitoring and oversight system is in place by [DATE] to review and address concerns related to the deficient practices identified in F678. Monitoring will include a system to ensure deficient practice is prevented. The monitoring and oversight system will ensure clinical staff are adequately trained to meet requirements of safe practice. Concerns identified will be provided by the DON or designee to the QAPI committee monthly, for a minimum of 6 months, for the discussion of sustaining compliance or correction of concerns identified. Monitoring The DON or designee will develop a short-term monitoring system for all areas of deficient practice identified for this deficiency. Monitoring will include a system to observe all clinical staff's adequate understanding of rapid response protocols on all shifts. Monitoring will be completed through direct observation, when possible, as well as through observation of mock codes. The monitoring will be documented on educational in-service forms and mock drills with staff's acknowledgment. The Director of Nursing/ designee will also conduct a chart review of any resident who has coded to validate that charting has been completed adequately and according to the education provided. This monitoring system will begin [DATE]. Data gathered will be measurable and monitoring will occur at least monthly and include weekend days and alternate shifts over the next 3 months and quarterly following. All concerns identified during the monitoring process will be addressed timely and documented for correction. The monitoring process, findings, and corrections will be presented to the facility QAPI committee each month for a minimum of 6 months for this plan of correction. Administrator will be responsible for monitoring DON compliance with system monthly. System compliance will be documented and discussed. The Administrator/designee will develop or ensure an ongoing long-term monitoring and oversight system is in place by [DATE] to review and address concerns related to the deficient practices identified in F678. Clinical Director of Operations will in-service Admin and DON over Rapid Response Policy and Procedure on [DATE]. Monitoring will be conducted monthly for 3 months to determine if compliance is being sustained. Sustained compliance or corrective actions will be discussed and documented in QAPI Meeting. The QAPI committee will meet monthly, and facility interdisciplinary team will meet daily to review the ongoing status of the corrections for this deficiency with the purpose to identify, evaluate, plan, implement, and address concerns or deficient practices identified as it relates, or to determine if compliance is being sustained. All corrections or steps taken and identified by QAPI will be documented and addressed immediately. Ad Hoc QAPI meeting will be held on [DATE] with the Medical Director, Administrator, Director of Nursing, and IDT to review and validate the plan of removal. Involvement of Medical Director The Director of Nursing notified the facility's Medical Director, of the Immediate Jeopardy tag on [DATE]. The Administrator will be responsible for implementation of ensuring the adequate process regarding Mock Code Monitoring. The new process/system was initiated on [DATE]. Please accept this letter as our plan of removal for determination of the alleged Immediate Jeopardy issued [DATE]. Plan Of Removal Verification Clinical Director of Operations will in-service Admin and DON over Rapid Response Policy and Procedure on [DATE]. Monitoring will be conducted monthly for 3 months to determine if compliance is being sustained. Sustained compliance or corrective actions will be discussed and documented in QAPI Meeting. A record review of the facility's in-service train the trainer, revealed, In-service Description: Rapid Response Policy, date: [DATE], Instructor Corp RN, in-service time: 1 hour.; the Administrator; the DON received CPR/AED training. Further review of the attached printed training revealed, .the chances of surviving a sudden cardiac arrest maybe increased if CPR is initiated immediately upon collapse .Early delivery of a shock with a defibrillator plus CPR within ,d+[DATE] minutes of collapse can further increase chances of survival .Provide periodic mock codes for training purposes .instruct a staff member to retrieve the automatic external defibrillators .when the AED arrives, assess for need and followed protocols as indicated .continue with CPR/BLS until emergency medical personnel arrive . The Director of Nursing/designee conducted an in-service with all nursing staff n Mock Code, Rapid Response, AED, and CPR Training with emphasis on the expectation that the AED is retrieved immediately after checking for pulse and respirations. Residents identified at risk are those with Advanced Directives of Full Code status. The Director of Nursing/designee initiated immediate training on Mock Codes, Rapid Response, AED, CPR and documentation of code process training with nursing staff on all shifts on [DATE]. All education was at 100% completion as of [DATE]. The Director of Nursing/designee-initiated education with clinical on all shifts on [DATE] on proper protocol and procedure during a rapid response event and including timely retrieval and proper use of AED. This education was completed on [DATE]. The education was completed as a mock drill and monitored with the DON's direct supervision and guidance to validate staff competency and understanding. Staff completed in-service training sheet. The Director of Nursing/designee completed all education and training was started on [DATE] and will continue until all clinical staff on all shifts have received training prior to the start of their work shift. A record review of the facility's nursing roster revealed 22 nurses were employed by the facility over all 3 shifts, 06:00 AM to 02:00 PM, 02:00 PM to 10:00 PM, and 10:00 PM to 06:00 AM. 22 of the 22 nurses on all shifts were interviewed for AED CPR training. And were able to identify and use of AED. During an observation of a mock CPR AED event on [DATE] at 01:06 p.m., revealed the ADMN AA called out to DON that a resident was unresponsive. The DON yelled out Code Blue and instructed RN R, LVN G, LVN Q and LVN E to follow her to the unresponsive mock resident's room. The DON then delegated responsibilities to each nurse and one nurse to go get the crash cart. The DON then proceeded to place a backboard under the mock resident while communicating out load he importance of the backboard and if there was no backboard then to place the unresponsive resident on the floor. The DON began compressions while counting out load to 30, followed by using the AMBU bag for the two breaths. The crash cart arrived during this time. The DON showed staff, while doing it, how to remove the AED from its case, opened the AED cover, which automatically began the verbal AED prompt protocols. The DON removed the AED pads from the case, attached the electrical pad leads to the AED, and placed the pads on the CPR mannequin, and continued to follow the AED verbal prompts. The DON stated to the mock CPR AED participants, Continue CPR with the AED until EMS arrives. During an interview on [DATE] at 01:08 AM LVN K stated she had received in person training for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED was presented. LVN K stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. Interviews done on [DATE] During an interview on [DATE] at 1:15 p.m., LVN E stated she worked ,d+[DATE] and ,d+[DATE] shifts. LVN E stated she had received training on [DATE], to include instructions, for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED is presented. LVN E stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. During an interview on [DATE] at 1:16 p.m., LVN G stated she worked ,d+[DATE] and ,d+[DATE] shifts. LVN G stated she had received training for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED is presented. LVN K stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. During an interview on [DATE] at 1:18 p.m., RN C stated she worked ,d+[DATE] shifts. RN C stated she had received training for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED is presented. RN C stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. During an interview on [DATE] at 1:19 p.m., LVN Q stated she worked ,d+[DATE] and ,d+[DATE] shifts. LVN Q stated she had received training on [DATE], to include instructions, for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED is presented. LVN Q stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. During an interview on [DATE] at 1:20 p.m., RN R stated she worked ,d+[DATE] and ,d+[DATE] shifts. RN R stated she had received training for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED is presented. RN R stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. During an interview on [DATE] at 01:33 PM LVN P stated she had received in-person training for CPR with the use of an AED during a mock CPR code event on [DATE]. LVN P stated the training included the immediate use of an AED as soon as the AED was presented on the crash cart. LVN P stated the training also focused on post documentation for the CPR event to include event time, description details, such as time CPR started, time AED used. During an interview on [DATE] at 1:55 p.m., LVN I stated he worked weekends and just started the previous weekend. LVN I stated he had received training on [DATE], to include instructions, for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED is presented. LVN I stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. During an interview on [DATE] at 1:56 p.m., RN K stated she was one of the ADONs. RN K stated she had received training for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED is presented. RN K stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. During an interview on [DATE] at 1:57 p.m., LVN L stated she worked on weekends. LVN L stated she had received training for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED is presented. LVN L stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. During an interview on [DATE] at 1:58 p.m., RN O stated she was one of the ADONs. RN O stated she had received training on [DATE], to include instructions, for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED is presented. RN O stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. During an interview on [DATE] at 2:01 p.m., LVN J stated she worked ,d+[DATE] shift. LVN J stated the training included the immediate use of an AED as soon as the AED was presented on the crash cart. LVN J stated the training also focused on post documentation for the CPR event to include event time, description details, such as time CPR started, time AED used. During an interview on [DATE] at 2:12 p.m., RN D stated she worked ,d+[DATE] shift. RN D stated she had received training for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED is presented. RN D stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. During an interview on [DATE] at 2:17 p.m., RN N stated she worked ,d+[DATE] shifts. RN N stated she had received training for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED is presented. RN N stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. During an interview on [DATE] at 2:21 p.m., LVN H stated she was the MDS Coordinator. LVN H stated she worked weekends. LVN U stated the training included the immediate use of an AED as soon as the AED was presented on the crash cart. LVN H stated the training also focused on post documentation for the CPR event to include event time, description details, such as time CPR started, time AED used. During an interview on [DATE] at 2:33 p.m., LVN A stated she had received training for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED is presented. LVN A stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. During an interview on [DATE] at 2:47 p.m., LVN M stated she worked ,d+[DATE] shift. LVN M stated she had received training on [DATE], to include instructions, for a mock CPR code event with specific training to include the immediate use of an AED as soon as the AED is presented. LVN M stated she received further training to include documentation to reflect the details and times of events for the CPR AED event. During an interview on [DATE] at 2:50 p.m., LVN U stated she worked weekends. LVN U stated the training included the immediate use of an AED as soon as the AED was presented on the crash cart. LVN U stated the training also focused on post documentation for the CPR event to include event time, description details, such as time CPR started, time AED used. The facility DON/designee completed a 100% audit of residents advanced directive. The audit was completed on [DATE]. Residents who did not have a proper advanced directive were corrected immediately. A record review of the facility census revealed 29 residents requested they receive CPR (CardioPulmonary Resuscitation) care and had full code orders signed by a physician. A record review of Resident #2's code status revealed Resident #2 was a full code. A record review of Resident #7's code status revealed Resident #7 was a full code. A record review of Resident #33's code status revealed Resident #33 was a full code. A record review of Resident #53's code status revealed Resident #53 was a full code. A record review of Resident #257's code status revealed Resident #257 was a full code. ADMN AA, DON, and designee will develop and ensure an ongoing long-term monitoring and oversight system is in place by [DATE] to review and address concerns related to the deficient practices identified in F678. Monitoring will include a system to ensure deficient practice is prevented. The monitoring and oversight system will ensure clinical staff are adequately trained to meet requirements of safe practice. Concerns identified will be provided by the DON or designee to the QAPI committee monthly, for a minimum of 6 months, for the discussion of sustaining compliance or correction of concerns identified. The DON or designee will develop a short-term monitoring system for all areas of deficient practice identified for this deficiency. Monitoring will include a system to observe all clinical staff's adequate understanding of rapid response protocols on all shifts. Monitoring will be completed through direct observation, when possible, as well as through observation of mock codes. The monitoring will be documented on educational in-service forms and mock drills with staff's acknowledgment. The Director of Nursing/ designee will also conduct a chart review of any resident who has coded to validate that charting has been completed adequately and according to the education provided. This monitoring system will begin [DATE]. Data gathered will be measurable and monitoring will occur at least monthly and include weekend days and alternate shifts over the next 3 months and quarterly following. All concerns identified during the monitoring process will be addressed timely and documented for correction. The monitoring process, findings, and corrections will be presented to the facility QAPI committee each month for a minimum of 6 months for this plan of correction. Administrator will be responsible for monitoring DON compliance with system monthly. System compliance will be documented and discussed. A record review of the facility's undated, F678 Quality of Care Life Support monitoring worksheet revealed, Administrator will conduct monitoring to ensure rapid response Mock drills are conducted once a month for 3 months and once a quarter for six months; a form designed to document and follow CPR Mock Codes to include corrective actions. A record review of the facility's undated, F678 Quality of Life CPR monitoring worksheet revealed, Clinical Resource [corporate nurse employee] will conduct monitoring to ensure Rapid Response Mock Drills are conducted once a month for 3 months; a form designed to do [TRUNCATED]

Based on interview and record review the facility must inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of, Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services for 4 of 5 (Residents #42, #3, #59, #38) residents reviewed for NOMC (Notice of Medicare Non-Coverage) services in that: 1 Resident #42 was discharged from therapy services on 04/7/2023 and did not receive/documentation of the cost if he would resume therapy. 2. Resident #3 was discharged from therapy services on 07/14/2023, and did not receive/documentation of the cost if she would resume therapy 3. Resident #59 was discharged from therapy services on 07/18/2023 and did not receive/documentation of the cost if he would resume therapy 4. Resident #38 was discharged from therapy services on 05/24/2023, and did not receive/documentation of the cost if he would resume therapy This failure could result in residents not receiving therapy services. The Findings were: 1. Record review of Resident #42 Admission record dated 8/4/2023 revealed he was admitted to the facility on [DATE], readmitted on [DATE], discharged on [DATE] and had Medicare health insurance. Resident #42 was diagnosed with diabetes II, dysphagia (Unspecified. It is a disorder characterized by difficulty in swallowing), dementia, anxiety, cognitive communication deficit, lack of coordination, muscle weakness, and anorexia(eating disorder). Review of Resident 42's Quarterly MDS dated [DATE] revealed his BIMs score was 5/15 (severely impaired). Record review of Resident #42's NOMNC revealed the effective dated coverage of the current SNF services would end: 4/7/2023. The form was signed by Resident #42 and dated on 4/4/2023. Resident #42's ABN revealed D. skilled nursing, E. Reason Medicare may not pay: no skill need, F. Estimated cost: was blank. The form was signed by Resident #42 and dated 4/4/2023. 2. Record review of Resident #38's Admission record dated 8/4/2023 revealed she was admitted to the facility on [DATE], discharged home on 7/15/2023 and had Medicare health insurance. Resident #38 was diagnosed with diabetes II, muscle weakness, dysphagia, heart failure, anemia, cognitive communications deficit, and anxiety. Review of Resident 38's Quarterly MDS dated 6/20/2023 revealed her BIMs score was 7/15 (severely impaired). Record review of Resident #38's NOMNC revealed effective date coverage exhausted for SNF services would end: 7/14/2023. The form was signed by Resident #38 and dated on 7/12/2023. Resident #38's ABN revealed D. skilled services, E. Reason Medicare may not pay: exhausted days, F. Estimated cost-was blank. The form was signed by Resident #38 and dated 7/12/2023. 3. Record review of Resident #59's Admission record dated 8/4/2023 revealed he was admitted to the facility on [DATE], discharged on [DATE] and had Medicare health insurance. Resident #59 was diagnosed with muscle weakness, age related physical debility, dysphagia and lack of coordination. Review of Resident 59''s Admission MDS dated [DATE] revealed his BIMs score was 10/15 (moderately impaired). Record review of Resident #59's NOMC effective date coverage exhausted of your current SNF services will end: 7/18/2023, this form was signed by Resident #59 and dated on 7/14/2023. Resident #59's Advanced Beneficiary Notice of Non-Coverage (ABN) D. skilled services, E. Reason Medicare may not pay: exhausted days, F. Estimated cost-was blank, this form was signed by Resident #59 and dated 7/14/2023. 4. Record review of Resident #3's Admission record dated 8/4/2023 revealed he was admitted to the facility on [DATE] and had Medicare health insurance. Resident #3 was his own responsible party and was diagnosed with muscle wasting and atrophy, respiratory failure, dysphagia, dementia, cognitive communications deficit, anxiety disorder, major depressive disorder, and repeated falls. Review of Resident 3's Annual MDS dated [DATE] revealed his BIMs score was 13/15 (cognitively intact). Record review of Resident #3's NOMC effective dated coverage exhausted of your current SNF services will end: 5/24/2023, this form was signed by Resident #3 and dated on 5/19/2023. Resident #3's Advanced Beneficiary Notice of Non-Coverage (ABN) D. skilled services, E. Reason Medicare may not pay: no skill need, F. Estimated cost-was blank, this form was signed by Resident #3 and dated 5/19/2023. Interview on 8/2/2023 at 4:14 PM revealed Resident #3 was confused and did not understand the surveyor. Interview on 8/3/2023 at 3:49 PM the BOM stated she started working as BOM on 7/5/2023. She stated she completed the NOMC for Resident #59 and was not aware that a cost should be documented and discussed with the resident. The BOM before her did the rest of the residents' NOMC/ABN letters with no cost, so, she followed that and she stated she was not trained before this week when Regional Account received resource was training her this week. Interview on 8/2/2023 at 1:02 PM ADMN AA stated he was made aware of residents not receiving the cost for services by the BOM. Administrator AA stated the risk would be residents would not receive services. Record review of the policy Medicare Advance Beneficiary and Medicare Non-Coverage Notices (ABN/NOMC) dated 9/2022 revealed 2c. termination- in the situation in which the facility proposes to stop furnishing all extended care items or services to a beneficiary because it expects that Medicare will not continue to pay for the items or services that is physician had ordered and the beneficiary would lie to continue receiving the care, the SNF ABN is issued to the beneficiary before such extended care items or services are terminated. 3. The resident (or representative) is informed that they may choose to continue receiving the skilled serviced that may not be paid for by Medicare and assume financial responsibility.

Based on interview and record review, the facility failed to consult the physician for 1 of 3 Residents (Resident #1) who experienced a significant change in the resident's physical status in that: Resident #1 had a fall, LVN B did not inform the physician of Resident #1's abnormal neurological signs which indicated a change in condition. This deficient practice could affect residents who had falls and could result in injury or death. The findings were: Review of Resident #1's Face Sheet, dated 10/6/20 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Admission MDS, dated [DATE], revealed a BIMS score of 7 which indicated severe cognitive impairment for daily decision-making skills. Further review of the Admission MDS revealed Resident #1 required 1-person physical assist when ambulating and the Resident was able to stabilize without staff assistance when walking. Review of Resident #1's Care Plan, revision date 8/12/20 revealed the Resident was at risk for falls related to confusion, incontinence, visual impairment, [MEDICAL CONDITION] and impaired safety awareness. Interventions included safe environment with even floors free from spills and/or clutter, adequate glare-free light, a working and reachable call light, bed in low position at night, side rails as ordered, handrails on walls and personal items within reach. Review of Resident #1's Neurological Record dated 8/5/2020, after a fall, revealed the Resident's vital signs, LOC (level of consciousness), pupil reaction and eye signs and Eye-Motor-Verbal Response were assessed beginning at 4:00 p.m. every 30 minutes until 5:30 p.m. and then every hour beginning at 5:30 p.m. until 7:30 p.m. LVN B consistently recorded Resident #1's pupil reaction on the left eye was NA and the right eye was 3mm in size. Further review of the Neurological Record revealed the following: Record review of Resident #1's LOC form from 4:00 p.m. to 5:00 p.m. as recorded by LVN B revealed: alert, eye response opens spontaneously, left upper, left lower, right upper and right lower extremities motor response revealed no deficits. LVN B documented Resident #'1 verbal response was Speech Oriented. Record review of Resident #1's LOC form at 5:30 p.m. as recorded by LVN B revealed: drowsy, eye response opens to speech, left upper, left lower, right upper and right lower extremities motor response revealed localizes signs of weakness, i.e., drifting of extremity. LVN B documented Resident #1's verbal response was Confused conversation. Record review of Resident #1's LOC form at 6:30 p.m. as recorded by LVN B revealed: drowsy, eye response opens to speech, left upper, left lower, right upper and right lower extremities motor response revealed localizes signs of weakness, i.e., drifting of extremity. LVN B documented Resident #1's verbal response was Incomprehensible Speech. Record review of Resident #1's LOC form at 7:30 p.m. as recorded by LVN B revealed: drowsy, eye response opens to pain, left upper, left lower, right upper and right lower extremities motor response revealed localizes signs of weakness, i.e., drifting of extremity. LVN B documented Resident #1's verbal response was Incomprehensible Speech. Review of the nursing note dated 8/5/20 at 7:25 p.m. by LVN B revealed Resident #1, complained of nausea, now with 2 episodes of emesis. This nurse called RN D to secure unit to assist in assessment of resident due to decreased response. Further review of the nursing note by LVN B revealed Resident #1 was unable to squeeze hand, unable to verbalize name, right eye pinpoint reaction, hematoma to left eye. LVN B further noted RN D paged the physician and the DON. Review of the nursing note dated 8/5/20 at 7:40 p.m. by LVN B revealed Resident #1 was transferred to the emergency room via 911. Review of the Nurse Practitioner's clinical note dated 8/6/20 revealed Resident #1 was sent to hospital earlier yesterday due to fall, admitted for brain bleed. Review of Resident #1's hospital record dated 8/5/20 revealed Resident #1's mental status deteriorated and required intubation. Resident #1 was noted with a left temple hematoma (a large collection of blood caused by injury or trauma) and left eye ecchymosis (bruising). Further review of the hospital record revealed Resident #1's condition was discussed with the family and the Resident was terminally extubated and comfort care measures were put in place. During an interview on 10/6/20 at 2:01 p.m., CNA A stated on 8/5/20 at approximately 3:00 p.m. Resident #1 was observed pacing back and forth and heard him fall really hard. CNA A stated she and CNA E went to check on Resident #1 and was seen on the floor laying on his left side and she noted his whole left side of his face was swollen. CNA A stated at around 5:00 p.m., when the dinner trays were being passed out, Resident #1 was given his dinner tray and when he was assisted to a sitting position the Resident vomited and it looked brown like coffee looking color. CNA A stated she reported the vomiting to LVN B but could not recall what occurred after that when her shift ended at 6:00 p.m. During an interview on 10/6/20 at 2:30 p.m., LVN B stated she was summoned by CNA E to the unit on 8/5/20 because Resident #1 had fallen. LVN B stated she did not recall the exact time but stated she worked the 2:00 p.m. to 10:00 p.m. shift and the incident occurred sometime before dinner at 5:00 p.m. LVN B stated Resident #1 was being assessed by the DON and RN D when she arrived on the unit. LVN B stated Resident #1 was alert and responding to questions and had some swelling on the left side of his face and eye. LVN B stated she began neurological checks per protocol. LVN B stated Resident #1 was legally blind in the left eye and wrote NA on the Neurological Record because she couldn't see the left pupil because it was swollen. LVN B further stated, I believe he (Resident #1) should have been sent sooner to the hospital because of the change he had at 5:30 p.m., but since his vitals were within range I continued with (neuro) protocol. During an interview on 10/6/20 at 3:14 p.m. the DON stated he recalled being asked to assist with a Resident #1 on 8/5/20 sometime after 2:00 p.m. The DON stated he asked Resident #1 what happened and the Resident told him in Spanish that he either just fell or got dizzy and fell . The DON stated Resident #1 told him he hit his head and was noted with some bleeding to the left temple and cheek. The DON stated he assisted Resident #1 to his bed and checked on the Resident again at approximately 5:30 p.m. and he continued to be alert. The DON stated he received a call from RN D informing him that the physician had been notified at approximately 7:35 p.m. with orders to call 911 for Resident #1 to be sent to the hospital. The DON further stated if the Resident had a significant change in mental status such as slurred speech, [MEDICAL CONDITION], facial droop or any other symptom of an internal bleed or stroke or trauma it would prompt me to stop and call 911 and call the doctor. I felt the nurses were assessing based on their judgement. The DON further stated Resident #1 passed away days later. During an interview on 10/6/20 at 3:45 p.m., RN D stated she was at the nurse's station on 8/5/20 during the 2:00 p.m. to 10:00 p.m. shift when CNA A summoned her about Resident #1 having had a fall. RN D stated she assessed the Resident with the DON and he was noted with bruising under the left eye and a knot on the left forehead. RN D stated she completed the first neurological check on Resident #1 at 4:00 p.m. and gave the results to LVN B to document. RN D stated NA was written on the Neurological Record for pupil reaction to the left eye because the Resident had a prosthetic. RN D stated LVN B did the subsequent neurological checks and did not summon her again until approximately 7:30 p.m. when LVN B asked her to evaluate Resident #1 because he was not responding well and didn't like the way he looked. RN D stated she went to see Resident #1 and he didn't look good and called the DON to inform him and was told by the DON to call 911. RN D was asked to look at the Neurological Record dated 8/5/20 for Resident #1 and stated, I would have called 911 if the Resident became drowsy after a fall because of a head injury. Looking at the neuro check flow sheet (Neurological Record) from 8/5/20 and the Resident showed he was drowsy at 5:30 p.m., that would have been considered a change in LOC and at that time the doctor should have been notified and I would have made the decision to call 911. During an interview on 10/6/20 at 4:56 p.m., CNA E stated she was working in the unit with CNA A when CNA E heard a thump and Resident #1 was seen on the floor. CNA E further stated the Resident was assisted to bed and later during dinner delivered his meal but the Resident was throwing up and didn't want to eat. CNA E stated she and CNA A reported the vomiting to LVN B. Review of the facility Neurologic Assessment, long-term care checklist, undated, revealed in part .Objective: To perform a neurologic assessment of a resident according to the standard or care .Assess LOC by evaluating the resident's responses to stimuli using a neurologic assessment tool . At the time of the exit the DON could not provide a copy of a Change in Condition policy requested on 10/7/2020.